Every finding on record at Medilodge of Westwood

This citation pertains to intake #3054443.Based on interview and record review, the facility failed to prevent significant medication errors in 1 of 1 resident (Resident #65) reviewed for medication errors, resulting in Resident #65 having an acute change of condition requiring hospitalization due to low blood sugar, decreased heart rate, low blood pressure, and admission to the ICU (intensive care unit). Findings include:Resident #65Review of an admission Record revealed Resident #65 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: Bipolar (mental health condition that causes extreme shifts in mood, energy, activity levels and concentration), dementia (a decline in mental ability, memory loss, thinking difficulties and behavioral changes), insomnia (inability to sleep), anxiety, hyperlipidemia (high cholesterol), type 2 diabetes (high blood sugar/lack of insulin), hypertension (high blood pressure) and chronic kidney disease.Review of Resident #65's Incident Report dated 5/26/26 at 7:28 PM revealed, Medication Error: .Resident was given the wrong medication: 40 mg Atorvastatin (common name is Lipitor: treats high cholesterol levels), 5 mg Eliquis (blood thinner), 1 mg Lorazepam (for anxiety), 1000mg Metformin (for high blood sugar), 25 mg Metoprolol (a beta blocker used for high blood pressure that causes the heart to beat more slowly and with less force), 100 mg Lyrica (for nerve pain), 4 mg Tizanidine (muscle relaxer), 34 units Toujeo (long-acting insulin for high blood sugar), 50 mg Trazodone (antidepressant).Immediate Action Taken: .In house provider contacted, DON was contacted, Residents blood sugar assessed qhr (every hour), vs (vital signs) monitored, snacks and fluids given and encouraged. Sent out to the hospital for evaluation.Review of Resident #65's Medication Administration Record for medications that were ordered at bedtime on 5/26/26 revealed: Latuda (antipsychotic medication used for bipolar disorder), Melatonin (helps to sleep at night), Rosuvastatin (treats high cholesterol), Memantine (to treat dementia), Aricept (for dementia), Sennosides (treats constipation), and Depakote (to treat bipolar disorder). There were no orders for any of the medications that Resident #65 received in error on 5/26/26. The resident did not have any medications ordered for high blood pressure, high blood sugar, nerve pain and/or a blood thinner. The record also indicated that Resident #65 was allergic to Lipitor, which was one of the medications the resident received in error on 5/26/26.Review of Resident #65's Hospital Records dated 5/26/26 revealed, .Chief Complaint: Received wrong medication at (facility name omitted); hypotensive (low blood pressure) and bradycardia (low heartrate); BS (blood sugar) 144; received Atropine (for severe low heart rate) 0.5 mg and Glucagon (for severely low blood sugar) from EMS (emergency medication services). presenting to the ED (emergency department) via EMS after inadvertently being given another resident's medications.Lipitor 40 mg (patient has documented allergy to Lipitor, unsure of reaction), Eliquis 5 mg, Lorazepam 1 mg, Metformin 1000mg, Metoprolol tartrate 25 mg, Lyrica 100mg, Tizanidine 4 mg, Toujeo 34 units, Trazodone 50 mg. Nursing knew within a few minutes that the wrong medications were given. He was given drinks and food, in lieu of the insulin being given.Around 7:50 PM, patient seemed pale and was becoming less communicative. Vitals were significant for a HR (heartrate) in the 40s, blood pressure was 90s/50s. At this time, staff called EMS in which patient was transported to (hospital name omitted) within an hour. The patient has right-sided deficits from a prior stroke, is slow to answer questions at baseline, and is alert and oriented 1-2. He is also wheelchair bound at the NH (nursing home). Upon arrival to ED, patient is complaining of chest pain, abdominal pain, back pain, and shortness of breath. He was placed on 6L (Liters) NRB (non-rebreather) (oxygen) mask.ED Course: .given two pushes of epinephrine (used for severe allergic reactions and to improve blood flow to the heart and brain), glucagon 1 mg, D5 (fluid containing sugar) with insulin, and potassium chloride (for low blood potassium).Assessment/Plan: Patient admitted to ICU on 5/26 for symptomatic hypotension and bradycardia requiring epinephrine infusion (administered through a vein) after accidental administration of another resident's medications at nursing facility. Clinical picture is concerning for medication-induced toxicity (this occurs when a drug accumulates to harmful levels in the bloodstream or tissues, causing adverse physical or mental reactions) resulting in hemodynamic instability (a state where the circulatory system fails to maintain adequate blood pressure and blood flow to vital organs). Suspect mixed medication overdose/toxicity, particularly from beta-blocker (causes the heart to beat slower) exposure with additional CNS (central nervous system) depressant (medications used for anxiety) and antihypertensive (lowers blood pressure) effects from Lorazepam, tizanidine, trazodone, and pregabalin (Lyrica).In an interview on 7/15/26 at 9:51 AM, Licensed Practical Nurse (LPN) T reported regarding Resident #65's medication error on 5/26/26: RN X came to LPN T and reported that she had accidently given Resident #65 his roommate's medications. LPN T reported that she carefully reviewed the medications with RN X that were given in error and then contacted the provider, Nurse Practitioner (NP) HH. NP HH instructed LPN T to monitor Resident #65 closely, check vital signs, check his blood sugar, and give him something to eat. LPN T reported that Resident #65 had been given insulin, blood pressure medication and others that he did not normally take. LPN T reported that after about 30 minutes Resident #65's heart rate started dropping, so they called 911 and had him sent to the hospital. LPN T reported that she spoke to the hospital several times that night to ensure they knew exactly what medications Resident #65 was given in error. LPN T reported that RN X was a new nurse to the facility and was not familiar with Resident #65.In an interview on 7/15/26 at 11:19 AM, NP HH reported that she had received a call from LPN T at home on 5/26/26 reporting that Resident #65 had been given another resident's medications. NP HH reported that as soon as she heard that insulin and blood pressure medication were involved, she instructed staff to monitor Resident #65's blood sugar and blood pressure closely and to call with any changes in the resident's condition.In an interview on 7/15/26 at 12:07 PM, Rehab Director (RD) JJ reported that Resident #65 was on therapy to improve his overall strength after he returned from the hospital on 6/3/26. In an interview on 7/16/26 at 10:50 AM, RN X reported that she had accidently administered another resident's medications to Resident #65 on 5/26/26, leading to an acute change in condition and hospitalization. RN X reported that she had only been working in the facility for a couple of months and was not familiar with Resident #65 at that time. RN X reported that she had prepared the medications, walked into Resident #65's room, asked the resident if his name was (roommate's name omitted), and Resident #65 answered yes. RN X reported that she checked Resident #65's blood pressure and blood sugar, then gave the insulin injection and administered all the pills whole. Then RN X explained that when she prepared Resident #65's roommate's pills and asked if his name was (Resident #65) the roommate said No. RN X reported she realized at that time she had mixed up the residents. RN X reported that she immediately panicked and asked LPN T for assistance with the medication error. RN X reported that they contacted NP HH and monitored Resident #65 closely for about 30 minutes; when Resident #65's heartrate started to decrease they made the decision to send him to the hospital for further evaluation. RN X reported that it was later that she learned Resident #65 answered yes to everything and she should had asked the resident to say his name. RN X reported that she had received extensive re-education following the incident and was no longer allowed to care for Resident #65.Review of witness statement by Registered Nurse (RN) X revealed, I knocked on the door and walked into the residents' (Resident #65) room. I walked over to the bed where the resident was laying with his back towards me. I called out (roommates name omitted) and he turned over. I asked him was he (roommates name omitted) and he said mhmm. I stated that I needed to get his BP (blood pressure) before I gave him his meds. After that I said here are you night meds, (Resident #65) grabbed the cup and took the meds. I then took his blood sugar and gave him the insulin. Once I found out that he was the wrong resident, I checked his allergies. (Company name omitted) on call was called, our house PA (physician assistant) and DON (Director of Nursing) was contacted and notified. I received orders to check his BS (blood sugar) every hour, give snacks, push fluids, and to continue to monitor, and if he becomes unstable to send to ER (emergency room). Resident was eventually sent out for further evaluation.In an interview on 7/16/26 at 11:03 AM, DON B reported that when the medication error for Resident #65 occurred she had been on vacation and it was not until the next day that it was brought to the manager's attention. DON B reported that it was determined that Resident #65 received multiple medications, including insulin and blood pressure medications which lead to an acute change of condition, hospitalization where they found significant bradycardia (low heartrate) and hypotension (low blood pressure), admission to ICU (intensive care unit) to stabilize his vital signs, and then he returned to the facility approximately 5 days later. DON B reported that Resident #65 had since received skilled therapy and had returned to his prior level of function. DON B reported that a full investigation was performed; re-education to all staff, RN X received disciplinary action, and the facility had been performing ongoing audits of medication administration. DON B reported that staff are expected to follow the standard rights of medication administration with all residents, including verification of the right resident by using their photo in record and/or asking another staff member that is familiar with the resident to verify the right resident prior to administration of medications. Review of Fundamentals of Nursing ([NAME] and [NAME]) revealed, Professional standards such as Nursing: Scope and Standards of Practice (ANA, 2010) .apply to the activity of medication administration. To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these six rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 39307-39313). Elsevier Health Sciences. Kindle Edition.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included training for nurses, monitoring of medication administration and ongoing audits. 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 maintain a safe and functional entry to the building, affecting all residents that utilize the exterior spaces. Findings Include: On 07/14/26 at 8:45 AM, numerous potholes were observed while entering the facility's parking lot through the north entrance.On 07/14/26 at 10:55 AM, Maintenance Director RR was interviewed and stated the parking lot has been an ongoing challenge for the facility. He reported a repair plan is in progress but could not provide a timeline for completion.In an observation on 7/16/26 at 10:05 am, a facility resident was noted sitting outside near the driveway to enter the parking lot smoking. The resident had to cross the parking lot from the front entrance, across the unrepaired driveway to get to the required smoking area. On 07/16/26 at 12:32 PM, a tour of the parking lot with Maintenance Director RR, identified multiple areas of severe disrepair, including potholes exceeding three inches in depth. Areas observed included the south driveway entrance, back service area, employee parking, visitor parking, main entrance, and north driveway entrance. Specific locations with significant deterioration included the south entrance near the dumpster, the south drive curve to staff parking, and most of the north entrance. These conditions presented potential hazards for residents, visitors, and staff who access or travel through these areas.A review of facility records found a proposal from an asphalt vendor dated 07/09/26. The vendor's field review date was documented as 10/03/25.

Based on observation, interview, and record review, the facility failed to ensure food items were stored, prepared, and maintained under sanitary conditions, increasing the risk of foodborne illness to all residents that consume food from the kitchen. Findings Inlcude:On 7/14/26 at 9:28 AM, the three-compartment sink was observed with a sanitizer pre-dispense system with no test strips to ensure accuracy of the sanitizer. When asked if there were any test strips, [NAME] SS was unable to find them.On 7/14/26 at 9:35 AM, the cook line preparation table was observed with clean pots and pans stored on the underside. A review of the pans found two half pans and two quarter pans stacked and stored wet with moisture in-between.On 7/14/26 at 10:37 AM, the dish machine rinse gauge was observed cracked and loose on the dial allowing the needle to be open and exposed.On 7/14/26 at 10:50 AM, the resident fridge in the dinning room was observed with the following: a container of spaghetti dated 7/7, a baked potato and meatloaf leftovers with no name or date, an unopened container of whipped topping that states its good for two weeks under refrigeration, an open container of carmel macchiato dated 6/17/26 and manufactures instructions for discard after 7-10 days after opening, a grocery bag container of strawberries and whipped topping with no name and date and the strawberries covered in white fuzz. A review of the document on the refrigeration unit found it stated, Prepared food items will have a 3-day use-by date and then discarded.On 7/16/26 on 1:15 PM, a follow up tour of the kitchen found the plate warmer with excess accumulation of debris, crumbs. silverware, and plastic wrappers stacked up in the inside bottom of the unit.According to the 2022 FDA Food Code:Section 4-302.14 Sanitizing Solutions, Testing Devices. A test kit or other device that accurately measures the concentration in MG/L of SANITIZING solutions shall be provided.Section 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD.Section 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2.Section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. 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.Section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17(A) .Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on interview and record review, the facility failed to maintain accurate medical records for 3 residents (Resident #3, #65, and #46) of 18 residents reviewed for complete and accurate medical record documentation, resulting in incomplete and inaccurate documentation of treatments completed by the licensed nurse and tasks performed by the CNA's (Certified Nursing Assistant).Finding include:Resident #3 Review of an admission Record revealed Resident #3 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: contractures (a permanent shortening of muscles, tendons, skin, or other soft tissues that restricts normal joint movement and can cause deformity). Review of Resident #3's Care Plan revealed, .ADL (activities of daily living) self-care performance deficit related to. contractures, and needs assistance with personal care. Date initiated: 5/24/24, Revision on: 5/11/26. Interventions: .Splint/Brace Care: Apply palm protectors to both hands/palms with AM care and removed at HS (bedtime) as tolerated. May substitute with washcloths. Monitor skin integrity with each application and removal. Date initiated: 7/6/25. During an observation of 07/14/2026 at 10:57 AM Resident #3 was lying in her bed with her eyes open. Resident #3's hands were observed closed tightly and palm protectors were not in place. During an observation on 7/15/26 at 12:27 AM in the dining room, Resident #3 was observed being assisted to eat lunch. Resident #3 was not wearing palm protectors. Review of Resident #3's Treatment Administration Record (TAR) for July 2026 revealed, Maintenance restorative nursing: Range of motion (passive: staff perform movements) to bilateral hands during AM care with application of palm protectors. The record indicated that the licensed nurse checked off and initialed 14 of 15 days, including 7/14/26 and 7/15/26. The record was not completed for 7/11/26. Review of Resident #3's CNA documentation from the past 30 days revealed, multiple task orders for PROM and application of palm protectors. There was no data recorded in the tasks related to if the task was completed and/or how the resident tolerated the PROM and palm protectors. Resident #65 Review of an admission Record revealed Resident #65 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: hemiplegia (inability to move one side of the body) and hemiparesis (muscle weakness and loss of movement on one side of the body) following cerebral infarction (stroke), affecting right dominant side. Review of Resident #65's Care Plan revealed, .ADL self-care performance deficit related to weakness.hemiplegia.Date initiated: 10/27/23. Revision on: 6/2/26. Interventions: .Splint/Brace Care: apply right hand T-bar orthosis (a medical device that helps stretch tight hand muscles and fingers) in AM and remove in afternoon, as tolerated. Monitor skin integrity with each application and removal. Date initiated: 6/30/25. During an observation on 07/14/2026 at 10:02 AM Resident #65 was lying in his bed. Resident #65's right hand/arm was observed and there was not a splint/brace in place. During an observation on 07/15/2026 at 7:45 AM Resident #65 was observed in the dining room. Resident #65's right hand/arm was observed and there was not a splint/brace in place. During an observation on 07/15/2026 at 10:35 AM Resident #65 was observed lying in his bed. Resident #65's right hand/arm was observed and there was not a splint/brace in place. During an observation on 7/15/26 at 12:25 AM Resident #65 was in the dining room. Resident #65 was not wearing a hand splint. In an interview on 7/15/26 at 4:01 PM, CNA NN reported that Resident #65 doesn't refuse wearing his hand splint. In an interview on 7/15/26 at 12:48 PM, Licensed Practical Nurse (LPN) U reported that she had not documented in the TAR yet for that day. LPN U reported she typically went through the treatment orders in the afternoon, so she wasn't aware that Resident #65 did not have his brace applied that morning. Review of Resident #65's TAR for July revealed, MAINTENANCE RESTORATIVE NURSING: Range of Motion (passive) to Right HAND as tolerated prior to application of T-bar splint. in the morning for Maintenance Restorative Nursing PROM to right hand prior to application of T-bar splint in AM, Start Date 6/10/26. And also Splint/Brace care: apply right hand T-bar orthosis in AM and remove in afternoon, as tolerated. Monitor color, motion, sensation, and skin integrity with each application and removal. Start date 6/10/26. The administration records both indicated that the licensed nurse checked off and initialed 10 of 15 days, including 7/14/26 and 7/15/26. The records were not completed for 7/1, 7/6, 7/7, 7/9, and 7/13. Review of Resident #65's CNA documentation from the past 30 days revealed, Splint/Brace assistance: Apply right hand T-bar orthosis in AM and remove in afternoon, as tolerated. Monitor skin integrity with each application and removal. Question #1 was how well did resident tolerate; 13 of 30 days indicated tolerated well and 13/30 days indicated did not occur. Question #3 was why did the restorative program not occur; 9 of 30 days indicated not scheduled this shift, 5of 30 days indicated resident refused. Review of Resident #65's CNA documentation from the past 30 days revealed, Maintenance Restorative Nursing: Range of motion (passive) to right hand as tolerated prior to application of T-bar splint. There was no documentation related to if the task was performed, how well the resident tolerated it and/or how many minutes were spent providing the ROM. In an interview on 7/16/26 at 11:53 AM, Director of Nursing (DON) B reported that the licensed nurses are expected to verify that residents had splints in place per orders and then check the order off in the TAR. DON B reported that nurses should not be waiting to go through the treatment orders in the afternoon because there are orders scheduled for the morning. In Legal and Ethical Issues in Nursing by G. [NAME] (2001), it documents that Documentation must show continuity of care, interventions that were used, and patient responses to the therapies implemented. Nurse's notes are to be concise, clear, timely, and complete. (pg. 171) Resident #46(R46) Review of an Face Sheet revealed R46 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: frontal lobe (area of the brain responsible for decision-making, reasoning and expressive language) and executive function (planning, remembering instructions and multi-tasking skills) deficits following a cerebral infarction (stroke), chronic pain and bed confinement status (inability to tolerate being out of bed). Review of a Minimum Data Set(MDS) assessment for R46 with a reference date of 5/14/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15/15, which indicated the resident was cognitively intact. Section GG revealed R46 required maximal assistance (helper provides more than half the effort) roll in bed and set up assistance for eating. Review of a Care Plan for R46 with a reference date of 9/19/23 revealed the following focus/goal/interventions: Focus: (R46) is at risk for impaired skin integrity r/t (related to) type 2 diabetes.prefers to remain in bed.chronic pain.decreased mobility.Goal: Resident will have intact skin to extent allowed by resident.Interventions: monitor skin integrity during weekly/routine skin nursing assessments, notify nurse of any new areas of skin impairment.redness, blisters.notify physician/NP (nurse practitioner) of any new areas of skin impairment. In an interview on 7/14/26 at 9:51am, R46 reported he suffered pain when a staff member recently knocked a hot beverage off his breakfast tray and it spilled on his groin and legs. R46 reported he was not sure if he had any open areas on his skin following the accident. Review of a Provider Note for R46 with a reference date of 6/24/26 revealed [AGE] year-old male.complains of pain in his groin due to spilling hot coffee yesterday. No areas of open or erythematous (abnormal redness) skin.skin is tender to touch. In an interview on 7/15/26 at 3:14pm, Certified Nursing Assistant (CNA) R reported on 6/23/26 she was setting up R46's breakfast tray as he sat supported in bed when she bumped a cup of hot water with her hand and it spilled into R46's lap. CNA R reported R46 was covered by a blanket, sheet and incontinence brief when the accident occurred, and she immediately removed the blanket and sheet. CNA R reported R46 complained of pain and she alerted the nurse. CNA R confirmed she told the nurse about the incident immediately. CNA R reported R46 continued talking about the incident later that same day and reported he was frustrated about it. Review of Skin Assessments for R46 revealed the last skin assessment for the resident was completed on 4/28/26. Via electronic communication on 7/15/26 at 8:41am, all skin assessments for R46 for the last 30 days were requested. No assessments were provided by the conclusion of the survey In an interview on 7/15/26 at 3:45pm, Director of Nursing (DON) B it was the expectation that nurses complete a skin assessment on each resident weekly and as needed, and incident/accident reports with every occurrence. DON B confirmed R46's skin had not been assessed since 4/28/26 and she was not aware of the issue prior to the survey. DON B reported she was aware R46 recently reported an accident in which a hot beverage was spilled onto his groin. In an interview on 7/16/26 at 10:00am, DON B reported due to a computer issue, nurses were not receiving prompts to complete skin assessments, but regardless, nurses were expected to know they should complete weekly skin assessments for every resident.

Based on observation, interview, and record review, the facility failed to obtain weights and ensure nutritional preferences were met in 1 of 1 resident (R5) reviewed for nutrition, resulting in the potential for decreased nutritional status. Findings include:Review of R5's medical records indicated the resident was admitted on [DATE] weighing 126 pounds. The resident did not have documentation in his medical records that he had been weighed from 6/25/26 until beginning of survey 7/14/26.According to R5's Minimum Data Set (MDS) dated , 7/1/26, the resident scored 5/15 on the BIMS (Brief Interview Mental Status) indicating he was severely cognitively impaired. Diagnoses of medically complex conditions included cancer, malnutrition, pressure ulcer of sacral region, acquired absence of right and left legs above knee, ulcer of esophagus (a muscular tube in the digestive system that connects the throat (pharynx) to the stomach) with bleeding, peripheral vascular disease, and renal disease. Section K-Swallowing/Nutritional Status revealed the resident was 69 inches and weighed 126 pounds. R5 was not on a physician-prescribed weight-loss program and had a loss of 5% or more of his total body weight in the last month.Review of R5's Hospital After Visit Summary, dated 5/30/26-6/25/26, revealed, Diet Instructions-Nutrition Recommendations.General diet, Trial vanilla magic cup (a high-calorie, high-protein frozen dessert designed to help prevent involuntary weight loss. It resembles ice cream when frozen and turns into a soft, pudding-like consistency when thawed) with lunch and vanilla ice cream with dinner.Review of Order Summary dated 6/25/26 at 10:00 PM revealed, Regular diet, regular texture, regular fluid, thin consistently. Dietary-Supplements included Health Shake (specialized nutrition shakes) three times a day for Protein calorie malnutrition and Prostat AWC (medical-grade concentrated liquid protein supplement designed to manage wounds and muscle loss) two times a day related to pressure ulcer of sacral region (dated 7/1/25).Review of R5's Care Plan, dated 6/30/26 with revision on 7/6/26, revealed, Focus-At Risk for Altered Nutritional Status-related to hospital course with sepsis, chronic osteomyelitis (infection in bone) with multiple impaired skin sites present, bilateral AKA (above knee amputation), esophageal ulcers noted with complicating diagnosis DMII (diabetes), COPD (chronic obstructive pulmonary disease), afib (atrial fibrillation), HTN (hypertension), PVD (peripheral vascular disease), metastatic prostate cancer, poor intake during hospital course (stay) with weight loss. Goal- was to have adequate nutrition to meet nutritional needs and have no signs/symptoms of malnutrition. Interventions to meet goals included-periodically obtain resident's weight, evaluate, and report to Dietician, Physician/NP/PA (nurse practitioner, physician's assistant) provide meals/fluids based on resident food preferences and as ordered, provide nutritional supplement(s) as ordered, update and honor resident's food preferences on tray ticket, encourage/provide intake of fluids throughout the day if not contraindicated.Review of R5's Care Plan, revision on 7/6/26, revealed, Focus-Malnourished as evidenced by Mini Nutritional Assessment. Has diagnosis of moderate protein calorie malnutrition. Goal-will have adequate nutrition to meet nutritional needs and have improved as evidenced by Mini Nutritional Assessment score. Interventions to meet goal included-monitor weight and obtain food preferences.Review of R5's Mini Nutritional assessment dated [DATE] indicated the resident with a score of 5.0 indicating he was malnourished. R5 had a severe decrease in food intake, with a weight loss greater than 6.6 pounds in the last 3 months. Review of R5's Nutrition Data Collection/Evaluation, Admission, dated 6/30/26, indicated he admitted to the facility with malnutrition. During R5's hospitalization the resident had sepsis, chronic osteomyelitis with multiple impaired skin sites present, bilateral above knee amputations, esophageal ulcers, metastatic prostate cancer, poor intake during hospital course with weight loss. R5 stated his appetite was back denying pain or discomfort related to esophageal ulcers and was eating well. Health shakes three times a day on admission to meet caloric intake needs as related to variable intake, noted weight loss, and wounds present.During an observation and interview on 7/14/26 at 10:56 AM, R5 had 3-unopened cartons of Health Shakes on bedside table room temperature to touch. Bedside table was out of sight and reach of resident along with Styrofoam drinking cup. R5 stated he would drink his water but did not like the taste of the Health Shakes and did not drink them. R5 appeared thin and gaunt (someone who is extremely thin, bony, and [NAME], often because of suffering, hunger, or illness) .During an observation and interview on 7/15/26 at 8:45 AM, R5 was awake in his bed stating had eaten every bit of his breakfast and it was good. No Healthy Shake was at bedside. R5 stated he did not like the taste of the Health Shakes and does not usually drink them. A foam cup with water dated 7/15 was on the bedside table in front of him.During an interview and record review on 7/15/2026 at 10:48 AM, Director of Nursing (DON) B stated, (R5) has been refusing his weights. Reviewed R5's progress notes that did not have documented refusals. DON B then stated CNAs (Certified Nursing Assistants) Tasks would indicate when CNAs were to weigh resident. DON B reviewed R5's Tasks for weight monitoring. DON B stated, R5 Task for Weight indicates on 6/28/26 NA (not applicable). I don't know what that means. There is a spot to indicate refusal but that was not indicated. CNAs are to take the weights when indicated and nurses help when they can. In R5's Tasks there was only one date for the CNA to take weight on 6/28/26. R5's admission weekly weights were not set up for the CNAs or nurses to know to take them weekly x4 weeks. Knowing R5's weight and nutritional status is important because he has multiple health concerns including cancer and wounds. I've heard (R5) likes vanilla and the facility can give him the Magic Cups which will help him with nutrition and weight.During an interview and record review on 7/15/2026 at 3:19 PM, Corporate Registered Dietician (RD) O stated while reviewing R5's medical records, It is important with (R5's) critical condition to monitor his weight. Unfortunately, his weights were not done weekly. He should be weighed upon admission and then weekly for 4 weeks to get a baseline weight on him. His nutritional needs are very important. If he does not like the Health Shakes, we can work on finding him something he likes to make sure he gets the protein and nutrition he needs. Reviewed R5's After Visit Summary, stating, The facility can give him the Magic Cup in Vanilla.Review of facility policy, Weight Monitoring, dated 10/26/2023, revealed, Policy: Reviewed/ Revised By: PHC 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.A weight monitoring schedule will be developed upon admission for all residents: a. Weights should be recorded at the time obtained. b. Newly admitted residents - monitor weight weekly for 4 weeks.6. Weight Analysis: The newly recorded resident weight should be compared to the previous recorded weight.

Based on observation, interview and record review, the facility failed to implement interventions to prevent a decrease in ROM (range of motion) for 2 residents (Resident #3 and #65) of 2 residents reviewed for range of motion, resulting in the potential for worsening of hand contractures (a permanent shortening of muscles, tendons, skin, or other soft tissues that restricts normal joint movement and can cause deformity). Findings include:Resident #3Review of an admission Record revealed Resident #3 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: contractures. Review of Resident #3's Care Plan revealed, .ADL (activities of daily living) self-care performance deficit related to. contractures and needs assistance with personal care. Date initiated: 5/24/24, Revision on: 5/11/26. Interventions: .Splint/Brace Care: Apply palm protectors to both hands/palms with AM care and removed at HS (bedtime) as tolerated. May substitute with washcloths. Monitor skin integrity with each application and removal. Date initiated: 7/6/25.During an observation of 07/14/2026 at 10:57 AM Resident #3 was lying in her bed with her eyes open. Resident #3's hands were observed closed tightly and palm protectors were not in place. In an interview on 07/15/2026 at 12:07 PM, Rehabilitation Director (RD) JJ reported that Resident #3 should be wearing palm protectors as much as possible to prevent skin breakdown and further contractures.During an observation on 7/15/26 at 12:27 AM in the dining room, Resident #3 was observed being assisted to eat lunch. Resident #3 was not wearing palm protectors.In an interview on 7/15/26 at 12:33 PM, Unit Manager (UM) LL reported that Resident #3 was not wearing her palm protectors, and UM LL was not sure where they were. UM LL reported that RD JJ had just contacted her to check to make sure Resident #3 was wearing the palm protectors.Review of Resident #3's Treatment Administration Record (TAR) for July 2026 revealed, Maintenance restorative nursing: Range of motion (passive: staff perform movements) to bilateral hands during AM care with application of palm protectors. The record indicated that the licensed nurse checked off and initialed 14 of 15 days, including 7/14/26 and 7/15/26. The record was not completed for 7/11/26.Review of Resident #3's Therapy to Nursing Communication Form dated 4/24/26 revealed, .Recommend PROM (passive range of motion) on BUE (bilateral upper extremities) with AM care. Donn (put on) BUE hand splint with am care and off around dinner or as tolerated.Review of Resident #3's CNA (Certified Nursing Assistant) documentation from the past 30 days revealed, multiple task orders for PROM and application of palm protectors. There was no data recorded in the tasks related to if the task was completed and/or how the resident tolerated the PROM and palm protectors.Resident #65Review of an admission Record revealed Resident #65 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: hemiplegia (inability to move one side of the body) and hemiparesis (muscle weakness and loss of movement on one side of the body) following cerebral infarction (stroke), affecting right dominant side.Review of Resident #65's Care Plan revealed, .ADL self-care performance deficit related to weakness.hemiplegia.Date initiated: 10/27/23. Revision on: 6/2/26. Interventions: .Splint/Brace Care: apply right hand T-bar orthosis (a medical device that helps stretch tight hand muscles and fingers) in AM and remove in afternoon, as tolerated. Monitor skin integrity with each application and removal. Date initiated: 6/30/25.During an observation on 07/14/2026 at 10:02 AM Resident #65 was lying in his bed. Resident #65's right hand/arm was observed and there was not a splint/brace in place. During an observation on 07/15/2026 at 7:45 AM Resident #65 was observed in the dining room. Resident #65's right hand/arm was observed and there was not a splint/brace in place. During an observation on 07/15/2026 at 10:35 AM Resident #65 was observed lying in his bed. Resident #65's right hand/arm was observed and there was not a splint/brace in place.In an interview on 7/15/26 at 12:07 PM, RD JJ reported that Resident #65 should have his hand splint applied during morning cares and could be taken off at lunch time or as tolerated. RD JJ reported that the splint was worn to prevent contracture due to his stroke that affected the right side of his body. RD JJ reported that Resident #65 was compliant with orders and did not refuse anything.During an observation on 7/15/26 at 12:25 AM Resident #65 was in the dining room. Resident #65 was not wearing a hand splint.In an interview on 7/15/26 at 12:37 PM, CNA MM reported that she had forgotten to apply Resident #65's hand splint that morning. In an interview on 7/15/26 at 4:01 PM, CNA NN reported that Resident #65 doesn't refuse wearing his hand splint.In an interview on 7/15/26 at 12:48 PM, Licensed Practical Nurse (LPN) U reported that CNA's apply splints and perform ROM for residents. LPN U reported that she had been informed that Resident #65's hand splint was not in place, so she notified the CNA to apply the splint. LPN U reported that she had not documented in the TAR yet for the day; she typically goes through the treatment orders in the afternoon, so she wasn't aware that Resident #65 did not have his brace applied that morning.Review of Resident #65's TAR for July revealed, MAINTENANCE RESTORATIVE NURSING: Range of Motion (passive) to Right HAND as tolerated prior to application of T-bar splint. in the morning for Maintenance Restorative Nursing PROM to right hand prior to application of T-bar splint in AM, Start Date 6/10/26. And also Splint/Brace care: apply right hand T-bar orthosis in AM and remove in afternoon, as tolerated. Monitor color, motion, sensation, and skin integrity with each application and removal. Start date 6/10/26. The administration records both indicated that the licensed nurse checked off and initialed 10 of 15 days, including 7/14/26 and 7/15/26. The records were not completed for 7/1, 7/6, 7/7, 7/9, and 7/13.Review of Resident #65's Therapy to Nursing Communication Form dated 6/25/26 revealed, .Recommend PROM on RUE (right upper extremity). Donn right splint, on with AM care and off at lunch or as tolerated.Review of Resident #65's CNA documentation from the past 30 days revealed, Splint/Brace assistance: Apply right hand T-bar orthosis in AM and remove in afternoon, as tolerated. Monitor skin integrity with each application and removal. Question #1 was how well did resident tolerate; 13 of 30 days indicated tolerated well and 13/30 days indicated did not occur. Question #3 was why did the restorative program not occur; 9 of 30 days indicated not scheduled this shift, 5of 30 days indicated resident refused.Review of Resident #65's CNA documentation from the past 30 days revealed, Maintenance Restorative Nursing: Range of motion (passive) to right hand as tolerated prior to application of T-bar splint. There was no documentation related to if the task was performed, how well the resident tolerated it and/or how many minutes were spent providing the ROM.In an interview on 7/16/26 at 11:53 AM, Director of Nursing (DON) B reported that the licensed nurses are expected to verify that residents had splints in place per orders and then check the order off in the TAR. DON B reported that nurses should not be waiting to go through the treatment orders in the afternoon because there are orders scheduled for the morning. Review of the facility's policy for Range of Motion dated 10/21/24 revealed, .1. The facility in collaboration with the medical director, director of nurses and as appropriate, physical/occupational consultant shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventive care. 3. Care Planning a. Based on the comprehensive assessment, the facility will provide interventions, exercises and/or therapy to maintain or improve range of motion. b. The facility will provide treatment and care in accordance with professional standards of practice. This includes, but is not limited to: i. Appropriate services (specialized rehabilitation, restorative, maintenance). ii. Appropriate equipment (braces or splints). iii. Assistance as needed (active assisted, passive, supervision). c. Care plan interventions will be developed and delivered through the facility's restorative program, or through specialized rehabilitative services as ordered by the attending practitioner. d. Interventions shall be documented on the resident's person-centered care plan/restorative care plan e. A nurse with responsibility for the resident will monitor for consistent implementation of the care plan interventions. Refusals of care or problems associated with range of motion exercises will be documented in the medical record. 4. Preventive Care a. Staff will be educated on the risk factors for a decline in range of motion. b. Staff will be educated on basic, restorative nursing care that does not require the use of a qualified therapist or licensed nurse oversight. c. Residents will receive services from restorative aides or therapists as needed.

Based on observation, interview, and record review, the facility failed to provide necessary ADL (activities of daily living) care to 1 resident (Resident #16) of 5 residents reviewed for ADL's, resulting in the potential for feelings of embarrassment, humiliation, and diminished self-esteem. Findings include:Review of an admission Record revealed Resident #16 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #16, with a reference date of 6/4/26 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #16 was cognitively intact. Review of the Functional Status revealed that Resident #16 required substantial to maximal (more than 50%) assistance with bathing.Review of Resident #16's Care Plan date initiated 12/5/26 revealed Resident #16 had an ADL (activities of daily living) self-care performance deficit related to impaired mobility and weakness. The interventions indicated that Resident #16 required assistance of 1 person for bathing, dressing, and personal hygiene. The care plan was revised on 5/28/26.During an observation and interview on 7/14/26 at 10:43 AM, Resident #16 was observed in his room with long dirty fingernails, and his shirt was on backwards. Resident #16 reported that he needed his fingernails cut and did not remember when the last time he had them cleaned.During an observation and interview on 7/15/26 at 9:34 AM, Resident #16 was observed in his room with long dirty fingernails. Resident #16 reported that he needed to get someone to cut his fingernails. During an observation and interview on 7/16/26 at 9:22 AM, Resident #16 was observed in his room; the fingernails on his left hand were cut short but the fingernails on his right hand remained long and dirty. Resident #16 reported that he had tried to cut his fingernails by himself today but was not able to cut the nails on his right hand.In an interview on 7/16/26 at 9:32 AM, Certified Nursing Assistant (CNA) NN reported that she had observed Resident #16 cutting his fingernails that morning. CNA NN explained that Resident #16 is scheduled for baths on second shift and that is when his nails would be cleaned and cut. CNA NN reported that the first shift CNA's were not responsible for taking care of his nails. CNA NN reported that Resident #16 liked a bed bath instead of a shower but did not refuse care.Review of Resident #16's Bathing Record documented in the CNA tasks indicated the resident had a bed bath on 7/15/26. There was no documentation related to fingernails.

Based on observation, interview, and record review, the facility failed to provide appetizing and palatable food at a palatable food temperature for 2 (Resident #8 and Resident 94) of 4 residents reviewed for food palatability and 4 of 4 residents from a confidential resident council meeting resulting in dissatisfaction with the food served and the potential for decreased intake and weight loss. Findings include: Resident #8 Review of an admission Record revealed Resident #8 was originally admitted to the facility on [DATE] with pertinent diagnoses which included essential hypertension (high blood pressure) and need for assistance with personal care. Review of a Minimum Data Set (MDS) assessment for Resident #8, with a reference date of 6/2/26 revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated Resident #8 was moderately cognitively impaired. During an interview on 7/14/2026 at 11:25 AM, Resident #8 reported concerns with food that was served at the facility. Resident #8 reported her food was often served cold, and when it was cold, she would not eat it. During an interview on 7/15/2026 at 12:54 PM, Resident #8 reported she had been served eggs and toast for breakfast that morning, but the eggs were too cold to eat, so she only ate the toast. Resident #8 reported that she felt like the eggs were cold because they had sat in the food cart (cart that holds meal trays) for too long as residents waited to have staff pass out the trays. Resident #8 reported since her room was towards the end of the hall, she was often one of the last residents to get her meal tray served. During an observation on 7/15/2026 at 1:15 PM, on the B hall, a test tray was tested as if it were the last meal on the unit. The meal tray had been sitting in the food cart until this writer checked the temperature. On the meal tray, there was a large piece of ham that had a temperature of 113 degrees. During an interview and observation on 7/15/2026 at 12:21 PM, Resident #8 reported that she had taken one bite of her ham and it was too cold to eat so she did not eat any more of it. Resident #94Review of an admission Record revealed Resident #94 was originally admitted to the facility on [DATE] with pertinent diagnoses which included essential hypertension and anxiety disorder. During an interview and observation on 7/14/2026 at 11:11 AM, Resident #94 reported ongoing concerns with the food served at the facility. Resident #94 reported she had been served cold eggs and cereal this morning, and when she asked for something else because she did not like eggs, staff brought her back oatmeal and bacon, but the oatmeal was bland and the bacon was swimming in grease. Resident #94 showed this writer the bacon that she had been served that was sitting in a sandwich bag covered in an estimated 1/4 cup size of grease. Resident #94 reported she had saved the bacon to show staff how greasy it was. Resident #94 then stated, I would have terrible stomach pain if I ate that much grease. Resident #94 reported the facility would provide alternate options when she did not like the food being served, but the options were worse. Resident #94 showed this writer a photo of a peanut butter and jelly sandwich that she reported she had been served as an alternate option for a few days prior. The photo showed two pieces of bread opened with a small dab of jelly and a large amount of peanut butter on the open bread pieces. Resident #94 reported she had given up on the food at the facility and had started ordering food out a lot more. Resident #94 voiced frustration that she had to spend money on food because the facility continued to serve food that was not palatable. During an interview on 7/16/2026 at 11:11 AM, Registered Nurse (RN) PP reported she was aware that Resident #94 had ongoing concerns with the food at the facility. RN PP reported that Resident #94 seemed to only order food and have it delivered now. In a confidential resident council meeting on 7/15/26 at 1:30 PM, 4 of 4 residents reported that they had received cold food that should have been served hot.Review of Resident Council Meeting Minutes dated 7/10/26 revealed, Issue: Meals not being delivered timely . Outcome: Not resolved, action still needed .Review of Resident Council Meeting Minutes dated 4/9/26 revealed, Issue: Food trays are still an issue. Not getting passed out fast enough and the food is cold .

Based on interview, observation, and record review, the facility failed to develop and/or implement a comprehensive care plan for 3 residents (Resident #73, #3, & #65) of 18 residents reviewed for care plan development/implementation, resulting in the potential for unmet medical, physical, mental, and psychosocial needs.Findings include: Resident #73Review of an admission Record revealed Resident #73 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: chronic respiratory failure (when the lungs cannot properly oxygenate the blood). Review of a Minimum Data Set (MDS) assessment for Resident #73, with a reference date of 5/19/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #73 was cognitively intact. In an interview on 7/14/26 at 10:27 AM, Resident #73 reported that she had complained of tooth pain to multiple nurses for several months before she was able to see a dentist and was still waiting to have the tooth extracted; she has had to eat softer foods and was concerned about infection. Resident #73 reported that the nurses and social worker kept telling her she was on the list to see the dentist, but then when she was seen in April it was the dental hygienist (person that cleans teeth) and she did not know anything about Resident #73's tooth pain and told her that she would need to see the dentist. Resident #73 reported that she eventually saw the dentist in June but he couldn't do the extraction because it required her to be off her blood thinner medication for 3 days before the procedure. Resident #73 reported that the facility physician had prescribed pain medication and antibiotics to treat the tooth infection until she could have the tooth removed.In an interview on 07/15/2026 at 4:00 PM, Certified Nursing Assistant (CNA) NN reported that Resident #73 complained about her tooth hurting. Review of Resident #73's Care Plan revealed no care plan related to dental services and/or tooth pain.Review of Resident #73's Social Services (SS) Medically Related SS Needs note dated 5/4/26 at 2:46 PM revealed, Need: .Dentist (broken R (right) tooth). New Concern/Follow-up/Referral: Nursing was notified of broken tooth on the right, nursing notified SSD (social services director).Resident/family involvement and notification: (space is blank). Comments: SSD will fax health drive paperwork to address broken tooth at next visit. This was the first mention of the tooth issue in Resident #73's record. This note was created by SSD C.Review of Resident #73's Nurse Practitioner (NP) note dated 6/1/26 at 8:00 AM revealed, .follow-up tooth pain. Patient reports that her right upper last molar is cracked and injuring her oral mucosal lining. She was told by dentist during previous visit in the facility to call him once the tooth becomes bothersome. There is no facial swelling or signs of local dental abscess on examination . ASSESSMENTS AND PLANS: .Fracture of tooth (traumatic). Broken tooth is injuring the oral lining. Order placed for STAT (immediate) in-house dental appointment. Others relevant intervention: Monitor patient and notify provider if new pain or facial swelling. Review of Resident #73's NP Note dated 6/8/26 revealed, .Tooth ache, swelling. Right face swelling. Tooth pain at 5/10. Add augmentin (antibiotic) twice daily for 10 days. Add Ibuprofen (pain reliever).In house dentist was notified and he is scheduled to see patient on 6/12/26.Review of Resident #73's NP Note dated 6/12/26 revealed, .Follow-up tooth pain, abscess . She reports that tooth pain is controlled with as needed ibuprofen (anti-inflammatory pain reliever) and facial swelling has reduced significantly. She consulted with the dentist earlier today and is scheduled for tooth extraction in 1 week . ASSESSMENTS AND PLANS:. Periapical abscess (a painful pocket of pus at the tip of a tooth root). Continue and complete course of Augmentin (antibiotic). Continue as needed ibuprofen for pain. Fracture of tooth (traumatic).Continue to monitor for resolution of tooth abscess. In an interview on 7/15/26 at 4:04 PM, Social Services Director (SSD) C reported that she didn't know when Resident #73 first started having the issue with her tooth, but that SSD C contacted the dentist office yesterday and got her appointment for the extraction moved up to 7/23/26 because we were told she was having problems with the tooth. SSD C reported that she had originally faxed a referral after she entered the note on 5/4/26 and the resident was put on the dental schedule to be seen the next time the dentist was in the facility, which was in June. SSD C could not tell me when she sent the original referral, if she communicated the urgency to the dental office, or if she followed up with Resident #73 about the appointments. Resident #3Review of an admission Record revealed Resident #3 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: contractures. Review of Resident #3's Care Plan revealed, .ADL (activities of daily living) self-care performance deficit related to. contractures, and needs assistance with personal care. Date initiated: 5/24/24, Revision on: 5/11/26. Interventions: .Splint/Brace Care: Apply palm protectors to both hands/palms with AM care and removed at HS (bedtime) as tolerated. May substitute with washcloths. Monitor skin integrity with each application and removal. Date initiated: 7/6/25.During an observation of 07/14/2026 at 10:57 AM Resident #3 was lying in her bed with her eyes open. Resident #3's hands were observed closed tightly and palm protectors were not in place. During an observation on 7/15/26 at 12:27 AM in the dining room, Resident #3 was observed being assisted to eat lunch. Resident #3 was not wearing palm protectors.In an interview on 7/15/26 at 12:33 PM, Unit Manager (UM) LL reported that Resident #3 was not wearing her palm protectors, and UM LL was not sure where they were. UM LL reported that RD JJ had just contacted her to check to make sure Resident #3 was wearing the palm protectors.Resident #65Review of an admission Record revealed Resident #65 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: hemiplegia (inability to move one side of the body) and hemiparesis (muscle weakness and loss of movement on one side of the body) following cerebral infarction (stroke), affecting right dominant side.Review of Resident #65's Care Plan revealed, .ADL self-care performance deficit related to weakness.hemiplegia.Date initiated: 10/27/23. Revision on: 6/2/26. Interventions: .Splint/Brace Care: apply right hand T-bar orthosis (a medical device that helps stretch tight hand muscles and fingers) in AM and remove in afternoon, as tolerated. Monitor skin integrity with each application and removal. Date initiated: 6/30/25.During an observation on 07/14/2026 at 10:02 AM Resident #65 was lying in his bed. Resident #65's right hand/arm was observed and there was not a splint/brace in place. During an observation on 07/15/2026 at 7:45 AM Resident #65 was observed in the dining room. Resident #65's right hand/arm was observed and there was not a splint/brace in place. During an observation on 07/15/2026 at 10:35 AM Resident #65 was observed lying in his bed. Resident #65's right hand/arm was observed and there was not a splint/brace in place.During an observation on 7/15/26 at 12:25 PM Resident #65 was in the dining room. Resident #65 was not wearing a hand splint.In an interview on 7/15/26 at 12:37 PM, CNA MM reported that she had forgotten to apply Resident #65's hand splint that morning. In an interview on 7/15/26 at 12:48 PM, Licensed Practical Nurse (LPN) U reported that CNA's apply splints and perform ROM for residents. LPN U reported that she had just been informed that Resident #65's hand splint was not in place, so she notified the CNA to apply the splint.The care plan (see Chapter 18) is a map for nursing care and demonstrates your accountability for patient care. By making accurate nursing diagnoses, your subsequent care plan communicates a patient's health care problems to other professionals and ensures that you select relevant and appropriate nursing interventions. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 16159-16161). Elsevier Health Sciences. Kindle Edition.A well-planned, comprehensive nursing care plan reduces the risk for incomplete, incorrect, or inaccurate care. As a patient's problems and status change, so does the plan. A nursing care plan is a guideline for coordinating nursing care, promoting continuity of care, and listing outcome criteria to be used later in evaluation (see Chapter 20). The plan of care communicates nursing care priorities to nurses and other health care providers. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 16878-16882). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview, and record review the facility failed to maintain a clean comfortable environment for 2 (Resident #8 and Resident #94) of 5 residents reviewed for environment resulting in unclean/unkempt resident rooms, resident frustration, and the potential for cross contamination and bacterial harborage. Findings include: Resident #8 Review of an admission Record revealed Resident #8 was originally admitted to the facility on [DATE] with pertinent diagnoses which included essential hypertension (high blood pressure) and need for assistance with personal care. Review of a Minimum Data Set (MDS) assessment for Resident #8, with a reference date of 6/2/26 revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated Resident #8 was moderately cognitively impaired. During an interview and observation on 7/14/2026 at 11:25 AM, Resident #8 reported concerns with the cleanliness of her room. Resident #8 reported she did not feel like the housekeeping staff in the facility were thoroughly cleaning her room. Resident #8's floor was noted to have several pieces of trash on the floor, and the floor was noted to be sticky. In Resident #8's bathroom, trash was noted on the floor. There were soiled wash cloths sitting in the sink. The trash was full and overflowing onto the floor. The toilet in Resident #8's bathroom (which was a bathroom shared with Resident #94) was noted to have several brown stains on the rim of the toilet. Resident #94Review of an admission Record revealed Resident #94 was originally admitted to the facility on [DATE] with pertinent diagnoses which included essential hypertension and anxiety disorder. During an interview and observation on 7/14/2026 at 11:11 AM, Resident #94 reported that she had concerns with cleanliness of the facility. Resident #94 reported she had not observed her room cleaned by housekeeping staff since she had been admitted to the facility. Resident #94 reported she had family bring her bleach wipes so that she could clean the bathroom herself because she was concerned about infection control as the bathroom she used was a shared bathroom. Resident #94 reported she had not had her sheets changed on her bed since admission, and that she had soiled her sheets with blood shortly after she was admitted and had been laying in soiled sheets since. Noted that Resident #94's sheets were soiled with a large red stain which did appear to look like a blood stain. Resident #94's bedside tray table was soiled with food crumbs and dried liquid stains. The floor in front of Resident #94's bed was noted to have several black and brown stains and was sticky to walk on. Resident #94's trash can was full, and there were several pieces of trash on Resident #94's floor. Resident #94 voiced feelings of frustration, reporting that she had asked multiple staff to clean her room, and she felt like staff were ignoring her requests to clean her room and change her sheets. During an interview and observation on 7/15/2026 at 12:21 PM, Resident #8 and Resident #94 were sitting together in their shared room eating lunch. Resident #8 and Resident #94's room was noted to be in the same condition as previous observation from the day before. Resident #94 confirmed that staff had not yet changed her bed sheets, and the stained sheets were noted to be on her bed. During an interview and observation on 7/16/2026 at 11:51 AM, Resident #8 and Resident #94 were sitting together in their shared room. Resident #8 and Resident #94's room was noted to have trash on the floor around both of their beds. The floor around Resident #8 and Resident #94's beds were noted to have black stains and was sticky to walk on. Resident #8 and Resident #94's tray tables were noted to be soiled with food crumbs and dried liquid stains. Resident #8 and Resident #94's shared bathroom was noted to have trash overflowing, sticky floors, and the toilet was noted to have brown stains in the rim of the toilet bowl. Resident #94 reported that her sheets had not been changed and showed this writer that she had moved the sheets so that she did not have to sleep directly on the red stained area that Resident #94 reported was dried blood. During an interview on 7/16/2026 at 11:11 AM, Registered Nurse (RN) OO reported that she had noticed that some housekeepers at the facility were better at cleaning than others. During an interview on 7/16/2026 at 11:25 AM, Housekeeper (HK) PP reported she was assigned to clean the hall that Resident #8 and Resident #94's room shared room was on. HK PP reported that every resident room was cleaned daily and housekeepers were supposed to empty resident trash, sweep and mop the floors, wipe down resident tray tables, and clean the counter and toilet in the bathrooms. HK PP reported she had not been made aware of room cleanliness concerns in Resident #8 and Resident #94's room, or any missed cleaning days. During an interview and observation on 7/16/2026 at 3:03 PM, Resident #8 and Resident #94 reported that their room had been cleaned around lunch time that day. Noted that Resident #8 and Resident #94's trash cans had been emptied and their tables had been wiped down. The floor was noted to be in the same condition as previous observations with food crumbs and markings around Resident #8 and Resident #94's bed. Resident #94 reported staff had finally changed her sheets and she thanked this writer for getting that staff to come in and change her sheets finally!

Based on interview and record review, the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) and Advanced Beneficiary Notice of Non-Coverage (ABN) for Medicare Part A services in 1 of 3 residents (Resident #33) reviewed for timely provision of notifications, resulting in the potential for the resident or resident representative to be unaware of changes regarding financial liability, frustration, and a delay in the ability to file an appeal.Findings include:Review of an admission Record revealed Resident #33 was originally admitted to the facility on [DATE].Review of SNF (skilled nursing facility) Beneficiary Notification Review for Resident #33 revealed, .Medicare part A skilled services episode start date: 1/12/26, last covered day of Part A service: 4/9/26.The facility/provider initiated the discharge from Medicare Part A services when benefit days were not exhausted.Was NOMNC, Form CMS-10123 provided to the resident? No.Review of an Advanced Beneficiary Notice of Non-Coverage (ABN) for Resident #33 revealed .We expect Medicare may not pay for the item, test, service or care listed below, if Medicare doesn't pay, you may have to pay. Care: Room and board. Reason: Therapy is complete/benefits exhausted. Estimated Cost: TBD (to be determined). Signature: Verbal Signature dated 4/10/26. Noted the ABN was signed 1 day after coverage ceased.In an interview on 7/14/26 at 2:39pm, Business Office Manager (BOM) P reported he did not know the cost the resident would incur for room and board, so he put TBD in the box.Review of an Advance Beneficiary Notices policy with a reference date of 10/30/23 revealed It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage.The facility shall inform Medicare beneficiaries of his or her potential liability for payment.before the facility provides an item or service that is usually paid for by Medicare but may not be paid for in particular instance.A Notice of Medicare Non-Coverage (NOMNC) shall be issued to the resident when Medicare covered service (s) are ending, no matter if resident is leaving the facility or remaining.This informs the resident on how to request an appeal.

Based on interview and record review, the facility failed to explain terms of and ensure the validity of understanding/consent to enter into the agreement for an Alternate Dispute Resolution Agreement (ADR)- a legally binding contract that specifies the use of an ADR process - such as arbitration instead of going to court) for 2 (Resident # 32 and Resident #94) of 3 residents reviewed for arbitration agreements resulting in Resident #32 and Resident #94 signing ADR agreements when they did not wish to. Findings include: Resident #32Review of an admission Record revealed Resident #32 was originally admitted to the facility on [DATE] with pertinent diagnoses which included chronic pain and anemia (Anemia is a condition characterized by a deficiency of healthy red blood cells or hemoglobin, leading to insufficient oxygen delivery to the body's tissues.)Review of a Minimum Data Set (MDS) assessment for Resident #32, with a reference date of 5/18/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #32 was cognitively intact. Review of Resident #32's ADR Agreement dated 12/22/25 revealed, . Consent Decision: I (Resident #32) consent to the ADR agreement. This ADR form was signed by Resident #32 and Former Admissions Director (FAD) AA on 12/23/25. During an interview on 7/15/2026 at 12:05 PM, Resident #32 reported she did not recall staff educating her on ADR agreements. Resident #32 was unable to report what her understanding of the arbitration process with the facility was. Resident #32 was unable to report what her understanding of the arbitration process was when a dispute arises. Resident #32 reported that she did not know that signing the ADR form was giving up her right to litigation in a court proceeding. Resident #32 reported she did not feel that the ADR form was explained in a process that she understood, and that she would have not wanted to sign the ADR form if she had known that she was giving up her right to litigation in a court proceeding. On 7/16/2026 at 11:39 AM, This writer attempted to reach FAD AA via telephone. FAD AA did not return this writer's call prior to survey exit. Resident #94Review of an admission Record revealed Resident #94 was originally admitted to the facility on [DATE] with pertinent diagnoses which included essential hypertension (high blood pressure) and anxiety disorder. Review of Resident #94's ADR Agreement dated 7/7/26 revealed, . Consent Decision: I (Resident #94) consent to the ADR agreement. This ADR form was signed by Resident #94 on 7/8/26. During an interview on 7/14/2026 at 9:02 AM, Nursing Home Administrator (NHA) A reported that the facility did offer arbitration agreements, but that they did not have any residents that had entered into an arbitration agreement with the facility. NHA A reported that the facility's Admissions Director was responsible for educating and completing arbitration agreements with residents upon admission, but the facility did not have a current Admissions Director, so she was providing the education on arbitration agreements to new residents when they admitted . NHA A reported that she had not had any residents sign an arbitration agreement since she had taken over completing them with residents 3 weeks prior. On 7/15/2026 at 9:26 AM, This writer requested a list of all residents residing in the facility that had signed an ADR agreement at admission via email to NHA A. Review of the Arbitration List revealed that there were 14 residents in the facility that had signed an ADR agreement upon admission to the facility. Noted that Resident #94 had admitted to the facility on [DATE] when NHA A was responsible for completing the education on ADR agreements. During an interview on 7/15/2026 at 12:21 PM, Resident #94 reported she had not received any education on the ADR form. When this writer reviewed the ADR form that was signed by Resident #94 on 7/8/26, Resident #94 reported that she was unaware of what the ADR process was, and that she would never have signed away her right to litigation in a court proceeding. Resident #94 reported she did not feel that the ADR form was explained in a process that she understood. During a follow up interview on 7/15/2026 at 12:52 PM, This writer queried NHA A about Resident #94's signed ADR form dated 7/7/26, as NHA A had previously reported that she was completing the ADR education with residents upon admission. NHA A reported that she was completing all admission documentation except ADR forms, but if a resident was interested in signing an ADR form, that Regional Director of Business Development (RDBD) N would complete the education on the ADR form and witness the resident sign the form. NHA A reported Resident #94's ADR education had been completed with RDBD N. During an interview on 7/16/2026 at 2:56 PM, RDBD NN reported that she was responsible for educating Admissions Directors on the ADR process and how they were supposed to educate any resident prior to the resident signing the ADR form. RDBD reported that the Admissions Director was supposed to verbally educate residents on the ADR process and then show residents a video the facility had that further explained and educated on the ADR process. RDBD N reported that she did not complete the education on ADR with new residents at the facility, and that she had not provided education on the ADR process to Resident #94. RDBD N reviewed Resident #94's ADR form dated 7/8/26 and confirmed that there was not a facility representative signature, but that NHA A had generated the form. During a subsequent interview on 7/16/2026 at 3:03 PM, Resident #94 reported that the facility had not provided her with a video to review regarding the ADR process.

Based on interview, and record review, the facility failed to provide prompt dental services for 1 of 1 resident (Resident #73) reviewed for dental care, resulting in Resident #73 experiencing pain, difficulty eating and the potential for spread of infection.Findings include:Resident #73Review of an admission Record revealed Resident #73 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: chronic respiratory failure (when the lungs cannot properly oxygenate the blood). Review of a Minimum Data Set (MDS) assessment for Resident #73, with a reference date of 5/19/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #73 was cognitively intact. In an interview on 7/14/26 at 10:27 AM, Resident #73 reported that she had complained of tooth pain to multiple nurses for several months before she was able to see a dentist and was still waiting to have the tooth extracted; she has had to eat softer foods and was concerned about infection. Resident #73 reported that the nurses and social worker kept telling her she was on the list to see the dentist, but then when she was seen in April it was the dental hygienist (person that cleans teeth) and she did not know anything about Resident #73's tooth pain and told her that she would need to see the dentist. Resident #73 reported that she eventually saw the dentist in June but he couldn't do the extraction because it required her to be off her blood thinner medication for 3 days before the procedure. Resident #73 reported that the facility physician had prescribed pain medication and antibiotics to treat the tooth infection until she could have the tooth removed.In an interview on 07/15/2026 at 4:00 PM, Certified Nursing Assistant (CNA) NN reported that Resident #73 complained about her tooth hurting. Review of Resident #73's Care Plan revealed no care plan related to dental services and/or tooth pain.Review of Resident #73's Social Services (SS) Medically Related SS Needs note dated 5/4/26 at 2:46 PM revealed, Need: .Dentist (broken R (right) tooth). New Concern/Follow-up/Referral: Nursing was notified of broken tooth on the right, nursing notified SSD (social services director).Resident/family involvement and notification: (space is blank). Comments: SSD will fax health drive paperwork to address broken tooth at next visit. This was the first mention of the tooth issue in Resident #73's record. This note was created by SSD C.Review of Resident #73's record for a referral or fax related to the resident's broken tooth; no documentation found until the provider note below dated 6/1/26.Review of Resident #73's Nurse Practitioner (NP) note dated 6/1/26 at 8:00 AM revealed, .follow-up tooth pain. Patient reports that her right upper last molar is cracked and injuring her oral mucosal lining. She was told by dentist during previous visit in the facility to call him once the tooth becomes bothersome. There is no facial swelling or signs of local dental abscess on examination . ASSESSMENTS AND PLANS: .Fracture of tooth (traumatic). Broken tooth is injuring the oral lining. Order placed for STAT (immediate) in-house dental appointment. Others relevant intervention: Monitor patient and notify provider if new pain or facial swelling. Review of Resident #73's record for notes related to status of the resident having an appointment scheduled with the dentist; no documentation found.Review of Resident #73's NP Note dated 6/8/26 revealed, .Tooth ache, swelling. Right face swelling. Tooth pain at 5/0. Add augmentin (antibiotic) twice daily for 10 days. Add Ibuprofen (pain reliever).In house dentist was notified and he is scheduled to see patient on 6/12/26.Review of Resident #73's NP Note dated 6/12/26 revealed, .Follow-up tooth pain, abscess . She reports that tooth pain is controlled with as needed ibuprofen (anti-inflammatory pain reliever) and facial swelling has reduced significantly. She consulted with the dentist earlier today and is scheduled for tooth extraction in 1 week . ASSESSMENTS AND PLANS:. Periapical abscess (a painful pocket of pus at the tip of a tooth root). Continue and complete course of Augmentin (antibiotic). Continue as needed ibuprofen for pain. Fracture of tooth (traumatic).Continue to monitor for resolution of tooth abscess.Review of Resident #73's record for a visit note and/or progress notes related to the resident being seen by the dentist and/or being scheduled for a tooth extraction; no documentation found. Review of Resident #73's Progress Note dated 6/19/26 at 11:01 AM revealed, (Resident #73) completed her course of oral antibiotic for her tooth infection on 6/18/26. No adverse reaction to medication noted throughout treatment. S&S (signs and symptoms) are resolved at this time. (Resident #73) is to see the dentist for tooth extraction. In an interview on 7/15/26 at 4:04 PM, Social Services Director (SSD) C reported that she didn't know when Resident #73 first started having the issue with her tooth, but that SSD C contacted the dentist office yesterday and got her appointment for the extraction moved up to 7/23/26 because we were told she was having problems with the tooth. SSD C reported that she had originally faxed a referral after she entered the note on 5/4/26 and the resident was put on the dental schedule to be seen the next time the dentist was in the facility, which was in June. SSD C could not tell me when she sent the original referral, if she communicated the urgency to the dental office, or if she followed up with Resident #73 about the appointments. This surveyor requested all dental visit notes from April 2026 through to present date, including all communication notes between SSD C and the dental office.In a subsequent interview on 7/15/26 at 4:36 PM, SSD C reported that she had found a dental visit note from 4/29/26 when Resident #73 was seen for a cleaning; the notes indicate that the resident was going to be getting her #2 tooth fixed and had a small area noted at the gumline of #14. SSD C reported that she did not know what that information meant and that she does not follow up with residents after they are seen by dental services; the dental office sends the facility their plans for the next time they visit the facility. SSD C could not find any additional visit notes and or communication notes.In an interview on 7/16/26 at 10:33 AM, Resident #73 reported that SSD C finally came into her room after this surveyor left on 7/14/26 and notified her that she was scheduled to have the tooth extracted on 8/7/26. Resident #73 reported that she was concerned about the timing and asked for the appointment to be moved up; the appointment was rescheduled for 7/23/26. Resident #73 reported that NP HH saw her today and prescribed another antibiotic to prevent infection until she can have the tooth removed.In an interview on 7/16/26 at 11:32 AM, Director of Nursing (DON) B reported that the dental provider they use was supposed to upload their visit notes to the record. This surveyor requested any documentation that the facility had promptly arranged for Resident #73 to see the dentist.The following documentation was provided by DON B just prior to survey exit:A dental visit note from 4/29/26 revealed, .Phophylaxis (routine teeth cleaning).Treatment notes: will be having #2 fixed and also while cleaning today, noticed a small area at the gumline #14.An email that was received on 6/8/26 which included a schedule from the dental office indicating that Resident #73 was on the schedule to be seen for a visit on 6/12/26.A dental visit note dated 6/12/26 revealed, .Patient has been taking antibiotic for the past week for a possible infection of tooth #2. The tooth has fractured further and is non-restorable. She would like to have it extracted (removed). She is taking Xarelto (blood thinner) which will have to be adjusted before the extraction. I smoothed the rough potion of the tooth.she though it felt more comfortable.Action Required by nursing home staff: .please have responsible party sign consent for extraction form; Xarelto prescription might need to be adjusted before the extraction - check with physician or nurse practitioner.An email that was received on 6/29/26 which included a schedule from the dental office indicating that Resident #73 was on the schedule to be seen for an extraction on 8/7/26.An email that was received on 7/15/26 at 11:33 AM that included a schedule from the dental office indicating that Resident #73 was now on the schedule to be seen for an extraction on 7/23/26.

This citation pertains to Intake # 2746228.Based on interview, and record review, the facility failed to ensure a safe/appropriate discharge in 1 of 3 residents (Resident #103) reviewed for discharge planning, resulting in an unsuccessful discharge to the community, resident distress, and rehospitalization.Findings include:Resident #103Review of an admission Record revealed Resident #103 was a female, with pertinent diagnoses which included left lower limb cellulitis (an infection of the deep skin layers and underlying tissue), diabetes, morbid obesity, atherosclerosis (plaque build-up resulting in hardening/narrowing of the arteries) in the left leg with gangrene (death of body tissue caused by a severe lack of blood flow or a serious bacterial infection), heart disease, high blood pressure, anemia (a lack of healthy red blood cells or hemoglobin), anxiety, and severe chronic kidney disease. Noted the resident was discharged from the facility on 2/14/26.Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 1/21/26, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated she was cognitively intact.Review of a Care Plan for Resident #103 revealed the focus .Resident plans to discharge to home . with interventions which included .Encourage resident/family/responsible party to participate in the discharge planning process .Involve specialized home care agencies and appropriate community support services as needed for safe discharge .Provide resident/family/responsible party with written instructions upon discharge to ensure a safe return to the community . all initiated 1/16/26.In an interview on 3/10/26 at 10:22 AM, Ombudsman V reported concerns related to Resident #103's discharge home on Saturday, 2/14/26. Ombudsman V reported Resident #103 called prior to the discharge and was upset because the facility was planning to discharge her home and she did not feel safe to do so. Ombudsman V reported Resident #103 verbalized that she had told several staff members that she was concerned about not being able to get into the home. Ombudsman V reported when the transport service brought Resident #103 to the home, the resident's wheelchair was too wide to fit through the door, and she could not get inside. Ombudsman V reported at that point Resident #103 was not feeling well, and was experiencing some pain, so Family Member R called for an ambulance and Resident #103 was transported to the hospital. Ombudsman V reported prior to the discharge, Family Member R attempted to pay for Resident #103 to stay a few additional days at the facility, but Director of Nursing (DON) B would not accept a personal check as payment, telling Family Member R she needed to bring in cash or a certified check. Ombudsman V reported Family Member R received a phone call while Resident #103 was in the hospital letting her know that a second-level appeal was approved and the resident could continue to stay at the nursing home.In an interview on 3/10/26 at 1:44 PM, Registered Nurse (RN) P reported she assisted RN G with Resident #103's discharge home on Saturday, 2/14/26. RN P reported RN G came to the desk, stating they needed to call DON B because R #103 was upset and crying about the upcoming discharge. RN P reported she overheard the phone call between DON B and RN G, and stated .it sounded like (DON B) had no choice (but to discharge the resident) . RN P reported she assisted Resident #103 with wheelchair mobility to the transport vehicle at the time of discharge, and stated .She was distraught .She was crying .I felt horrible . RN P reported she had concerns with Resident #103's discharge and stated .If I knew someone was going to go home without care I would not have discharged them .In an interview on 3/10/26 at 2:57 PM, RN G reported she completed Resident #103's discharge from the facility to home on Saturday, 2/14/26. RN G stated .It was planned, but I didn't know about it until I came in and saw I was the discharge nurse . RN G reported she saw Family Member R on Friday, 2/13/26, talking with DON B. RN G reported Family Member R was tearful, asking DON B how she was supposed to get a certified check after 5:00 PM on a Friday. RN G reported she spoke with Family Member R on Saturday, 2/14/26, and stated .she was clearly distraught. She said she didn't know what to do. Her daughter was supposed to come home and there was no way to get into the house . RN G reported she went to speak to Resident #103 in her room prior to the discharge and stated .She was distraught. She was crying. She couldn't take care of herself . RN G reported she .didn't feel safe . discharging Resident #103 to the home. RN G reported she called DON B to express her concerns regarding an unsafe discharge and was told that if Family Member R did not provide a certified check upfront to pay for the additional days, Resident #103 had to leave. RN G reported when the transport driver came to pick up Resident #103, she was crying and did not want to leave. RN G reported she herself refused to sign Resident #103's discharge paperwork because she felt it was inappropriate.Review of a Nurses Note for Resident #103, dated 2/14/26 at 12:26 PM, revealed .This nurse and (RN G) assist(ed) with resident discharge .(resident's) advocate and mother (Family Member R) called facility at approximately (9:03 AM) tearful and distressed related to discharge. (Family Member R) explained that she was unable to take care of resident being discharged . (Family Member R) explained that her electric wheelchair is in front of the door and (she is) unable to move it in the home which makes the resident being discharged unable to get into the home .(Family Member R) cried and stated that she cannot care for her (Resident #103) and can barely take care of herself. (Family Member R) also explained that she was told by (DON B) that she will need to pay ($1200) .(but) when the check was brought to the facility (DON B) explained to (Family Member R) that checks were not a reliable source of payment and (Family Member R) would need to bring a (cashier's) check .(RN G) approached resident with concerns that were expressed by (Family Member R) and resident was crying and distraught regarding discharge arrangements .(RN G) contacted (DON B) .related to questions regarding discharge plan. (DON B) explained .that resident has no choice (but to) discharge if money was not obtained .Resident was discharged at (12:02 PM) via (transport company name) with all belongings .resident was crying when leaving facility and stated that she was going to have to contact 911 .because she is unable to take care of herself .In an interview on 3/10/26 at 4:00 PM, Business Office Manager (BOM) J reported Resident #103 was here under a managed insurance plan, and her insurance was cut with a last covered day of 2/13/26. BOM J reported Resident #103 was issued a Notice of Medicare Non-Coverage on 2/11/26 which she appealed. BOM J reported Resident #103 had no secondary payer source. BOM J reported they explained the private pay rate for the room and offered assistance to apply for Medicaid which Resident #103 declined. BOM J reported when Resident #103's insurance appeal was rejected, the facility started working on a discharge plan. BOM J reported Resident #103 completed a .second-level appeal . which he was not aware of and found out the week after Resident #103 discharged that the second-level appeal had been approved. BOM J reported Resident #103 and Family Member R inquired about paying privately and stated .We asked for a week or two up front . BOM J reported the facility is pretty flexible with the payment method, however .We try and stay away from personal checks because those frequently bounce . BOM J reported when he came into work on Monday, 2/16/26, and learned Resident #103 had discharged he was .shocked . because that didn't appear to be the plan the Friday before (2/13/26). BOM J reported on Friday, 2/13/26, it was anticipated that Resident #103 was going to stay at the facility for an additional period of time.In an interview on 3/11/26 at 8:10 AM, RN E reported she was Resident #103's assigned nurse on Saturday, 2/14/26. RN E reported RN G completed Resident #103's discharge. RN E stated Resident #103 .seemed like she was a little anxious about having the right equipment at home . RN E reported Resident #103's equipment concerns were related to a wheelchair and not being able to get into her house.In an interview on 3/11/26 at 8:26 AM, Family Member R reported concerns with Resident #103's discharge on [DATE]. Family Member R reported she spoke with DON B on 2/13/26, prior to Resident #103's discharge, and stated .I said (that) she (Resident #103) was in no condition to be discharged . (DON B) said there (was) no more they can do for her . Family Member R reported DON B told her that Resident #103 could stay for an additional three days if she paid $1200 up front. Family Member R reported she attempted to make the payment with a personal check, but DON B told her (Family Member R) that the facility would only accept a certified check. Family Member R reported she contacted her bank to confirm the money was available but was not able to get to the bank in time to get a certified check (since at that point it was Friday 2/13/26 and the bank closed in fifteen minutes). Family Member R reported she was unable to obtain a certified check and the facility .ended up sending (Resident #103) home . on Saturday 2/14/26 via a transport service. Family Member R reported when Resident #103 arrived at home, her wheelchair would not fit through the door because it was too wide. Family Member R stated .It was so cold out .I ended up calling (an ambulance) and sent her to (the hospital) .She is still in there . Family Member R reported Resident #103 had appealed the insurance decision prior to her discharge, and they found out while Resident #103 was in the hospital that the appeal had been approved. Family Member R reported Resident #103 did not feel ready to discharge home on 2/14/26 and wanted to remain in the facility.In an interview on 3/11/26 at 9:24 AM, Social Services Director Q reported Resident #103's insurance coverage ended, and a discharge was planned for 2/14/26. Social Services Director Q reported Resident #103 had a managed insurance plan, which only gave a 48-hour notice prior to the insurance ending. Social Services Director Q reported Resident #103's discharge plan had always been to return home with Family Member R. Social Services Director Q reported she ordered a wheelchair and a bedside commode for Resident #103 prior to her discharge and set up home health services. Social Services Director Q reported Resident #103 was feeling .anxious . prior to the discharge, and Family Member R was also concerned and requested to speak with BOM J about the potential to stay at the facility for a while longer. Social Services Director Q reported Resident #103 did not have a secondary payer source, so if she wanted to stay at the facility longer, she would have been private pay. Social Services Director Q reported Resident #103 and Family Member R expressed concerns prior to the discharge about not being able to get into the home, and stated .I think they really just wanted to have her stay at the facility .In an interview on 3/11/26 at 10:29 AM, Certified Nursing Assistant (CNA) O reported she worked with Resident #103 on the day of her discharge home, 2/14/26. CNA O reported Resident #103 was upset and crying about the upcoming discharge, and stated .She was saying she had nowhere to go .She was talking about a check .and that if she didn't have the money she had to leave (the facility) .She was really upset .In an interview on 3/11/26 at 10:38 AM, DON B reported Resident #103 had reached the end of her insurance-covered stay, so a discharge was planned for Saturday, 2/14/26. DON B reported she talked with Family Member R on Friday, 2/13/26, regarding Family Member R and Resident #103's concerns related to the upcoming discharge, and them wanting Resident #103 to stay at the facility for a few more days. DON B reported the facility policy is to not accept personal checks due to the risk for nonpayment. DON B reported she discussed the situation with BOM J, and they informed Family Member R of the amount of money needed for Resident #103 to remain in the facility. DON B reported Family Member R was unable to provide cash or a certified check prior to Resident #103's scheduled discharge date /time, so when transportation arrived, Resident #103 was discharged home.In an interview on 3/11/26 at 11:00 AM, Regional Director of Operations X reported he was contacted by DON B on Friday, 2/13/26 at approximately 4:10 PM, regarding Resident #103's upcoming discharge on [DATE], and her wanting to stay at the facility for a few more days. Regional Director of Operations X reported he discussed with DON B that the facility policy is to not accept personal checks for room and board. Regional Director of Operations X stated the facility accepts debit card, credit card, cash, or certified check for payment. Regional Director of Operations X reported if a resident has a discharge location, and the discharge was pre-planned, they would be required to either pay ahead of time to remain in the facility, or discharge.In an interview on 3/12/26 at 10:28 AM, Therapy Director Y reported on the last day of Resident #103's physical therapy, Family Member R reported a concern about Resident #103 being able to enter the home. Therapy Director Y reported Resident #103 and Family Member R wanted Resident #103 to remain in the facility for a few more days so they had more time to prepare for her discharge, and stated .They vocalized that loud and clear . Therapy Director Y reported DON B and BOM J were aware of Family Member R and Resident #103's concerns, and DON B told her (Therapy Director Y) that the facility had made arrangements for someone to bring Resident #103 into the house.Review of a Physical Therapy Treatment Encounter Note for Resident #103, dated 2/13/26, revealed .Pt (patient) up on w/c (wheelchair), very (emotional), stating I cannot go home, I cannot get into the house .Much consoling provided .requesting to please ask nursing and BOM to allow her to pay to stay until (Tuesday) .DON and BOM were notified about this request .In an interview on 3/12/26 at 11:05 AM, Transport Driver AA reported he picked up Resident #103 with a transport van and took her home when she discharged from the facility on 2/14/26. Transport Driver AA stated .When we got to the door (of the home) I couldn't get her chair through the door. It was too wide . Transport Driver AA reported Resident #103 became upset and started complaining of pain in her arm and in her chest. Transport Driver AA reported Family Member R called an ambulance at that point, and they arrived within ten minutes to take Resident #103 to the hospital. Transport Driver AA stated that when he picked Resident #103 up from the facility, staff were .rushing her out the door . Transport Driver AA reported Resident #103 appeared apprehensive about the discharge and started crying after they arrived at the home. Transport Driver AA reported that even if Resident #103's wheelchair had fit through the door, there were items blocking her path within the home.Review of the policy/procedure Discharge Planning Process, dated 10/30/23, revealed .It is the policy of this facility to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions .The facility will support each resident in the exercise of his or her right to participate in his or her care and treatment, including planning for discharge .The ongoing process of developing the discharge plan will include a regular re-evaluation of the resident to identify changes that require modification of the discharge plan, and updating of the discharge plan, as needed, to reflect the modifications .

Based on observation, interview, and record review, the facility failed to revise a care plan in 1 of 3 residents (Resident #105) reviewed for comprehensive care plans and accuracy of medical records, resulting in an inaccurate reflection of the resident's status and the potential for care and services to be provided that are inconsistent with the resident's needs.Findings include:Resident #105Review of an admission Record revealed Resident #105 was a female, with pertinent diagnoses which included dementia, intellectual disability, high blood pressure, heart failure, epilepsy (a seizure disorder), anxiety, muscle weakness, and reduced mobility.Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 9/5/25, revealed she had severe cognitive impairment. No history of falls noted since the prior assessment.Review of a current Care Plan (accessed 10/29/25) for Resident #105 revealed the focus .Resident is at risk for falls/injury related to history of falls, pain, epilepsy, (atrial fibrillation - an irregular heart rhythm that results in poor blood flow), intellectual disabilities, respiratory failure, dementia and osteoarthritis . revised 10/27/23, with interventions which included .floor mat next to bed . and .scoop mattress (a mattress with raised/contoured edges that creates a concave center to prevent the user from falling out of bed) . both initiated 3/27/24.In an observation on 10/29/25 at 11:04 AM, Resident #105 was noted in bed in her room with her eyes closed. No fall mats were observed beside Resident #105's bed. Noted Resident #105 had a regular mattress.In an observation on 10/29/25 at 3:10 PM, Resident #105 was noted in bed in her room. No fall mats were observed beside Resident #105's bed. Noted Resident #105 had a regular mattress.In an observation on 10/29/25 at 3:40 PM, Resident #105 was noted in bed in her room. No fall mats were observed beside Resident #105's bed. Noted Resident #105 had a regular mattress.In an observation on 10/30/25 at 8:21 AM, Resident #105 was noted in her wheelchair in the hallway, just outside of her room. Noted Resident #105 had a regular mattress. No fall mats were observed beside Resident #105's bed, or anywhere visible in her room.In an interview on 10/30/25 at 8:52 AM, Certified Nursing Assistant (CNA) H reported Resident #105 previously had fall mats in her room that were placed along the sides of her bed (when she was in bed). CNA H reported she was unsure where the mats were at this time. CNA H reported she did not recall a scoop mattress in use for Resident #105.In an interview on 11/3/25 at 12:51 PM, Director of Nursing (DON) B reported the interventions for Resident #105 related to the fall mats and scoop mattress were put in place after a fall more than a year prior. DON B reported Resident #105 no longer required these interventions, and the decision was made to remove them from the care plan. DON B reported the care plan should be reviewed and updated quarterly, and when any changes happen.

Based on observation, interview and record review, the facility failed to provide adequate supervision and implement appropriate care planned interventions to prevent a fall in 2 of 7 residents (Resident #77, #75) reviewed for accidents and hazards, resulting in a fall with fracture for Resident #77 and the potential to negatively affect the residents' highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #77: Review of an Admission Record revealed Resident #77 was a female with pertinent diagnoses which included dementia, history of falling, multiple fractures of pelvis, unsteadiness on feet, insomnia, muscle weakness, reduced mobility, adult failure to thrive, aphasia ((loss of the ability to understand or express speech caused by brain damage, like with a stroke) and cognitive communication deficit (progressive degenerative brain disorder resulting in difficulty with thinking and how someone uses language). Review of a Care Plan for Resident #77 revised on 5/23/35 revealed the focus, .Resident is at risk for falls/injury related to history of falling, adult failure to thrive, muscle weakness, arthritis, cognitive status, pelvic fractures . with the intervention .Bed in low position .Frequent reorientation .Activity program/group program .Educate resident on safety interventions .Encourage resident to keep needed items within reach .Encourage resident to use call light .Ensure the resident's room is free from accident hazards (e.g., providing adequate lighting, ensuring there are no trip hazards, providing assistive devices) .Mat to floor next to bed on the left side .Bed against wall for better mobility around room, safety and to provide space to provide care in a safe manner . Review of an IDT Functional Abilities Assessment for Resident #77, dated 3/19/25, revealed, .8. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair) .03. Partial/moderate assistance .10. Walk 10 feet .88. Not attempted due to medical condition or safety concerns . Review of a Therapy Fall Screen for Resident #77, dated 4/5/25, revealed, .Visual Observations: Transfer concerns - yes .Ambulation concerns .yes .Balance concerns .yes .Safety awareness concerns .yes .Pain concerns .yes .Staff Questions: Any noted change in mobility or ADLs? .yes .Any pain or change in ROM (range of motion)? .yes .Any therapy needs (PT,OT,SLP)? .yes . Review of an Encounter note for Resident #77, dated 4/20/2025 at 00:00 AM, revealed, .Reported unwitnessed fall at 2335 (11:35 PM). No injury noted, able to move all extremities and bear weight. Pt (Patient) is confused per baseline and unable to state how fall occurred. Neuro checks initiated. Monitoring . Review of Progress Notes for Resident #77, dated 04/21/25 at 00:00 AM, revealed, .Patient is 87- year-old female with history of diet controlled diabetes and dementia. She is being seen for follow-up following a reported fall with no injuries. Patient is seen today, no obvious injuries, or bruising. She denies pain. Due to advance dementia is unable to give any more valuable assessment data. Nursing has no concerns about her care at this time. Vitals reviewed and remain stable .ASSESSMENTS AND PLANS: Muscle weakness (generalized):Patient seen, no visible injuries , no indication for imaging at this time. Denies pain from fall and unable to give any more valuable details due to cognitive impairment. Nursing has no new concerns at this time .Continue fall and safety precautions as patient is confused at baseline . Review of an Alert Note for Resident #77, dated 4/21/2025 at 03:16 AM, revealed, .Was observed by both nurse and CNA (Certified Nursing Assistant), approximately 10-15 minutes prior to fall (in hall), laying in bed. Bed was at w/c (wheelchair) height and call light was within reach. This nurse was at med cart prior to fall, which was parked next to patient's room. At 2335 (11:35 PM), This nurse and CNA were walking down hall and observed resident sitting on the floor, in the hallway, across from room. She was sitting next to room [ROOM NUMBER] doorway with back against wall. She was sitting on her bottom with legs out in front of her and gown was half off. She was not wearing a brief .She was trying to scoot towards her room. The floor was clean and dry in hallway where she was sitting and also in room. Call light was on bed and was not activated. When asked how she ended up on the floor in the hall, she stated, I don't know and I guess I fell . Nursing assessment completed prior to assisting off of the floor with x2 assist. No injury was noted. Able to move all extremities and bear weight without difficulty. Was assisted into w/c and assisted to bathroom for toileting/incontinence cares. Wet brief was observed at the foot of the bed. Gripper socks put on and was assisted back into bed. Bed placed in low position and call light within reach Review of a Therapy Screen for Resident #77, dated 4/21/25, revealed, .Provided to hall staff with importance for pt's (patient's) needs anticipation as pt is not alert enough to request for help . Review of Nurses' Notes for Resident #77, dated 4/25/2025 at 13:41 PM (1:41 PM), revealed, .Resident taken to (local hospital) via (Emergency Transport Company) at 1341. Increased pain in left hip. x-rays confirm fracture . Review of Progress Notes for Resident #77, dated 4/25/25 at 00:00 AM, revealed, .Received following message from nurse resident returned from ER. Family declined hip surgery new order for Keflex 500mg QID for 7 DAYS. Notified rounding for follow up . Review of an Emergency Department (Local Hospital) note for Resident #77, dated 4/25/25 revealed, .Started cephalexin (Keflex) .Reason for Visit: Hip Injury .Diagnoses: - Fall at nursing home, initial encounter .Closed fracture of multiple pubic rami, initial encounter . Review of Progress Notes for Resident #77, dated 4/28/2025 at 00:00 AM, revealed, .Patient is [AGE] year-old female with history of diet controlled diabetes and dementia being seen to follow-up on ER visit of 4/25 where patient was evaluated for left hip fracture. Not a candidate for surgical intervention and return to facility same day pain /conservative management. Also noted with UTI (Urinary Tract Infection) and sent back to complete course of Keflex .Reported left hip pain when being assisted with ADLs .Apply lidocaine 4% patch daily. Continue Tylenol . Review of a Progress Note-General Note for Resident #77, dated 4/29/2025 at 10:48 AM, revealed, .(Resident #77) had a fall on 4/20/25, resulting in a closed fracture of multiple pubic rami per x-ray. She has complaints of pain, reduced mobility, and has experienced a reduction in ADL's. It was determined by the IDT team that a significant change in status has occurred, and an assessment is scheduled. Based on the severity of her injury, a return to her baseline is not expected within 2 weeks. A referral to therapy has been placed . During an observation on 06/03/25 at 08:51 AM, Resident #77 was lying in her bed, the lights were off. Observed no fall mat next to the side of her bed, wheelchair was not by the side of the bed as it was located at the end of the foot of the bed at an angle to the side of the foot of the bed, the seat of her wheelchair was facing away from the resident, and it was not in reach. During an observation on 06/03/25 at 09:44 AM, Resident #77 was observed in her bed, she did not have a fall mat next to the side of her bed per the care planned need. The fall mat was folded up and was placed behind the head of her bed. During an observation on 06/03/25 at 11:40 AM, Resident # 77 was observed lying in her bed, she did not have a fall mat next to the side of her bed. There was a blue mat folded up behind the head of her bed. The bed was observed to be low to the ground and her wheelchair was out of reach in the same position it was earlier. During an observation on 06/03/25 at 02:40 PM, Resident #77 was observed in the dining room unsupervised seated in her wheelchair with coloring papers all over the floor, no staff were observed in the small area of the dining room as well as the larger dining room area. Resident #77 was attempting to pick up the papers off the floor as she was leaning forward in her wheelchair attempting to grab a paper. During an observation on 06/04/25 at 10:28 AM, Resident #77 was observed lying in her bed, tray table over her bed, fall mat was on the floor but not next to the bed it was at an angle away from the side of the bed at the head of the bed providing no safety if Resident #77 fell and angled with the bottom more towards the foot of the bed. In an interview on 06/04/25 at 10:16 AM, Unit Manager (UM) XX reported staff had to keep a close eye on Resident #77 as she would free roam the halls and would go into other resident's rooms. UM XX reported activities staff help supervise Resident #77. In an interview on 06/04/25 at 01:19 PM, UM RR reviewed the record, reported Resident #77 had a fall on 4/20/25 and ultimately fractured her hip. UM RR reported for a resident who had a need for increase in supervision, the staff would want them in visible areas like the nurse's station or with activities. UM RR reported the facility did not send Resident #77 to the emergency room following her fall as she had not complained of any pain. UM RR reported after a few days, she noticed the resident wasn't weight bearing on that leg and sent her out for an x-ray and evaluation. In an interview on 06/04/25 at 09:52 AM, Family Member (FM) VV reported Resident #77 could be impulsive and the facility should keep a closer eye on her due to her impulsiveness and dementia. Review of Fall Prevention Program reviewed/revised on 1/1/2022, revealed, .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 .4. When a resident who does have a history of falling experiences a fall, the resident will be placed on the facility's Fall Prevention Program .5. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care .a. Interventions will be monitored for effectiveness .b. The plan of care will be revised as needed . Resident #75 Review of an Admission Record revealed Resident #75 was a female with pertinent diagnoses which included stroke, paralysis on right dominant side, anxiety, muscle weakness, reduced mobility, lack of coordination, and bed confinement status. Review of a current Care Plan for Resident #75, revised on 3/24/25 revealed the focus, .Care Plan: Resident has an ADL (Activities of Daily Living) self-care performance deficit related to generalized weakness following hospitalization for acute cystitis and encephalopathy, right sided weakness following stroke . with the interventions .AMBULATION: 2 person assist with use of FWW (four wheeled walker) until screened by therapy .TRANSFERS: 2 person assist .Reduce the risk of injury through the next review .2 person assist for toileting, transfers and ambulation until screened by therapy . Review of an IDT (Interdisciplinary Team) Functional Abilities Assessment for Resident #75, dated 3/24/25 at 4:00 PM, revealed, .B. Activities of Daily Living: 8. Chair/Bed to Chair Transfer: The ability to transfer to and from a bed to a chair (or wheelchair) .02. Substantial/Maximal assistance .10. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space .88. Not attempted due to medical condition or safety concerns . During an observation on 06/02/25 at 10:30 AM, Resident #75 was observed in her room seated in her wheelchair. Resident #75 had her call light on and Certified Nursing Assistant (CNA) II responded. CNA II backed Resident #75's wheelchair to the head of the bed and placed it along the side of her bed. CNA II leaned over and told Resident #75 to give her a hug, counted and then assisted her to her feet. CNA II did not have a gait belt around Resident #75's body for her safety. CNA II did not use the wheeled walker to assist with her mobility. CNA II prompted Resident #75 to shuffle her feet as she was assisting her in turning to back up and sit on the side of the bed. CNA II had her sit on the side of her bed while still hugging her. CNA II moved her wheelchair out of the way, had Resident #75 hug her again, stood her up, and had her sit down further back on the bed. CNA II did not have a gait belt around Resident #75 for safety. CNA II placed Resident #75's wheelchair out of her reach along the wall, at the foot of the bed, on the left side of her room, where her wheeled walker was located at as well. In an interview on 06/04/25 at 01:25 PM, Unit Manager (UM) RR reported a gait belt should be used every time the staff were to transfer a resident. Review of a document titled Using a Gait Belt received on 6/4/25, revealed, .Why should I use a gait belt? Gait belts prevent falls .Use a gait belt whenever the person is weak or unsteady .gait belt should go at the patient's waist and be snug .

Based on observation, interview, and record review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living, affecting the following areas: Findings Include During a tour of the kitchen, at 8:48 AM on 6/3/25, observation of the dish machine area found worn and missing grout along portions of the back left floor juncture underneath the dish machine. Further review found multiple tiles pushed up from the floor underneath the garbage disposal allowing moisture to accumulate and create an environment conducing for the growth of insects and bacteria. Multiple gnats were found under the dish machine at this time. Mainly grouping around the unused floor drain and sections of the floor where grout is worn low, and water can accumulate and stagnate. An interview with Dietitian SS, at 8:50 AM on 6/3/25, found that the exhaust for the dish machine has been down for some time and the facility is looking to replace it, but she's not sure where the repair is at this point. The surveyor noted the moisture accumulation in and around the dish machine area is being exacerbated by the fact there is no exhaust for the high temperature dish machine, which creates a large amount of steam and humidity. During a tour of the B hall shower room, at 11:11 AM on 6/3/25, with Maintenance Director (MD) UU and Housekeeping General Manager (HGM) TT, it was found that a crusted white powder debris was found on the back top of the commode seat and further observation of the room found that no paper towels or holder was available in the shower room. An interview with MD UU found that there was a large renovation project in the shower room awhile back and they must not have installed a new paper towel holder when they were done. Observation of the shower bed found an accumulation of trash, debris, and white and brown staining underneath the shower mat stuck into the crevices and holes of the netting underneath. When asked who would typically take care of this area. HGM TT stated that care staff should be cleaning this area between residents. During a tour of the central supply room, off the service hall, at 11:28 AM on 6/3/25, it was observed that numerous boxes of briefs were found stored on the floor of the room. Further observation found that two newer shelving units were found with press-board racks that are not smooth and easily cleanable. During a tour of the C Hall Soiled Utility room, at 1:57 PM on 6/3/25, it was found that vinyl coving had fallen and was observed sunk back into the wall for portions of the perimeter of the room. Further observation found that coving was placed over areas with little to no backing to give structure or support to the coving. During a tour of the D Hall Soiled Utility room, at 2:11 PM on 6/3/25, it was found that no exhaust fan was working in the room. When asked if the whole hall would be out if this one exhaust was not working, MD UU stated the whole hall is connected to this one, so yes. 41424 During an observation on 06/02/25 at 10:37 AM, room [ROOM NUMBER], bed 1 this writer observed on the floor along the side of the head of the bed, running over to the recliner was dried liquid on the tile floor, and it had brown outline to it. The wall next to the side of the bed had brown dried material smeared on the wall. During an observation on 06/03/25 at 11:44 AM, this writer observed the floor in room [ROOM NUMBER], bed 1 and it still had the dried spilled liquid on the floor by the side of the bed, and then flowing over to the recliner. The wall next to the side of the bed had brown dried material smeared on the wall. During an observation on 06/02/25 at 01:39 PM, room [ROOM NUMBER] this writer observed the window in the room had cobwebs in the corner of the sills attached to his blinds, the window sill had not been dusted. There were cobwebs noted to be in the upper corner of the wall by the bathroom. During an observation on 06/03/25 11:45 AM, room [ROOM NUMBER] still had cobwebs in the corners of the window. far right left corner of the window. The wall in the room had scraps along the walls and baseboard areas. The threshold to the room was dirty appearing and appeared to need to be stripped. During an observation on 06/02/25 at 02:00 PM, room [ROOM NUMBER] this writer observed several cobwebs on his window sill which were attached to the blinds. There was dirt and debris on the window sill. As well as cobwebs in the upper right corner of his wall by the head of the bed. During an observation on 06/03/25 09:03 AM, room [ROOM NUMBER] the wall bead strip came off and was leaning against the wall in the corner of the room by the window, the heater had chips of paint missing from the sides of the box, cracks on the wall. The front of the heater had paint missing scrapped off, and there were nails/screws in the wall where the strip was supposed to go. In an interview on 06/04/25 at 09:31 AM, Housekeeper ZZ reported when she entered a room she would do all the trash first, wipe all surfaces, such as the table, light and dust too the window sills and everything else, then she would sweep all the floors and mop. She reported when she dusted she would dust the light fixtures, tv, and the upper areas in the room. Housekeeper ZZ reported she would ensure the room was stocked with needed toiletry items as well. Housekeeper ZZ reported the housekeepers followed a 5 or 7 step procedure when they cleaned the rooms. She reported she had worked for the facility for several years as when she originally started she was trained to follow the steps she reported during the interview. She reported if the resident was in the room, the housekeepers would ask if they could clean the room and it would be noted on the checklist they were unable to clean the room. In an interview on 06/04/25 at 02:13 PM, Registered Nurse (RN) KK reported there was an electronic system for maintenance work orders so they would be assigned by maintenance for completion. If staff noticed a need for maintenance, they would complete an online work order for maintenance.

This citation pertains to MI00152360 and MI00153353. Based on observation, interview, and record review, the facility failed to follow up and resolve grievances for 12 residents (R34, R2, R52, R15, R26, R17, R54, R12, R65, R5, R32, R55) of 12 reviewed for grievances and 3 of 7 residents in Resident Council resulting in residents missing items and the potential for further unresolved grievances to occur. Findings include: Resident #34(R34) Review of the Admission Record and Minimum Data Set (MDS) dated [DATE] revealed R34 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R34 was cognitively intact (13 to 15 cognitively intact). During an interview on 6/02/2025 at 9:23 AM, R34 reported that on 4/8/2025 during the overnight shift she had $150 in her phone wallet and when she woke up, her phone wallet was moved and out of reach and her money was gone. R34 said the facility looked into her concern but she didn't hear anything about the outcome of whether she would be reimbursed for her missing money. Review of R34's Quality Assistance form dated 4/9/2025 revealed Details: Money was taken from her wallet phone. $150 cash was in her wallet. She noticed the money missing at 6am on 4/9/25 Findings: Administrator notified at 10:21 am on 4/10/25. Interviewed resident 10:30 am on 4/10/25 . Plan/Actions, whether the concern was resolved, whether the results were reported to R34, whether R34 was satisfied with the resolution, and signatures of completion were blank. During an interview on 6/3/2025 at 7:45 AM, Social Services Director (SSD) D reported that she wasn't involved with the investigation of R34's missing money. SSD D said the previous Nursing Home Administrator (NHA) E was taking care of the incident but she thought R34 was reimbursed the money. Review of R2's Quality Assistance form dated 4/10/2025 revealed Assistance needed: lost clothing, lost item. Details: Jeans, scarf, and a list she (resident) has already inquired about Findings: Unable to find items. Plan/Actions, whether the concern was resolved, whether the results were reported to R2, and whether R2 was satisfied with the resolution were blank. Review of R52's Quality Assistance form dated 4/10/2025 revealed Assistance needed: lost clothing. Details:1 pair of sweatpants, med (medium) blue with hole in thigh of L (left) leg-XL (extra-large) .Findings unable to locate . The form didn't indicate whether the concern was resolved, whether the results were reported to R52, and whether R52 was satisfied with the resolution. Review of R15's Quality Assistance form dated 4/10/2025 revealed Assistance needed: lost item. Details: Phone cord. Findings R15 claims it is rainbow colored .Plan/Actions: check inventory list-phone cord was placed on inventory list. Search for phone cord in resident room. The form didn't indicate whether the concern was resolved, whether the results were reported to R15, and whether R15 was satisfied with the resolution. Review of R26's Quality Assistance form dated 4/10/2025 revealed Assistance needed: lost clothing. Details: 2 shirts (blue, Pfizer), 2 scrub pants, 1 camo pants Findings .checked closet and lost and found-unable to find The form didn't indicate whether the concern was resolved, whether the results were reported to R26, and whether R26 was satisfied with the resolution. Another Quality Assistance form for R26 dated 4/11/2025 revealed Details: 2 light blue Pfizer t-shirts, 2 pairs grey scrub pants XL (extra-large), 2 black t-shirts (Bleached), camo pants-hole, black Findings unable to find Pfizer t-shirts and grey scrub pants . Plan/Actions, whether the concern was resolved, whether the results were reported to R26 and whether R26 was satisfied with the resolution were blank. Review of R17's Quality Assistance form dated 4/10/2025 revealed Assistance needed: lost item. Details: Passport Findings .found bag, passport not in bag. Resident does have papers and documents stacked up throughout room. Passport missing for months The form didn't indicate whether the concern was resolved, whether the results were reported to R32, and whether R32 was satisfied with the resolution. Review of R54's Quality Assistance form dated 4/10/2025 revealed Assistance needed: lost clothing. Details: 4 t-shirts, black pants w/ (with) zipper on side-XL (extra-large), shrinkage sock for leg-grey Findings .unable to locate items in room, laundry room or lost and found . Plan/Actions, whether the concern was resolved, whether the results were reported to R54 and whether R54 was satisfied with the resolution were blank. Review of R12's Quality Assistance form dated 4/10/2025 revealed Assistance needed: lost clothing, lost item. Details: 2-3 shirts, 2 lounge wear pants .Findings .unable to locate any of these items in room, laundry or lost and found. The form didn't indicate whether the concern was resolved, whether the results were reported to R12, and whether R12 was satisfied with the resolution. Review of R65's Quality Assistance form dated 4/10/2025 revealed Assistance needed: lost clothing. Details: clothing (not sure what clothes)-Resident states this was before she switched rooms. She asked about the clothes and never got them back The form didn't indicate whether the concern was resolved, whether the results were reported to R65, and whether R65 was satisfied with the resolution. Review of R5's Quality Assistance form dated 4/10/2025 revealed Assistance needed: lost clothing. Details: 1 pair of socks and 2 shirts . The form didn't indicate whether the concern was resolved, whether the results were reported to R5, and whether R5 was satisfied with the resolution. Review of R32's Quality Assistance form dated 4/10/2025 revealed Assistance needed: lost clothing, lost item. Details: 1 pair of socks, [NAME] colors, tube socks Findings .not in laundry, resident room or lost and found. Wears size 8W . The form didn't indicate whether the concern was resolved, whether the results were reported to R32, and whether R32 was satisfied with the resolution. Review of R55's Quality Assistance form dated 4/10/2025 revealed Assistance needed: lost clothing, lost item. Details: 1 pair of jeans and 1 belt .Findings .unable to locate items . The form didn't indicate whether the concern was resolved, whether the results were reported to R55, and whether R55 was satisfied with the resolution. Review of Resident Council Minutes dated 4/23/2025 revealed Laundry is not coming back some residents are missing things that go to laundry and they don't come back Review of the Quality Assistance form dated 4/23/2025 from the Resident Council Meeting revealed Laundry is not coming back on time and lost clothing. Potential Department involved: Laundry Findings and Plan/Actions were blank. Review of Resident Council Minutes dated 5/21/2025 revealed .Old Business Review: Issue: Old Business Review . Status Update and Person Responsible were blank. There was no mention of April's meeting and concerns regarding laundry. Review of Resident Council Minutes dated 5/24/2025 revealed .Old Business Review There was no mention of April's meeting and concerns regarding laundry. An email received from NHA A on 6/2/2025 at 2:59 PM revealed We do not have a specific policy regarding missing items. However, if the facility is at fault for the missing item, we will replace the item. During an interview on 6/3/2025 at 12:02 PM, Regional Director of Operations (RDO) C acknowledged that the forms did not have a thorough investigation, resolution and the residents weren't informed of the resolution. RDO C' reported that she realized the facility was late in resolving these grievances but a staff member was going around and checking with these residents to see if their missing items concerns from April were resolved. RDO C said that she was going through Amazon to see if items were purchased for reimbursement for these specific residents. Review of the Quality Assistance Policy with a review date of 10/30/2023 revealed Policy Explanation and Compliance Guidelines 4. Quality Assistance request may be submitted orally or in writing. The administrator may delegate the responsibility of Quality Assistance investigation to appropriate department manager. 5. Upon receipt of a written Quality Assistance Form/request, the department manager will investigate the allegations and submit a written report of such findings to the administrator 6. The administrator will review the findings with the person investigating the complaint to determine what corrective actions, if any, need to be taken 7. The resident, or person filing the Quality Assistance Form on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. 41424 Resident #55 Review of an Admission Record revealed Resident #55 was a male with pertinent diagnoses which included legal blindness, stroke, end stage renal disease, dialysis, and depression. Review of a current Care Plan for Resident #55, revised on 3/6/25, revealed the focus, .Resident has visual impairment related to legally blind . with the interventions .Announce yourself when entering the resident's room/space .Encourage resident to keep call bell, water pitcher, and personal belongings in the same place . In an interview on 06/02/25 at 10:55 AM, Resident #55 reported his debit care information was stolen. Resident #55 reported he had staff assist him with purchases at the facility when he was having issues using his phone applications. Resident #55 reported he was unsure what was happening with his concern as he had not heard anything from the facility administration or the local police. Resident #55 reported he had to call his bank and dispute the transactions. Resident #55 reported when he contacted one of the companies about the charge to his debit card, they suggested to him he should contact the police and file a report and Resident #55 reported he did contact the police. Resident #55 reported the card was used at (local grocery store) he had never shopped at, there were a couple transport service company charges on his card, and there were charges at (local restaurants) as well. Resident #55 reported there were cameras in the transport service company's vehicles the police should be able to determine who used the card. Resident #55 reported $202.00 was charged to his card and he was requesting to be discharged to another facility as he was concerned with the fact staff had used his card and he had items stolen when he was at the hospital and the facility had not followed up with him on the concerns. Resident #55 reported this morning the staff tried to give him clothes to wear that were another residents, and he has had multiple items of clothing lost even with the items labeled. Resident #55 reported this happened quite frequently to him and other residents. Review of Social Services Progress Notes dated 5/20/2025 at 08:00 AM, revealed, .SSD (Social Services Director) reported incident to administrator and wrote it on a concern form. The appropriate steps will be taken to make sure resident is reimbursed . Review of Social Services Progress Notes dated 5/20/2025 at 11:56 AM, revealed, .SSD spoke with resident in room regarding him wanting to be transferred out of the facility due to some suspicious activity. SSD told him they would put it on a concern form and let the administrator know. Resident disclosed there have been some odd charges on his card that he has never made before . In an interview on 06/03/25 at 11:32 AM, SSD D reported Resident #55 had concerns with someone using his debit card. SSD D reported she let the previous administrator know right away and completed a concern form. SSD D reported he cancelled his debit card. SSD D reported she thought the facility was going to reimburse him for his losses when informed Resident #55's concerns had not been addressed. Review of a Quality Assurance Form for Resident #55, dated 5/20/25, revealed, .Resident states toothbrush, shampoo, and conditioner were stolen when he was in the hospital. States there are charges on his credit card for (local grocery store), (local Mexican restaurant), (local chicken restaurant), and 2 (transportation services company) rides that he did not have. He states only (Receptionist GG) and (CNA N or CNA O) have helped him make purchases in the past . Further review of the Quality Assurance Form for Resident #55, dated 5/20/25, revealed the concern was not assigned to a department head, investigation was not completed or follow up completed noted on the form. There was not a signature from Previous Nursing Home Administrator E. Review of an Incident Summary for Resident #55 revealed, .Resident alleging charges on debit card that he did not approve, for items he did not purchase .Resident alleges that receptionist or CNA must have stolen from him. Resident reports that his debit card is never off of his person, and that he has charges on his account that he does not recognize. He alleges that one of the staff members that have assisted him with transactions due to visual impairment had to have stolen his information. He alleges that (CNA, N or O, or receptionist, GG) must have stolen from him. Provider notified. Law enforcement notified. Alleged staff members suspended pending full investigation to follow. Resident will be monitored for changes in psychosocial well-being . This writer attempted to contact Previous Nursing Home Administrator E to discuss investigation and was unable to speak to her prior to exit from facility. In an interview on 06/03/25 at 12:48 PM, Receptionist GG reported she had assisted Resident #55 with a food order for a local Chinese restaurant due to his (food ordering service app) was not working and she used her personal cell phone to call the restaurant. Receptionist GG reported the resident handed her his card and she had it long enough to give the number to the person on the phone taking the food order for the local Chinese restaurant. In an interview on 06/03/25 at 10:54 AM, Regional Director of Operations (RDO) C reported the staff were returned back to work following the investigation. This writer asked for the full investigation as the report indicated it was Pending final investigation. This writer also inquired from RDO C what was the outcome of the investigation to the use of Resident #55's debit card as well as the replacement of the missing items, toothbrush, shampoo, and conditioner, which Resident #55 reported missing after his return from the hospital, and she indicated she would have to follow up on the concerns to ensure what the outcome was. In an interview on 06/03/25 at 12:41 PM, Human Resources HH reported the staff members were allowed to come back to work following the approval of the previous Nursing Home Administrator on 5/28/25. In an interview on 06/04/25 at 09:06 AM, Social Services Director (SSD) D reported she would assist Resident #55 with any assistance he needed and with financial transactions there would be a witness at all times. SSD D reported if she was unavailable to assist him then administration or a nurse would be the one to help him, no other staff members should be assisting him with any updating or ordering. In an interview on 06/04/25 at 01:51 PM, RDO C reported the police were unable to go any further with the investigation, therefore the facility was unable to substantiate the allegations. RDO C reported as Resident #55 did have a visual impairment, SSD D with another staff member present would assist Resident #55 with any financial needs he may have. RDO C reported there would be two staff members present for any transaction assistance. RDO C reported there was always a manager on duty in the building to assist him with any needs he may have outside of SSD D's working hours. RDO C reported Resident #55 had not been reimbursed for the $202.00 used on his debit card as well as the personal care items missing upon his return from the hospital on 5/13/25. 41027 In a Confidential Group Meeting on 06/03/25 at 10:40 AM, 3 of 7 residents reported that their concerns and missing items were not being addressed and/or resolved.

Based on observation, interview, and record review the facility failed to ensure proper infection control protocols and practices for 1. enhanced barrier precautions (EBP) for 3 residents (Resident #30, #540, #37) and 2. infection control practices with injections for 1 (Resident #33) and 3. soiled shared equipment from of total sample of 18 residents reviewed for infection control, resulting in the increased potential for the spread of infection, bacterial harborage, cross contamination, and disease transmission for residents residing in the facility. Findings include: Resident #30 Review of an Admission Record revealed Resident #30 was a male with pertinent diagnoses which included diabetes, heart failure, COPD, bipolar disorder, and mitral valve disorder. Review of current Care Plan for Resident #30, revised on 5/1/2025, revealed the focus, .The resident is at risk for skin impairment related to hx (history) of wound to left heel which resolved .Resident frequently refused to wear heel protection boots . Review of current Care Plan for Resident #30, revised on 6/2/2025, revealed, the focus, .Resident requires enhanced barrier precautions related to pressure ulcer . with no interventions. Review of Skin & Wound Evaluation dated 5/26/25, revealed, .Pressure .Deep Tissue Injury .Left heel .In house acquired .length 0.3 CM x width 0.5 CM x depth < 0.1 CM .90% of wound covered .10% affected area covered with dermal tissue . Review of Skin assessment dated [DATE], revealed, .Left heel .black/purple spot on heel . During an observation on 06/03/25 at 08:56 AM, Resident #30 had a PPE bin and a sign on the wall outside of his room which indicated he was under EBP. This side was not present the previous day. In an interview on 06/03/25 at 11:53 AM, Registered Nurse (RN) YY reported Resident #30 had a wound on his heel and he had it prior to entry on 6/2/25. Resident #540 Review of an Admission Record revealed Resident #540 was a male with pertinent diagnoses which included right foot transmetarsal amputation (partial foot amputation where the bones of the forefoot (metatarsals) are removed while preserving the ankle joint and most of the foot's length: often performed as a limb saving procedure for conditions like infection, gangrene, or diabetic ulcers), cellulitis of right lower limb, foot drop-right foot, edema, and muscle weakness. Review of current Care Plan for Resident #540, revised on 5/22/25, revealed the focus, .Resident requires enhanced barrier precautions related to R (right) foot surgical incision . with the interventions .Use gown and gloves when providing direct care. Face protection may be needed if performing activity with risk of splash or spray .Utilize enhanced barrier precautions when providing high contact resident care activities (dressing, bathing, transferring, personal hygiene, changing linens, changing briefs/assisting with toileting, device care: central lines, urinary catheters, feeding tubes, tracheostomy/ventilators, wound care, dialysis) .Review with visitors and family members how to follow the recommended precautions when visiting if prolonged physical contact is anticipated . Review of current Care Plan for Resident #540, revised on 5/22/25, revealed the focus, .Resident has impaired skin integrity as evidenced by (SPECIFY: wound type and location) related to . with the interventions .Administer treatment (s) per orders .Notify Nurse of any new areas of skin impairment noted during bathing or daily care .Notify physician/NP/PA of noted worsening skin condition or any new areas of skin impairment .Notify physician/NP/PA of signs/symptoms of infection . Review of Order dated 5/7/25 for Resident #540, revealed, .Use enhanced barrier while performing high-contact activity with the resident related to wounds. every shift . Review of Order dated 5/12/25 for Resident #540, revealed, .Patient to consult wound clinic due to worsening foot wound . Review of Order dated 5/26/24 for Resident #540, revealed, .TX: R (right) foot surgical site: Cleanse area with normal saline and blot dry. Apply Bacitracin Zinc Ointment to surgical site BID (twice a day). Leave open to air. Monitor area for any worsening s/sx (signs and symptoms) of skin integrity. Notify MD/NP of any s/sx of infection. every day and evening shift for RLE (right lower extremity) stump wound . During an observation on 06/02/25 at 09:35 AM, a personal protective equipment (PPE) cart was observed placed along the wall outside Resident #540's room. There was no enhanced barrier precautions sign on the wall outside of the room to indicate enhanced barrier precautions were required when providing high contact resident care activities. During an observation on 06/02/25 at 10:16 AM, Resident #540 was seated on the side of his bed, he was dressed. Next to the recliner over on the far wall was placed a black trash bin traditional used for PPE when staff were finished providing high contact resident care activities. During an observation on 06/02/25 at 10:27 AM, Resident #540 was observed sitting on the side of his bed. Certified Nursing Assistant (CNA) II donned gloves and was observed entering Resident #540's room. CNA II went to his bed, grabbed the urinal hanging from the enabler bar on his bed, and went to the bathroom to empty it. CNA II did not don any other PPE prior to performing this care. CNA II doffed her gloves, grabbed the trash in his room, and performed hand sanitization as she exited the room. In an interview on 06/02/25 at 10:37 AM, Resident #540 reported he had to have his toes amputated, they were healing but kinda slow. In an interview on 06/02/25 09:38 AM, Unit Manager (UM) RR reported for a resident who was on enhanced barrier precautions (EBP), the facility normally had a sign for EBP, and highlighted the resident's name which would indicate who had the precautions. UM RR reported it was a team effort for the placement of the EBP signs but the infection preventionist was the responsible person. When queried if staff had been providing high contact resident care activities for Resident #540 since his return from the hospital, she reported he had wounds and required hands on assistance, so it would be logical staff would have been providing care without PPE. UM RR reported the PPE carts were strategically placed and not necessarily for this room so if not the PPE bin wasn't present, staff and visitors would not know their were residents in the room under EBP. During an observation on 06/02/25 at 09:42 AM, observed UM RR place an Enhanced Barrier Precautions (EBP)sign on the wall outside the door for Resident #540's room. During an observation on 06/02/25 10:24 AM hoyer was observed outside of room [ROOM NUMBER] in the the hallway, purple wipes, plastic bag. The blue grasp cover for residents had dried soiled material which was tan in color and appeared to be soiled with dried food and dirt. 47955 Resident #37 During an observation on 6/2/25 no signage was noted outside or around Resident #37's room indicating to staff that resident was in enhanced barrier precautions (EBP), and that personal protective equipment should been work during high contact care activities. Review of Order Summary for Resident #37 revealed .Use enhanced barrier precautions while performing high-contact activity with the resident every shift for wound care with a start date of 3/31/2025. Review of Care plan for Resident #37 revealed no indication of enhanced barrier precautions use. Review of Skin and Wound Evaluation for Resident #37 dated 6/2/25 revealed pressure .stage 2- partial thickness skin loss with exposed dermis .location-coccyx .exact stated it began was 5/19/2025 . During an observation and interview on 6/3/25 at 4:20 pm Licensed Practical Nurse (LPN) V visualized Resident #37's wound dressing to be dry and intact, and repositioned Resident #37 in bed and adjusted her bed linens. LPN V was not wearing an PPE while providing care with Resident #37. LPN V reported she was assisting Resident #37 to reposition in bed, and she wanted to make sure Resident #37's dressing was still intact. LPN V reported she did not think that Resident #37 was in EBP. In an interview on 6/4/25 at 11:15 am Unit Manger (UM) RR reported Resident #37's wound was resolved, and she was not in EBP. In an interview on 6/4/25 at 11:21 am, Registered Nurse (RN) BB reported she was the wound nurse, and Resident #37 did have a wound on her coccyx. RN BB reported Resident #37 should be in EBP and that she should fix that. RN BB reported she was responsible for updating care plans, and confirmed Resident #37's care plan did not include EBP and that she would need to fix that too. 41027 Resident #33 During an observation of medication administration on 06/03/25 at 08:32 AM Registered Nurse (RN) EE prepared an insulin (used to manage blood sugar levels) injection (when a needle is used to administer medication) for Resident #33. The medication was labeled Lantus (a long acting insulin). Observed RN EE inject 10 units of the Lantus into Resident #33's right abdomen. RN EE did not use hand sanitizer prior to entering the room and did not wear gloves during the injection. In a subsequent interview on 6/3/25 at 8:35 AM, RN EE reported that she did not normally wear gloves with injections, nor did the person that trained her. Review of Centers for Disease Control and Prevention (CDC) dated March 20,2024, revealed, .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities .EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .EBP are indicated for residents with any of the following: o Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or o Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO .Effective Date: April 1, 2024 . Review of Centers for Disease Control (CDC) poster for Enhanced Barrier Precautions, revealed, .Enhanced Barrier Precautions: Everyone Must .Clean Their Hands, including before entering and when leaving a room .Providers and Staff Must Also .Wear Gown and Gloves for the following High Contact Resident Care Activities .Dressing .Bathing/Showering .Transferring .Changing linens .Providing hygiene .Changing briefs or assisting with toileting .Device care or use: central line, urinary catheter, feeding tube, tracheostomy .Wound Care: any skin opening requiring a dressing .

Based on observation and interview, the facility failed to ensure a dignified dining experience for 2 (Residents #590 and #50) of 4 residents reviewed for a dignified dining experience, resulting in the potential for feelings of frustration and loss of self-worth. Findings include: During a dining observation in the main dining room on 6/3/25 beginning at 12:09 PM, it was noted that Resident #56 and Resident #590 were seated at the same table. Resident #56 had received his lunch meal and was eating, while Resident #590 had not. At 12:12 PM, 2 additional residents arrived at the same table, Resident #50 and an unnamed male resident. At 12:17 PM, the unnamed male received his lunch meal and began eating. Resident #56 continued to eat his meal as well. Neither Resident #590 nor Resident #50 had their meals. At 12:24 PM, the unnamed male finished eating his meal and left the table. At 12:30 PM, Resident #56 finished eating and left the table and Resident #590 was served her lunch meal. At 12:32 PM, Resident #50 took a baggie with an uneaten slice of bread from the place where the unnamed male had been eating and began to consume the slice of bread. At 12:36 PM, Resident #590 left the table with her meal uneaten. Resident #50 remained at the table alone. At 12:37 PM, Resident #50 was served his meal tray. In an interview on 6/3/25 at 1:27 PM, Regional Registered Dietitian (RRD) MM reported if residents are seated at the same table, they should get their meals at the same time. RRD MM reported when a resident arrived at a table with others already eating, that resident should be the next tray to be served or as soon as possible. RRD MM reported waiting 20 minutes or more to be served a tray when other residents were eating was a bit longer than normal.

This citation pertains to Intakes: MI00147677 and MI00149818. Based on interview and record review, the facility failed to ensure the safety and 1.) fully implement a documented intervention of 1:1 supervision to prevent a fall for 1 (Resident #102) resident and 2.) ensure an enabler (grab) bar was securely engaged before moving a resident in bed for 1 (Resident #103) resident of 3 residents reviewed for accidents/hazards/falls, resulting in a preventable fall with a head injury for Resident #102 and a preventable fall with a skin tear for Resident #103. Findings include: Resident #102 Review of an Admission Record revealed Resident #102 was a female, with pertinent diagnoses which included: Alzheimer's disease, unspecified (a form of dementia), muscle weakness (generalized), and repeated falls. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 3/18/24 revealed a Staff Assessment for Mental Status assessment that Resident #102 was Moderately impaired for cognitive skills for daily decision making. Review of Resident #102's Incident Report dated 6/2/24 revealed, Incident Description Nursing Description: Nurse found resident on the floor of C hall. Resident was self transferring down the hall without her walker .Resident Description: I was walking and tripped over my own feet. I fell on my right arm and then right leg . Review of Resident #102's IDT Interdisciplinary Progress Note dated 6/3/24 at 10:56 AM revealed, Note Text: IDT review of resident fall on 6/2/24. Resident found on floor, VS (vital signs) and ROM (range of motion) assessed, resident sent to ER (emergency room ) for evaluation of pain in right upper and lower extremity. Immediate intervention of added 1:1 (one on one supervision) when resident returns from ER due to fall risk and resident is uncooperative with use of walker. Review of Resident #102's Incident Report dated 6/7/24 revealed, resident was walking out of her room towards the nursing station, she stumbled over her own feet looking dizzy, then fell on to her right side hitting her hip, shoulder then head. immediately after the fall she was unresponsive for 6 min (minutes), breathing normally .Immediate Action Taken Description: called 911, placed into spinal precautions and laid resident on back as directed by 911 dispatch . Review of a statement dated 6/7/24 by Certified Nurse Aide (CNA) E (the staff assigned to provide 1:1 supervision for Resident #102 at the time of the fall) revealed, At approximately 3:30 p.m. (Resident #102) was in her bed watching T.V. Went to let her nurse know that her brace on the L (Left) leg was taken off and roommate needed something for pain. When I returned to room, she was on the floor in the hall. She landed on her R (right) side sorning (sic). Vital (sic) were taken lot of movement on L side. She was communicating with staff EMS (Emergency Medical Services) was called .Additional Questions: 1. Do you know that you should never leave a 1:1? Answer: I know I should never leave a 1:1 . In an interview on 2/19/25 at 2:16 PM, CNA E reported she had been the staff providing the 1:1 supervision for Resident #102 at the time of the fall on 6/7/24. CNA E reported Resident #102 had been complaining about the brace on her leg and wanted to take it off. CNA E reported the other resident in the room needed assistance and she (CNA E) had gone to find somebody to assist the other resident and to look at Resident #102's brace. CNA E reported as soon as she walked out of the room, Resident #102 was on the floor. Review of Resident #102's Emergency Department report dated 6/7/24 at 4:28 PM revealed, HPI (history of present illness) .Patient is an [AGE] year-old female presents from (Facility Name) with concerns for a ground-level fall today with loss of consciousness and subsequent altered mental status .Patient is anticoagulated on Eliquis . Review of a Radiology CT (a form of imaging that uses x-rays) Trauma Brain Without Contrast report from (hospital name omitted) for Resident #102 signed on 6/7/24 at 6:62 PM revealed, Final Result 1. Acute focal hematoma (blood clot) in the right middle cranial fossa (a depression in the inner surface of the skull that houses the brain)/right anterior temporal lobe (a part of the brain on the sides of the head) measuring up to 0.8 cm (centimeters) .2. Additional focal hematomas in the right [NAME] (a part of the brain stem) measuring up to 0.5 cm .4. Moderate to large right-sided scalp hematoma (bruise) and soft tissue swelling . In an interview on 2/19/25 at 10:57 AM, Regional Nurse Consultant (RNC) G reported Resident #102 had been on 1:1 supervision on 6/7/24 at the time of her fall because she was a fall risk. RNC G reported a 1:1 supervision entails that the CNA should be sitting at the bedside with the resident watching for the resident to get up or try to walk and to walk with the resident if the resident chose to do so. RNC G reported the resident fell because the CNA had turned her back and was not watching the resident at the time of the fall. Resident #103 Review of an Admission Record revealed Resident #103 was a male, with pertinent diagnoses which included: morbid (severe) obesity due to excess calories, pain in right knee, and gout (a form of arthritis resulting in severe pain and swelling in the joints). Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 11/23/24 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #103 was cognitively intact. Review of Resident #103's Incident Report dated 12/3/24 revealed, Incident Description Nursing Description: CNA (Certified Nurse Aide) was in room performing AM (morning) care, resident rolled to the right, grab bar was not locked in place, as the resident rolled he grabbed the bar and it moved causing resident to roll out of bed, resident was laying prone (lying face-down on the stomach). Resident Description: I just rolled out of bed and banged up my elbow .Immediate Action Taken Description: resident was assessed for injury, found skin tear on right forearm . In an interview on 2/13/25 at 11:47 AM, Resident #103 reported a CNA was giving him a bed bath and when she told him to roll over, he rolled out of bed and onto the floor. Resident #103 reported when he fell , he had blood all over his elbow and a lot of black and blue marks on his shoulder. In an interview on 2/18/25 at 1:43 PM, Nursing Home Administrator (NHA) A reported Resident #103 had fallen out of bed on 12/3/24 because one of the enabler bars on the side of Resident #103's bed wasn't latched properly and had moved when he rolled over. In an interview on 2/19/25 at 9:59 AM, CNA F reported she was the staff member giving Resident #103 a bed bath when he fell out of bed on 12/3/24. CNA F reported Resident #103 was turning toward the door and the enabler bar was not properly engaged. CNA F reported when Resident #103 went to grab the bar, the bar went flying in the opposite direction and he fell on to the floor.

This citation pertains to intake #MI00141735 Based on interview, and record review, the facility failed to assess a resident after a outpatient medical procedure in 1 (Resident #100) of 4 residents reviewed for quality of care, resulting in a delay of treatment for Resident #100, who ultimately passed away. Findings include: Review of an Admission Record dated 10/18/23 revealed Resident #100 was admitted to the facility with the following pertinent diagnoses: wedge compression fracture of second lumbar vertebra (fracture of the spine), dependence on renal dialysis (procedure to remove waste products and excessive fluid from the blood), chronic systolic heart failure (condition in which the heart does not properly circulate the blood), peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), chronic respiratory failure (chronic respiratory condition causing inadequate exchange of oxygen and carbon dioxide in the body), hypertension (condition in which the force of the blood against the artery walls is too high), and diabetes with hyperosmolarity (condition resulting elevated blood sugar levels over a long period of time often with serious and potentially fatal complications). Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 was admitted from an acute care hospital, required assistance with dressing, toileting, transferring from one surface to another, and changing position in bed. The MDS reflected Resident #100 used a power wheelchair for mobility. The primary diagnosis for this admission was indicated as fractures. Review of hospital records for Resident #100, dated 10/26/23, revealed the resident underwent replacement of an internal jugular catheter (an indwelling device inserted into a large, central vein in the neck) due to occlusion at 12:10pm. A nursing report was given to Unit Manager Q at 12:42pm via telephone. The records revealed Resident #100 was anxious, restless, drowsy, and complained of pain at a level as high as 8 on the pain scale. Resident #100 had a rapid heart rate ranging from 95-120 beats per minute during the outpatient stay. According to the American Nephrology Nurses Association (https://www.annanurse.org/download/reference/practice/vascularAccessFactSheet.pdf), A Central Venous Catheter (CVC) is a narrow, flexible tube used to access the bloodstream. The CVC may be inserted into a large vein in the neck, chest, back, or groin. There are tunneled and non-tunneled catheters. Sites preferred for tunneled catheter insertion are the right internal jugular or the right external jugular. While CVCs have the advantage of being ready for use immediately after placement, CVCs: Have a greater chance of becoming infected or clotted. Have a slower blood flow, thus not adequately cleaning the blood. Are at greater risk for central vein thrombosis or stenosis. Cause high risk for sepsis, hemorrhage, or air embolism. In an interview on 1/17/24 at 4:39 pm, Business Owner (BO) T, owner of the transportation service that transported Resident #100 back to the facility on [DATE], reported the company uses a GPS (global positioning system) that was time stamped to track customer pick up and drop off times. Review of a transportation record provided by BO T revealed Resident #100 left the hospital at 1:33pm and returned to the facility at 1:55pm on 10/26/23. In an interview on 1/18/24 at 4:45pm, Nursing Home Administrator (NHA) A reported she reviewed the facility's video surveillance footage and confirmed that Resident #100 returned to the facility at 1:55pm on 10/26/23. In an interview on 1/17/24 at 3:41pm, Unit Manager (UM) Q reported he received a telephoned report from a nurse at the hospital regarding Resident #100. UM Q reported Resident #100's assigned facility nurse, Registered Nurse (RN) K, was too busy to take the call, so UM Q assisted by taking the report. UM Q reported the hospital nurse told him Resident #100 did not tolerate the procedure well, that the resident didn't seem very healthy, and had been approached at the hospital about signing on for end-of-life care. UM Q reported he share the nursing report with RN K but was unsure what time he did so. UM Q reported he did not see Resident #100 when he returned to the facility because he was in his office in a meeting regarding employee insurance benefits. When queried about the facility's process for ensuring nursing staff is aware when a resident is returned to the facility, UM Q reported sometimes the staff see them come in, I don't really know if there's a process. In an interview on 1/17/24 at 3:03pm, Registered Nurse (RN) K reported Resident #100 was on his caseload on 10/26/23. RN K reported he was unsure what type of procedure Resident #100 had on 10/26/23 but received a summary of a nursing report for Resident #100 from Unit Manager (UM) Q upon returning from a break. RN K reported he did not know what time Resident #100 returned from the procedure, but that the resident must have returned while I was on my break. RN K reported he went to check on Resident #100 for the first time at approximately 3:15pm (1 hour and 20 minutes after returning from the hospital) and found the resident unresponsive. In an interview on 1/18/24 at 4:45pm, Nursing Home Administrator (NHA) A reported she reviewed the facility's video surveillance and confirmed that Registered Nurse (RN) K went on a 30-minute break at 2:30pm (35 minutes after Resident #100 had returned from hospital) on 10/26/23. In an interview on 1/18/24 at 2:14pm Registered Nurse (RN) H reported he was the nurse covering Resident #100's hall on 10/26/23 while RN K took his break. RN H reported he recalled giving Resident #100 pain medication while covering for RN K but was unsure how he became aware that Resident #100 was experiencing pain. RN K reported the resident's complaint of pain may have been reported by a staff member or the resident may have put his call light on. RN K reported he did not do a full assessment of Resident #100 when he provided the pain medication and was unsure what type of procedure the resident had. RN K reported he was unsure what time Resident #100 returned to the facility on [DATE] then added that overall notification of a resident's return to the facility was not very well communicated. RN K reported it was not uncommon for a resident to return to the facility following a medical appointment or procedure and the nurse was unaware. In an interview on 1/18/24 at 9:20am Confidential Informant (CI) C reported Resident #100 reported pain and difficulty breathing upon returning to the facility on [DATE]. CI C reported Resident #100 sat with his eyes closed, head down and had a pale complexion. CI C stated something just looked off about him (Resident #100). When queried as to whether a nurse was informed about Resident #100's condition, CI C reported I told several nurses, but they didn't come. In an interview on 1/18/24 at 10:19am, Certified Nursing Assistant (CENA) I reported she heard Confidential Informant (CI) C tell Registered Nurse K on 10/26/23 that Resident #100 was not feeling well and needed to be assessed. CENA I was unsure what time this occurred. In an interview on 1/18/24 at 2:06pm, Certified Nursing Assistant (CENA) L reported she saw Resident #100 after he returned from his procedure on 10/26/23. CENA L reported the resident was sitting in his wheelchair in his room with his head down, eyes closed, appeared sleepy. CENA L described Resident #100's appearance as tired and worn out. CENA L reported she heard Confidential Informant (CI) C tell a nurse that Resident #100 said he didn't feel right. In an interview on 10/18/23 at 2:43pm, Unit Manager (UM) P reported she was unaware Resident #100 had returned from his procedure on 10/26/23 but responded to his room when a code blue (cardiac arrest) was called. UM P reported a resident who had undergone placement of an intrajugular catheter would need a full nursing assessment upon their return to the facility. When queried, UN P confirmed that it was a concern that Resident #100 had not been assessed following his return to the facility. In an interview on 10/18/23 at 3:44pm, Director of Nursing (DON) B reported the facility did not have a specific process it followed regarding alerting nursing staff when a resident returned from a procedure. DON B stated our nurses are always on the floor, so they see them. DON B reported when a resident returns from a procedure the floor nurse would complete an assessment when they did rounds and passed medications. Regarding Resident #100, DON B stated he was alert and oriented so he could tell the nurses what he needs, and it doesn't sound like he seeked (sic) out anybody. DON B reported she did not see Resident #100 when he returned from the hospital on 10/26/23. When further queried regarding what actions a nurse should take when caring for a resident who had just undergone placement of an internal jugular catheter, DON B stated assessing the dressing to ensure it's dry and intact, getting a good set of vitals and writing a progress note detailing how they're doing. In an interview on 10/18/24 at 2:21pm, Registered Nurse (RN) K reported he did not complete an assessment on Resident #100 when the resident came back to the facility following a procedure because he did not have time. RN K. RN K upon returning from a break at approximately 3:15pm, he went to check on Resident #100 and he had passed out. RN K confirmed that a resident should be assessed following the procedure Resident #100 had, and that assessment should include monitoring of blood pressure, pulse oxygenation and pulses. Review of nursing assessments for Resident #100 revealed the only assessment completed for the resident on 10/26/23 was a Fall Assessment with an effective date and time of 10/26/23 at 3:34pm (after the resident had a cardiac arrest on 10/26/23 at 3:17pm). The assessment contains the most recent vital signs which were taken at 1:38am on 10/26/23. Review of a nursing progress note written by Registered Nurse (RN) K for Resident #100, dated 10/26/23 at 3:17pm, revealed a statement: nurse came back from a 15-minute break and went down to assess resident following graft procedure at (name of local hospital) .(Resident #100) leaving the building early AM and returning at approx (sic) 3pm. Nurse observed resident face down .nurse did not find a pulse and initiated code blue . Review of a nursing progress note written by Unit Manager (UM) Q, for Resident #100 dated 10/26/23 at 5:38pm, revealed a statement: This writer was in a meeting .a code blue was called overhead .this writer arrived, and a nurse was doing compressions .EMS arrived at 1548 .first responds (sic) continued care until 1604 when time of death was called by the first responder team. Review of a Prehospital Care Report Summary provided the emergency medical service, dated 10/26/23, revealed under a section titled Narrative History Text a statement: Patient (Resident #100) had right tunneled dialysis catheter replacement performed in hospital this morning .discharged back to SNF (skilled nursing facility) .last seen by staff looking unwell. Review of Completing a Health Assessment in Nursing written by Nalea [NAME], MFA, 9/22/22 revealed .Nursing health assessments help health professionals diagnose diseases and illnesses. Assessments also inform preventative care plans . A complete nursing health assessment requires a health professional to examine a patient in a systematic fashion, from head to toe. Nurses rely on self-reported symptoms, visual observation, reported health histories, and a physical medical examination to make a health assessment. This data then informs the nursing care plan . A proper nursing health assessment can lead to early intervention, which saves lives . https://nursejournal.org/resources/nursing-health-assessment/

Based on interview and record review, the facility failed to provide immediate cardiopulmonary resuscitation (CPR) per the standards of practice and facility policy for 1 of 1 resident (Resident #382) reviewed for CPR, from a total sample of 24 Residents, resulting in an immediate jeopardy for Resident #382 whose advanced directive indicated she was a full code. Resident #382 was found by Licensed Practical Nurse (LPN) S on [DATE] at 11:48pm without respirations or a pulse and did not receive CPR for at least 15 minutes. Resident #382 was pronounced dead at 12:37am on [DATE]. Findings include: A review of a facility policy titled Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS), dated [DATE] revealed guidelines as follows: If a Resident experiences a cardiac arrest or respiratory arrest .facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services, in accordance with the Resident's advance directives and any related physician order, such as code status or in the absence of advance directives or a DNR order. A review of the American National Red Cross CPR and AED for Professional Rescuers Participant Handbook (2016) revealed that for every minute Cardiopulmonary Resuscitation is delayed, the victim's chance for survival is reduced by about 10 percent. A review of an Admission Record for Resident #382 dated [DATE], revealed pertinent diagnoses that included: Chronic Respiratory Failure (condition in which the lungs cannot get adequate oxygen into the blood), Chronic Obstructive Pulmonary Disease (constriction of the airways), Pulmonary Embolism (blood clot in the lungs), Congestive Heart Failure (chronic condition in which the heart does not pump the blood as well as it should) and Diabetes Mellitus (chronic condition that affects the way the body processes blood sugar). In an interview on [DATE] at 2:31pm Confidential Informant NNN revealed that Resident #382's Cardiopulmonary Resuscitation was delayed as the result of staff not correctly identifying the Resident during a cardiac arrest. Confidential Informant NNN reported that all staff had been re-educated regarding identifying a Resident's code status because of the incident. A review of an Admissions Worksheet for Resident #382, dated [DATE], revealed Advanced Directives: Full Code. A review of Orders- Administration Note for Resident #382, dated [DATE] at 12:08pm, entered by Registered Nurse UU, revealed Resident #382 was pronounced deceased at 0037 that day. In an interview on [DATE] at 2:35pm, Admissions Coordinator T revealed that Resident #382 was admitted to the facility after 6:30pm on [DATE]. The Admission Coordinator was not present at the time of Resident #382's admission to the facility. Admission Coordinator T reported Resident #382's code status was listed as full code in the admissions worksheet which was included in an admission packet left at the nurse's station on [DATE] at 6:00pm. In a telephone interview on [DATE] at 3:08pm, Registered Nurse (RN) UU reported she completed the nursing admission assessment for Resident #382 on [DATE] and that Resident #382 was listed as a full code for her advanced directives. In a telephone interview on [DATE] at 3:40pm, Certified Nursing Assistant (CENA) MMM reported [DATE] was the first time in which she had cared for Resident #382. CENA MMM reported that at 11:48pm on [DATE], CENA MMM saw a Resident (whom she believed to be Resident #61) lying face down on the bathroom floor with blood coming from her mouth. CENA MMM went to get a nurse, found Licensed Practical Nurse (LPN) S on A Hall, and they returned to Resident who was laying on bathroom the floor unresponsive. CENA MMM stated we thought it (the Resident on the floor) was (Resident #61 who shared an adjoining bathroom with Resident #382) . because Resident #382 was doing so well, we could not imagine it was her. As a result, CENA MMM and LPN S asked for the code status for Resident #61, rather than for Resident #382. CENA MMM stated it was confusing because both Residents were new, they had names that sounded similar, and we didn't know them very well. CENA MMM reported that when the staff realized the Resident on the floor was Resident #382 and that her advanced directives were for a full code, Registered Nurse (RN) LLL began chest compressions. CENA MMM recalled hearing RN LLL call out compressions initiated at 12:06am. In a telephone interview on [DATE] at 3:58pm, Licensed Practical Nurse (LPN) S reported she was working on A hall on [DATE] at 11:50pm, when Certified Nursing Assistant MMM approached her for help with a Resident who had fallen in the bathroom. LPN S reported she ran to a bathroom which was shared by two Residents and found a Resident lying on her left side, partially face down with no pulse. LPN S instructed CENA MMM to get the crash cart and LPN S ran to the hallway to a nearby phone to call a code. LPN S reported that Registered Nurse LLL, the nurse responsible for Resident #382's hall, yelled from the nurse's station that the Resident down had a do not resuscitate (DNR) code status. As a result, LPN S did not initiate cardiopulmonary resuscitation. LPN S then called a Unit Manager on the telephone to report the death. During that conversation, the staff realized the Resident's name and room number did not match. The Unit Manager described Resident #61 and that description did not match the Resident who was on the floor. The staff realized the Resident on the floor, with no pulse, was Resident #382. LPN S reported several minutes had passed since Resident #382 had been found. Both LPN S and Registered Nurse (RN) LLL returned to the nurse's station to determine Resident #382's code status. Upon finding Resident #382 advanced directive status was for a full code, Registered Nurse (RN) LLL ran back to Resident #382 and began chest compressions. In an interview on [DATE] at 7:44am, Registered Nurse (RN) LLL reported on [DATE] she was assigned to Resident #382's hall. RN LLL reported she had been off work for several days prior to that night and had not cared for Resident #61 or Resident #382 before. RN LLL also reported that because Residents frequently changed rooms, it was often difficult to know the Residents' room assignments. At 11:45pm, RN LLL was on another hall signing out a narcotic when she heard someone say they needed the crash cart. RN LLL pushed the crash cart toward the scene but stopped at the nurse's station when Licensed Practical Nurse (LPN) S asked for the code status of (Resident #61). RN LLL looked in Resident #61's paper chart, located the code status and yelled back that the Resident had a Do Not Resuscitate (DNR) code status. RN LLL reported that the internet service was down that night so staff did not have access to the electronic medical record and had to rely on the paper charts, which had limited information. RN LLL noticed that LPN S came from Resident #382's room, rather than from Resident #61's room, and RN LLL realized the Resident experiencing cardiac arrest was Resident #382. Both staff quickly returned to the nurse's station to review the code status for Resident #382. RN LLL then returned to Resident #382's room, 2 staff members positioned Resident #382 on her back and RN LLL began chest compressions. RN LLL confirmed the time was 12:06am when chest compressions began. Review of a Prehospital Care Report Summary provided by the responding Emergency Medical Services company, section titled Cardiac Arrest Information included the estimated time of arrest as: 23:42 (11:42pm), Time of First CPR: 00:06 (12:06am). Section titled Additional Assessment Notes revealed the following information: Pt (patient) found at 23:48 face down in restroom. Staff stated initial discrepancy on DNR (Do Not Resuscitate) status and CPR (Cardiopulmonary Resuscitation) was not initiated until 0006. Staff initially did not have Pt hx (history) and demographics. Pt was pronounced dead in field by physician on scene. On [DATE] at 5:15pm Nursing Home Administrator (NHA) A was notified of an Immediate Jeopardy concern that began on [DATE] and was identified on [DATE] when staff failed to provide Cardiopulmonary resuscitation to Resident #382. On [DATE] the survey team verified the facility completed the following steps to remove the Immediate Jeopardy: 1. On [DATE], the facility audited Resident names on door plaques to ensure accuracy. 2. On [DATE], the facility audited Resident code status to ensure each Resident had a code status listed and the information matched. 3. On [DATE], the facility audited the purple binder in the nurse's station to ensure each Resident had a face sheet. 4. On [DATE] the facility completed educated of all staff regarding: a. Actions to take when a Resident is found unresponsive. b. During a code, Residents should always be referred to by their room number c. Ways to confirm a Resident's identity d. When in doubt, divert to Full code and start cardiopulmonary resuscitation e. Code status location in medical record f. How to announce a code g. Code status must be obtained at admission and entered in electronic medical record h. Overnight and weekend admissions will have a resident photo taken by the Manager on Duty and uploaded into the electronic medical record. Manager on Duty will print the face sheet with the photo and place it in the Resident's chart and the purple binder. 5. An Adhoc QAPI meeting was held on [DATE] 6. DON (Director of Nursing) or designee will review new admissions to ensure code status was ordered and identified in each location of the medical record, a picture was taken and uploaded to the electronic medical record, face sheet was added to the Resident's paper chart and the purple binder. 7. DON(Director of Nursing) or designee will audit new admissions weekly. The facility was identifed as in compliance effective [DATE] due to a concern identified during the onsite survey of inaccurate medical record for code status.

This citation pertains to intake MI00133629. Based on interview and record review, the facility failed to ensure licensed staff adequately assessed and communicated an acute change in condition to the medical provider for 1 if 1 resident (Resident #331) reviewed for acute change in condition, resulting in an immediate jeopardy beginning the morning of [DATE] when the CNA (certified nursing assistant) recognized a change of condition in Resident #331 and notified the RN (Registered Nurse) who noted the change of condition but failed to contact the medical provider for further orders. Resident #331 was transported to the local hospital on [DATE] when during a video chat her family member demanded that the facility send her to the hospital due to her lethargy and decreased responsiveness. Resident #331 was evaluated at the local Emergency Department and was found to be actively having a myocardial infarction with a completely blocked coronary artery (STEMI). Resident #331 was admitted to critical care with cardiogenic shock and urosepsis and expired on [DATE]. This deficient practice placed all residents in the facility (79 residents on [DATE]) at risk for serious harm, injury, and/or death. Findings include: Review of an Admission Record revealed Resident #331 admitted to the facility on [DATE] with pertinent diagnoses which included Alzheimer's Disease, cognitive communication deficit, and bipolar disorder. Review of a Minimum Data Set (MDS) assessment for Resident #331, with a reference date of [DATE] revealed a Staff Assessment for Mental Status score of 3, which indicated Resident #331 was severely cognitively impaired. Review of Resident #331's active orders on [DATE] revealed that Resident #331 was full resuscitate (full code). Review of a current Care Plan focus for Resident #331, initiated [DATE], revealed that Resident #331 had elected full code status. Further review revealed a current dementia and anxiety Care Plan intervention, initiated [DATE], directing staff to observe Resident #331 for symptoms of an acute physical/psychiatric condition and notify the medical provider as indicated. Further review revealed a current altered cardiovascular status Care Plan intervention, initiated [DATE], directing staff to monitor, document, and report to the medical provider as needed any symptoms of coronary artery disease including shortness of breath. In an interview on [DATE] at 3:45 PM, Family Member of Resident #331 GGG reported he requested the facility send Resident #331 to the hospital on [DATE] when during a video chat he noticed that she did not look good and staff were unable to wake her for the visit. In an interview on [DATE] at 8:46 AM, CNA C reported the morning before Resident #331 went to the hospital he noticed she was hardly talking, was breathing different, and she was gasping for breath. CNA C stated she (Resident #331) just seemed really different. CNA C reported he notified the nurse of Resident #331's change in condition. CNA C reported the next day Resident #331 was a little worse and he was present during the video chat when Family Member of Resident #331 GGG noticed that something was wrong with Resident #331 and wanted her to be sent to the hospital. CNA C' reported he notified the nearest nurse of Family Member of Resident #331 GGG's request and RN (Registered Nurse) QQ coordinated transfer of Resident #331 to the local emergency department. In an interview on [DATE] at 9:25 AM, CNA C reported that Resident #331 had dementia and was unable to communicate her condition to staff. CNA C reported that Resident #331 relied on staff to recognize any changes from her baseline. In an interview on [DATE] at 2:19 PM, RN QQ reported he was Resident #331's nurse the day that she was sent to the hospital and the prior day. RN QQ reported he was notified by CNA C that Resident #331 was not acting like herself the day before she was transferred to the hospital. RN QQ reported Resident #331 was lethargic, not yelling out like she normally would, and was slumped over in her chair more than normal. RN QQ reported Resident #331 was still acting lethargic the next day and was quiet. RN QQ reported that Resident #331's family member during a video chat insisted that she be sent to the hospital. RN QQ reported that he coordinated EMS transfer to the hospital at the son's request and then notified the on-call doctor. In an interview on [DATE] at 2:48 PM, RN QQ reported he took Resident #331's vital signs the day before she went to the hospital when her change in condition was reported to him. RN QQ checked the electronic medical record and was unable to find any documentation of these vital signs. RN QQ reported that he did not notify the medical provider of Resident #331's change of condition when he was first aware the day prior to her hospitalization . RN QQ reported he did not notify the medical provider of the change in condition until the following day when Family Member of Resident #331 GGG requested she be sent to the local emergency department. In an interview on [DATE] at 9:59 AM, CNA OO reported she was working with Resident #331 the day she went to the hospital and the day before. CNA OO reported she noticed something was off with Resident #331, she was having a hard time breathing. CNA OO reported during a video chat Resident #331's son stated, I want her out now. In an interview on [DATE] at 10:06 AM, Activities Aide G reported he went to Resident #331's room at noon the day she went to the hospital to initiate a video chat with Family Member of Resident #331 GGG. Activities Aide G reported Family Member of Resident #331 GGG requested she be sent to the hospital when she did not respond to him on the video chat. Activities Aide G reported Resident #331 was not talkative like normal, was not moving much, and sounded wheezy. Activities Aide G reported Resident #331 could not articulate well and was not able to verbalize what was wrong with her because of her dementia. In an interview on [DATE] at 8:35 AM, Medical Doctor RRR reported he expects to be contacted by nursing staff for new open wounds, fevers, abnormal vital signs, patient complaints, new admissions, history and physicals, discharges, and changes in resident condition. Review of hospital records from Resident #331's hospitalization on [DATE] revealed the local hospital found Resident #331 to be actively having a myocardial infarction upon her arrival to the emergency department. Resident #331 was reported as having shortness of breath that was abnormal for her by family members in the emergency department. An EKG (electrocardiogram) revealed Resident #331 to be having a STEMI (ST Elevation Myocardial Infarction) and she was sent to the cardiac catheterization lab and treated for total occlusion of the left anterior descending artery of the heart by stenting. Resident #331 was admitted to critical care with cardiogenic shock versus sepsis and expired two days later on [DATE]. Review of Resident #331's death certificate revealed cause of death to be multiple organ failure, refractory shock, STEMI, and sepsis due to complicated UTI (urinary tract infection). Review of facility policy/procedure Notification of Changes, reviewed [DATE], revealed .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification . Circumstances requiring notification include: Significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: life-threatening conditions, or clinical complications . Circumstances that require a need to alter treatment . On [DATE] at 11:35 AM, NHA (Nursing Home Administrator) A was notified of an Immediate Jeopardy that began on [DATE] and was identified on [DATE] when clinical staff failed to recognize an acute change of condition in Resident #331 and the need to notify the medical provider. On [DATE], the survey team verified the facility completed the following to remove the Immediate Jeopardy. 1- Resident #331 expired on [DATE]. 2- On [DATE], the Medical Director was notified of the immediate jeopardy. The Medical Director reviewed the Ad-Hoc QAPI plan for assessing residents residing in the facility for a change of condition and deemed the actions appropriate. 3- On [DATE], all 72 residents were assessed by the licensed nurse and direct care staff were interviewed for changes in condition. Any identified changes were reviewed with the provider with orders received as needed for treatment. 4- On [DATE], the Notification of Change policy was reviewed by the NHA and DON and deemed appropriate. 5- On [DATE], an Ad-Hoc QAPI was meeting was held to review the Notification of Changes Policy and this plan. 6- Beginning on [DATE], direct care staff is being re-educated on the Notification of Changes Policy, including education regarding SBAR and/or Stop and Watch program for changes in condition. At the time this abatement was submitted, 24 of 67 direct care staff members have been educated. No direct care staff member will be allowed to work without education. 7- New admissions and residents with any changes in condition will be reviewed 5x per week by the DON/designee to ensure that the provider was notified and any ordered follow up was completed. 8- Weekly x 4 and then monthly the DON/designee will conduct an audit of residents with changes in condition to ensure that the provider was notified and that the follow up was completed. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of actual harm that is not immediate jeopardy, and severity of isolated due to not all education had been completed and sustained compliance had not yet been verified by the State Agency.

This citation has five (5) Deficiency Practice Statements (DPS). DPS #1 Based on observation, interview and record review, the facility failed to properly identify and accurately assess residents to ensure safety and prevent an elopement for 1 of 4 residents (Resident #71) reviewed for elopement/wandering, resulting in an Immediate Jeopardy when on 5/13/23 Resident #71 exited the facility at an unknown time, unbeknownst to staff, and was identified walking outside by a laundry staff member, between 6:30PM-7:00PM. This deficient practice placed 4 residents, identified as at risk for elopement, at risk for serious harm, injury, and/or death. Findings include: Review of an Admission Record revealed Resident #71 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: cerebral infarction (stroke) and hemiplegia (paralysis) effecting right dominant side. Review of a Minimum Data Set (MDS) assessment for Resident #71, with a reference date of 4/21/23 revealed a Brief Interview for Mental Status (BIMS) score of 8, out of a total possible score of 15, which indicated Resident #71 was cognitively impaired. Review of the Functional Status revealed that Resident #71 was independent with transfers and ambulation. In an interview on 05/15/23 at 12:54 PM, Assistant Manager Housekeeping (AMH) AA reported that she exited the facility's service door to get some fresh air on 5/13/23 at approximately 6:30-7:00 PM, to find Resident #71 walking in the driveway. AMH AA reported that she did not encourage Resident #71 to come back into the facility, but immediately went back into the facility and notified Licensed Practical Nurse (LPN) ZZ. In an interview on 05/15/23 at 01:38 PM, LPN ZZ reported that AMH AA told her that Resident #71 was outside of the patio in the driveway and stated, .I had just started my shift and was getting report .so I went out and he (Resident #71) was just about to cross the street .I followed him down the sidewalk .then he turned around and walked right back in with me . LPN ZZ reported that she did not observe Resident #71 exit the building and did not know how long he had been outside. LPN ZZ reported that Resident #71 is a smoker and goes outside to the patio on his own to smoke, but that she had not given him cigarrettes that night. LPN ZZ reported that she phoned Director of Nursing (DON) while she was outside with Resident #71 and stated, .she (DON) did not have any concerns .just to do the assessments and to explain to the resident that he had to sign the LOA book before he left the facility . In an interview on 05/15/23 at 01:24 PM, DON reported that she had received a call from LPN ZZ on 5/13/23 reporting that Resident #71 had exited the building and stated .she (LPN ZZ) said that he (Resident #71) was on the sidewalk across the street by the high school .taking a walk while he was smoking .he was never out of her (LPN ZZ's) sight .she (LPN ZZ) saw him walk out the door and was trying to catch up with him (Resident #71) when she called . DON reported that this was not an elopement because Resident #71 was never out of sight and stated, .I don't know what door he exited .I assumed the front door .I didn't ask . DON reported that she requested that LPN ZZ complete a safe smoking assessment and an elopement risk assessment for Resident #71 following the incident on 5/13/23, and that the assessment confirmed that Resident #71 was not at risk for elopement and was safe to smoke unsupervised on the patio. DON reported that the incident was discussed in a managers meeting that morning. In an interview on 05/15/23 at 01:15 PM, Resident #71 reported that on 5/13/23 he had asked for his cigarettes around 6:30 PM and then went outside to smoke on the patio. Resident #71 reported that there was no one around, he was out there for a while, and then decided to go for a walk. Resident #71 reported that he knew that facility didn't want him to do that, but that he had done it before and just came back before anyone noticed him gone. In an interview on 05/15/23 at 01:46 PM, Resident #71's legal guardian (LG) QQQ reported that Resident #71 has always been a smoker and reported that Resident #71 was allowed to smoke on the back patio of the facility alone. LG QQQ reported that he does not want Resident #71 to leave the facility unsupervised, except when Resident #71 is on the patio smoking and stated, .he still gets confused and forgets what he is doing and where he is sometimes .I don't want him walking around outside alone . LG QQQ reported that he had not been contacted by the facility at all regarding Resident #71 exiting the building unsupervised on 5/13/23 and stated, .I went through my phone and don't see any contact from the facility . In an interview on 05/15/23 at 03:30 PM, DON reported that Resident #71 was assessed not at risk for elopement upon admission on 1/14/23 because he was not able to ambulate safely, and when he did try to walk he fell and stated, .he has improved since then, but was not reevaluated . DON reported that Resident #71 had been assessed on 1/14/23 as non-smoking, and did not know when Resident #71 started smoking or where Resident #71 got his cigarettes. DON reported that Resident #71 was reassessed for elopement risk on 5/14/23 by LPN ZZ (the nurse that assisted him back into the facility) and he was determined not at risk, and was also determined to be safe to smoke independently. In a subsequent interview on 5/15/23 at 3:40 PM, DON reported that she had found another elopement risk assessment completed on 4/17/23 for Resident #71 and that he was determined to not be at risk at that time. DON reiterated and reported that on 5/13/23 Resident #71 did not elope, but that he left the building unsupervised and did not tell anyone, and that Resident #71 did not have orders for independent LOA. Review of Resident #71's Progress Note dated 05/13/2023 at 6:48 PM written by DON revealed, (Resident #71) decided to go out the front door to smoke and took a walk with (LPN ZZ) directly behind him. (Resident #71) was in no danger, stayed on the side walk, and was never out of visual site of nurse. (Resident #71) came back to facility with (LPN ZZ) without complications. No concerns/ Educated on him needing to sign out in the LOA book and have his dad's permission to go for walks. This note was inaccurate considering the above statements from staff. Review of Resident #71's Progress Note dated 05/14/2023 at 12:31 AM written by LPN ZZ revealed, .multiple attempt to notify resident's son that resident left campus this evening vm (voicemail) is full and no call back thus far. This nurse immediately notified (on call staff) of walk, no new orders att (at this time). This nurse educated (Resident #71) on importance of using LOA book and having permission of guardian for going off campus to maintain safety also went over safe smoking practices with (Resident #71) who verbalized understanding. Review of Resident #71's Care Plan revealed no care plan related to smoking, and no care plan related to independent LOA (leave of absence). Review of Resident #71's Physician Orders indicated that Resident #71 did not have orders for an independent LOA (leave of absence), and did not have orders for being safe to smoke. Review of Resident #71's Nursing Admission Evaluation dated 1/14/23 indicated that Resident #71 was not a smoker at that time, and had no plans to smoke or use tobacco related products while staying at the facility. Review of Resident #71's Safe Smoking Evaluation revealed no record existed. Review of Resident #71's Fall Risk Evaluation dated 5/3/23 indicated that over the past 90 days, Resident #71 had 1-2 falls, no change in cognition and was at low risk for falls. Review of Resident #71's Risk of Elopement/Wandering Review dated 4/17/23 revealed, 1. Is the resident cognitively impaired with poor decision making skills (ie. intermittent confusion, cognitive defects or disorientation)? NO, 2. Elopement History: .Leaving the facility without supervision when supervision is required? NO. Leaving the facility without informing staff? NO .Summary of Review: Resident is at list for elopement/wandering at this time? NO . Review of Resident #71's Risk of Elopement/Wandering Review dated 5/14/23 at 1:08 AM revealed, 1. Is the resident cognitively impaired with poor decision making skills (ie. intermittent confusion, cognitive defects or disorientation)? NO, 2. Elopement History: .Leaving the facility without supervision when supervision is required? NO. Leaving the facility without informing staff? NO .Summary of Review: Resident is at list for elopement/wandering at this time? NO . This document was inaccurate considering that Resident #71 eloped on 5/13/23 and has a BIMS of 8. During an observation on 5/16/23, the distance from the patio gate where Resident #71 exited, to the road was approximately 250 feet of paved driveway surface that sloped downhill towards the road. The road was a busy main street with a 45 mph speed limit. There was a school and sidewalk on the far side of the road. The patio gate was not locked. On 5/15/23 at 04:20 PM, Nursing Home Administrator (NHA) and DON were notified and received written notification of the immediate jeopardy that began on 5/13/23 due to the facility's failure to properly identify and accurately assess to ensure safety, and prevent an elopement for Resident #71. Review of Resident #71's updated Risk of Elopement/Wandering Review dated 5/15/23 at 5:43 PM revealed, 1. Is the resident cognitively impaired with poor decision making skills (ie. intermittent confusion, cognitive defects or disorientation)? NO, 2. Elopement History: .Leaving the facility without supervision when supervision is required? YES, Times: 1. Leaving the facility without informing staff? YES, Times: 1 .Summary of Review: Resident is at list for elopement/wandering at this time? YES. Elopement/Wandering risk as evidence by: left facility without LOA book signing and his guardian being notified, he has been educated and does verbalize understanding .Comments: at risk for elopement, wander guard in place. Review of Resident #71's Physician Orders revealed, Elopement Risk: Wander Guard placed to right wrist .Check function and expiration date of wanderguard/electronic bracelet. Start date 5/16/23. Review of Resident #71's Safe Smoking Evaluation dated 5/14/23 at 1:05 AM indicated that Resident #71 was safe to smoke independently. There was no documentation prior to this indicating that Resident #71 was a smoker. On 5/16/23 at 10:00 AM a review of Residents at Risk for Elopement/Wandering indicated a total of 4 residents at risk in the facility, including Resident #71. On 5/16/23 at 10:30 AM, the exit door on the southeast side of the dining room was observed unlocked, and opened easily without a delay or an alarm sounding. This door opened to a fenced in patio where residents went to smoke. RMD SS reported that the dining room door was a fire exit door, but that it gets locked with an [NAME] wrench from 6:00 PM to 6:00 AM every day. RMD SS reported that the fence around the patio does not lock and cannot be locked, because it is a fire exit. RMD SS reported that the exit door originally required a code to open, but the system no longer worked, therefore the door had a screecher installed that alarmed when the door was open and stopped automatically when the door was closed, but the batteries were removed from the screecher alarm early this morning when a new keyed alarm was installed, which was observed on the top right-hand side of the door. RMD SS reported that the new keyed alarm was not functioning yet on the dining room door. RMD SS reported that the dining room exit door was not connected to the wanderguard system, and therefore would not alarm if a wanderguard bracelet was near the door. There was no staff observed supervising the door prior to or during this observation. The interview and observation presented safety concerns related to an unsupervised, unlocked door with no alarm, that lead to an unlocked patio. In an interview on 5/16/23 at 9:30 AM, Regional Maintenance Director (RMD) SS reported that the facility had 9 exit doors and 2 of them were connected to the Wanderguard system, the main entrance and the therapy door. RMD SS reported that he was not able to test those doors to ensure they were functioning, and reported that 3 residents were newly assigned Wanderguard bracelets last night and there are no extras to use for testing. RMD SS reported that the wanderguard doors are checked along will all doors, daily, weekly, and monthly. RMD SS reported that he ordered additional wanderguard bracelets and that he would notify me as soon as they arrived. In an interview on 5/16/23 at 10:35, NHA reported that she was not aware that the dining room exit door did not have a functioning alarm and stated, .the screecher should have been utilized until the new alarm was up and running .the door should not be locked until 10:00 PM . NHA reported that the door had been unlocked and unsupervised for approximately 3 1/2 hours, and was not able to confirm that none of the residents exited through the door. On 5/16/23, NHA initiated a Code Yellow emergency to ensure all residents were accounted for and safe. On 5/16/23 at 10:40 AM observed RMD SS installed batteries in the screecher door alarm in the dining room. At that time the NHA assigned a staff member to sit at the door to ensure that no residents exited the building unsupervised. In an interview on 5/16/23 at 10:55 AM, NHA reported will revise the immediate jeopardy removal plan and date of compliance to reflect the non-compliance discovered when the dining room door was observed open and unsupervised, and complete re-education to all staff related to Code Yellow policy and procedures. 1. Resident #71 returned to the building voluntarily and accompanied by the nurse on 5/13/2023. 2. Following this event, Resident #71 was re-assessed per policy via elopement risk review and skin assessment. Upon reviewing the assessment that was completed 5/14/2023, a new assessment was completed showing the resident is an elopement risk. Resident #71 is free from physical and emotional trauma related to the event. 3. On 5/13/2023, Resident #71's father was contacted and voicemail was full. Resident #71's provider was informed of him exiting the facility on 5/13/2023 with no new orders received. 4. On 5/15/2023, an audit of current residents residing in the facility was completed to insure (sic) current residents were safe and accounted for. 5. From 5/15/2023, residents residing in the facility had new Risk of Elopement Assessment completed by licensed nurses to verify accuracy of risk. 6. On 5/15/2023, residents residing in the facility who were identified as being at risk for elopement per the Risk of Elopement Assessment were reviewed by the nursing leadership to review current elopement risk, orders requiring documentation, care plan, and Kardex (direct care guide) to ensure appropriate assessment and intervention were in place. 7. An audit was completed on 5/15/2023 by DON, of the elopement book to verify that residents at risk for elopement had an elopement photo sheet in place. Resident #71's photo and elopement profile was placed in facility elopement book. 8. Beginning 5/15/2023 re-education was provided by the Staff Development Coordinator/designee related to the facilities Elopement Prevention Policies and Procedures which included prevention and management, reporting responsibilities, maintaining door alarms and wander control systems, responding to alarms and ensuring doors are secured when passing through and no employee was allowed to work without receiving education. Currently, 36 out of 110 employees have been educated. 9. The Elopement Prevention and Management Program was reviewed by the NHA and DON on 5/15/2023, and deemed appropriate. 10. An Ad -Hoc QAPI (Quality Assessment Performance Improvement) meeting was held on 5/15/2023 to review the Risk for elopement, orders requiring documentation, care plan, and Kardex to ensure appropriate assessment and interventions were in place. 11. On 5/15/2023, a code yellow drill was conducted to validate that employees on the schedule were able to complete the procedure per policy. 12. On May 16, 2023, from roughly 7 AM through 10:30 AM, the back door of the facility was temporarily disengaged due to Maintenance Director changing alarms. This door was not watched, and a Code Yellow was called shortly after and all residents were accounted for. 13. On May 16, 2023, all staff were re-educated on Code Yellow policies and procedures. Currently, 40 of 110 staff members have been re-educated. During an observation and interview on 5/18/23 at 1:50 PM, RMD SS reported that he had borrowed a wanderguard bracelet from a sister facility to test the door alarms. The therapy door locked and alarmed loudly when the wanderguard bracelet was near the door. The door at the main entrance did not lock and did not alarm when the wanderguard bracelet was near the door. RMD SS reported that he would look into why the door at the main entrance door was not functioning as expected with the wanderguard system. At 2:00 PM RMD SS reported that the shipment of wanderguard bracelets had arrived by mail and they did worked, but then when observed by this surveyor, the door at the main entrance still did not lock or alarm when the wanderguard bracelet was near. This door did have an alarm when opened without using the code. Although the Immediate Jeopardy was removed on 5/16/2023, the facility remained out of compliance at a scope of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and severity of isolated due to not all education had been completed and sustained compliance had not yet been verified by the State Agency. DPS #2 Based on interview, and record review, the facility failed to ensure falls were identified and included the completion of post fall assessments and a comprehensive fall investigation in 1 of 16 residents (Resident #1) reviewed for accidents, resulting in a delay in coordination of care post fall and incomplete documentation of an unwitnessed fall. Findings include: Review of an Admission Record revealed Resident #1 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: COPD (chronic obstructive pulmonary disease). Review of a Minimum Data Set (MDS) assessment for Resident #1, with a reference date of 3/23/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #1 was cognitively intact. Review of the Functional Status revealed that Resident #1 was independent for transferring and walking. In an interview on 05/09/23 at 10:04 AM, Resident #1 reported that she had constant chronic pain and that she had new pain in her tailbone due to a fall about 2 weeks ago. Resident #1 reported that she had slipped on her mask that was on the floor and fell backwards onto her bed. Resident #1 reported that when she puts her call light on, its usually for pain medication and sometimes during the night she waits 1-2 hours for someone to come and stated, .I get up and go to the nurses station to find someone . Resident #1 reported that call light long wait times is repeatedly talked about in resident council and still remains a problem. Review of Resident #1's records did not include any documentation related to a fall on 4/27/23. Review of Resident #1's Fall Risk Evaluation dated 11/30/22 indicated that Resident #1 had no falls in the past 90 days and was at low risk for falls. This was the most recent documentation related to falls. In an interview on 05/17/23 at 01:00 PM, Resident #1 reported that she had fallen on 4/27/23 just before 2:00 PM, and Unit Manager Registered Nurse (UM-RN) P had heard the crash and came to see what happened. Resident #1 reported that she did not feel bad initially, but then later that day she began having pain in her tailbone and stated, .the nurses and aides knew .they got me ice packs . Resident #1 reported that she had a brief visit with the doctor and he had mentioned doing an x-ray and stated, .I guess he forgot . Resident #1 reported that her bones were very brittle due to osteoporosis, and she had broken her sternum last year just by bumping the hand rail on her bed. Resident #1 reported that she has had to ask for assistance with toileting since the fall and stated, .I definitely haven't been able to do the things that I used to . In an interview on 05/17/23 at 01:19 PM, RN E reported that she was not working the day Resident #1 fell , but that Resident #1 had told her about it that day. In an interview on 05/17/23 at 01:47 PM, UM-RN P reported that he had heard crash in Resident #1's room and he had went to see what the noise was and stated, .she (Resident #1) was on the ground .she said that she had slipped and fell against the bed, but couldn't get up so she lowered herself to the floor . UM-RN P reported that this was not considered a fall, and he did not document it, that Resident #1 did not have any injuries and stated, .she always has pain . UM-RN P reported that he did not complete an assessment, did not perform neurological checks, did not notify the physician and stated, .she was able to get herself back up .it wasn't a fall . In an interview on 05/17/23 at 04:08 PM UM-LPN O reported that she was not aware of Resident #1 falling on 4/27/23 and that there was no documentation in the record of a fall. UM-LPN O reported that if Resident #1 fell back onto her bed, it would be considered a fall, and an assessment should be completed and documented, and the physician should be notified. In an interview on 05/17/23 at 04:22 PM, Certified Nursing Assistant (CNA) BBB reported that Resident #1 did fall a couple weeks ago and stated, .I had to help her more that next week, she couldn't get her feet up onto the bed herself .she asks for ice packs .she said her tailbone hurts . CNA BBB reported that Resident #1 had been independent with transfers prior to the fall. Review of Resident #1's Nurse Note dated 5/17/2023 at 6:52 PM revealed, This nurse was made aware of this incident today and went to speak with the resident (Resident #1) to see what she needed if she was ok and what her pain level was. She indeed is doing ok her tailbone hurts, and she is still able to independently ambulate around her room and down the hall provider notified. Review of Resident #1's Provider Telehealth Visit Note dated 5/17/2023 revealed, Resident is complaining of tailbone pain. She had a fall on 4-27-2023 and did not report any pain. X-ray of L-S (lower) spine and coccyx. 46999 DPS #3 This citation pertains to intake # MI00135634 Based on observation, interview, and record review, the facility failed to identify hazards and risks for 2 of 6 Residents (Resident #49 and Resident #72) who were seated in specialty wheelchairs not recommended for transport use when transported by the facility to medical appointments, resulting in a fall for Resident #49, emotional distress, and a potential for more than minimal harm as the result of improper use of assistance devices. Findings include: Resident #49 Review of an Admission Record for Resident #49, dated 3/14/23 revealed pertinent diagnoses which included: unspecified sequelae of cerebral infarction(residual effects of a stroke), left hemiplegia and hemiparesis (loss of movement and paralysis on left side of the body), diabetes mellitus(chronic metabolic disease characterized by elevated blood sugar levels), malignant neoplasm of the lung (cancer of the lung that may spread to other parts of the body), major depressive disorder, muscle weakness, lack of coordination, reduced mobility. Review of a Minimum Data Set (MDS) assessment for Resident #49 dated 2/24/23, section G Functional Status revealed Resident #49 required total assistance for bed mobility and transferring (moving from one surface to another) and required a wheelchair for mobility. Review of a care plan for Resident 349 dated 11/5/22 revealed focus/goal/interventions as follows: Resident is at risk for falls related to .weakness .hemiplegia . Goal: Reduce risk of serious injury .Interventions: Determine causative factors of fall and resolve . Review of a Incident Report for Resident #49 dated 3/13/23 at 10:40am revealed the Resident was being transported in the facility van while seated in his specialty wheelchair. The van turned a corner and the specialty wheelchair tipped to the left and landed on the floor of the van, resting on its side. Resident #49 remained in the specialty wheelchair, also resting on his life side. Transportation Driver Y called the facility, described Resident #49's position on the floor of the van to Director of Nursing(DON) B, and under the direction of DON B, Resident #49 was transported back to the facility (distance of 1.5 miles) in the specialty wheelchair as it rested on its side on the van floor. Resident #49 was assessed for injuries, assisted to the original upright position, and then transported to a medical appointment approximately 100 miles away. In an interview on 5/9/23 at 10:22am Resident #49 reported he had a fall in his specialty wheelchair during transport to a medical appointment. Resident #49 reported feelings of distress about the fall, and that he worried regularly that he may have undiagnosed injuries as a result of the fall. Resident #49 did not recall the date of the incident, but reported it occured when he was en route to a dental appointment. Resident #49 described seeing the driver fasten the wheelchair to the floor and placing a seatbelt across Resident #49's body. When the van hit a curb, the chair tipped over and landed on its side. Resident #49 reported feeling emotional distress about possibly being required to use the specialty chair again for transport and stated it's not safe. Resident #49 reported feeling emotional distress because he wanted an appointment to get fitted for dentures, felt dentures would improve his quality of life, but was fearful of using the specialty wheelchair in the van again. Resident #49 reported having weakness in his torso and left side and stated If I start to fall, I can't stop myself. I was really scared that day (referring to the incident on 3/13/23). In an interview on 5/10/23 at 9:23am, Transportation Driver Y reported he had worked for the facility for about a year and half and had received a brief (5-10 minute) training on securing wheelchairs using the van's four-point tie down system when he began the job. Transportation Driver Y reported Resident #49 was transported in his specialty wheelchair on 3/13/23. Resident #49's wheelchair was affixed to the floor of the van using the van's four-point tiedown system and a seatbelt which also connect to the floor, was positioned across the torso of the Resident. Transportation Driver Y reported he hit a curb on the second turn of the trip at which time Resident #49's wheelchair tipped onto its side, resting on the van floor with Resident #49 still seated in it. Transportation Driver Y stopped the van, attempted to lift Resident #49 and his wheelchair back into an upright position but could not do so. He called the facility, explained the incident/Resident #49's positioning on the floor of the van to Director of Nursing (DON) B who instructed him to transport Resident #49 back to the facility. The Resident was assessed at the facility, cleared to resume transport to the medical appointment and Resident #49 agreed. Transportation Driver Y reported Resident #49 whined the whole way to the appointment and was frustrated when he arrived too late and could not be seen. When queried about how the chair tipped over, Transportation Driver Y stated I think the front tiedowns came off the chair. Transportation Driver Y reported there were no factory installed tie down latches on Resident #49's specialty chair. Transportation Driver Y reported feeling uncomfortable using this type of wheelchair for transporting Residents, that he believed the chairs aren't necessarily safe for this use, but the facility had continued to do so. Transportation Driver Y confirmed he had transported Resident #49 and Resident #72 multiple times in their specialty wheelchairs. Review of Resident transportation trips from 2/23-5/23 (provided by the facility) revealed Resident #49 had been transported by the facility on 2/6/23, 2/14/23 and 3/13/23. In an interview on 5/10/23 at 11:58am, Unit Manager, Registered Nurse (UM,RN)P reported he assessed Resident #49 in the facility parking lot on 3/13/23. Resident #49 was initially lying on his left side, encased in the wheelchair which was also lying on its side. UM, RN P reported Resident #49 had no visible injuries, voiced a desire to continue to his medical appointment so UM, RN P lifted the Resident and his wheelchair to into an upright position, Transportation Driver Y affixed the chair using the same four-point tie down system and the van left. UM, RN P reported the Interdisciplinary Team (IDT) later decided Resident #49 would only be transported via stretcher for subsequent medical appointments. UM, RN P was unsure if anyone told Resident #49 about the plan to use a stretcher for future transport. In an interview on 5/11/23 at 11:31am Rehab Program Manager EEE reported therapy staff recommended the specialty wheelchair used by Resident #49 due to his poor trunk control and rotated posture. Rehab Program Manager EEE reported the manuals for specialty chairs are kept with the device so the information is accessible to all staff. When queried about the appropriateness of Resident #49 using the specialty wheelchair for vehicle transport, Rehab Program Manager said she was unsure if the manufacturer recommended use for transport for that particular device. In an interview on 5/16/23 at 9:53am with Nursing Home Administrator A, it was revealed that therapy staff determine when a Resident needs a specialty wheelchair and select the wheelchair that best meets the Resident's needs. NHA A reported she did not know if staff members reviewed the manuals provided with each specialty chair to determine appropriate use, if staff members were trained on appropriate use of specialty chairs, and reported she was unsure if specialty wheelchairs in use were regularly inspected for defects. NHA A reported she would look into the questions and follow up. At the conclusion of the survey, no additional information had been provided by NHA A. NHA A did report she was believed all (name brand)specialty chairs being used to transport Residents of the facility were approved for such use. Review of the manufacturer's manual (2018) for Resident #49's specialty wheelchair, revealed section 2 titled Safety Requirements, 2.1 stated: Before the chair is put into service, this manual must be read thoroughly by the caregiver(s) directly responsible for the resident's care. Section 2.5.6 Unintended Movement-Danger of Falling stated: We recommend (brand name) chairs for indoor use within a long-term care institution and where there is not enough slope to cause the chairs to move unaided. Chairs used where the surface is uneven or sloped are at risk of unintended movement and could become a serious danger to the resident . Section 2.8 Maintenance stated: In regular use, after the initial inspection and functional testing, the chair should be inspected and tested bimonthly. We recommend visually inspecting for signs of wear, damage, loose or missing fasteners, and other safety concerns. Section 7 Warranty revealed

This citation pertains to intake #MI 923 Based on observation, interview, and record review the facility failed as a result of the facility's failure to implement established infection control interventions to provide care for, and prevent the spread of Norovirus type symptoms to residents and staff members in the facility for 21 out of 26 residents (Resident #100, #101, #102, #103, #104, #105, #106, #107, #108, #109, #110 # 111, #112, #113, #114, #115, #116, #117, #118, #119, and #123) reviewed for infection control, resulting in an immediate jeopardy when, beginning on 12/9/18, facility staff did not perform surveillance, implement established infection control standard interventions to provide care for, and prevent the spread of a gastrointestinal infection to staff members and residents in the facility. This deficient practice placed all residents at risk for serious harm and/or death. Findings include: Review of the facility policy and procedure Employee Health-Infection Control last reviewed/revised on 02/2018 revealed, Our facility's employee health practices include infection control and prevention of communicable disease transmission .The objectives of the infection control aspects of our employee health practices are to .monitor and investigate exposure to, and presentation of, infections among employees; c. Counsel personnel about work-related illnesses or exposures; d. Address infection-related issues that impact absenteeism. Review of the facility policy and procedure Surveillance for Healthcare-Associated Infections last reviewed/revised on 02/2018 revealed, The Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions .The purpose of surveillance of infections is to identify both individual organisms and Healthcare-Associated Infections, to permit interventions to try to slow or stop the transmission of such infections .Nursing Staff will monitor residents for signs and symptoms that may suggest infection, according to current criteria and definitions of infections, and will document and report suspected infections to the Charge Nurse as soon as possible. 4. If a communicable disease outbreak is suspected, this information will be communicated to the Charge Nurse immediately. 5. The nurse should implement precautions per standards of practice based on signs and symptoms .7. The Nurse will notify the Attending Physician and the Infection Preventionist of suspected infections. The Physician will determine if laboratory tests are indicated .8. If transmission-based precautions or other preventative measures are implemented to slow or stop the spread of infection, the Infection Preventionist will collect data to help determine the effectiveness of such measures .1. The Infection Preventionist or designee will gather and interpret surveillance data. 2. The surveillance should include a review of any or all of the following information to help identify possible indicators of Healthcare-Associated Infections: a. Laboratory records .c. Infection control rounds or interviews; d. Infection surveillance sheets; 3. Temperature logs .5. Collect the following data as appropriate: a. Identifying information (i.e., resident's name, room number, unit, nurse obtaining order and Attending Physician); b. Diagnoses; c. admitted , date of onset of infection .d. infection site (be as specific as possible .e. Pathogens; f. Invasive procedures or risk factors .g. Pertinent remarks .h. Preventative measures and comments .7. Organize the data on a tracking log. Indicate in the appropriate column the number of infections that correspond to the pathogenic organism and site of infection .9. Compare prevalence of current infections to previous data to identify trends and patterns. Use an average infection rate over a previous time period .as the baseline. Compare subsequent rates to the average rate to identify possible outbreaks. 10. Using the tracking logs, summarize the information for presentation, review, and recommendations at the facility's QAPI monthly meetings. Review of the facility policy and procedure Outbreak of Communicable Diseases last reviewed/revised 02/2018 revealed, Outbreaks of communicable disease within the facility will be promptly identified and appropriately handled .5. Symptomatic residents and employees are to be considered potentially infected and are to be cultured and isolated as indicated and directed by the Medical Director and/or Health Department .7. The Infection Control Coordinator and Director of Nursing Services will be responsible for: a. Receiving surveillance information and tabulating data; b. Maintaining a line listing of identified cases .; c. Notifying the Medical Director and the Attending Physicians; d. Assigning nursing personnel to same residents group for the duration of the outbreak .8. The nursing staff will be responsible for: a. Notifying the Director of Nursing Services of symptomatic residents; b. Providing infection surveillance data in a timely manner .d. Initiating isolation barriers as directed or as necessary; and e. Confining symptomatic residents to their rooms as much a feasible, when indicated. 9. All employees should .b. Report any gastrointestinal or respiratory illnesses to their supervisor. 10. The Medical Director is responsible for: a. Working with the Attending Physician(s) and the health department to determine the need for laboratory specimens. Review of the facility policy and procedure Isolation-Categories of Transmission-Based Precautions last reviewed/revised 02/2018 revealed, 27. Examples of infections requiring Contact Precautions include, but are not limited to: 28. Gastrointestinal .infections .41. Place the individual in a private room if it is not feasible to contain drainage, excretions, blood or body fluids (e.g., the individual is incontinent on the floor, or wanders and touches others0. 42. If a private room is not available, the Infection Control Coordinator will assess various risks associated with other resident placement options (e.g., cohorting) .46. Remove gloves before leaving the room and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent. (not the same as the CDC and MDCH recommendations noted below) 47. After removing gloves and washing hands, do not touch potentially contaminated environmental surfaces or items in the resident's room .56. If use of common items in unavoidable, then adequately clean and disinfect them before use for another resident. Review of the Centers of Disease Control General Information about Norovirus last revised (MONTH) 25, 2013 revealed, Noroviruses are a group of viruses that cause gastroenteritis (gas-tr?-en-ter-?-tis) in people. Gastroenteritis is an inflammation of the lining of the stomach and intestines, causing an acute onset of severe vomiting and diarrhea .Norovirus infections spread very rapidly. Healthcare facilities and other institutional settings .are particularly at-risk for outbreaks because of increased person-to-person contact. The symptoms of norovirus illness usually include nausea, vomiting, diarrhea, and some stomach cramping. Sometimes people also have a low-grade fever, chills, headache, muscle aches, and tiredness. People may suddenly feel very sick and vomit frequently or have several episodes of diarrhea .Noroviruses are found in the feces and vomit of infected people. This virus is very contagious and can spread rapidly throughout healthcare facilities .In a healthcare facility, patients with suspected norovirus may be placed in private rooms or share rooms with other patients with the same infection. Additional prevention measures in healthcare facilities can decrease the chance of coming in contact with noroviruses: *Follow hand-hygiene guidelines, and carefully washing of hands with soap and water after contact with patients with norovirus infection *Use gowns and gloves when in contact with, or caring for patients who are symptomatic with norovirus *Routinely clean and disinfect high touch patient surfaces and equipment with an Environmental Protection Agency-approved product with a label claim for norovirus .Healthcare workers who have symptoms consistent with norovirus should be excluded from work. Review of the Michigan Department of Community Health form Norovirus Investigations in Long Term Care Facilities Things to Consider form revealed, What constitutes an outbreak at a LTC .The presence of more diarrhea or vomiting than would usually be seen at the facility/unit for that time of year .Prevention and Control- Do not delay prevention and control measures while waiting for confirmation. *Begin disinfecting with bleach Increase housekeeping frequency *QUATs are ineffective .Handwashing emphasized for EVERYONE in the facility *Alcohol rubs are ineffective, can be used in addition to hand washing, but not as the primary method .Residents: * Cohort ill residents * Place ill under contact precautions o Restricted to their rooms as much as possible for at least 48 hours after symptoms end * Cancel group activities .Staff : * Send ill staff home immediately * Staff remain out for at least 48 hours after symptoms end .Visitors: *Encourage all visitors and volunteers to wash their hands * Visits from immuno-compromised people should be postponed o Distribute educational information (fact sheets) - monitor for illness Communicate with ICP or DON * Request line listing with the following information on number of ill residents, number of ill staff , illness onset dates (times if possible) , symptoms , duration of illness (average), distribution of illness (wing/unit) , hospitalization s or deaths associated with outbreak .If no testing performed . norovirus likely when * Stools negative for bacterial pathogens * Mean or median incubation period 24-48 hours * Vomiting in at least 50% * Mean or median duration of illness 12-60 hours. During an interview on 12/20/2018 at 10:59 A.M., Health Department (HD) C reported that Director of Nursing (DON) B reported 2 Residents with a gastrointestinal illness. The following day an additional 11 residents were identified with a gastrointestinal illness. HD C reported at that time she instructed the facility staff to treat the outbreak as norovirus and follow the Centers for Disease Control (CDC) guidelines. HD C stated, I sent them the guidelines from MDDHS (Michigan Department of Health and Human Services). We follow the norovirus guidelines because of the specific guidelines for cleaning. Use soap and water not hand sanitizer, restrict visitors, cohorting residents with same symptoms and not sharing staff. My recommendation was to treat it as norovirus. Sometimes we ask for stools (for sampling to identify if it is norovirus) but I didn't with them (the facility staff/DON B) because we (the city name Health Department) have seen noro(virus) in the area so I went with following the norovirus guidelines. We have a couple of different outbreaks in the area going on at the same time right now. HD C reported that she instructed to facility staff to follow the MDCH (Michigan Department of Community Health) for titled, Norovirus Investigations in Long Term Care Facilities Things to Consider, as well as, the CDC guidelines for Norovirus. Review of an email correspondence from HD C and DON B dated 12/11/18 at 3:13 P.M. revealed, Thank you for the report today. Following are the links to the norovirus cleaning and investigation guidelines. We will be contacting you daily to follow this outbreak. Be sure to continue to isolate the ill resident and stop group activities. Ill staff should remain off for at least 48 hours after resolution of symptoms and should not be shared with other facilities. If you have any questions regarding either of these documents please feel free to call. https://www.michigan.gov/documents/mdch/NorovirusInvestLTCF_ 5_7.pdf https://www.michigan.gov/documents/mdch/NorovirusEnvironCleaning_ 8_7.pdf During an interview on 12/19/18 at 9:17 A.M., DON B (Nurse Consultant (NC) D was present) reported that residents in the facility were able to move freely on the units whether they were in isolation or not. Residents that were showing signs of the gastrointestinal illness were encouraged to stay in their rooms until they were 48 hours symptom free. NC D reported that the facility staff do not cohort ill residents because there's a chance that the other resident (the healthy resident) could be sick but not showing symptoms yet. During an interview on 12/19/18 at 9:47 A.M., Certified Nursing Assistant (CNA) E reported that she had observed nursing staff that looked pretty sick with a gastrointestinal illness and were working with residents during the outbreak because staff can't call in here due to concerns with disciplinary action from absenteeism. During an interview on 12/19/18 at 9:17 A.M., DON B (Nurse Consultant (NC) D was present) reported that staff who called in were tracked with the date they called in as well as their symptoms. DON B reported she did not identify any trends with employee illnesses. DON B reported that staff that called in with gastrointestinal illness symptoms did not return to work for 48 hours. DON B reported that she began tracking staff call-ins after the outbreak was identified. DON B reported she did not look back to prior employee call-ins to identify staff members that had symptoms of a gastrointestinal illness. DON B reported that the facility practice is to staff call in to the night shift nurses until she (DON B) or a clinical coordinator arrive to work. DON B provided the Staff List W/SX (with symptoms) (a complete staff list of CENA's, nurses, and transportation staff). The names of 8 staff members were highlighted and 3 additional names were handwritten (first name only) and identified as having symptoms of nausea, vomiting, or diarrhea with the onset date written next to the name. DON B reported that this form was used as her employee illness tracking for the gastrointestinal illness outbreak. This form did not identify the resolution of the employees' symptoms or the date they were able to return to work. (Per the CDC and the MDCH form utilized for the outbreak, employees must remain out of work for at least 48 hours after symptoms end.) Review of a CALL OFF LOG with the names of facility nursing staff that called off from their shift for the month of (MONTH) revealed a column for the TIME/DATE OF CALL OFF and SIGNS & SYMPTOMS. This form did not identify the resolution of the employees' symptoms or the date they were able to return to work. The CALL OFF LOG did not incorporate the names of the employees in housekeeping, maintenance, or the kitchen that had gastrointestinal illness symptoms during the time of the outbreak (1 kitchen staff member reported gastrointestinal illness symptoms at the time of the outbreak). Review of the CALL OFF LOG (COL) which was compared to the Daily Staffing Plan revealed that COL was not complete and accurate. On 12/5/18 CNA I called off of work and it was not documented on the COL (CNA I called off on 12/7/18 which was documented on the COL). CNA K called off of work on 12/12/18 and it was not documented on the COL. CNA L called off of work on 12/17/18 and it was not documented on the COL (It was documented only on the Staff List W/SX). CNA M called off of work and it was not documented on the COL. During an interview on 12/20/18 at 2:25 P.M., DON B reported that she did not know why these staff called off of work and/or why they were not added to the COL. DON B reported that she, as the Infection Preventionist, was responsible for tracking employee call ins. DON B reported that she only kept a log of nursing staff (CNA's and nurses) who were ill and did not track housekeeping staff, maintenance staff, or kitchen staff. DON B reported they the staff in those departments call in to their manager and not to the DON. Review of the COL revealed CNA O called off of work 12/15/18 at 6:30 P.M. for diarrhea vomiting. Review of CNA O's time clock print out revealed that she punched in for work on 12/16/18 at 9:58 P.M. and punched out of work at 6:14 A.M. (indicating that she was not symptom free for 48 hours before returning to work.) Review of the Daily Staffing Plan revealed that CNA O worked on the A1 Unit (100 unit) for her shift. During an interview on 12/19/18 at 9:17 A.M., DON B reported that a visitor fell ill with gastrointestinal illness following a visit to the facility after the outbreak but she could not identify which visitor fell ill. DON B reported that a sign was posted on the main entrance and on each closed unit (Units 100 and 200) for visitors to speak with nursing staff before entering. NC D reported that visitors had not been restricted because the health department didn't say to stop. During an interview on 12/19/18 at 12:15 P.M., Visitor G reported that she was not given education on why the units were on quarantine. She reported no verbal education or written education was given. Visitor G reported she saw a sign on the door to the unit but it did not explain why the unit was closed. During an interview on 12/21/2018 at 9:13 A.M., Confidential Informant AA stated, They had the hallway locked down and the stench was terrible. They have an outbreak or something and I wasn't told about it when I went in to get my (family member's) things. During an interview on 12/19/18 at 2:27 P.M., DON B reported that visitors are educated about the gastrointestinal illness outbreak verbally and no educational handouts were provided for the visitors. During an interview on 12/19/2018 at 5:19 P.M., Administrator A reported that all resident guardians/emergency contacts will be mailed educational material regarding the gastrointestinal illness present in the facility. During an observation on 12/18/2018 at 3:47 P.M. the 200 unit had a strong odor of stool. During an observation on 12/19/2018 at 11:50 A.M. the 200 unit had a strong odor of urine and stool. During an interview on 12/18/18 at 11:10 A.M., Dietary Manager (DM) Y reported that no disposable trays are used for residents in isolation. DM Y reported that, during an outbreak, all meals trays are delivered to rooms using a large enclosed tray cart during. When the residents are done eating, all trays are placed into the enclosed tray cart with no special precautions. When the tray cart is brought to the kitchen, staff members wear gloves and run the trays through a high temperature dishwasher. The large enclosed tray cart is then washed with a sanitizer. During an interview on 12/19/18 at 1:10 P.M., DM Y reported that the quat (cleaning solution) used to sanitize the large enclosed tray cart, is the quat used in the kitchen. Review of the cleaning agent revealed that the concentration of the quat used for cleaning the cart was not effective in killing norovirus. During an interview on 12/18/18 at 11:55 A.M., Housekeeping Assistant Manager (HAM) W reported that all floors are cleaned with the solution Prominence. HAM W reported that the same floor cleaner is used in an isolation room as a non-isolation room. HAM W reported that tray tables and railings are sprayed with a quat spray, Virex II 256. HAM W reported that the concentration of quat is not tested . During an interview on 12/19/18 at 12:23 P.M., Diversity Technical Support Z reported that the Virex II 256 is not effective in killing norovirus. During an interview on 12/19/18 at 1:20 P.M., Housekeeper F was observed cleaning a resident's room with Virex. Housekeeper F reported that the Virex is used for surface cleaning in hallways and the non-isolation rooms. Housekeeper F reported that bleach wipes are used only in rooms where a resident is in isolation (residents in contact isolation were noted to be able to freely move around the units and come into contact with highly used surfaces). Resident #100 Review of a Face Sheet revealed Resident #100 was an 88 -year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of the Line Listing of Resident Infections revealed that on 12/10/18 Resident #100 exhibited symptoms of diarrhea. Treatment: oral hyd (hydration) sympt (symptom) mgmt. (management). Precautions and other actions-shut unit down increased cleaning handwashing (sic). Review of Resident #100's Bowel Elimination Description dated 12/17/18 revealed, Diarrhea (watery). This episode was not documented on the Line Listing of Resident Infections. Progress notes for the month of (MONTH) (YEAR) for Resident #100 were requested on 12/21/18 and were not received prior to the survey exit with the exception of a single entry progress note dated 12/20/18 that was provided prior to survey exit and revealed, no c/o (complaints of) n/v/d (nausea/vomiting/diarrhea) resident resting well in bed. fluids increased as needed spoke with resident stated that she is doing well (sic). Care plans regarding Resident #100's bowels were requested on 12/21/18 and were not received prior to the survey exit. Resident #101 Review of a Face Sheet revealed Resident #101 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 11/16/18 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #101 was cognitively intact. Review of the Line Listing of Resident Infections revealed that on 12/10/18 Resident #101 exhibited symptoms of diarrhea. Treatment: oral hyd (hydration) sympt (symptom) mgmt. (management). Precautions and other actions-shut unit down increased cleaning handwashing (sic). Review of Resident #101's progress notes dated 12/10/18 revealed no documentation regarding Resident #101's symptoms or monitoring of the symptoms. Review of Resident #101's Bowel Elimination Description dated 12/11/18 revealed, Diarrhea (watery). Review of Resident #101's progress note Pertinent Charting-Infections/Signs Symptoms dated 12/11/18 9:23 P.M. revealed, Site of infection: GI .res (resident) has had several episodes of diarrhea today. Intervention(s): (area left blank). Precautions followed: (area left blank). Comments: (area left blank). Review of Resident #101's progress note Pertinent Charting-Infections/Signs Symptoms dated 12/12/18 12:15 A.M. revealed, Site of originally identified infection: [MEDICAL CONDITION]. Review of Resident #101's progress note Pertinent Charting-Infections/Signs Symptoms dated 12/13/18 8:58 P.M. revealed, Site of originally identified infection: [MEDICAL CONDITION]. Review of Resident #101's progress note Pertinent Charting-Infections/Signs Symptoms dated 12/17/18 2:46 A.M. revealed, Site of originally identified infection: [MEDICAL CONDITION]. Review of Resident #101's care plan for bowel incontinence revealed, Focus-The resident has bowel incontinence r/t (related to) debility and dx (diagnosis) of [MEDICAL CONDITION] (sic) disease and DJD ([MEDICAL CONDITION] joint disease). Goal-The resident will be continent during daytime through the review date. Interventions-Check resident every two hours and assist with toileting as needed. Observe pattern of incontinence, and initiate toileting schedule if indicated. Provide pericare after each incontinent episode. See care plans on mobility, ADLs (activities of daily living), Cognitive Deficit, Communication. The care plan did not indicate that Resident # 101 had a history of [REDACTED]. During an interview on 12/19/2018 at 11:53 A.M., Resident #101 complained of nausea. Resident #101 reported she had not been feeling well for 2 weeks but reported an increase in nausea right now. During an observation on 12/19/2018 at 11:53 A.M. Registered Nurse (RN) Q was speaking with Resident #101. Resident #101 told RN Q that she was feeling nauseated and would prefer to have chicken broth and tea for her lunch. During an interview on 12/19/2018 at 12:02 P.M., RN Q stated, she (Resident #101) isn't eating, I can't force her to eat. She hasn't had loose stools or vomiting. RN Q reported that she did not report the symptoms to Director of Nursing (DON) B because RN Q did not believe the symptoms were related to the outbreak. During an interview on 12/19/2018 at 2:27 P.M., DON B reported that RN Q did not report Resident #101's symptoms to her. DON B reported her expectation is for all staff to notify her of any symptoms of a gastrointestinal illness during an outbreak. DON B reported that Resident #101 frequently complains of nausea. DON B stated that the health department told me we only had to watch for vomiting or diarrhea. Review of Resident #101's care plan revealed no care plan regarding frequent complaints of nausea. Resident #102 Review of a Face Sheet revealed Resident # 102 was an 82 -year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of the Line Listing of Resident Infections revealed that on 12/11/18 Resident #102 exhibited symptoms of diarrhea. Treatment: oral hyd (hydration) sympt (symptom) mgmt. (management). Precautions and other actions-shut unit down increased cleaning handwashing (sic). Review of Resident #102's Bowel Elimination Description dated 12/11/18 revealed, Diarrhea (watery). Progress notes for Resident #102 were requested on 12/21/18 and were not received prior to the survey exit. Physician orders for Resident #102 were requested on 12/21/18 and were not received prior to the survey exit. Care plans regarding Resident #102's bowels were requested on 12/21/18 and were not received prior to the survey exit. Resident #103 Review of a Face Sheet revealed Resident #103 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of the Line Listing of Resident Infections revealed that on 12/11/18 Resident #103 symptoms of diarrhea rtn (returned) 12/19/(18). Treatment: oral hydration symptom mgmt. (management). Precautions and other actions-shut unit down increase cleaning handwashing (sic). Review of Resident #103's Bowel Elimination Description dated 12/9/18 at 1:59 P.M. revealed, Diarrhea (watery). Review of Resident #103's Bowel Elimination Description dated 12/9/18 at 9:15 P.M. revealed, Diarrhea (watery). (Resident #103 was not placed on the Line Listing for symptoms until 12/11/18). Review of Resident #103's Bowel Elimination Description dated 12/10/18 at 5:59 A.M. revealed, Diarrhea (watery). Review of Resident #103's Bowel Elimination Description dated 12/20/18 at 5:59 A.M. revealed, Diarrhea (watery). Review of Resident #103's progress notes dated 12/9/18 through 12/10/18 revealed no documentation regarding Resident #101's clinical status. Review of Resident #103's progress note Pertinent Charting-Infections/Signs Symptoms dated 12/11/18 6:18 P.M. revealed, Site of infection: GI .several episodes of diarrhea today. Intervention(s): (area left blank). Precautions followed: (area left blank). Comments: (area left blank). Review of Resident #103's progress note Pertinent Charting-Infections/Signs Symptoms dated 12/12/18 at 8:08 A.M. revealed, Event Date: 12/09/2018 site of originally identified infection: [MEDICAL CONDITION] .continues to have diarrhea. Review of Resident #103's progress note Pertinent Charting-Infections/Signs Symptoms dated 12/12/18 revealed, Event Date: 12/12/2018 site of originally identified infection: [MEDICAL CONDITION]. Review of Resident #103's progress note Pertinent Charting-Infections/Signs Symptoms dated 12/19/18 10:45 P.M. revealed, Event Date: 12/19/2018 site of originally identified infection: GI (gastro intestinal) Contact isolation continues as ordered .She (Resident #103) has had c/o (complaints of) mild nausea without emesis today, as well as loose stools. A specimen is ordered to be sent to lab to r/o (rule out) norovirus . Review of Resident #103's care plan for bowel incontinence revealed, Focus-The resident has bowel incontinence r/t Immobility d/t dementia. Goal-The resident will be clean/odor free through the review date. Interventions-Check resident every two hours and assist with toileting as needed. Provide bedpan/bedside commode. Provide pericare after each incontinent episode. The care plan did not indicate that Resident # 103 had a history of [REDACTED]. During an observation on 12/19/2018 at 9:31 A.M., Certified Occupational Therapy Assistant (COTA) P was observed in Resident #103's room. Resident #103 was in contact isolation. COTA P was noted to be in Resident #103's room and was not wearing any personal protection equipment (gown and gloves required for contact isolation). COTA P donned gloves at 9:35 A.M. COTA P and Resident #103 were noted to be doing a therapy exercise which required Resident #103 to stack 8 small cones. After the completion of the exercise, COTA P wiped each cone down for less than 5 seconds with a bleach wipe. COTA P stacked the cones on top of each other on Resident #103's tray table without a barrier between the bottom cone and the tray table. COTA P placed the cones on her cart, washed her hands, and exited the room. Resident #104 Review of a Face Sheet revealed Resident #104 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of Resident #104's Bowel Elimination Description dated 12/9/18 at 1:59 P.M. revealed, Diarrhea (watery). Review of Resident #104's Bowel Elimination Description dated 12/9/18 at 9:15 P.M. revealed, Diarrhea (watery). (Resident #104 was not identified and placed on the Line Listing until 12/11/18). Review of the Line Listing of Resident Infections revealed that on 12/11/18 Resident #104 exhibited symptoms of diarrhea Treatment: oral hyd symptom mgmt. (management). Precautions and other actions-on contact isolation. Review of Resident #104's Bowel Elimination Description dated 12/11/18 at 12:01 P.M. revealed, Diarrhea (watery). Progress notes for Resident #104 were requested on 12/21/18 and were not received prior to the survey exit. Care plans regarding Resident #104's bowels were requested on 12/21/18 and were not received prior to the survey exit. Resident #105 Review of a Face Sheet revealed Resident #105 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of the Line Listing of Resident Infections revealed that on 12/11/18 Resident #105 exhibited symptoms of nausea Treatment: oral hyd (hydration) symptom mgmt (management). Precautions and other actions-shut unit down handwashing increase cleani

This citation pertains to MI 652. Based on observation, interview, and record review, the facility failed to revise person centered comprehensive care plans in 3 of 5 residents (Residents #102, #103 & #105 ) reviewed for falls/at risk for falls, resulting in a fall with serious injury for Resident #102, the potential for continued falls for Resident #103 and #105. Findings include: Resident #102 Review of a Face Sheet revealed Resident #102 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 3/6/18 revealed a Brief Interview for Mental Status (BIMS) score of 8, out of a total possible score of 15, which indicated Resident #102 was cognitively impaired and required cueing to remember the simple questions on the BIMS interview. The MDS indicated Resident #102 was not steady, only able to stabilize with human assistance when moving from a seated to standing position, moving on and off the toilet, or during surface-to-surface transfers. Resident #102 had functional limitations on his range of motion on both lower extremities. Review of the Fall Care Plan dated 2/22/18 revealed Resident #102 had a history of [REDACTED].and brain disorder. Goal: The resident will be free of fall through the review date. Interventions: anticipate and meet the residents needs based on nursing assessments. Encourage rest periods as needed to avoid overtiring. Provide for activities for daily living such as incontinence care, transfers, ambulation, as written in the activities of daily living plan of care. Review of the Activities of Daily Living care plan dated 2/21/18 revealed Resident #102 required assistance with activities of daily living that included Transfer: The resident requires sit to stand with 2 or more staff assist for transfers and Encourage the resident to use the call bell for assistance (resident is cognitively impaired). Review of Resident #102's incident accident dated 2/25/18 at 11:45 p.m., revealed brief description- found (Resident 102) laying face down on floor. called for emergency help. (Resident #102) states he had an accident in his pants so he laid on floor. Review of Resident #102's progress notes revealed on 2/25/2018 at 11:00 p.m., Nurses' Notes Text: Responded to emergency page to residents' room. (Resident #102) lying face down on floor. CENA present and states this is how she walked in and found him. Called (Resident #102) by name and he lifted his head and responded with a yes. Asked if he (Resident #102) fell and he (Resident #102) stated no. I asked him (Resident #102) if he knows how he came to be on the floor and he (Resident #102) stated, I had an accident. I asked if he (Resident #102) tripped and he (Resident #102) said no. I asked what kind of accident and he (Resident #102) stated he had an accident in his pants, so he (Resident #102) laid on the floor. Review of Resident #102's progress notes revealed on 2/28/2018 01:10 a.m., Nurses' Notes Text: (Resident #102) was observed on floor in his room face down with soiled brief around his ankles, when name (Resident #102's) called he answered yes, asked what happened he stated he (Resident #102) had an accident in his (Resident #102) pants and wanted to take them off. Review of the Fall Care Plan dated 2/22/18 revealed revealed no changes to the care plan to prevent further falls. Review of Resident #102's incident accident dated 3/8/18 at 12:05 a.m., revealed brief description:-(Resident #102) at nurses station at 11:45 p.m., and was told he would be put to bed in a moment by CNA.(Resident #102) stated I just wanted to lay down. (Resident #102) took self down hall to room. was observed on floor with glasses next to him on floor. small open are to corner of left eye and small scratch under left eye. Review of Resident #102's Emergency Physician Documentation dated 3/8/18 revealed (Resident #102) is a [AGE] year old male who was brought to the emergency department (ED) by EMS (ambulance) after being found down and unresponsive at his nursing home. Per report, patient (Resident #102) was last seen around midnight, was discovered around 3 AM laying on the floor, completely unresponsive, with a hematoma (blood area-under skin) over left eye. During an interview on 10/24/18 at 3:52 p.m., RN/UM Q indicated she is responsible for updating all resident care plans. RN/UM Q indicated Resident #102's care plan was not updated after his fall on 2/25/18 was not updated to reflect that fall. RN/UM Q indicated she is unaware of who was responsible at that time to update care plans, as herself, the DON, and the NHA are all new to the facility. Resident #103 Review of a Face Sheet revealed Resident #103 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 8/3/18 revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated Resident #103 was cognitively impaired. Review of the Fall Care Plan dated 2/19/16 and a revision date of 9/14/17 revealed: Focus (Resident #103) had a history of [REDACTED]. occasionally sleeps in bed with feet resting on wheelchair seat. Goal: The resident not sustain serious injury through the review date. Interventions: anticipate and meet the residents needs. Appropriate footwear. Be sure the residents call light is within reach and encourage the resident to use it. Provide activities of interest. Review of Resident #103's progress notes revealed on 8/10/2018 at 5:49 p.m., Falls New Fall/Follow-Up: new Situation (where/when/what/who): (Resident #103) slipped off toilet grabbing loose toilet bars -Injury/No injury: occipital swelling Factors involved (acute condition/environment, etc.): Analysis of interventions to implement: tighten toilet handle. Review of Resident #103's progress notes revealed on 10/8/2018 3:05 p.m., Pertinent Charting-Falls Note Text: Date of Fall: 10/08/2018 Situation Details: observed (Resident #103) on the floor sitting position in front of toilet next to w/c (wheelchair). Review of Resident #103's incident accident dated 10/8/18 at 12:30 p.m., revealed brief description:-(Resident #103) observed on the floor in front of toilet next to wheelchair. During an interview on 10/23/18 at 1:15 Resident #103 indicated he had a fall a few days ago and hit his head. Resident #103 indicated it takes staff about 30 minutes to answer call lights. Review of Resident #103 progress notes no noted documentation on Resident #103's fall a few days ago. Review of Resident #103's incident accident dated 10/17/18 at 4:35 p.m., revealed brief description:-(Resident #103) tried to place self on toilet. This nurse (licensed practical nurse-LPN-G) heard a fall/loud noise and observed (Resident #103) on floor in bathroom. Resident #105 Review of a Face Sheet revealed Resident #105 was an 86 -year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 8/22/18 revealed a Brief Interview for Mental Status (BIMS) score of 5, out of a total possible score of 15, which indicated Resident #105 was cognitively impaired. Review of the Fall Care Plan dated 3/3/16 and a revision date of 8/26/16 revealed: Focus (Resident #105) had a history of [REDACTED]. Interventions: anticipate and meet the residents needs. Be sure the residents call light is within reach and encourage the resident to use it. Encourage gripper socks. Follow the facility fall protocol. Provide activities of interest. further review of the care plan for Resident #105 revealed the last intervention dated 9/22/17: Independent with transfers. Review of a CNA care guide with no date revealed: (Resident #105) Transfer-the resident (Resident #105) requires 1 minimal assist with walker by 1 staff to moved between surfaces as necessary. (Resident #105) will self transfer without asking for help. Review of Resident #105's progress notes revealed on 8/12/2018 01:40 a.m., Nurses' Notes Text: when walking by resident room observed her on floor in room sitting in front of bed and dresser. Review of Resident #105's incident accident dated 8/12/18 at 1:00 a.m., revealed brief description:-(Resident #105) was reaching for something on the floor when she fell out of bed. Review of Resident #105's progress notes revealed on 9/21/18 2:52 p.m., Pertinent Charting-Falls Note Text: Date of Fall: 09/21/2018 (Resident #105) is sitting up in chair. continuous reminders to keep nasal cannula (oxygen) in nose. she (Resident #105) does have a bruise over the right eye that is presenting in various colors. also, a knot is present, skin is intact. pupils are reactive to light. Review of Resident #105's incident accident report dated 9/21/18 at 1:00 a.m., revealed brief description:-(Resident #105) found on the floor calling for help (Resident #105) was oriented and alert and stated she fell from her bed trying to go to the bathroom. Review of Resident #105's progress notes revealed on 9/29/2018 12:02 a.m., Progress Note-General Note Text: (Resident #105) found on the floor in her room, alert, oriented, able to sit herself, and assisted back to bed. The resident (Resident #105) stated that she (Resident #105) was trying to go to the bathroom. She (Resident #105) had a cut on the back of her (R) (right) hand and a small dressing applied. During an interview on 10/23/18 at 11:00 a.m., Registered Nurse (RN) M indicated Resident #105 had fallen on shift, she (Resident #105) had a pretty good bump on her head, a Goose egg. Review of Resident #105's incident accident dated 10/13/18 at 3:00 p.m., revealed brief description:-(Resident #105) observed sitting on the floor back upright against her (Resident #105) wheelchair, legs extended towards bed. when asked what happened (Resident #105) gave unintelligible response. Review of Resident #105's progress notes revealed on 10/13/2018 6:31 p.m., Nurses' Notes Text: At approximately 3:00 p.m., this nurse heard a loud noise come from this (Resident #105) room. Upon entry this nurse observed the resident (Resident #105) sitting upright on the floor facing her (Resident #105's) bed with her wheelchair directly behind her (Resident #105). During an observation on 10/23/18 at 12:45 p.m., observed Resident #105's room-mate's call light on floor, resident #105's room mate was calling out help, help stating you're going to fall to Resident #105. Resident #105 was observed getting up from her bed, call light was on the floor. Resident #105 removed her oxygen cannula from her face, stood up unassisted and walked to the bathroom unassisted. During an interview on 10/23/18 at 1:00 p.m., CNA L indicted staff is suppose to place call lights within reach of all residents. CNA L indicated when walking by all resident rooms, staff should be looking into rooms as they pass to ensure the residents are not standing on their own, call lights were in reach, as well as being able to hear if someone (residents) are calling for help. During an interview on 10/24/18 at 2:43 p.m., LPN G indicated for every fall she treats all residents as if they are injured, assessing for injury. LPN G indicted protocol is to watch the resident and put them on 15-minute checks LPN G indicated if the resident is a risk for falls, or might fall again, LPN G takes the resident out of their room if they are willing LPN G indicated she will also park the medication cart outside their out room. LPN G indicated the nurses fills out the incident report, then the incident report goes to the unit managers. LPN G indicated the unit managers update the care plans accordingly. During an interview on 10/24/18 at 3:52 p.m., RN/UM Q indicated she is responsible for updating all resident care plans. RN/UM Q indicated after a incident report for something such as fall the nurse may put in an intervention such as gripper socks on the incident. RN/UM Q stated I (RN/UM Q) get the incident reports, I (RN/UM Q) take the incident reports to the morning meetings for discussion. We or I (RN/UM Q) come up with a new intervention. I (RN/UM Q) go into the computer system and add the new intervention RN/UM Q indicated she looks to see if the interventions already in place are appropriate. RN/UM Q indicated the falls/at risk for falls care plans for Resident #103 and #105 were not updated. RN/UM Q indicated she is unaware of who was responsible at that time to update care plans, as herself, the DON, and the NHA are all new to the facility.

This citation pertains to intake: MI 562 Based on observation, interview and record review, the facility failed to ensure a safe environment and provide adequate assistance and/or monitoring for residents in 3 residents (Resident #102, #103 & #105) reviewed for falls, from a total sample of 5 residents, resulting in a fall with serious injury for Resident #102, and the potential for continued falls, and fall with serious injury. Findings include: Resident #102 Review of a Face Sheet revealed Resident #102 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 3/6/18 revealed a Brief Interview for Mental Status (BIMS) score of 8, out of a total possible score of 15, which indicated Resident #102 was cognitively impaired and required cueing to remember the simple questions on the BIMS interview. The MDS indicated Resident #102 was not steady, only able to stabilize with human assitance when moving from a seated to standing position, moving on and off the toilet, or during surface-to-surface transfers. Resident #102 had functional limitations on his range of motion on both lower extremities. Review of the Fall Care Plan dated 2/22/18 revealed Resident #102 had a history of [REDACTED].and brain disorder. Goal: The resident will be free of fall through the review date. Interventions: anticipate and meet the residents needs based on nursing assessments. Encourage rest periods as needed to avoid overtiring. Provide for activities for daily living such as incontinence care, transfers, ambulation, as written in the activities of daily living plan of care. Review of the Activities of Daily Living care plan dated 2/21/18 revealed Resident #102 required assistance with activities of daily living that included Transfer: The resident requires sit to stand with 2 or more staff assist for transfers and Encourage the resident to use the call bell for assistance (resident is cognitively impaired). During an in interview on 10/23/18 at 8:10 a.m., Confidential Informant (CI) O indicated Resident #102 was admitted to the facility as a known fall risk. CI O indicated Resident #102 was placed at the very end of the hall, in the room farthest from the nurses station. CI O indicated many times Resident #102's call light was not within his reach, also he had recently undergone a major surgery to removed a mass from Resident #102's head. CI O indicated the surgery involved removing a portion of the brain, which impaired Resident #102's cognition, memory, and overall awareness. CI O stated (Resident #102) would have a difficult time using a call light, as well as knowing boundaries of self transferring, and safety awareness. CI O further stated after Resident #102 fell on [DATE] Resident #102 was sent to the emergency department Resident #102 had to undergo another emergency surgery to reduce the swelling in his brain. Review of Resident #102's progress notes revealed on 2/25/2018 at 11:00 p.m., Nurses' Notes Text: Responded to emergency page to residents' room. (Resident #102) lying face down on floor. CENA present and states this is how she walked in and found him. Called (Resident #102) by name and he lifted his head and responded with a yes. Asked if he (Resident #102) fell and he (Resident #102) stated no. I asked him (Resident #102) if he knows how he came to be on the floor and he (Resident #102) stated, I had an accident. I asked if he (Resident #102) tripped and he (Resident #102) said no. I asked what kind of accident and he (Resident #102) stated he had an accident in his pants, so he (Resident #102) laid on the floor. Review of Resident #102's incident accident dated 2/25/18 at 11:45 p.m., revealed brief description- found (Resident 102) laying face down on floor. called for emergency help. (Resident #102) states he had an accident in his pants so he laid on floor. Review of Resident #102's progress notes revealed on 2/28/2018 01:10 a.m., Nurses' Notes Text: (Resident #102) was observed on floor in his room face down with soiled brief around his ankles, when name (Resident #102's) called he answered yes, asked what happened he stated he (Resident #102) had an accident in his (Resident #102) pants and wanted to take them off. Review of the Fall Care Plan dated 2/22/18 revealed revealed no changes to the care plan to prevent further falls. Review of Resident #102's progress notes revealed on 3/8/2018 01:26 a.m., Nurses' Notes Text: (Resident #102) was observed on the floor next to his w/c had small amount of blood on floor near doorway d/t his (Resident #102) glasses still being on his face, they are now bent but not broken, small cut (less than 1 cm) observed at outer corner of his left eye and a small (less than 1 cm ) open area under his left eye, no c/o of pain or discomfort, cleaned up and brief was changed, area to his eye was cleaned with ns, and band-aids applied, call to on call MD at 12:30 a.m., no new orders, call to DON at 12:40 a.m., neuro checks started, resident is now resting in bed with eyes closed, will continue to monitor. Review of Resident #102's progress notes revealed on 3/8/2018 5:49 a.m., Nurses' Note Text: (Resident #102) was observed to be not his normal self when cna was changing his brief at 2:30 a.m., hand grip was strong on right and diminished to left, his (Resident #102) left eye was very swollen and red, call to on call order to send to hospital for treatment, call to don (DON-Director of Nursing) to inform her of transfer, (Resident #102) out of building at 3:00 a.m. Review of Resident #102's incident accident dated 3/8/18 at 12:05 a.m., revealed brief description:-(Resident #102) at nurses station at 11:45 p.m., and was told he would be put to bed in a moment by CNA.(Resident #102) stated I just wanted to lay down. (Resident #102) took self down hall to room. was observed on floor with glasses next to him on floor. small open are to corner of left eye and small scratch under left eye. Review of Resident #102's Emergency Physician Documentation dated 3/8/18 revealed (Resident #102) is a [AGE] year old male who was brought to the emergency department (ED) by EMS (ambulance) after being found down and unresponsive at his nursing home. Per report, patient (Resident #102) was last seen around midnight, was discovered around 3 AM laying on the floor, completely unresponsive, with a hematoma (blood area-under skin) over left eye. Review of Resident #102's hospital H&P (history & physical) dated 3/8/18 revealed: Radiological images and Studies: There is a CT scan of the head that was obtained. There is a large acute subdural hematoma over the right hemisphere that is large. Looking at the CT of the facial bones, there is extensive fracture in the left lamina (facial bones) --with stretching of the optic nerve. Review of Resident #102's Hospital Consultation Documentation dated 3/8/18 revealed: Recommendation: (physician) went over this imaging (CT-scan of Resident #102's head) with trauma surgeon. I think his (Resident #102's) outcome likely would be devastating with aggressive therapy, though I believe he may be salvageable. It was understood that his (Resident #102) outcome would likely be poor; however, he had reasonable performance prior to this. I do not think it is unreasonable to take him to surgery, the surgery I had recommended is a right-sided trauma flap for evacuation of acute subdural hematoma. Further review of the document revealed: I (physician at ED) believe the risk of death is not small; however, I do believe the only way he would have a chance to survive this (injury from fall) is to perform an emergency surgery. Resident #103 Review of a Face Sheet revealed Resident #103 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 8/3/18 revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated Resident #103 was cognitively impaired. Review of the Fall Care Plan dated 2/19/16 and a revision date of 9/14/17 revealed: Focus (Resident #103) had a history of [REDACTED]. occasionally sleeps in bed with fee resting on wheelchair seat. Goal: The resident not sustain serious injury through the review date. Interventions: anticipate and meet the residents needs. Appropriate footwear. Be sure the residents call light is within reach and encourage the resident to use it. Provide activities of interest. Review of Resident #103's progress notes revealed on 8/10/2018 17:49 p.m., Falls New Fall/Follow-Up: new Situation (where/when/what/who): (Resident #103) slipped off toilet grabbing loose toilet bars -Injury/No injury: occipital swelling Factors involved (acute condition/environment, etc.): Analysis of interventions to implement: tighten toilet handle. Review of Resident #103's progress notes revealed on 10/8/2018 3:05 p.m., Pertinent Charting-Falls Note Text: Date of Fall: 10/08/2018 Situation Details: observed (Resident #103) on the floor sitting position in front of toilet next to w/c (wheelchair), (Resident #103) alert and oriented to name and person, no apparent injury noted Assessment: no apparent injury noted, FROM (full range of motion) of all extremities without discomfort no apparent injury noted Mitigating Factors: none Environmental Factors: none Interventions: encourage to ask for assist. Review of Resident #103's incident accident dated 10/8/18 at 12:30 p.m., revealed brief description:-(Resident #103) observed on the floor in front of toilet next to wheelchair. During an interview on 10/23/18 at 1:15 p.m., Resident #103 indicated he had a fall a few days ago and hit his head. Resident #103 indicated it takes staff about 30 minutes to answer call lights. Review of Resident #103 progress notes revealed : no noted documentation on Resident #103's fall a few days ago. Review of Resident #103's incident accident report dated 10/17/18 at 4:35 p.m., revealed brief description:-(Resident #103) tried to place self on toilet. This nurse (licensed practical nurse-LPN-G) heard a fall/loud noise and observed (Resident #103) on floor in bathroom. During an interview on 10/24/18 LPN G indicated an incident report was completed for Resident #103's fall on 10/17/18. LPN G indicated she thought she put a note in the computer system as well. Resident #105 Review of a Face Sheet revealed Resident #105 was an 86 -year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 8/22/18 revealed a Brief Interview for Mental Status (BIMS) score of 5, out of a total possible score of 15, which indicated Resident #105 was cognitively impaired. Review of the Fall Care Plan dated 3/3/16 and a revision date of 8/26/16 revealed: Focus (Resident #105) had a history of [REDACTED]. Interventions: anticipate and meet the residents needs. Be sure the residents call light is within reach and encourage the resident to use it. Encourage gripper socks. Follow the facility fall protocol. Provide activities of interest. further review of the care plan for Resident #105 revealed the last intervention dated 9/22/17: Independent with transfers. Review of a CNA care guide with no date revealed: (Resident #105) Transfer-the resident (Resident #105) requires 1 minimal assist with walker by 1 staff to moved between surfaces as necessary. (Resident #105) will self transfer without asking for help. Review of Resident #105's incident accident dated 8/12/18 at 1:00 a.m., revealed brief description:-(Resident #105) was reaching for something on the floor when she fell out of bed. Review of Resident #105's progress notes revealed on 8/12/2018 01:40 a.m., Nurses' Notes Text: when walking by resident room observed her on floor in room sitting in front of bed and dresser. slightly leaning onto dresser. No injury found, no raised areas on head, no bruising to body noted. She is alert able to state she was reaching for object on floor when she went off bed. (lift) hoyered to bed. neuro checks started. Review of Resident #105's incident accident dated 9/21/18 at 1:00 a.m., revealed brief description:-(Resident #105) found on the floor calling for help (Resident #105) was oriented and alert and stated she fell from her bed trying to go to the bathroom. Review of Resident #105's progress notes revealed on 9/21/18 2:52 p.m., Pertinent Charting-Falls Note Text: Date of Fall: 09/21/2018 (Resident #105) is sitting up in chair. continuous reminders to keep nasal cannula (oxygen)in nose. she (Resident #105) does have a bruise over the right eye that is presenting in various colors. also, a knot is present, skin is intact. pupils are reactive to light. Review of Resident #105's progress notes revealed on 9/29/2018 12:02 a.m., Progress Note-Text: (Resident #105) found on the floor in her room, alert, oriented, able to sit herself, and assisted back to bed. The resident (Resident #105) stated that she was trying to go to the bathroom. She (Resident #105) had a cut on the back of her (R) (right) hand and a small dressing applied. During an interview on 10/23/18 at 11:00 a.m., Registered Nurse (RN) M indicated Resident #105 had fallen on shift, she (Resident #105) had a pretty good bump on her head, a Goose egg. Review of Resident #105's incident accident dated 10/13/18 at 3:00 p.m., revealed brief description:-(Resident #105) observed sitting on the floor back upright against her (Resident #105) wheelchair, legs extended towards bed. when asked what happened (Resident #105) gave unintelligible response. Review of Resident #105's progress notes revealed on 10/13/2018 6:31 p.m., Nurses' Notes Text: At approximately 3:00 p.m., this nurse heard a loud noise come from this (Resident #105) room. Upon entry this nurse observed the resident (Resident #105) sitting upright on the floor facing her (Resident #105's) bed with her wheelchair directly behind her (Resident #105). During an observation on 10/23/18 at 12:45 p.m., observed Resident #105's room-mate's call light on floor, resident #105's room mate was calling out help, help stating you're going to fall to Resident #105. Resident #105 was observed getting up from her bed, call light was on the floor. Resident #105 removed her oxygen cannula from her face, stood up unassisted and walked to the bathroom unassisted. During an interview on 10/23/18 at 1:00 p.m., CNA L indicted staff is suppose to place call lights within reach of all residents. CNA L indicated when walking by all resident rooms, staff should be looking into rooms as they pass to ensure the residents are not standing on their own, call lights were in reach, as well as being able to hear if someone (residents) are calling for help. During an interview on 10/24/18 at 2:43 p.m., LPN G indicated for every fall she treats all residents as if they are injured, assessing for injury. LPN G indicted protocol is to watch the resident and put them on 15-minute checks LPN G indicated if the resident is a risk for falls, or might fall again, LPN G takes the resident out of their room if they are willing LPN G indicated she will also park the medication cart outside their out room. LPN G indicated the nurses fills out the incident report, then the incident report goes to the unit managers. LPN G indicated the unit managers update the care plans accordingly. During an interview on 10/24/18 at 3:52 p.m., RN/UM Q indicated she is responsible for updating all resident care plans. RN/UM Q indicated after a incident report for something such as fall the nurse may put in an intervention such as gripper socks on the incident. RN/UM Q stated I (RN/UM Q) get the incident reports, I (RN/UM Q) take the incident reports to the morning meetings for discussion. We or I (RN/UM Q) come up with a new intervention. I (RN/UM Q) go into the computer system and add the new intervention RN/UM Q indicated she looks to see if the interventions already in place are appropriate. RN/UM Q indicated the falls/at risk for falls care plans for Resident #103 and #105 were not updated. RN/UM Q indicated Resident #102's care plan was not updated after his fall on 2/25/18 was not updated to reflect that fall. RN/UM Q indicated she is unaware of who was responsible at that time to update care plans, as herself, the DON, and the NHA are all new to the facility.

This citation pertains to MI 849 Based on interview and record review the facility failed to designate a legal surrogate for the purpose of healthcare decision-making, for a severely cognitively impaired resident on palliative care and not allowing next-of-kin to make advance directive decisions for 1 (Resident #104) of 6 sampled residents reviewed for advance directives, from a total sample of 6 residents, resulting in Resident #104 and the family representative not being allowed to make quality of life decisions. Findings include: Review of the Admission Record revealed Resident #104 was a [AGE] year old male, originally admitted [DATE] from another facility with a discharge date of [DATE] and pertinent [DIAGNOSES REDACTED]. Advance Directives revealed, Refer to Medical Records. Review of a Minimum Data Set (MDS) assessment for Resident #104 with a reference date of 12/02/2017, revealed a Brief Interview for Mental Status (BIMS) score of 0, which indicated Resident #104 was severely cognitively impaired. Section Q. revealed, A. Yes, Resident participated in assessment. B. Yes, Family or significant other participated in assessment. Review of Resident #104 progress note dated 10/31/2017, Nurse Practitioner (NP) HH stated, .does not have guardianship in place. Social Work working to obtain guardianship. Review of Resident #104 progress note date 11/1/2017, NP HH stated, Guardianship is pending. Review of Resident #104 progress note dated 11/2/2017, Physician II stated, Patient does have a guardian. No record of guardianship could be found. Review of Resident #104 progress note dated 11/6/2017, Social Services Director (SSD) GG stated, .Family U .will follow up with guardianship process. Review of Resident #104 progress note dated 11/7/2017, SSD GG stated, I spoke to Family U today .wants Resident #104 to be comfortable and hospice care, doesn't want aggressive measures. Review of hospital discharge summary dated 12/7/2017 revealed, .and was DNR per hospice paperwork signed by (Family U) who is next of kin. Patient is not decisional. (Family U) states he applied for guardianship on Dec. 4. Prognosis .there is risk of death within 1-6 weeks .Symptom Management: 3) Palliative/comfort care focus and hospice desired by family. Medical Social Work (MSW) contacted facility re: transfer back there tonight, but they declined to accept patient back .Final Report History of Present Illness .(facility) staff eventually indicated that they want the patient admitted to the hospital to expedite DPOA paperwork that was initiated by the patient's (Family U). Discussion with the patient's (Family U) revealed that the patient would not want further hospital management and that the patient would prefer to be sent back to the facility at this time .Palliative care was consulted for assistance in this matter and attempts were made to get patient back to facility however they declined to accept him at this time .Impression and Plan: .Reported [MEDICAL CONDITION]-Doubt legitimacy of report from facility staff in order to have patient admitted , no evidence of [MEDICAL CONDITION], Registered Nurse at facility unable to give any account of the [MEDICAL CONDITION] activity. Findings: There is a left lower lobe infiltrate consistent with pneumonia . Review of Resident #104 nurses' notes on 12/7/2017 at 5:00 p.m., revealed, received a call from the hospital that they were not going to admit (Resident #104) but were sending back as a DNR .the family made (Resident #104) a DNR .explained to the case manager that (Resident #104) was here as a full code and that currently did not have an activated DPOA or a guardian so we would have keep him a full code. The case manager stated, 'All of the family here wants him to be a DNR'. I told case manager we were aware that (Family U) was seeking guardianship and had a court date in near future, . On 4/13/2018 a request of Social Worker P to present Resident #104's Advance Directive/Medical Treatment Decisions revealed no document available. Review of physician's orders [REDACTED]. Advance Directive Status: Current and Verified. Review of physician's orders [REDACTED]. During an interview on 4/11/2018 at 10:19 a.m., Ombudsman C stated, I was not notified of Resident #104's discharge. I received several calls from hospital that the facility was not taking Resident #104 back. That is not appropriate, they have to take the resident back. The only reason (they didn't take him back) is because there was no DNR. During an interview on 4/11/2017 at 10:30 a.m., Hospital Palliative Care Social Worker Y stated, No one at the facility filled out the DNR status on time. The family of (Resident #104) was there for 10 hours in ER and very upset. The facility wouldn't take back (Resident #104) without a code status, without a DPOA. Medicaid Act states next-of-kin can sign for code status. The facility told us, 'We are not going to take (Resident #104) back. If we don't have a code on (Resident #104) we don't have to take him back'. Review of hospice Do Not Resuscitate Order Allow a Natural Death (this form was prepared pursuant to, and complies with the Michigan Do Not Resuscitate Procedure Act 193 of 1996. (4/19/2017) revealed, Family U signed 11/27/2017, two witnesses signed 11/27/17, and Physician KK signed 12/6/2017. During an interview on 4/13/2018 at 10:37, Director of Nursing (DON) B stated, We don't take hospice forms; its not allowed. We are not allowed to follow hospice forms. During an interview on 4/13/2018 at 10:10 a.m., Medical Records Coordinator LL stated, The admissions nurse should fill out the advance directives first thing when admitted . The Social Worker should follow up to make sure they are filled out. During an interview on 4/13/2018 at 11:00 a.m., Social Worker P stated, Advance directives and code status should be done right away upon admission in case something happens with a resident. I follow up to make sure they are done ASAP. I believe next-of-kin can sign if no legal guardian or DPOA. That is what the hospital goes by. During an interview on 4/13/2018 at 3:40 p.m., Family U stated, The facility wouldn't allow me to sign forms for advance directives because I wasn't (Resident #104's) legal guardian yet. The hospital talked to me about advance directives; we didn't want (Resident #104) to suffer. Family U indicated how difficult and stressful it was for the family to have to fight the facility to allow Resident #104 be a DNR. During an interview on 4/13/2018 at 4:10 p.m., Director of Hospice T stated, There should be coordination of care between the facility and us. If there is no legal representative the State of Michigan says next-of-kin can sign. The facility wanted their own forms signed and didn't want to use ours. After our DNR form was signed we sent it to the facility for the physician to sign and it was done. The facility would not take back (Resident #104) because there was no decision maker. Again, the State of Michigan states next-of-kin can make code status. The facility would not take back (Resident #104), it was very messy. I believe (Resident #104) had some behavioral issues. During an interview on 4/13/2018 at 4:10 p.m., Hospice Home Health Manager W stated, There was a discrepancy with (Resident #104's) code status. (Resident #104) was DNR at hospital admission while still a resident at the facility. They (undetermined who they are) said (Resident #104) left the facility with a [MEDICAL CONDITION], wanted no treatment at the hospital per family and wanted to go back to the facility. To make as smooth as possible for residents, next-of-kin is legal in Michigan. Our hospice social worker was working with family for DPOA. If we hadn't had a hospice facility that had room for (Resident #104) where would the resident had gone?

This citation pertains to intake numbers MI 142, MI 060, and MI 076. Based on observation, interview, and record review the facility failed prevent staff to resident abuse in 1 of 9 sampled residents (Resident #107) reviewed for abuse, from a total sample of 9 residents resulting in an Immediate Jeopardy when Resident #107 was found in bed on 7/22/16 at 5:00 a.m. yelling of pain and had bruising and elevated area to the right upper arm, was sent to the hospital on [DATE] at 5:20 a.m., and found to have a spiral fracture mid humerus (long bone in the upper arm that runs from shoulder to the elbow) after receiving perineal care from Certified Nurse Aide (CNA) D on 7/21/16 at approximately 11:00 p.m. This deficient practices place all 66 residents of the facility at risk for harm, injury, and continued abuse. Findings include: Review of the facility Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed Resident #107 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #107 was severely impaired for daily decision-making skills and required the assistance of one to two staff members for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of the Daily Worksheet for the Nursing Assistant dated 7/19/16, reflected Resident #107 Two CNA's to assist in care if agitated, if allows for care. Review of the Incident Report dated 7/22/16 at 5:00 a.m., reflected that Resident #107 was found in her room with a possible humerus fracture. Review of the Emergency Department Note - Physician dated 7/22/16 at 10:27 a.m., reflected X-ray two-views humerus: Spiral fracture mid humerus with 4 cm of shortening and angulation . Review of Exhibit #1 Facility Incident Report dated 7/22/16, reflected 12:30 p.m., 7/22/16 .Hospital ER called and spoke to Director of Nursing (DON B) informing DON resident had a spiral fracture, a type of fracture that could not happen from a fall. Review of the Statement of Witness CNA E dated 7/22/16 time of incident 4:50 a.m., reflected CNA E went into Resident #107's room to do rounds. The statement revealed CNA E reported, I asked (CNA C) to help me with Resident #107 as myself and (CNA C) started to roll her she (Resident #107) started screaming 'my arm, my arm'. I then looked at her arm and noticed bruises, when I went to touch the bruises she went to swing with left arm and started yelling my arm my arm and I then noticed a hump that didn't look normal so I got the nurse . In an interview on 8/3/16 at 9:40 a.m., Administrator A reported that he did not have the original notes from his telephone interview with CNA D but Administrator A reported that on 7/22/16 when he spoke with CNA D she informed him that Resident #107 had a bowel movement and when she started changing her, Resident #107 started fighting (hitting her) so CNA D stated 'I secured her hands with her night gown' (typed by Administrator as took the gown and wrapped it around her arms to keep her from hitting me). Administrator A reported that CNA D stated that she turned Resident #107 on her right side when she was cleaning her. In interviews on 8/2/16 at 4:50 p.m. and 8/3/16 at 9:30 a.m., CNA D reported that after water was passed sometime after 11:00 p.m. on 7/21/16, she found Resident #107 with bowel movement on her hands and she had to put her hands in the bottom of her night gown to clean her. CNA D reported that the night gown 'swallowed her' and she just lifted the gown over her hands, did perineal care, cleaning her front then her back. CNA D reported that she did not recall if Resident #107 was a 2 person assist with care (as the Daily Worksheet had indicated), just that she was combative and feisty (hits and swings). CNA D reported that she did rounds prior to 2:00 a.m. when she left and Resident #107 was sleeping. In an interview on 8/3/16 at 12:35 p.m., CNA C reported that on 7/21/16 at approximately 11:30 p.m. she heard Resident #107 screaming, the door was closed and CNA D was in there. CNA C reported that Resident #107 always screamed so she thought CNA D was just waiting for her to calm down and continue care so she went to answer call lights. CNA C reported that when she came back approximately 20 minutes later the screaming had stopped but the door to Resident #107's room was still closed, so she knocked on the door and ask if CNA D needed help and she stated no I'm fine. CNA C reported that CNA D did not normally work this hall, but that most night shift staff do care for Resident #107 independently (not with 2 person assist), if she fights and screams she (CNA C) just sings to her till she calms and lets her hold her hand. CNA C reported that there was usually only 2 CNA's on the hall on night shift. In an interview on 8/3/16 at 8:05 a.m., CNA E reported that she did not do rounds on Resident #107 until after 4:00 a.m. because CNA D had reported off at 2:00 a.m. that she had already completed the rounds. CNA E reported that Resident #107 was very quiet and had her arms crossed on her chest with fists up by shoulder, which was unusual for her since she usually has her hands in her brief. In an interview on 8/2/16 at 3:15 a.m., Certified Nursing Assistant (CNA) F reported that Resident #107 could be a little feisty, and two staff members were to be in the room when care is provided. CNA F reported that she worked the day shift and Resident #107 was a two person for cares even before the incident on 7/21/16. In an interview on 8/3/16 at 10:25 a.m., CNA Q reported that when Resident #107 returned from the hospital on [DATE] she appeared scarred to death of one of the CNA's, who had a similar coloring and was about the same height and build as CNA D. In an interview on 8/9/16 at 8:50 a.m., CNA P reported that Resident #107 after she came back from the hospital on [DATE] was trying to get to me swing arms and called me a B .h and even though she said it slowly and in broken word you could tell what she was saying. We CNA's just changed assignments and I stayed out of the room. In an interview on 8/4/16 at 4:30 p.m., Family Member X reported that when Resident #107 came back to the facility on on 7/21/16 there were (2) CNA's who resembled the person who caused the injury with same build and color Resident #107 would scream when they came in the room. In an interview on 8/13/16 at 1:30 p.m., Activity Director/Social Services (AD/SS) AE reported that there was no complaints about staff from Resident #107 after she fractured her arm, in fact she was a different person, not combative with care anymore. AD/SS AE reported that she believed Resident #107 has shown no fear of staff members. AD/SS AE reported that she did not have any documentation of visits she had completed with Resident#107, and that she had not seen any concern form about Resident #107. On 8/3/16 at 4:09 p.m., Administrator A was notified of the Immediate Jeopardy that began on 7/21/16 at approximately 11:00 p.m., and was identified on 7/22/16 at 5:00 a.m., when the facility failed to prevent staff to resident abuse for Resident #107, which resulted in a fracture. On 8/4/16, this surveyor confirmed that the facility staff implemented the following to remove the Immediate Jeopardy: 1. On 7/22/2016 at 4:30 a.m., facility staff assessed resident and found a dark purplish color and protruding bulge to right upper arm. 2. On 7/22/16 at approximately 4:30 a.m. facility staff contacted the physician, an order to send Resident #107 to hospital was obtained. The Director of Nursing (DON B) was notified at this time. 3. On 7/22/16 at 5:15 a.m. Resident #107 was transported to the Hospital ER for evaluation (possible fracture). 4. On 7/22/2016 at 5:15 a.m. resident's DPOA was contacted of possible fracture. 5. On 7/22/16 DON B interviewed 17 of 17 residents that were able to make needs known on A hall. 6. On 7/22/16 the DON B observed 11 non inter-viewable residents for evidence of abuse, non-identified. 7. On 7/22/16 at 10:45 a.m. CNA D was interviewed and based on her statement, placed on suspension. 8. Beginning 7/22/16 facility staff were re-educating regarding abuse education, unnecessary use of restraints, care delivery guides, reporting abuse, Elder Justice Act, and combative behaviors with specific care plan interventions. On 8/2/201, 78 of 83 scheduled employees were educated. Uneducated staff members were not allowed to work until they received the education. New Hires will receive the above mentioned education during their general orientation prior to providing care to residents. 9. On 7/22/2016 at 12:45 p.m. the fracture was reported to the police department. 10. On 7/25/2016 employee CNA D was terminated from employment. 11. On 7/25/2016 the Michigan Community Health System for CNA Registry was contacted to report the CNA. 12. On 7/26/2016 resident queries were initiated for 5 residents on A hall to identify any unreported abuse. 13. Staff queries were started the week of 7/25/2016 for 10 employees to validate knowledge of types of abuse, abuse officer, how to care for residents that resist care, and Elder Justice Act. 14. Visual audits were started the week of 8/3/2016 for 3 of 3 residents requiring 2 person assist to validate two person assist occurred. 15. On 8/3/2016 an audit was conducted of current employees to validate pre hire screening was in place to include background check, drug screen, current license and/or certification (if applicable) and reference checks. Although the Immediate Jeopardy has been removed as of 8/3/2016, the facility remained out of compliance at a scope and severity of actual harm that is not Immediate Jeopardy due to facility had not all received the education and the State Agency had not verified sustained compliance by the state agency.

Based on observation, interview, and record review, the facility failed to prevent a fall with fracture in 1 of 2 sampled residents (Resident #108) reviewed for falls, from a total sample of 9 residents, resulting in repeated falls and a fall with injury and/or serious harm. Findings include; Review of the Admission Record and Minimum Data Sheet ((MDS) dated [DATE], reflected Resident #108 was a [AGE] year old female re-admitted to the facility on [DATE]. The MDS reflected Resident #108's [DIAGNOSES REDACTED]. The MDS reflected that Resident #108's ability to make daily decisions was severely impaired and she currently required supervision when walking in her room, and the assistance of one staff member for dressing and hygiene. Review of the Cognitive Function Care Plan dated 1/14/16, reflected Resident #108 The resident has: impaired cognitive function related to Short term memory loss, impaired decision making, Long term memory loss, Difficulty making decisions due to ongoing dementia . Interventions/Tasks- Cue, prompt and reminders and supervise as needed for needs she does not acknowledge. Review of the Incident Report dated 1/23/16 at 6:00 a.m., reflected Resident #108 was in her room, confused/disoriented, and the incident was not witnessed Resident was observed sitting on the floor next to her bed. Resident stated she was sitting on the side of the bed and slipped off, she sated to the nurse that she hit her head on something . Action taken Resident Education .mental status, confused oriented to self. Review of the IDT (Interdisciplinary Team) Progress Notes dated 1/26/15 (DIT) IDT has met to review recent fall on 1/23/16 without injury Resident (#108) observed sitting on the floor next to her bed on buttock. Holding her head with both hands Resident (#108) stated she hit her head on something no bruising noted to head. Resident (#108) stated she was sitting on the side of the bed and slid off, she denies having on shoes at the time of fall, she is alert and oriented x 2, call light was within reach, and functioning. Resident (#108) had 2 bedside tables at the bedside against the wall with her belongings on bedside table, removed to decrease clutter in room. Resident (#108) was also referred to therapy immediate intervention was to encourage Resident (#108) to use call light for assistance. Review of the Falls Care Plan dated 2/17/16, reflected Resident #108 is at risk for falls related to her History of falls, pain medication, and diuretics, dementia, and frequently falls asleep sitting on side of bed. Goal- the resident will not sustain serious injury through the review date 10/2/16. Interventions/Tasks- Determine causative factors of fall and resolve or minimize, Encourage gripper socks at all times, . Encourage to lay down when sleeping on side of bed 7/22/16, .Review information on past falls and attempt to determine cause of falls . Review of the Falls Care Area assessment dated [DATE], reflected Resident #108 was At risk for falls related to poor safety awareness due to dementia. Se is alert and oriented x2 Ambulates with walker and supervision. Review of the Incident Report dated 7/18/16 at 5:35 a.m., reflected Resident #108 was in her room and the incident was not witnessed Resident (#108) found on floor between bed and wall with blood coming from posterior right part of head. Also skin tear to left arm and lacerations to right elbow. Sent Resident (#108) to .hospital via ambulance. The Incident Report Fall Scene Investigation Report reflected Resident #108 was sitting on the side of the bed just prior to the fall and was last toileted at 4:30 a.m. Resident has a long nightgown that she was wearing and it appears she may have stepped on it and fell . Review of the Hospital Imaging Information dated 7/18/16, reflected Impression: 1. New lucent defects involving the pars interarticularis bilaterally at C7 compatible with fractures, although age indeterminate. Given the progressive fusion across C6-C7, these findings could be on the basis of stress related injury/fracture, however acute traumatic fracture from the recent fall is not excluded. Review of the Hospital Emergency Reported dated 7/18/16, reflected HPI (Health Professions Institute) comments: This is a [AGE] year old female with a past medical history of [REDACTED]. She had an unwitnessed fall from her bed at the nursing home According to nursing home staff she is acting her norm. They also say she has no history of passing out, but does fall asleep often. She also has a habit of lying on her bed improperly. she has fallen from her bed in the past, but was never injured Number of [DIAGNOSES REDACTED].scalp laceration was repaired with 2 staples . During observations on 8/2/16 at 3:07 p.m., 8/3/16 11:10 a.m., 8/4/16 at 3:15 p.m., 8/5/16 at 4:10 p.m., and 8/9/16 at 2:15 p.m., Resident #107 was noted sitting on the edge of her bed, positioned towards roommates bed, bent over from the waist with head and neck towards floor with her eyes closed. In an interview on 8/2/16 at 3:07 p.m., Resident #108's roommate reported that on 7/18/16 her curtain was half closed but she could see Resident #108 sleeping on the side of her bed and called out to her to try and wake her before she rolled out of bed and broke her neck. Resident #108's roommate reported that at about 5:30 a.m. Resident #108 was bent way over sleeping sitting on the side of the bed, and she put her call light on after Resident #108 fell and called for help. Resident #108's roommates MDS reflected she was cognitively intact for decision making. In an interview on 8/9/16 at 12:02 p.m., Occupational Therapist (OT) T reported that Resident #108 was safe most of the time, but was not educateable to use the call light and to not sit at the side of the bed and fall asleep. OT T reported that Resident #108's roommate is alert and oriented and reliable. In an interview on 8/9/16 at 6:30 p.m., CNA O reported that the call light alerted her to go to Resident #108's room was turned on by her roommate. CNA O reported that the privacy curtain was only closed about half way and the roommate could see Resident #108 on the floor. In an interview on 8/10/16 at 10:25 a.m., Licensed Practical Nurse (LPN) (MDS) AF reported that when she does the MDS she talks to CNA's, Residents, and Nurses to gather the data. LPN AF reported that Resident #108 can walk to the dining room independently, but when she was up independently in her room she was always a fall risk, CNA's monitor her when they walk by the room. LPM AF reported that Resident #108 was always going to be a fall risk, it was hard to get her to comply to put call light on for assistance with transfers, she knows how to use the call light but was a very determined independent woman. LPN AF reported that she did not update plans of care for residents. In an interview on 8/10/16 at 10:35 a.m., RN AA reported that on 7/18/16 at approximately 5:30 a.m., that she was getting ready to leave and Resident #108's roommate called out to me that she needed help, the call light had come on and I asked the CNA to get the light, the CNA's were getting other residents up and dressed. RN AA reported that the CNA's stated that they were going in there next, but she arrived first approximately 5-8 minutes after the time she had seen the call light. RN AA reported that there were a lot of call lights on at that time and the roommate has a touch light that at times she does not mean to push. RN AA reported that Resident #108 was sitting on the floor facing the bathroom, there was blood on the over the bed table and the walker was right by the end of the bed. RN AA reported that the roommate said she saw her on the ground, she did not say she saw Resident #108 fall, the curtain was pulled 1/2 way. RN AA reported that Resident #108 was sent out to the hospital. RN AA reported that maybe a week prior to the incident on 7/18/16 she had told day shift nurse to talk to the family about the long gowns Resident #108 wore, and RN AA would watch for her to wear the gowns, but Resident #108 would change clothing during the night so she did not always see her in the gown. RN AA reported that if she noticed Resident #108 on the side of the bed she would put her back to bed because Resident #108 does not realize she is not independent. In an interview on 8/10/16 at 12:55 p.m., Director of Nursing (DON) B reported that Resident #108 was independent and safe when she was up in her room and the MDS data was just a tool to use for a guideline, not to have to use. In an interview on 8/10/16 at 1:45 p.m., OT AG reported that Resident #108 was safe when she was up walking, but not sleeping on the side of the bed and that she had fallen from the side of the bed before she hurt her neck. In an interview on 8/10/16 at 3:30 p.m., LPN Z reported that Resident #108 was safe in her room, but really busy, washes clothes in the sink and hangs them to dry, washes her hair in the sink, she was non stop. LPN Z reported that Resident #108 was not sleeping, moving all the time and was not sure if Resident #108 had any medication to help her sleep at night. LPN Z reported that Resident #108 does fall asleep sitting on the side of the bed and staff tries to check on her to see if she has sat down. LPN Z reported that during the shift that she works Resident #108 will be found sleeping on the side of the bed 2-3 times and she was not sure what was on the care guide for this. LPN Z reported that after Resident #108 fell and broke her neck the action plan to prevent falls included rearranging her room, de[DIAGNOSES REDACTED], and having long gowns removed. In an interview on 8/10/16 at 1:17 p.m., CNA M reported that Resident #108 was reckless, very busy, moves around so much and wears self out. CNA M reported that Resident #108 was up and down all day and night, she will fold her clothes, wash them or her hair in the sink in the bathroom and that staff try and watch for her to sit on the side of the bed so they can ask her if she want s to lay down. In an interview on 8/10/16 at 1:30 p.m., CNA Y reported, she did not feel Resident #108 was safe in her room by herself, she falls asleep on the edge of her bed or will try and bend over when she was sitting on the edge of the bed to pick up the facility cat and wants to put it on her bed. CNA Y reported that Resident #108's roommate reported that she had seen Resident #108 sit on the corner or edge of her bed, nod off, and slip off bed. CNA Y reported that staff can tell her to use her call light or to lay down in bed, but she is own person and does what she wants.

This citation pertains to intake number MI 867. Based on observation, interview and record review, the facility failed to prevent worsening of pressure ulcers in 1 of 4 sampled residents (Resident #103) reviewed for pressure ulcers, in a total sample of 9 residents, resulting in the worsening of the buttock ulcer and heel ulcer, pain and the potential for systemic infection. Findings include: Review of the facility Turning and Repositioning Program dated (revised) April 2009, reflected the The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. Interventions/Care Strategies-2. For residents that recline and depend on staff for repositioning, change positions at least every 2 hours. If resident has a Stage I or above pressure ulcer, every 2 hour turning may be inadequate .Documentation-The following information should be recorded in the resident's medical record: 10. The effectiveness of the pressure relief regime and steps taken if ineffective. Review of the facility Prevention of Pressure Ulcers dated 3/23/2011, reflected The purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. 1. Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue .Additional Factors That Indicate Residents at Risk- The following are addition clinical conditions, treatments, and abnormal lab values that indicate that a resident is at risk for pressure ulcers: 1. Impaired/decreased mobility and decreased functional ability; 2. co-morbid conditions, .[MEDICAL CONDITION] disease 7. Exposure of skin to urinary and fecal incontinence; 9. a healed ulcer. The history of a healed pressure ulcer and its stage (if known) is important, since areas of healed Stage III or IV pressure ulcers are more likely to have recurrent breakdown. Review of the facility Pressure Ulcer Protocol - Avoidable vs. Unavoidable Pressure Ulcers dated 3/23/11, reflected a pressure ulcer is defined as any [MEDICAL CONDITION] caused by unrelieved pressure resulting in damage to underlying tissue, and are classified based on depth of penetration through soft tissue layers to bone. The facility must establish that it provided the care that was reasonably necessary to prevent the formation of pressure ulcers unless clinically unavoidable, and must institute prevention measures promptly for any individual identified at high risk for developing pressure ulcers.5. Implement care planned interventions - for all selected medical conditions and risk factors identified on admission, or on at risk assessment including, but not limited to: b Minimize prolonged pressure in bed or chair- .heel relief d. Identifying repositioning needs- it is important to assess each resident individually to determine appropriate turning needs. For some, repositioning every two hours in bed may be adequate. For others, repositioning every hour may be necessary to minimize the potential for skin breakdown. For persons in a chair or to provide heel relief, every hour repositioning is important to support skin integrity. Review of the Admission Record and Minimum Data Sheet ((MDS) dated [DATE], reflected Resident #103 was a [AGE] year old female re-admitted to the facility on [DATE]. The MDS and Admission Record reflected Resident #103's [DIAGNOSES REDACTED]. The MDS reflected that Resident #103's ability to make daily decisions was moderately impaired and she currently required the assistance of one to two staff member for transfer, bed mobility, toileting, hygiene, and bathing. Review of the Pressure Ulcer Care Area Assessment (CAA) dated 3/22/16, reflected Resident #103 readmits with two unstageable wounds. They are on her bilateral heels. She is wearing heel protection per order. Staff to assess heels weekly and as needed. Notify MD of changes. Encourage heel elevation. Staff to encourage and asssit with frequent reposition. Review of the Skin Integrity Assessment : Prevention and Treatment Care Plan dated 4/23/15, reflected Resident #103 was a Moderate Risk for skin breakdown. Review of the Pressure Ulcer Care Plan dated 3/21/16, reflected Focus- The resident has pressure ulcers related to dementia with behaviors, decreased mobility, and major [MEDICAL CONDITION]. Right heel unassuageable area of pressure, and area of pressure to right buttocks-unassuageable .Interventions/Task-s Avoid positioning the resident with heels on bed .Evaluate dressing every shift and as needed to ensure it is intact and adhering. Report loose dressing to treatment nurse .Float heels while in bed with pillows. Review of the Record of In-Service dated 7/1/16-7/6/16, reflected Yellow Dot Program: Yellow Dot on the name plate outside of room means they are at risk for pressure and/or have pressure and need to be repositioned every two hours. Yellow Dot will be on the care guide and plan of care. A Norton (skin) score completed in admission packet - a score of 10 or less means they are at risk for pressure and need to be added to the Yellow Dot Program. Right Heel Wound Review of the Wound Notes dated 2/18/16, reflected unassuageable right heel, [MEDICATION NAME] tissue (outer layer of body tissue), measurement 9.5 x 9.0, pressure reducing chair, pressure reducing device for bed, turn program, treatment as ordered. Review of the Wound Notes dated 3/18/16, reflected unassuageable right heel, necrotic tissue (dead), measurement 4.0 x 4.8, painful, pressure reducing chair, pressure reducing device for bed, turn program, treatment as ordered. Review of the Wound Notes dated 3/24/16, reflected unassuageable right heel, necrotic tissue, measurement 4.3 x 4.7, clear light drainage, painful, pressure reducing chair, pressure reducing device for bed, turn program, treatment as ordered. Review of the Wound Notes dated 3/31/16, reflected unassuageable right heel, necrotic tissue, measurement 4.6 x 4.7 x 0.1, red sanguinous(blood mixed with fluid), light drainage, painful, pressure reducing chair, pressure reducing device for bed, turn program, treatment as ordered. Review of the Wound Notes dated 4/4/16, reflected unassuageable right heel, necrotic tissue, measurement 5.5 x 6.7 x 0.1, brown/red sanguinous(blood mixed with fluid), light drainage, painful, pressure reducing chair, pressure reducing device for bed, turn program, treatment as ordered. Review of the Wound Notes dated 4/13/16, reflected unassuageable right heel, necrotic tissue, measurement 7.7 x 7.6 x 0.1,brown/ red sanguinous(blood mixed with fluid), light drainage, painful, pressure reducing chair, pressure reducing device for bed, turn program, treatment as ordered. Review of the Wound Notes dated 4/22/16, reflected unassuageable right heel, necrotic tissue, measurement 9.6 x 7.5 x 0.2, brown sanguinous(blood mixed with fluid), light drainage, painful, pressure reducing chair, pressure reducing device for bed, turn program, treatment as ordered. Review of the Report of Consultation dated 4/25/16 at 2:00 p.m., reflected unassuageable pressure ulcer right heel. Review of the Wound Clinic Notes dated 5/10/16, reflected site Black; Necrotic; Eschar, 7.3 cm x 5.7 cm x unable, moderate, brown drainage with foul odor, measurements after debridement (remove dead damaged or infected tissue) 10.7 cm x 10.5 cm x unable. Review of the Wound Clinic Notes dated 5/17/16, reflected Resident #103 does not have her prevalon foam protective boots on (3rd visit without wearing them) .Nurse Practitioner called and spoke to the Director of Nursing at facility regarding the need for patient to wear her foam boots for protection and padding. Review of the Wound Clinic Notes dated 5/23/16, reflected Resident #103's right and left heel had unassuageable heel pressure ulcers. Review of the Wound Clinic Note reflected right heel wound continues and has become larger. Prevalon boots at all time to avoid continued heel pressure. 5.9 cm x 6.2 cm, moderate, Brown; Tan; Yellow; drainage with foul odor. She is to wear her prevalon boots when in bed and float heels off the bed. And at all times. Review of the Wound Clinic Notes dated 6/21/16, reflected Resident #103 arrived at the wound clinic prevalon boots are not on. Review of the Wound Notes dated 8/2/16, reflected right heel thickness Stage III, measurements 6.0 x 6.0 x 0.2, light drainage. Right Buttock Review of the Treatment Administration Record TAR dated 6/1/16-6/30-16, reflected 6/3/16 cleanse open area right lower buttock with normal saline pat dry. apply solosite (skin treatment) to open area and cover with cover-site every day and as needed until healed. out of 27 opportunities 10 were not completed, there was no indication that the order had changed and stopped on 6/22/16. An order was written Cleanse open area right lower buttock with normal saline, pat dry. apply solosite to wound cover with Allevyn change every 7 days and prn until healed, 1 opportunities were completed, no start date was noted and the order was not found in the records on the 7/1/16 -7/31/16 TAR available at the time of the survey, from 8/2/16- 8/10/16. Review of the Wound Notes dated 7/8/16, reflected pressure ulcer to right buttocks, slough (mass of dead tissue), measurements 3.5 x 3.5 x 0.2, moderate yellow drainage, pressure reducing chair, pressure reducing device for bed, turn program. Review of the Wound Notes dated 7/15/16, reflected pressure ulcer to right buttocks, slough (mass of dead tissue), measurements 3.0 x 3.5 x 2.5, moderate yellow drainage, pressure reducing chair, pressure reducing device for bed, turn program. Review of the Physician Phone Order dated 7/15/16, reflected wound clinic to evaluate and make recommendations for right buttock, wound culture to be obtained. Review of the physician progress notes [REDACTED].#103 was being seen to re-evaluate wound to right buttock, increased odor, increased drainage, deeper said tender ow with wound care. The Progress Note reflected depth 1.5 - 2 cm. Review of the Wound Notes dated 7/20/16, reflected pressure ulcer to right buttocks, stage IV, granulated (new) tissue, measurements 3.0 x 3.5 x 0.2, moderate yellow drainage, pressure reducing chair, pressure reducing device for bed, turn program. Review of the Wound Notes dated 7/28/16, reflected pressure ulcer to right buttocks, stage IV, slough (mass of dead tissue), measurements 3.0 x 2.5 x 2.5, moderate yellow sero-sanguious drainage, pressure reducing chair, pressure reducing device for bed, turn program. Review of the Wound Notes dated 8/2/16, reflected right buttocks, pressure wound Stage IV, light drainage, measurement 3.0 x 2.5 x 2.5. Review of the Interdisciplinary Team (IDS) notes dated 3/17/16-3/21/16 reflected new orders obtained for bilateral heels 3/21/16 no other discussion was noted prior to 7/20/16 met to review chart as resident has pressure to right buttocks that has improved in the last 5 days. There is less necrotic tissue and more granulation tissue noted.Right heel continues to remain free from s/sx of infection Review of a Physician Telephone Order dated 8/5/16 revealed facility staff were to check dressing (for intactness and if change needed) at each shift. During an observation on 8/5/16 at 10:37 a.m., Licensed Practical Nurse (LPN) AD and Certified Nursing Assistant (CNA) AC removed covers from Resident #103's lower extremities and her legs were up on the padded foot rest with heels in protective boot. A dressing dated 8/3/16 was noted on the right heel, a dime to nickle size of black gel was noted on the dressing when it was removed. The heel wound was about a half inch larger that a half dollar coin with areas of uneven skin and appeared about a 1/4 inch deep in areas. A new dressing was applied per physician orders. The brief was removed from Resident #103, watery blackish stool was noted, perineal care was completed and Resident #103 was rolled to her left side. There was no dressing on the wound or in the resident's brief and blackish watery stool was noted in the wound. The wound was cleaned and a new dressing applied per physician orders. Resident #103 was rolled on her back to secure her brief and the new dressing became unsecured on the lower section and on the right side. This was unnoticed by both CNA AD and LPN AD. In an interview on 8/10 16 at 8:50 a.m., Director of Nursing (DON) B and Regional Clinical Consultant (RCC) AH reported that Resident #103 was diagnosed with [REDACTED].#103 was being turned and repositioned as needed. DON B reported that although it may have been identified that Resident #103 needed to be on the Yellow Dot Program in May 2016 she cannot be sure that it was implemented. DON B reported that heel protection was in place, but may not have been used while Resident #103 was up in her chair and that could have caused additional pressure on the heel wounds, she could not be sure. DON B and RCC AH reported that Resident #103 had a nutrition review on 3/24/16 and 6/18/16, and that dietary did a review in May but did not voice any concerns. DON B and RCC AC reported that Resident #103 had a low air loss mattress in place and a cushion for her wheelchair. In an interview on 8/9/16 at 8/9/16 at 9:15 a.m., Regional Clinical Coordinator (RCC) Registered Nurse (RN) reported that a past non compliance for pressure ulcers was put in place on 5/23/16, residents at risk were place in the yellow dot program so that all staff would know who was at risk. RCC AB reported that during a quality assurance meeting in July the past non compliance for pressure ulcer was re-evaluated, because more information was brought to light and the follow through from May meeting was not completed. The facility requested a Past Non-Compliance (PNC) with an alleged compliance date of 8/4/16, two days after this surveyor entered the facility. The PNC was not accepted due to monitoring for correction had not yet been started (no paperwork provided) and sustained compliance was unable to be verified. #

This citation pertains to intake number MI 866. Based on observation, interview, and record review, the facility failed to use to appropriate transfer method in 1 of 3 residents reviewed (Resident #103) for transfer status of a total of 5 sampled residents, resulting in a fracture and/or worsening of an existing fracture. Findings include: According to the Face Sheet dated 7/23/13, and [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), dated [DATE], Resident #103 scored a "5" on the Brief Interview for Mental Status (a scale used to determine cognitive ability). A score of a "5" indicated Resident #103 was severely cognitively impaired. In addition, the MDS listed Resident #103 as totally dependent on the assistance of two staff members to transfer from the wheelchair to the bed under the "Functional Status" section. This indicated that Resident #103 could not assist with transferring. According to the "Resident Lifting, Transferring, and Repositioning Data Collection" form, dated 9/13/13, Resident #103 was to be transferred using a hoyer (a device used to transfer a resident when the resident can not help with the transfer) with 2 person assist (assistance). According to the "Daily Worksheet for the Nursing Assistant", dated 9/23/13, Resident #103 was to be transferred using a maxi lift (a type of hoyer device). According to Resident #103's "ADL (Activities of Daily Living)/ Mobility Plan of Care", dated 9/13/13, Resident #103 was to be transferred using a TL (total lift) (which a hoyer lift is) X 2 (with 2 assist). According to the Facility Incident Report- 5 Working Days, dated 9/30/13, while attempting to prepare Resident #103 for a transfer using a sit-to-stand lift (a device used to assist a resident into a standing position from a seated position), facility staff discovered Resident #103 had a right tibial fracture (a broken right leg bone) on 9/23/13. In addition, Resident #103 was noted to have bruises to both lower legs that were "caused by the initiation of the sit to stand lift, her legs against the leg rests of the lift with a noted elevated PT/INR (a laboratory value used to determine bleeding time) level of 9.6 (critically high)". According to the radiology report, dated 9/24/13, Resident #103 had an impacted communuted tibial fracture (a fracture in which one broken end is wedged into the other broken end) of the right leg. "Injuries caused by collisions, falls, or any other accident are the primary causes of impacted fracture. Elderly people are more prone to this type of fracture as their bones are fragile" (orthopedics.ygoy.com, 2013). According to Resident #103's nursing progress note, dated 9/23/13 at 2155 (9:55 p.m.), "Resident transferring with sit to stand (an assistive device used when a resident can help with standing up), (R) (right) leg bent abnormally observed bruising on (R) leg. increased swelling, (R) leg warmer than left leg. Pedal pulse present bilaterally (pulse on left and right feet). Unable to bear weight on right leg. c/o (complained of) pain in right leg stated "oh thats burning pain". pain level of 6 on faces scale (a scale used to determine pain for residents unable to express pain level verbally)" (sic). According to the emergency department nurse's notes, dated 9/24/13 at 0026 (12:26 a.m.), the emergency room nurse spoke with Registered Nurse (RN) "S" and RN "S" "explained tech (nursing assistant) transferred pt (patient) (Resident #103) from sitting position to standing position, bearing weight on feet and noticed right leg was bent abnormal. RN "S" states pt has been transferred by a lift for the past 2 days". On 10/8/13 at 3:20 p.m., Licensed Practical Nurse (LPN) "G" was interviewed regarding the incident on 9/23/13. LPN "G" stated Certified Nursing Assistant (CNA) "F" told her that Resident #103's "leg doesn't look right". LPN "G" stated when she entered Resident #103's room, she noticed Resident #103 was pulled up to the sit-to-stand, both legs were straight, the sling was around Resident #103's waist and attached to the sit-to-stand, the strap was around Resident #103's left leg and attached to the sit-to-stand but loose, and Resident #103's right leg wasn't strapped onto the machine. LPN "G" stated Resident # 103's right leg "had a lot of bruising and was almost bowed (abnormally bent). LPN "G" stated she had to tell CNA "E" and CNA "F" to stop using the sit-to-stand and to use the hoyer lift to transfer Resident #103 to the bed for an assessment of the right leg. LPN "G" stated that she was under the impression CNA "E" and CNA "F" had tried to use the sit-to-stand, but when she asked them a second time what happened CNA "E" and CNA "F" stated they had not tried to stand Resident #103 with the sit-to-stand. LPN "G" also stated that Resident #103's transfer device was changed from a sit-to-stand to a hoyer lift about 2 weeks before this incident occurred. On 10/8/13 at 4:10 p.m., CNA "E" was interviewed regarding the incident on 9/23/13. CNA "E" stated, "We (CNA "E" and CNA "F") were going to hook her (Resident #103) up to the sit-to-stand and I noticed the right leg was lying straight. The leg didn't look right. I didn't know she was a hoyer (lift)". "I told them I started to use the wrong lift". "We didn't use the sit-to-stand because her leg didn't look right". CNA "E" stated she ignored Resident #103's complaint of pain because "she always says you're breaking my hand or leg". CNA "E" denied attaching the sling around Resident #103's waist because "you have to get the legs hooked up first". On 10/9/13 at 9:15 a.m., Resident #103 was interviewed regarding the incident on 9/23/13. Resident #103 stated she did not know how her leg was broken. On 10/9/13 at 9:30 a.m., Certified Nursing Assistant "F" was interviewed regarding the incident on 9/23/13. CNA "F" stated, "I saw her leg was bent. We couldn't get the strap on her leg (used to secure the leg to the sit-to-stand). Her leg wouldn't go on the foot pedal (of the sit-to-stand)". In addition, CNA "F" stated, "I used the sit-to-stand to transfer her the day before (9/22/13). She was fine the day before and went into her chair". On 10/9/13 at 9:50 a.m., CNA "J" was interviewed regarding the incident on 9/23/13. CNA "J" stated she worked first shift that day and Resident #103 complained more than usual about pain. CNA "J" stated she notified LPN "L" that Resident #103 was complaining more of pain than she usually does. On 10/9/13 at 10:05 a.m., Director of Nursing (DON) "B" was interviewed regarding Resident #103's fracture. DON "B" stated that prior to 9/13/13, Resident #103 was having difficulty with transfers. DON "B" stated Resident #103 was not able to bear weight on 9/13/13 and Resident #103's transfer status was changed to a hoyer lift at that time as a result. DON "B" stated, "She (Resident #103) was a transfer risk and not safe (to transfer with a sit-to-stand). That's why she was changed to a total lift on 9/13". In addition, DON "B" stated that the bruises that were on Resident #103's lower legs were consistent with use of the sit-to-stand. When asked about the type of fracture Resident #103 had and what could have caused it, DON "B" stated, "The impact fracture is one in which it would have been caused by standing". On 10/9/13 at 11:00 a.m., Resident #103's legs were observed while Resident #103 was in bed in her room. LPN "L" was present. Resident #103 had a large hematoma (an area where blood has collected and clotted) on the lower left leg approximately meatball size. In addition, an area of discoloration was observed on Resident #103's right lower leg at approximately the same height as the heamtoma on the left leg. LPN "L" verified these observations. LPN "L" stated, "That's where they noticed the swelling. I think her leg was slammed against something". LPN "L" confirmed CNA "J" had notified her the day before about Resident #103's increased pain. LPN "L" stated she immediately assessed Resident #103 and did not see any abnormalities at the time. On 10/10/13 at 11:40 a.m., emergency room Charge Nurse/ Trauma Nurse (TN) "T" was interviewed regarding the amount of time it takes for visible signs of a fracture to appear (for example swelling) on a leg in an obese person. TN "T" stated that it could depend, however "with a lower extremity you should see it (swelling) generally within 12-24 hours". On 10/10/13 at 3:20 p.m., RN "S" (the nurse who took over care after Resident #103 was found to have a fracture) was interviewed regarding shift report on the night of 9/23/13 and what she had been told happened to Resident #103. RN "S" stated, "My understanding is when she was transferred she (Resident #103) complained of pain. She complained of the pain after she was transferred. She complained of pain after she was transferred, not before". According to the "Pain Data Collection and Assessment" form, dated 9/13/13, Resident #103 had no complaints of pain (prior to the incident). According to the "Pain Data Collection and Assessment" form, dated 9/24/13 (the day after the incident occurred), Resident #103 had a pain level of "8" ("0"=no pain and "10"= worst pain ever experienced) on the Face Pain Scale (a scale used to determine amount of pain in a resident who is not able to verbally rate pain because of confusion). In addition, the form revealed Resident #103 had impaired mobility, changes in daily activities, and change in appetite. According to the "Pain Data Collection and Assessment" form, dated 10/1/13, Resident #103 had a change in physical activity over the last 5 days. In addition, Resident #103 made vocal complaints of pain ("stop", "ouch", "that hurts") , facial expressions (wrinkled brow) , and used protective body movements (bracing). According to Resident #103's physician order, dated 9/5/13, prior to Resident #103 sustaining a fracture she had tylenol scheduled twice a day for pain. According to Resident #103's physician order, dated 10/3/13, Resident #103's pain medications were changed from scheduled tylenol to scheduled norco 5/325mg (milligrams) (a narcotic for pain) every 6 hours. This increase in pain medication and timing of administration of pain medication, coupled with the pain assessments, indicated Resident #103 had a substantial increase in pain as a result of the fracture.

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO TRANSCRIBE INFORMATION RELATED TO A FOOD ALLERGY, FAILED TO DISSEMINATE RESIDENT ALLERGY INFORMATION TO THE RESIDENT CARE STAFF AND FOOD SERVICE DEPARTMENT, AND FAILED TO ENSURE THAT FOODS SERVED WERE IN ACCORDANCE WITH physician's orders [REDACTED].#29) AND 1 SAMPLE RESIDENT REVIEWED FOR FOOD ALLERGIES, FROM A TOTAL SAMPLE OF 10 RESIDENTS, RESULTING IN RESIDENT #29 CONSUMING A FACILITY PROVIDED DESSERT CONTAINING BANANAS (A FOOD TO WHICH RESIDENT #29 WAS SEVERELY ALLERGIC), PLACING HER IN IMMEDIATE JEOPARDY TO HER HEALTH AND SAFETY. RESIDENT #29 DEVELOPED SYMPTOMS OF TINGLING IN HER TONGUE WITH IN ONE HOUR OF EATING HER EVENING MEAL AND SUBSEQUENTLY EXPIRED. THE IMMEDIATE JEOPARDY (IJ) WAS IDENTIFIED ON [DATE] AT APPROXIMATELY 10:30 A.M. THE IMMEDIATE JEOPARDY BEGAN ON [DATE] AT APPROXIMATELY 7:30 P.M. WHEN, ACCORDING TO THE FACILITY REPORTED INCIDENT (FRI) DOCUMENT FOR THAT SAME DATE, THE FOLLOWING OCCURRED: "(RESIDENT #29) REPORTED THAT HER TONGUE WAS TINGLING AND THAT SHE WAS ALLERGIC TO BANANAS AND THOUGHT THAT THERE WERE BANANAS IN HER DESSERT..." ACCORDING TO THE FRI, FACILITY NURSING STAFF IMMEDIATELY ASSESSED RESIDENT #29 AND "NOTIFIED THE PHYSICIAN THAT (RESIDENT #29) HAD EATEN A DESSERT CONTAINING BANANAS WHICH THE MEDICAL RECORD INDICATED SHE WAS ALLERGIC TO. ORDERS WERE OBTAINED TO ADMINISTER [MEDICATION NAME] 1:1000, 1 MILLIGRAM (MG) IM (INTRAMUSCULAR) NOW AND TRANSPORT TO THE EMERGENCY DEPARTMENT FOR EVALUATION." ACCORDING TO THE FRI, RESIDENT #29 RETURNED to the facility on [DATE] AT APPROXIMATELY 10:30 P.M. HOWEVER, AT APPROXIMATELY 11:00 P.M. THAT EVENING, RESIDENT #29 STARTED TO COMPLAIN THAT SHE WAS NOT RECEIVING OXYGEN THROUGH HER NASAL CANNULA (DEVICE THAT DELIVERS OXYGEN TO THE RESIDENT'S NASAL PASSAGES). RESIDENT #29 CONTINUED TO COMPLAIN OF DIFFICULTY BREATHING. RESIDENT #29 REMAINED AWAKE, BUT HER OXYGEN SATURATION LEVELS DROPPED TO 50% (NORMAL OXYGEN SATURATION IS GREATER THAN 90%). AT APPROXIMATELY 11:20 P.M. THE AMBULANCE WAS CALLED, AND RESIDENT #29 WAS TRANSPORTED BACK TO THE emergency room . LATER THAT SAME NIGHT, AT APPROXIMATELY 1:30 A.M., THE FACILITY RECEIVED A CALL INDICATING THAT RESIDENT #29 HAD PASSED AWAY. ACCORDING TO THE FACILITY'S "ROOT CAUSE ANALYSIS OF THE EVENTS" (ON THE DOCUMENT TITLED "PAST NONCOMPLIANCE FOR ALLERGIC REACTION [DATE]") THEY HAD DETERMINED THE FOLLOWING: 1) THE NURSE TRANSCRIBING admission orders DIETARY COMMUNICATION TICKET." 2) THE CLINICAL DIETARY MANAGERS (CDM) DID NOT IDENTIFY RESIDENT #29'S ALLERGIES ON THE NUTRITIONAL ASSESSMENT. 3) RESIDENT #29'S DIET ORDER DID NOT HAVE BANANAS IDENTIFIED AS AN ALLERGY. THE CDM HAD DONE THE FOOD PREFERENCE SHEET, AND HAD NOTED BANANAS AS AN ALLERGY, BUT DID NOT PUT IT ON THE RESIDENT'S FOOD TICKET. THE FACILITY ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON [DATE] AT 1:15 P.M., AND A WRITTEN PLAN FOR REMOVAL WAS REQUESTED. ON [DATE] AT APPROXIMATELY 1:30 P.M. THE IMMEDIATE JEOPARDY WAS REMOVED WHEN THE FOLLOWING WERE VERIFIED: - RESIDENT MEDICAL RECORDS, INCLUDING NEW ADMISSIONS, WERE REVIEWED BY THE FACILITY FOR FOOD ALLERGIES FOR ALL 77 RESIDENTS RESIDING IN THE FACILITY AS OF [DATE]. - DIET TICKETS WERE AUDITED FOR ALL RESIDENTS TO VERIFY THAT FOOD ALLERGIES WERE CLEARLY IDENTIFIED. - ALL RESIDENT MEDICATION ADMINISTRATION RECORDS (MAR'S), TREATMENT ADMINISTRATION RECORDS (TAR'S), DIET TICKETS, ALLERGY STICKERS (AFFIXED TO THE FRONT OF THE MEDICAL CHARTS) AND PHYSICIAN ORDERS [REDACTED]. - ALL (100%) OF THE FACILITY'S LICENSED NURSING STAFF HAD BEEN RE-EDUCATED REGARDING (1) TRANSCRIBING ORDERS THAT CORRECTLY IDENTIFIED ALLERGIES AND (2) FILLING OUT NUTRITIONAL SERVICES REQUEST FORMS. - ALL (100%) OF THE FACILITY'S DIETARY MANAGERS HAD BEEN RE-EDUCATED REGARDING DOCUMENTING COMPLETE AND ACCURATE RESIDENT ADMISSION NUTRITIONAL ASSESSMENTS. - ALL (100%) OF THE NURSING MANAGEMENT STAFF HAD BEEN EDUCATED REGARDING UPDATING RESIDENT CARE-GUIDES WITH ALL ALLERGIES IDENTIFIED THAT WERE APPLICABLE TO NURSING ASSISTANTS PROVIDING CARE. - ALL ONGOING MONITORING RELATED TO IDENTIFIED RESIDENT FOOD ALLERGIES HAD BEEN CONDUCTED AS OF [DATE]. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED AND REMAINED AT A SCOPE AND SEVERITY LEVEL OF A PATTERN WITH THE POTENTIAL FOR MORE THAN MINIMAL HARM, PENDING COMPLETION OF THE FOLLOWING: - ALL NEW RESIDENT ADMISSIONS WOULD FOLLOW THE FACILITY'S NEW INTERNAL PROTOCOL TO ENSURE THE VALIDATION BY TWO CHARGE NURSES OF PHYSICIAN ORDERS, DIET COMMUNICATION SLIPS AND TRAY TICKETS. - ALL NEWLY admitted RESIDENTS' ALLERGIES WOULD BE CHECKED USING THE FACILITY'S AUDIT TOOL, AND ALL ALLERGIES WOULD BE LISTED IN THE APPROPRIATE AREAS AS INDICATED (I.E., RESIDENT MAR'S, TAR'S, DIET TICKETS, ALLERGY STICKERS, CARE-GUIDES AND PHYSICIANS ORDERS). - VALIDATION BY THE STATE AGENCY OF THE FACILITY'S ABILITY TO MAINTAIN SUBSTANTIAL COMPLIANCE RELATED TO THE IDENTIFICATION AND DOCUMENTATION OF ALL RESIDENT ALLERGIES. FINDINGS INCLUDE: RECORD REVIEW OF THE HOSPITAL "PATIENT TRANSFER FORM" DATED [DATE] REFLECTED THAT RESIDENT #29 WAS discharged FROM THE HOSPITAL to the facility on [DATE] WITH THE FOLLOWING KNOWN ALLERGIES: BANANAS, [MEDICATION NAME], IODINE AND [MEDICATION NAME]. RECORD REVIEW OF THE FACILITY'S ADMISSION [DIAGNOSES REDACTED]. REVIEW OF RESIDENT #29'S FACILITY FACE SHEET DATED [DATE] REFLECTED NO DOCUMENTED ALLERGIES; THE SPOT RESERVED FOR THIS INFORMATION HAD BEEN LEFT BLANK. THE FACILITY RESIDENT INCIDENT REPORT DATED [DATE] (TWO WEEKS AFTER THE RESIDENT'S ADMISSION TO THE FACILITY) REFLECTED THE FOLLOWING: "(NAME OF RESIDENT #29) RECEIVED A DESSERT CONTAINING BANANAS WHICH SHE STATES SHE IS ALLERGIC TO. REVIEW OF DIETARY TRAY CARD NOTES NO KNOWN ALLERGY. REVIEW OF CHART NOTES ALLERGY ON STICKER AND admission orders [REDACTED]. STATES THAT THE LAST TIME SHE ATE A BANANA WAS IN 1973 AND SHE WAS IN THE HOSPITAL FOR 9 DAYS. REPORTS TONGUE, EARS AND FACIAL SWELLING WITH BLISTERS AT THAT TIME. CURRENTLY TRESIDENT (SIC) REPORTS TONGUE IS ITCHY/[MEDICATION NAME] GIVEN IM AND SENT TO ER (emergency room ) FOR EVAL..." THE FACILITY INCIDENT REPORT DATED [DATE] FOR THE EVENTS THAT BEGAN ON [DATE] IDENTIFIED THE "TIME OF RESIDENT'S LAST MEAL" AS 6:30 PM. ON [DATE]. THE AMBULANCE/PRE-HOSPITAL CARE SUMMARY REPORT FOR [DATE] DOCUMENTED, AT APPROXIMATELY 7:42 P.M. ON [DATE], THE AMBULANCE ARRIVED AT THE FACILITY TO TRANSPORT RESIDENT #29 TO THE emergency room FOR DISPATCH REASONS OF "HISTORY OF SEVERE ALLERGIC REACTION." THE EMERGENCY MEDICAL SERVICE (EMS) DOCUMENTED THAT AS THEY WERE PULLING UP TO THE emergency room , RESIDENT #29 BEGAN TO STATE THAT SHE WAS GETTING SOME TINGLING IN HER MOUTH. THE emergency room REPORT DOCUMENTED THAT RESIDENT #29 SHOWED COMPLETE RESOLUTION OF HER SYMPTOMS AFTER TREATMENT AND WAS TRANSPORTED BACK TO THE NURSING FACILITY ON [DATE] AT APPROXIMATELY 10:30 P.M. THE FACILITY "RESIDENT INCIDENT" REPORT DATED [DATE] (AS DOCUMENTED UNDER THE HEADINGS "INCIDENT STATUS: IN PROCESS-INVESTIGATOR, CATEGORY: DEATH, SUBCATEGORY: UNEXPECTED") REFLECTED THE FOLLOWING: "RESIDENT HAD EATEN PUDDING WITH BANANAS ON THE BOTTOM OF THE DESSERT DURING DINNER ON THE PREVIOUS SHIFT. RESIDENT HAS AN ALLERGY TO BANANAS. RESIDENT WAS TRANSFERRED TO HOSPITAL AND LATER RETURNED TWO AND A HALF HOURS LATER. RESIDENT WAS IN THE FACILITY APPROXIMATELY AN HOUR AND A HALF BEFORE COMPLAINING OF DIFFICULTY BREATHING. RESIDENT WAS IN ACUTE RESPIRATORY DISTRESS PRIOR TO TRANSFER VIA AMBULANCE (BACK) TO HOSPITAL. HOSPITAL STAFF CALLED LATER TO REPORT THAT RESIDENT HAD EXPIRED AT THE HOSPITAL." A HOSPITAL REPORT (FACSIMILE DATE OF [DATE]) UNDER THE HEADINGS "PHYSICAL EXAM" AND "ALLERGIES" DOCUMENTED: "ALLERGEN BANANAS - REACTIONS [MEDICATION NAME]." THE FACILITY'S "ROOT CAUSE ANALYSIS" OF THE EVENTS (ON THE DOCUMENT TITLED "PAST NONCOMPLIANCE FOR ALLERGIC REACTION [DATE] / RECAPITULATION") REFLECTED THE FOLLOWING: "...AT APPROXIMATELY 10:50 P.M. (ON [DATE]) THE NURSE ASSISTED THE RESIDENT (#29) INTO THE BATHROOM TO VOID AND SHORTLY AFTER THIS THE RESIDENT COMPLAINED OF NOT RECEIVING OXYGEN THROUGH THE NASAL CANNULA. THE NURSE ASSESSED THE CONCENTRATOR (OXYGEN DELIVERY DEVICE) AND FOUND IT TO BE FUNCTIONAL...AT 11:15 P.M. A NEW CANNULA WAS OBTAINED AND APPLIED...THE NURSE INITIATED A PRN (AS NEEDED) NEBULIZER TREATMENT. RESIDENT HAD CONTINUED COMPLAINTS OF DIFFICULTY BREATHING...HER OXYGEN SATURATION WAS CHECKED AT THE TIME AND WAS 50%...AT APPROXIMATELY 11:20 PM EMS (EMERGENCY MEDICAL SERVICES) WAS CALLED. THE AMBULANCE ARRIVED AT 11:25 PM...AT APPROXIMATELY 1:30 AM ON [DATE] TH, THE (FACILITY) RECEIVED A CALL INDICATING (NAME OF RESIDENT #29) HAD PASSED AWAY..." THE AMBULANCE REPORT FOR [DATE] REFLECTED, AT APPROXIMATELY 12:07 A.M., THE AMBULANCE ARRIVED TO TRANSPORT RESIDENT #29 TO THE emergency room FOR DISPATCH REASONS OF "CHEST PAIN/ABNORMAL BREATHING." THE EMS DOCUMENTED: "THE PT (PATIENT) WAS INITIALLY AWAKE AND ALERT WITH NO MAJOR NEURAL DEFICITS NOTED AND NO MAJOR TRAUMA NOTED. PRIOR TO TRANSPORTING THE PT'S LOC (LEVEL OF CONSCIOUSNESS) DIMINISHED RAPIDLY WITH HER BECOMING UNRESPONSIVE TO VERBAL STIMULI..." THE HOSPITAL "emergency room NOTES" FOR ENCOUNTER DATE [DATE] AT APPROXIMATELY 12:58 A.M. REFLECTED: "EMS BROUGHT THE PATIENT IN IN RESPIRATORY DISTRESS WHEN EVALUATING THE PATIENT HERE IN THE EMERGENCY DEPARTMENT TRAUMA ANY (SIC) PATIENT WAS NOTED TO HAVE NO PULSE BY PALPATION OF THE CAROTID OR FEMORAL ARTERIES. CPR (CARDIOPULMONARY RESUSCITATION) WAS STARTED. IT WAS NOTED THE PATIENT WAS IN ASYSTOLE (WITHOUT HEART BEAT). NARRATIVE NOTES ATTACHED WITH THE THE FACILITY'S INVESTIGATION AND "RESIDENT INCIDENT" REPORT FOR THE EVENTS OF [DATE] AND [DATE] DOCUMENTED THAT ON [DATE] AT APPROXIMATELY 1:30 A.M., FACILITY NURSING STAFF RECEIVED A TELEPHONE CALL FROM THE HOSPITAL emergency room NURSE STATING THAT RESIDENT #29 HAD EXPIRED AT THE HOSPITAL. ACCORDING TO THE NOTES, THE HOSPITAL emergency room CHARGE NURSE HAD STATED: "...THE [MEDICATION NAME] GIVEN TO RESIDENT #29 (ON [DATE]) HAD MOST LIKELY WORN OFF BY THE TIME THE RESIDENT HAD REACHED THE NURSING HOME AFTER THE INITIAL HOSPITAL VISIT, EXPLAINING WHY SHE (RESIDENT #29) MAY HAVE HAD A RESPIRATORY RESPONSE AS SHE DID." REVIEW OF THE FACILITY'S MINIMUM DATA SET (MDS) assessment dated [DATE] REFLECTED THAT RESIDENT #29 WAS A [AGE] year OLD FEMALE WHO HAD BEEN ASSESSED BY THE FACILITY AS BEING ALERT AND ORIENTED WITH EXPECTATIONS OF RETURNING HOME TO THE COMMUNITY FOLLOWING HER STAY AT THE FACILITY. THE FACILITY'S "PT (PHYSICAL THERAPY PROGRESS & DISCHARGE SUMMARY) DATED [DATE] INDICATED THAT RESIDENT #29 HAD PASSED HER HOME SAFETY ASSESSMENT ON [DATE]. THE PHYSICAL THERAPIST, STAFF "H" HAD DOCUMENTED THE FOLLOWING COMMENTS ON [DATE]: "PATIENT WAS DOING VERY WELL ALL AROUND. HOME EVALUATION WAS DONE AND PASS AND HAS RECOMMEND FOR 2 MORE WEEKS. I AM SO SHOCK (SIC) THAT PATIENT EXPIRED." BASED ON REVIEW OF THE FACILITY'S CLINICAL RECORDS, RESIDENT #29'S PHYSICIAN'S "HISTORY AND PHYSICAL" DATED [DATE] LISTED NO KNOWN DRUG ALLERGIES (NKDA) UNDER THE HEADING TITLED ALLERGIES. RESIDENT #29'S "NUTRITION RISK DATA COLLECTION AND ASSESSMENT" DATED [DATE] DOCUMENTED NO KNOWN FOOD ALLERGIES (NKFA). HOWEVER, THE ORIGINAL DOCUMENTATION WAS CROSSED OUT AND AMENDED TO REFLECT: "BANANA ALLERGY [DATE]." RESIDENT #29'S FACILITY "FOOD PREFERENCE RECORD" DID NOT REFLECT ANY RESIDENT ALLERGIES BUT, ON [DATE], THE FORM HAD BEEN AMENDED TO REFLECT BANANAS AS AN ALLERGY. RESIDENT #29'S Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. RESIDENT #29'S "NUTRITIONAL RISKS PLAN OF CARE" (INITIATED BY THE FACILITY ON [DATE]) REFLECTED NO ALLERGIES UNTIL IT WAS AMENDED ON [DATE]. RESIDENT #29'S "NURSING COMPREHENSIVE ADMISSION DATA COLLECTION AND ASSESSMENT" DATED [DATE] DOCUMENTED THAT RESIDENT #29 DID HAVE KNOWN ALLERGIES TO BANANAS, [MEDICATION NAME], IODINE AND [MEDICATION NAME], AND THE ORIGINAL PHYSICIAN ORDERS [REDACTED]. THE FACILITY'S "WEEK AT A GLANCE THERAPEUTIC MENU" DOCUMENTED THAT ON [DATE] THE FACILITY HAD SERVED A "BANANA-SPLIT DESSERT" FOR THE EVENING MEAL. RESIDENT #29'S MEAL TICKET FAILED TO IDENTIFY ANY KNOWN FOOD OR MEDICATION ALLERGIES. AFTER REVIEWING THE MEDICAL RECORDS FOR RESIDENT #29, THE FACILITY'S DIRECTOR OF NURSING (DON) WAS INTERVIEWED ON [DATE] AT 08:30 A.M. IN THE CONFERENCE ROOM THAT WAS LOCATED TOWARDS THE BACK OF THE MAIN DINING HALL. WHEN ASKED ABOUT THE CIRCUMSTANCES SURROUNDING RESIDENT #29'S DEATH, THE DON STATED, "WE (THE FACILITY) REALIZE WE HAD A SYSTEMS BREAKDOWN THAT HAD A NEGATIVE OUTCOME FOR (NAME OF RESIDENT #29), BUT THE HOSPITAL PROBABLY SHOULD HAVE NEVER discharged HER BACK TO US." WHEN ASKED SPECIFICALLY ABOUT THE REASONS WHY THE FACILITY HAD SERVED RESIDENT #29 A DESSERT CONTAINING BANANAS, THE DON STATED THAT THE NURSE WHO DID THE admission orders DIETARY COMMUNICATION FORM." THE DIETARY MANAGER (STAFF MEMBER "D") WAS INTERVIEWED ON [DATE] AT APPROXIMATELY 08:30 A.M. WHEN ASKED ABOUT RESIDENT #29, STAFF "D" STATED, "WE'RE NOT POINTING FINGERS HERE AT WHOSE FAULT THIS WAS. IT'S EVERYONE'S RESPONSIBILITY, ESPECIALLY MY OWN. WE (THE FACILITY) ARE CURRENTLY WORKING ON IDENTIFYING ALLERGIES AS PART OF OUR PLAN OF CORRECTION...WE ARE ALL DEVASTATED." REVIEW OF THE FACILITY'S PROCEDURES RELATED TO "ALLERGY IDENTIFICATION" (EFFECTIVE DATE JULY, 2010), THE FOLLOWING WERE DOCUMENTED UNDER PROCEDURES: "1) PAPERS UPON ADMISSION. 2) DOCUMENT RESIDENT ALLERGIES WITH AN ALLERGY ALERT ON THE FRONT OF THE CHART. DOCUMENTATION INCLUDES BUT IS NOT LIMITED TO THE FOLLOWING: NURSING DATA COLLECTION ASSESSMENT, RESIDENT FACE SHEET, CARE DELIVERY GUIDE, MAR, AND TAR. 3) NOTIFY PHARMACY." ACCORDING TO THE FACILITY'S PLAN FOR "ABATEMENT TO REMOVE THE IJ (IMMEDIATE JEOPARDY) THERE WERE 6 OTHER RESIDENTS IN THE FACILITY'S TOTAL CENSUS OF 77 RESIDENTS WHO WERE IDENTIFIED AS HAVING FOOD ALLERGIES. ( )

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO TRANSCRIBE INFORMATION RELATED TO A FOOD ALLERGY, FAILED TO DISSEMINATE RESIDENT ALLERGY INFORMATION TO THE RESIDENT CARE STAFF AND FOOD SERVICE DEPARTMENT, AND FAILED TO ENSURE THAT FOODS SERVED WERE IN ACCORDANCE WITH physician's orders [REDACTED].#29) AND 1 SAMPLE RESIDENT REVIEWED FOR FOOD ALLERGIES, FROM A TOTAL SAMPLE OF 10 RESIDENTS, RESULTING IN RESIDENT #29 CONSUMING A FACILITY PROVIDED DESSERT CONTAINING BANANAS (A FOOD TO WHICH RESIDENT #29 WAS SEVERELY ALLERGIC), PLACING HER IN IMMEDIATE JEOPARDY TO HER HEALTH AND SAFETY. RESIDENT #29 DEVELOPED SYMPTOMS OF TINGLING IN HER TONGUE WITH IN ONE HOUR OF EATING HER EVENING MEAL AND SUBSEQUENTLY EXPIRED. THE IMMEDIATE JEOPARDY (IJ) WAS IDENTIFIED ON [DATE] AT APPROXIMATELY 10:30 A.M. THE IMMEDIATE JEOPARDY BEGAN ON [DATE] AT APPROXIMATELY 7:30 P.M. WHEN, ACCORDING TO THE FACILITY REPORTED INCIDENT (FRI) DOCUMENT FOR THAT SAME DATE, THE FOLLOWING OCCURRED: (RESIDENT #29) REPORTED THAT HER TONGUE WAS TINGLING AND THAT SHE WAS ALLERGIC TO BANANAS AND THOUGHT THAT THERE WERE BANANAS IN HER DESSERT. ACCORDING TO THE FRI, FACILITY NURSING STAFF IMMEDIATELY ASSESSED RESIDENT #29 AND NOTIFIED THE PHYSICIAN THAT (RESIDENT #29) HAD EATEN A DESSERT CONTAINING BANANAS WHICH THE MEDICAL RECORD INDICATED SHE WAS ALLERGIC TO. ORDERS WERE OBTAINED TO ADMINISTER [MEDICATION NAME] 1:1000, 1 MILLIGRAM (MG) IM (INTRAMUSCULAR) NOW AND TRANSPORT TO THE EMERGENCY DEPARTMENT FOR EVALUATION. ACCORDING TO THE FRI, RESIDENT #29 RETURNED to the facility on [DATE] AT APPROXIMATELY 10:30 P.M. HOWEVER, AT APPROXIMATELY 11:00 P.M. THAT EVENING, RESIDENT #29 STARTED TO COMPLAIN THAT SHE WAS NOT RECEIVING OXYGEN THROUGH HER NASAL CANNULA (DEVICE THAT DELIVERS OXYGEN TO THE RESIDENT'S NASAL PASSAGES). RESIDENT #29 CONTINUED TO COMPLAIN OF DIFFICULTY BREATHING. RESIDENT #29 REMAINED AWAKE, BUT HER OXYGEN SATURATION LEVELS DROPPED TO 50% (NORMAL OXYGEN SATURATION IS GREATER THAN 90%). AT APPROXIMATELY 11:20 P.M. THE AMBULANCE WAS CALLED, AND RESIDENT #29 WAS TRANSPORTED BACK TO THE emergency room . LATER THAT SAME NIGHT, AT APPROXIMATELY 1:30 A.M., THE FACILITY RECEIVED A CALL INDICATING THAT RESIDENT #29 HAD PASSED AWAY. ACCORDING TO THE FACILITY'S ROOT CAUSE ANALYSIS OF THE EVENTS (ON THE DOCUMENT TITLED PAST NONCOMPLIANCE FOR ALLERGIC REACTION [DATE]) THEY HAD DETERMINED THE FOLLOWING: 1) THE NURSE TRANSCRIBING admission orders [REDACTED]. 2) THE CLINICAL DIETARY MANAGERS (CDM) DID NOT IDENTIFY RESIDENT #29'S ALLERGIES ON THE NUTRITIONAL ASSESSMENT. 3) RESIDENT #29'S DIET ORDER DID NOT HAVE BANANAS IDENTIFIED AS AN ALLERGY. THE CDM HAD DONE THE FOOD PREFERENCE SHEET, AND HAD NOTED BANANAS AS AN ALLERGY, BUT DID NOT PUT IT ON THE RESIDENT'S FOOD TICKET. THE FACILITY ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON [DATE] AT 1:15 P.M., AND A WRITTEN PLAN FOR REMOVAL WAS REQUESTED. ON [DATE] AT APPROXIMATELY 1:30 P.M. THE IMMEDIATE JEOPARDY WAS REMOVED WHEN THE FOLLOWING WERE VERIFIED: - RESIDENT MEDICAL RECORDS, INCLUDING NEW ADMISSIONS, WERE REVIEWED BY THE FACILITY FOR FOOD ALLERGIES FOR ALL 77 RESIDENTS RESIDING IN THE FACILITY AS OF [DATE]. - DIET TICKETS WERE AUDITED FOR ALL RESIDENTS TO VERIFY THAT FOOD ALLERGIES WERE CLEARLY IDENTIFIED. - ALL RESIDENT MEDICATION ADMINISTRATION RECORDS (MAR'S), TREATMENT ADMINISTRATION RECORDS (TAR'S), DIET TICKETS, ALLERGY STICKERS (AFFIXED TO THE FRONT OF THE MEDICAL CHARTS) AND PHYSICIAN ORDERS [REDACTED]. - ALL (100%) OF THE FACILITY'S LICENSED NURSING STAFF HAD BEEN RE-EDUCATED REGARDING (1) TRANSCRIBING ORDERS THAT CORRECTLY IDENTIFIED ALLERGIES AND (2) FILLING OUT NUTRITIONAL SERVICES REQUEST FORMS. - ALL (100%) OF THE FACILITY'S DIETARY MANAGERS HAD BEEN RE-EDUCATED REGARDING DOCUMENTING COMPLETE AND ACCURATE RESIDENT ADMISSION NUTRITIONAL ASSESSMENTS. - ALL (100%) OF THE NURSING MANAGEMENT STAFF HAD BEEN EDUCATED REGARDING UPDATING RESIDENT CARE-GUIDES WITH ALL ALLERGIES IDENTIFIED THAT WERE APPLICABLE TO NURSING ASSISTANTS PROVIDING CARE. - ALL ONGOING MONITORING RELATED TO IDENTIFIED RESIDENT FOOD ALLERGIES HAD BEEN CONDUCTED AS OF [DATE]. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED AND REMAINED AT A SCOPE AND SEVERITY LEVEL OF A PATTERN WITH THE POTENTIAL FOR MORE THAN MINIMAL HARM, PENDING COMPLETION OF THE FOLLOWING: - ALL NEW RESIDENT ADMISSIONS WOULD FOLLOW THE FACILITY'S NEW INTERNAL PROTOCOL TO ENSURE THE VALIDATION BY TWO CHARGE NURSES OF PHYSICIAN ORDERS, DIET COMMUNICATION SLIPS AND TRAY TICKETS. - ALL NEWLY admitted RESIDENTS' ALLERGIES WOULD BE CHECKED USING THE FACILITY'S AUDIT TOOL, AND ALL ALLERGIES WOULD BE LISTED IN THE APPROPRIATE AREAS AS INDICATED (I.E., RESIDENT MAR'S, TAR'S, DIET TICKETS, ALLERGY STICKERS, CARE-GUIDES AND PHYSICIANS ORDERS). - VALIDATION BY THE STATE AGENCY OF THE FACILITY'S ABILITY TO MAINTAIN SUBSTANTIAL COMPLIANCE RELATED TO THE IDENTIFICATION AND DOCUMENTATION OF ALL RESIDENT ALLERGIES. FINDINGS INCLUDE: RECORD REVIEW OF THE HOSPITAL PATIENT TRANSFER FORM DATED [DATE] REFLECTED THAT RESIDENT #29 WAS discharged FROM THE HOSPITAL to the facility on [DATE] WITH THE FOLLOWING KNOWN ALLERGIES: BANANAS, [MEDICATION NAME], IODINE AND [MEDICATION NAME]. RECORD REVIEW OF THE FACILITY'S ADMISSION [DIAGNOSES REDACTED].#29 FOR [DATE] REFLECTED THE FOLLOWING Diagnoses: [REDACTED]. REVIEW OF RESIDENT #29'S FACILITY FACE SHEET DATED [DATE] REFLECTED NO DOCUMENTED ALLERGIES; THE SPOT RESERVED FOR THIS INFORMATION HAD BEEN LEFT BLANK. THE FACILITY RESIDENT INCIDENT REPORT DATED [DATE] (TWO WEEKS AFTER THE RESIDENT'S ADMISSION TO THE FACILITY) REFLECTED THE FOLLOWING: (NAME OF RESIDENT #29) RECEIVED A DESSERT CONTAINING BANANAS WHICH SHE STATES SHE IS ALLERGIC TO. REVIEW OF DIETARY TRAY CARD NOTES NO KNOWN ALLERGY. REVIEW OF CHART NOTES ALLERGY ON STICKER AND admission orders [REDACTED]. STATES THAT THE LAST TIME SHE ATE A BANANA WAS IN 1973 AND SHE WAS IN THE HOSPITAL FOR 9 DAYS. REPORTS TONGUE, EARS AND FACIAL SWELLING WITH BLISTERS AT THAT TIME. CURRENTLY TRESIDENT (SIC) REPORTS TONGUE IS ITCHY/[MEDICATION NAME] GIVEN IM AND SENT TO ER (emergency room ) FOR EVAL. THE FACILITY INCIDENT REPORT DATED [DATE] FOR THE EVENTS THAT BEGAN ON [DATE] IDENTIFIED THE TIME OF RESIDENT'S LAST MEAL AS 6:30 PM. ON [DATE]. THE AMBULANCE/PRE-HOSPITAL CARE SUMMARY REPORT FOR [DATE] DOCUMENTED, AT APPROXIMATELY 7:42 P.M. ON [DATE], THE AMBULANCE ARRIVED AT THE FACILITY TO TRANSPORT RESIDENT #29 TO THE emergency room FOR DISPATCH REASONS OF HISTORY OF SEVERE ALLERGIC REACTION. THE EMERGENCY MEDICAL SERVICE (EMS) DOCUMENTED THAT AS THEY WERE PULLING UP TO THE emergency room , RESIDENT #29 BEGAN TO STATE THAT SHE WAS GETTING SOME TINGLING IN HER MOUTH. THE emergency room REPORT DOCUMENTED THAT RESIDENT #29 SHOWED COMPLETE RESOLUTION OF HER SYMPTOMS AFTER TREATMENT AND WAS TRANSPORTED BACK TO THE NURSING FACILITY ON [DATE] AT APPROXIMATELY 10:30 P.M. THE FACILITY RESIDENT INCIDENT REPORT DATED [DATE] (AS DOCUMENTED UNDER THE HEADINGS INCIDENT STATUS: IN PROCESS-INVESTIGATOR, CATEGORY: DEATH, SUBCATEGORY: UNEXPECTED) REFLECTED THE FOLLOWING: RESIDENT HAD EATEN PUDDING WITH BANANAS ON THE BOTTOM OF THE DESSERT DURING DINNER ON THE PREVIOUS SHIFT. RESIDENT HAS AN ALLERGY TO BANANAS. RESIDENT WAS TRANSFERRED TO HOSPITAL AND LATER RETURNED TWO AND A HALF HOURS LATER. RESIDENT WAS IN THE FACILITY APPROXIMATELY AN HOUR AND A HALF BEFORE COMPLAINING OF DIFFICULTY BREATHING. RESIDENT WAS IN ACUTE RESPIRATORY DISTRESS PRIOR TO TRANSFER VIA AMBULANCE (BACK) TO HOSPITAL. HOSPITAL STAFF CALLED LATER TO REPORT THAT RESIDENT HAD EXPIRED AT THE HOSPITAL. A HOSPITAL REPORT (FACSIMILE DATE OF [DATE]) UNDER THE HEADINGS PHYSICAL EXAM AND ALLERGIES DOCUMENTED: ALLERGEN BANANAS - REACTIONS [MEDICATION NAME]. THE FACILITY'S ROOT CAUSE ANALYSIS OF THE EVENTS (ON THE DOCUMENT TITLED PAST NONCOMPLIANCE FOR ALLERGIC REACTION [DATE] / RECAPITULATION) REFLECTED THE FOLLOWING: .AT APPROXIMATELY 10:50 P.M. (ON [DATE]) THE NURSE ASSISTED THE RESIDENT (#29) INTO THE BATHROOM TO VOID AND SHORTLY AFTER THIS THE RESIDENT COMPLAINED OF NOT RECEIVING OXYGEN THROUGH THE NASAL CANNULA. THE NURSE ASSESSED THE CONCENTRATOR (OXYGEN DELIVERY DEVICE) AND FOUND IT TO BE FUNCTIONAL.AT 11:15 P.M. A NEW CANNULA WAS OBTAINED AND APPLIED.THE NURSE INITIATED A PRN (AS NEEDED) NEBULIZER TREATMENT. RESIDENT HAD CONTINUED COMPLAINTS OF DIFFICULTY BREATHING.HER OXYGEN SATURATION WAS CHECKED AT THE TIME AND WAS 50%.AT APPROXIMATELY 11:20 PM EMS (EMERGENCY MEDICAL SERVICES) WAS CALLED. THE AMBULANCE ARRIVED AT 11:25 PM.AT APPROXIMATELY 1:30 AM ON [DATE] TH, THE (FACILITY) RECEIVED A CALL INDICATING (NAME OF RESIDENT #29) HAD PASSED AWAY. THE AMBULANCE REPORT FOR [DATE] REFLECTED, AT APPROXIMATELY 12:07 A.M., THE AMBULANCE ARRIVED TO TRANSPORT RESIDENT #29 TO THE emergency room FOR DISPATCH REASONS OF CHEST PAIN/ABNORMAL BREATHING. THE EMS DOCUMENTED: THE PT (PATIENT) WAS INITIALLY AWAKE AND ALERT WITH NO MAJOR NEURAL DEFICITS NOTED AND NO MAJOR TRAUMA NOTED. PRIOR TO TRANSPORTING THE PT'S LOC (LEVEL OF CONSCIOUSNESS) DIMINISHED RAPIDLY WITH HER BECOMING UNRESPONSIVE TO VERBAL STIMULI. THE HOSPITAL emergency room NOTES FOR ENCOUNTER DATE [DATE] AT APPROXIMATELY 12:58 A.M. REFLECTED: EMS BROUGHT THE PATIENT IN IN RESPIRATORY DISTRESS WHEN EVALUATING THE PATIENT HERE IN THE EMERGENCY DEPARTMENT TRAUMA ANY (SIC) PATIENT WAS NOTED TO HAVE NO PULSE BY PALPATION OF THE CAROTID OR FEMORAL ARTERIES. CPR (CARDIOPULMONARY RESUSCITATION) WAS STARTED. IT WAS NOTED THE PATIENT WAS IN ASYSTOLE (WITHOUT HEART BEAT). NARRATIVE NOTES ATTACHED WITH THE THE FACILITY'S INVESTIGATION AND RESIDENT INCIDENT REPORT FOR THE EVENTS OF [DATE] AND [DATE] DOCUMENTED THAT ON [DATE] AT APPROXIMATELY 1:30 A.M., FACILITY NURSING STAFF RECEIVED A TELEPHONE CALL FROM THE HOSPITAL emergency room NURSE STATING THAT RESIDENT #29 HAD EXPIRED AT THE HOSPITAL. ACCORDING TO THE NOTES, THE HOSPITAL emergency room CHARGE NURSE HAD STATED: .THE [MEDICATION NAME] GIVEN TO RESIDENT #29 (ON [DATE]) HAD MOST LIKELY WORN OFF BY THE TIME THE RESIDENT HAD REACHED THE NURSING HOME AFTER THE INITIAL HOSPITAL VISIT, EXPLAINING WHY SHE (RESIDENT #29) MAY HAVE HAD A RESPIRATORY RESPONSE AS SHE DID. REVIEW OF THE FACILITY'S MINIMUM DATA SET (MDS) assessment dated [DATE] REFLECTED THAT RESIDENT #29 WAS A [AGE] year OLD FEMALE WHO HAD BEEN ASSESSED BY THE FACILITY AS BEING ALERT AND ORIENTED WITH EXPECTATIONS OF RETURNING HOME TO THE COMMUNITY FOLLOWING HER STAY AT THE FACILITY. THE FACILITY'S PT (PHYSICAL THERAPY PROGRESS & DISCHARGE SUMMARY) DATED [DATE] INDICATED THAT RESIDENT #29 HAD PASSED HER HOME SAFETY ASSESSMENT ON [DATE]. THE PHYSICAL THERAPIST, STAFF H HAD DOCUMENTED THE FOLLOWING COMMENTS ON [DATE]: PATIENT WAS DOING VERY WELL ALL AROUND. HOME EVALUATION WAS DONE AND PASS AND HAS RECOMMEND FOR 2 MORE WEEKS. I AM SO SHOCK (SIC) THAT PATIENT EXPIRED. BASED ON REVIEW OF THE FACILITY'S CLINICAL RECORDS, RESIDENT #29'S PHYSICIAN'S HISTORY AND PHYSICAL DATED [DATE] LISTED NO KNOWN DRUG ALLERGIES (NKDA) UNDER THE HEADING TITLED ALLERGIES. RESIDENT #29'S NUTRITION RISK DATA COLLECTION AND ASSESSMENT DATED [DATE] DOCUMENTED NO KNOWN FOOD ALLERGIES (NKFA). HOWEVER, THE ORIGINAL DOCUMENTATION WAS CROSSED OUT AND AMENDED TO REFLECT: BANANA ALLERGY [DATE]. RESIDENT #29'S FACILITY FOOD PREFERENCE RECORD DID NOT REFLECT ANY RESIDENT ALLERGIES BUT, ON [DATE], THE FORM HAD BEEN AMENDED TO REFLECT BANANAS AS AN ALLERGY. RESIDENT #29'S Medication Administration Record [REDACTED]. RESIDENT #29'S NUTRITIONAL RISKS PLAN OF CARE (INITIATED BY THE FACILITY ON [DATE]) REFLECTED NO ALLERGIES UNTIL IT WAS AMENDED ON [DATE]. RESIDENT #29'S NURSING COMPREHENSIVE ADMISSION DATA COLLECTION AND ASSESSMENT DATED [DATE] DOCUMENTED THAT RESIDENT #29 DID HAVE KNOWN ALLERGIES TO BANANAS, [MEDICATION NAME], IODINE AND [MEDICATION NAME], AND THE ORIGINAL PHYSICIAN ORDERS [REDACTED].#29 HAD ALLERGIES TO BANANAS, [MEDICATION NAME], IODINE AND [MEDICATION NAME]. THE FACILITY'S WEEK AT A GLANCE THERAPEUTIC MENU DOCUMENTED THAT ON [DATE] THE FACILITY HAD SERVED A BANANA-SPLIT DESSERT FOR THE EVENING MEAL. RESIDENT #29'S MEAL TICKET FAILED TO IDENTIFY ANY KNOWN FOOD OR MEDICATION ALLERGIES. AFTER REVIEWING THE MEDICAL RECORDS FOR RESIDENT #29, THE FACILITY'S DIRECTOR OF NURSING (DON) WAS INTERVIEWED ON [DATE] AT 08:30 A.M. IN THE CONFERENCE ROOM THAT WAS LOCATED TOWARDS THE BACK OF THE MAIN DINING HALL. WHEN ASKED ABOUT THE CIRCUMSTANCES SURROUNDING RESIDENT #29'S DEATH, THE DON STATED, WE (THE FACILITY) REALIZE WE HAD A SYSTEMS BREAKDOWN THAT HAD A NEGATIVE OUTCOME FOR (NAME OF RESIDENT #29), BUT THE HOSPITAL PROBABLY SHOULD HAVE NEVER discharged HER BACK TO US. WHEN ASKED SPECIFICALLY ABOUT THE REASONS WHY THE FACILITY HAD SERVED RESIDENT #29 A DESSERT CONTAINING BANANAS, THE DON STATED THAT THE NURSE WHO DID THE admission orders [REDACTED]. THE DIETARY MANAGER (STAFF MEMBER D) WAS INTERVIEWED ON [DATE] AT APPROXIMATELY 08:30 A.M. WHEN ASKED ABOUT RESIDENT #29, STAFF D STATED, WE'RE NOT POINTING FINGERS HERE AT WHOSE FAULT THIS WAS. IT'S EVERYONE'S RESPONSIBILITY, ESPECIALLY MY OWN. WE (THE FACILITY) ARE CURRENTLY WORKING ON IDENTIFYING ALLERGIES AS PART OF OUR PLAN OF CORRECTION.WE ARE ALL DEVASTATED. REVIEW OF THE FACILITY'S PROCEDURES RELATED TO ALLERGY IDENTIFICATION (EFFECTIVE DATE JULY, 2010), THE FOLLOWING WERE DOCUMENTED UNDER PROCEDURES: 1) PAPERS UPON ADMISSION. 2) DOCUMENT RESIDENT ALLERGIES WITH AN ALLERGY ALERT ON THE FRONT OF THE CHART. DOCUMENTATION INCLUDES BUT IS NOT LIMITED TO THE FOLLOWING: NURSING DATA COLLECTION ASSESSMENT, RESIDENT FACE SHEET, CARE DELIVERY GUIDE, MAR, AND TAR. 3) NOTIFY PHARMACY. ACCORDING TO THE FACILITY'S PLAN FOR ABATEMENT TO REMOVE THE IJ (IMMEDIATE JEOPARDY) THERE WERE 6 OTHER RESIDENTS IN THE FACILITY'S TOTAL CENSUS OF 77 RESIDENTS WHO WERE IDENTIFIED AS HAVING FOOD ALLERGIES. ( )

This citation pertains to MI 168 and MI 372. Based on observation, interview, and record review, the facility failed to provide a safe environment and adequate supervision to prevent injuries in 1 of 5 residents reviewed for accidents (Resident #102), from a total of 10 sampled residents, resulting in Resident #102 falling and sustaining a pelvic fracture, and Resident #104 sustaining a burn with blister from a hot pack, and the potential for electrical shock for Resident #101. Findings include: On 3/22/13 at 1:25 PM, in the presence of DON/Director of Nursing #27, off sample resident #26 was observed lying in bed; there was a pressure alarm pad on the bed but the alarm cord was hanging unhooked from the alarm box. Off sample resident #26 stated, "It's not connected. I didn't disconnect it." DON #26 stated, "It's not broken; It was fine this morning. I checked it myself." In an interview, on 3/26/13 at 3:45 PM, wife of off sample resident #26 reported, "They took the alarm off of (off sample resident #26's) bed because it was always hanging disconnected." Resident #102 An unannounced investigation was conducted 3/19/13-3/28/13. Resident #102 no longer resided at the facility at the time of the investigation. According to the Minimum Data Set, dated dated [DATE], Resident #102 had resided at the facility since 12/30/09, had severe cognitive impairment, and had [DIAGNOSES REDACTED]. Per the Fall/Injury Assessment: Prevention and Management Plan of Care for Falls, dated 2/13/13, Resident #102 was to have a chair alarm and a bed alarm. Review of Resident #102's medical record, including behavioral charting, nursing progress notes, care plans, and nurse aide care guides revealed no history of Resident #102 or anyone else, turning Resident #102's bed alarm off or chair alarms off. According to the Facility Investigation Report - 5 Working Days, dated 2/26/13, on 2/14/13 at 3:40 AM, "...(Resident #102)...self transferred from bed to wheelchair...she was then observed by (nurse aide #15) on the floor...(NP/Nurse Practitioner #3) gave order for x-ray...Approx (approximately) one hour later (RN/Registered Nurse #14) called NP back to report pain unrelieved...Symptoms of persisting pain noted during care with (Resident #102) often guarding left hip...second x-ray ordered showed osteoporosis...a third x-ray showed bilateral pelvic fx (fracture). New order to place (Resident #102) on bed rest, and continue to manage pain. Family was made aware, and agreed with plan of care..." Review of Resident #102's medical record revealed that the legal medical decision maker was family member #12. Per an x-ray report, dated 2/14/13 at 9:11 AM, "Left hip, 2 views...No ...evidence of acute (sudden) fracture or dislocation." Per an x-ray report, dated 2/15/13 at 8:25 PM, "Pelvis, single view...No...evidence of acute fracture or dislocation..." Per an x-ray report, dated 2/23/13 at 6:39 PM, "Hips bilat (both)/pelvis...Bilateral pubic fracture not seen on prior study." In an interview on 3/22/13 at 1:38 PM, RN #14, identified herself as the nurse assigned to Resident #102 on 2/14/13 at 3:40 AM. RN #14 stated, "(Resident #102) got up in her chair a lot. The aides would transfer (Resident #102), but she was headstrong and from time to time she would transfer herself." RN #14 reported that at the time of the fall, Resident #102's bed pressure alarm cord was not connected to the alarm box. RN #14 stated, "It (the cord) should have been hooked." When asked why the pressure alarm was unhooked, RN #14 stated, "There are 2 reasons it could have been disconnected. 1) There are frequent alarms on (Resident #102's) hall; people get tired of answering it. It stress staff. It is possible they unhooked it. 2). (Resident #102) may have disconnected it; she was not known to have disconnected it before." RN #14 stated, "On second shift, I've had nurse aides admit they disconnected the alarms. (Resident #102) would tell us to, Turn that darn thing off! I did an assessment while she was on the floor. (Resident #102) said, Get me off this cold floor. She wasn't bleeding, her legs were equal in length, I didn't suspect a leg fracture. When she got back in bed she said she was in pain..." In an interview, on 3/22/13 at 11:45 AM, nurse aide #15 identified herself as the nurse aide assigned to Resident #102 on 2/14/13 at 3:40 AM. Nurse aide #15 stated, "I started my rounds at 2/45 AM; at around 2:50 AM, Resident #102 was in her wheelchair sitting in the doorway of her room. No alarms were sounding when I saw her on the floor." In a telephone interview, on 3/18/13 at 10:59 AM, son #1 stated, "(Resident #102) never got her out of her chair after she broke her hip." ( )

This citation pertains to MI 258 Based on observation, interview and record review the Facility failed to ensure residents are not left unattended in the bathroom in 1 of 6 sampled residents (#107), from a total sample of 6 residents, resulting in the potential for a fall with injury. Findings include: According to the Face Sheet, Resident #107 was admitted to the facility 9/24/2009 with [DIAGNOSES REDACTED]. Resident #107 was observed on 7/9/12 at 1:00 PM in the Main Dining Room sitting in a padded geri-chair. She was well groomed with no noted odors. Resident #107 did not respond verbally to questions and had spastic movements of both arms and legs. According to the facility MDS dated [DATE], Resident #107 rarely was able to make herself understood or understand others, was severely impaired with daily decision making skills and required extensive two person assistance with transfers, dressing, eating, toileting and all activities of daily living and was incontinent of both bowel and bladder. Review of the Facility Comprehensive Care Plan Summary dated 2/14/12, revealed "falls care plan reviewed fall history" 7 falls were listed the most recent on 5/21/12 with a fall from a shower chair which collapsed during care in which Resident #107 sustained bruising. Review of the Nursing Care Plan Fall/Injury Assessment, Prevention plan of care dated 6/6/12 "never leave resident unattended on the toilet". Review of the Facility investigation on 6/27/2012, revealed Resident #107 was left unattended in the bathroom on the toilet without assistance and was found by another staff member with Resident #107's assigned aide not present. The facility investigation also revealed Resident #107's roommate confirmed on 6/26/12 at 5:10 AM Resident #107 was alone in the bathroom until 5:35 AM when another staff member entered the room and discovered the resident alone in the bathroom. During an interview with the Administrator on 7/9/12 at 9 AM, she stated that the investigation confirmed the resident was alone in the bathroom and was considered a "significant fall risk" and the CNA involved was suspended and has since returned to work. ( )

This citation pertains to intake number MI 186 Based on observation, interview, and record review the facility failed to ensure the safety in 1 of 2 sampled residents (Resident # 502), from a total sample of 4 residents, (when Resident #502 had 3 falls, 2 of which Resident #502 was left unattended while in the bathroom and 1 of which Resident #502 fell in the bathroom while attempting to stand without assistance), resulting in Resident #502 receiving a fractured nose and a laceration requiring staples above her right eye. Findings include: Per the facility face sheet Resident #502 was an [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a "Minimum Data Set" ((MDS) dated [DATE] revealed Resident #502 required extensive assistance with transferring, did not ambulate, and required extensive assistance with toileting. Review of a care plan dated 2/7/2012 for "ADL (activities of daily living)/Mobility: Plan of Care" revealed Resident #502 was a one person assist to transfer. Fall #1: Review of an "Accident/Incident Report" dated 2/28/2012 revealed that on 2/27/2012 Resident #502 was using the toilet, and that Certified Nursing Assistant (CNA) #8 was in Resident #502's room and had checked on Resident #502 but Resident #502 was not ready to get off the toilet. CNA #8 educated Resident #502 to use the call light in the bathroom to alert her (CNA #8) when she was ready to get up off the toilet. CNA #8 then responded to another resident's call light and therefore left Resident #502 alone on the toilet. The report indicated that CNA #8 checked on Resident #502 again and Resident #502 was still not ready to get off the toilet. Resident #502 was again educated to use the call light when she was ready to get off the toilet. CNA #8 left Resident #502's room again to assist other residents in the hall. The report indicated CNA #8 went back to check on Resident #502 and found Resident #502 on the floor in the bathroom. Resident #502 was transferred to the hospital for evaluation. Review of hospital records dated 2/28/2012 revealed that a Cat Scan was conducted of Resident #502's face. The Cat Scan report revealed, "There is a minimal, mesially (midline on the face along the dental arch) displaced fracture of the right nasal bone, Extensive right-sided soft tissue swelling is present. A hematoma (collection of clotted blood) is present..." Review of a written interview with CNA #8, not dated and not noted as to whom the interviewer was, revealed that CNA #8 reported (on 2/27/2012) she had left Resident #502 on the toilet to go assist in another resident's room. The interview revealed Resident #502 was found on the floor in her bathroom after Resident #502's roommate alerted CNA #8 of the fall. In an interview on 5/31/2012 at 12:21 PM, CNA #8 said she took Resident #502 to the bathroom on 2/27/2012 and assisted Resident #502 to the toilet. CNA #8 said she told Resident #502 to put her call light on when she was ready to get up from the toilet. CNA #8 said she told Resident #502 to not get up on her own and then left Resident #502's room to answer another call light. CNA #8 said Resident #502's roommate (no longer at the facility) put on her call light and reported to her that she thought Resident #502 had fallen. CNA #8 said she found Resident #502 on the floor in the bathroom. CNA #8 said Resident #502 was attempting to pull her pants up when she fell forward and hit her face on the bathroom sink. CNA #8 said Resident #502's head was under the sink when she found her and stated that Resident #502's face was bleeding and right eye was bruising. CNA #8 said Resident #502 would always attempt to get up out of her wheelchair but stated that she (CNA #8) was usually able to catch Resident #502. CNA #8 said she left Resident #502 alone in the bathroom because she had to answer another resident's call light. Registered Nurse (RN) #9 was interviewed on 5/31/2012 at 11:50 AM. RN #9 said Resident #502 had a habit of "sneaking" out of her bed or wheelchair. RN #9 said when Resident #502 fell on [DATE] Resident #502 did not have any fall alarms in place. RN #9 said when she responded to Resident #502's room Resident #502 had fallen and hit the bridge of her nose on the bathroom sink counter. RN #9 said she sent Resident #502 to the hospital for an evaluation. RN #9 said CNA #8 had reported to her that she knew Resident #502 was in the bathroom and told Resident #502 to pull her call light when she was done. RN #9 said sometimes Resident #502 would pull her bathroom call light and other times she would not. RN #9 said it was not the first time Resident #502 had gotten up from the toilet without assistance. RN #9 said CNA #8 reported to her that she (CNA #8) was right outside of Resident #502's room when she (CNA #8) heard Resident #502's roommate call for help. RN #9 said Resident #502 should not have been left alone while in the bathroom. RN #9 said she told CNA's to not leave Resident #502 alone while in the bathroom, but stated that she did not add the intervention to Resident #502's care plan. RN #9 said she did add fall alarms to Resident #502 after the fall on 2/27/12. Fall #2: Review of an incident report dated 5/12/2012 revealed Resident #502 was found on the floor in her bathroom between the sink and her wheelchair. CNA #11 was interviewed on 6/1/2012 at 10:00 AM. CNA #11 said she was in another room when she heard Resident #502's voice. CNA #11 said she went into Resident #502's room and found Resident #502 on the floor in her bathroom. CNA #11 said Resident #502 was not injured but stated Resident #502 would self transfer all the time and would not follow commands to use the call light. CNA #11 said that she did not recall any fall alarms sounding at the time of the fall. Fall #3: Review of an incident report dated 5/18/2012 revealed Resident #502 was found on the floor in her bathroom and blood was noted on her forehead and on the floor. The report revealed that a laceration was noted above Resident #502's right eye. The report revealed, "When asked the resident (Resident #502) what she was doing on floor she stated, "I was getting off the toilet." Resident (#502) has a history of fallens (sig) in the past. Resident (#502) seems to think she is independent. The cena (CNA #12) informed me (LPN #13) they had asked her (Resident #502) once done to let them know by putting on the call light." The report revealed, under "describe the injury", "laceration above right eye, near forehead. Swelling noted on the right cheek. Skin tear on right arm..." LPN #13 was interviewed on 5/31/2012 at 2:00 PM. LPN #13 said she was told by CNA #12 Resident #502 was on the floor. LPN #13 said Resident #502 was a fall risk. LPN #13 said CNA #12 had put Resident #502 on the toilet. LPN #13 said she asked CNA #12 why she left Resident #502 alone while in the bathroom and CNA #12 reported that she wanted to go check on another resident who was yelling out. LPN #13 said CNA #12 told her that she wanted to go see what was wrong with the other resident who was yelling out and stated that she (CNA #12) had told Resident #502 to put her call light on when she was ready to get up off the toilet. LPN #13 said Resident #502 did not use her call light and stood up on her own to pull her pants up and fell forward. LPN #13 said Resident #502 had a laceration above her right eye. Attempts to contact CNA #12 were unsuccessful. RN #14 was interviewed on 5/31/2012 at 1:40 PM. RN #14 said she responded to the fall Resident #502 had on 5/18/2012. RN #14 said she found Resident #502 lying on the floor under the bathroom sink. RN #14 said Resident #502's head was under the sink and her arm was twisted behind her back. RN #14 said she turned Resident #502 over and saw that Resident #502 had a laceration above her right eye. RN #14 said she held pressure to the laceration until the ambulance arrived. RN #14 said CNA #12 had left Resident #502 alone in the bathroom after assisting Resident #502 to the toilet. RN #14 said CNA #12 went to assist another resident. RN #14 said she added to Resident #502' care plan and CNA care guide to not leave Resident #502 alone while in the bathroom. RN #14 said she told the CNA's to not leave residents alone while in the bathroom even if the resident is not a fall risk. Review of a "Policy/Procedure Mini-Review" dated 5/18/2012 revealed an employee review for CNA #12. The document revealed that the reason for the review was, "Resident (#502) left unattended in restroom & fell with injury noted." Review of a "Report of Consultation" dated 5/23/2012 revealed Resident #502 had 6 of 9 total staples removed from above her right eye with the last 3 remaining to be removed at a later date. On 5/29/2012 at 3:10 PM, Resident #502 was observed sitting in her chair in her room with a large purple/yellow bruise around her right eye and a healing scar above her right eye. Review of a care plan titled, "Fall/Injury Assessment: Prevention and Management Plan of Care." dated 2/27/2012 revealed that on 5/18/2012 an intervention was added that indicated Resident #502 was not to be left unattended while in the bathroom. Resident #502 was observed and interviewed, in her room, on 5/30/2012 at 1:55 PM. Resident #502 was observed to be eating lunch and stated that she could only see shadows. Resident #502 was observed to have a large call light button on her bed and was able to locate the button when asked. Resident #502 was not able to see her pepper packets or crackers but was able to feel for them. ( )

This citation pertains to Event ID LMPD12. Based on observation, interview, and record review the facility failed provide adequate supervision to prevent falls of 2 of 5 sampled residents (Resident #600 and #601) identified as a risk for falls, from a total sample of 5 residents, resulting in Resident #600 falling out of her wheelchair while unattended in a shower room and sustaining a neck fracture and Resident #601 falling after being left unattended in the bathroom. Findings include: According to Legal and Ethical Issues in Nursing, 4th Edition, (Guido, G, 2006),...nursing homes have the responsibility to supervise and protect residents for the potential consequences of their own cognitive and volitional impairments. Resident #600 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] revealed, Resident #600 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #600 was moderately cognitively impaired for daily decision making skills, had clear speech, the ability to express ideas and wants, understand others and a history of two or more falls with injury. Review of the Physician Phone Order dated 7/6/12, revealed Resident #600 had a [DIAGNOSES REDACTED].ataxia.org/learn/ataxia-diagnosis.aspx#what-is-ataxia; ataxia means without coordination). Review of the Nursing Comprehensive Admission Data Collection and assessment dated [DATE], revealed Resident #600's vision was impaired, she had a sling to her left arm, and needed extensive assistance of one person for transfers. Review of the Care Area Assessments dated 7/19/12, revealed Resident #600 had a fall with a left humerus fracture and falls since admission (7/5/12), "She is monitored for unmet needs every 2 hours and prn (as needed). Safety checks every 15 minutes. She is to bed (sic) kept in highly visible areas when OOB (out of bed)..." Review of the Fall/Injury Assessment: Prevention and Management Plan of Care dated 7/5/12, revealed interventions were updated on 7/10/12 "offer activities, every 15 minutes check for safety, 7/11/12 "keep in highly visible areas when OOB (out of bed)". Review of Nursing Progress Note dated 7/10/12 at 9:00 AM revealed, an unwitnessed fall when Resident #600 was "observed lying on ground", an x-ray of left arm and shoulder was ordered. Review of Nursing Progress Note dated 7/12/12 at 9:20 PM, revealed an unwitnessed fall when Resident #600 was "observed" on her bedroom floor lying on her right side, 2 lacerations were noted above right eye and Resident #600 was sent to Emergency Department for sutures. Review of Resident Incident Report dated 7/19/12 at 2:42 PM, revealed Resident #600 had an unwitnessed fall in her bathroom, no injuries from fall were noted. Review of Resident Incident Report dated 8/3/12 at 2:05 PM, revealed Resident #600 had an unwitnessed fall in her room and was found lying on the floor, on her left side with the wheelchair on top of her, and was noted to have a bloody nose. The Resident Incident Report dated 8/10/12 at 1:51 PM, revealed Resident #600 had an unwitnessed fall in the shower room, and was sent to the Emergency Department. Review of the Emergency Department Record dated 8/10/12 revealed, Resident #600 "with chronic history of falls presents to the emergency room (ER)", Resident #600 had fallen from her wheelchair and imaging in the ER demonstrated a C6 fracture with dissection of the left vertebral artery (a flap-like tear of the inner lining of the vertebral artery, which is located in the neck and supplies blood to the brain; cited from http://en.wikipedia.org/wiki/Vertebral_dissection). Review of the Hospital physician progress notes [REDACTED].#600 "has had multiple very serious falls. Her MRI Brain is normal with atrophy and previously it was felt she had particular cerebellar ataxia and atrophy related to medication and HTN small vessel disease. She has fractured her humerus, clavicle and now neck. She in my opinion should not be ambulating without assist and should be limited to WC (wheelchair)...". In an interview dated 8/23/12 at 1:55 PM, Director of Nursing (DON) #2 reported 14 falls of facility residents since the end of July 2012. DON #2 reported Resident #600 had an unwitnessed fall on 8/3/12 in her room when she leaned forward in her wheelchair and fell with the wheelchair attached via a self releasing seat belt and on 8/10/12 Resident #600 had an unwitnessed fall in B Hall shower room, was sent to the ER, resulting in a C6 fracture. DON #2 reported that shower rooms are suppose to be locked when they are not in use. In interviews on 8/24/12 at 10:40 AM and 12:26 PM, Certified Nursing Assistant (CNA) #3 reported, on 8/10/12 she was working on B Hall during lunch, picking up lunch trays, answering call lights, and doing 15 minute checks on Resident #600. CNA #3 reported the last time Resident #600 was noted (at 1:30 PM according to the 24 Hour Resident flow Record dated 8/10/12, used to track Resident #600's 15 minute checks) she was in her wheelchair self propelling by the central nursing station and was entering B hall. CNA #3 reported she heard a safety alarm, went towards the central nursing station, found Resident #600 in shower room B on the floor. CNA #3 reported Resident #600's head was on the floor scale, blood on the floor, her wheelchair tipped forward, and foot peddles were noted on the wheelchair. CNA #3 reported that she could not explain how the key pad locked shower room door was opened for Resident #600 to enter. CNA #3 reported receiving education on residents who are high fall risk, which included staying with the resident until care is completed and the resident is safe even if another call light or safety alarm is sounding. In an interview on 8/24/12 at 2:06 PM, CNA #15 reported that on 8/10/12 she and CNA #13 were walking past shower room B, saw Resident #600 laying on the floor with a lot of blood, and CNA #3 saying "help". CNA #15 reported running to the nurses station about 20 feet from shower room B and stating "(Resident #600) fell and she is bleeding". CNA #15 reported it was almost shift change and at least 3 nurses were at the nursing station and no one looked up. CNA #15 reported she then started clapping her hands and raised her voice stating "(Resident #600) is on the floor and she is bleeding and one of the nurses said Resident who, and CNA #15 re-stated "(Resident #600) is in the shower room bleeding", at that time all the nurses ran to the shower room. CNA #15 reported she did not recall a safety alarm sounding. In an interview on 8/24/12 at 2:27 PM, Registered Nurse (RN) #16 reported on 8/10/12 he was at the nursing station and a CNA said to anyone listening Resident #600 had fell and was on the floor. RN #16 reported that several nurses responded and found Resident #600 in shower room B half on the floor scale and half on the floor. RN #16 reported that "highly visible" area means with view of staff members. In an interview on 8/24/12 at 1:05 PM, Licensed Practical Nurse (LPN) #5 reported hearing CNA #15 call for help and as soon as she made sure the resident she was caring for was safe, went to the B Hall shower room. LPN #5 reported noted Resident #600 half lying on the floor scale with her feet propped up on the seat cushion of her wheelchair, which was completely tipped over. LPN #5 reported seeing blood everywhere, Resident #600's right leg looked shorter than her left, bruising to the side of her face, and a black and blue laceration to her left forehead, which could have been from a previous fall. LPN #5 reported the blood was from a nose bleed and pressure was applied, but they were unable to do a complete assessment because Emergency Medical Services (EMS) arrived. LPN #5 reported highly visible when OOB means to keep the resident at the nursing station, activities, or where there is staff, and to expect staff to be in those areas at all times. LPN #5 reported that "everyone knows Resident #600 is a high fall risk". In an interview on 8/24/12 at 11:59 AM, Unit Manager LPN #11 reported Resident #600 was to be in highly visible areas so that nursing and other staff could put eyes on her, and Resident #600 was also on 15 minute checks. LPN #11 reported when she arrived at shower room B, Registered Nurse #16 and LPN #5 were in with Resident #600 who was laying on the floor on her left side, with her face on the floor scale, and her feet towards the door. LPN #11 showed this surveyor where Resident #600 was laying in shower room B which was approximately 8 feet from the shower room door. LPN #11 reported that as part of the investigation all employees in the building were interviewed to find out how shower room B's door was left open and no one admitted to leaving shower room B unlocked and open. Observations of Resident #600 on 8/23/12 at 8:30 AM and various time throughout the day, and on 8/24/12 between 10:00 AM and 4:00 PM revealed, Resident #600 resting in bed, up in a wheelchair, or in the dining area, a neck brace was noted in place, and a staff member was assisting with 1:1 care. Resident #601 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] revealed, Resident #601 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #601 was severely cognitively impaired for daily decision making skills, clear speech, the ability to express ideas and wants, understand others and a history of two or more falls with no injury. Review of the Falls Care Area assessment dated [DATE], revealed Resident #601 "remains at risk for falls and injury d/t (due to) impaired mobility and gen. weakness, as well as poor safety awareness". The Progress Note dated 8/11/12 at 5:00 AM, revealed an unwitnessed fall when Resident #601 was seen "sitting on the floor near the head of his bed". The Progress Note revealed Resident #601 had set off the safety alarm to go to the bathroom, a CNA responded to the safety alarm and assisted him to the bathroom, the CNA then went in the room adjoining to Resident #601's bathroom. Resident #601 was found on the floor in his room calling for help with a skin tear to his left forearm. Review of the Fall/Injury Assessment:Prevention and Management Plan of Care dated 11/7/11, revealed Resident #601 transferred with one assist and used a walker. The Fall/Injury Assessment:Prevention and Management Plan of Care assessment dated [DATE], revealed Resident #601's had falls prior to admission, the history of falls after admission listed 2/18/12 "bed - w/c (wheelchair) bruising, steri strips, 2/20/12 bed - w/c no injury, 2/27/11 fall no injuries, 3/2/12 fall no injury, 3/3/12 fall - bruise, 4/26/2012 fall no injury, 5/22/12 fall no injury, 5/16/12 fall, no injury unwitnessed, 6/20/12 slid from bed to floor using urinal no injuries, 7/712 observed on floor near foot of bed, 8/20/12 stood up without assist slid down to mat on floor no injuries". The Fall/Injury Assessment:Prevention and Management Plan of Care Interventions dated 6/6/12 revealed "never leave Resident #601 alone on the toilet, clarification 8/10/12 Do not leave Resident #601 unassisted (sic) in bathroom... 8/10/12 sent to ER (emergency room for eval. after unwitnessed fall. No injuries noted at ER". In an interview dated 8/23/12 at 1:55 PM, Director of Nursing (DON) #2 reported on 8/11/12 Resident #601 had an unwitnessed fall which was reported to the State Agency because the Certified Nursing Assistant (CNA) did not follow the care plan and left Resident #601 who is care planned to not be left alone because he is a high fall risk, unattended in the bathroom and he fell . DON #2 reported staff have been instructed to stay with high fall risk residents when providing care even if a call light or safety alarm sounds. In an interview on 8/28/12 at 10:40 AM, CNA #17 reported working night shift on 8/10-11/12, when she heard a safety alarm and found Resident #601 standing next to his bed facing the wall. CNA #17 reported Resident #601 asked to go to the bathroom, she assisted Resident #601 to the toilet, reoriented him to the use of the call light, and made sure he understood not to get up without using the call light. CNA #17 reported that a call light went off in the room next door that shares the bathroom with Resident #601 so she answered the call light and opened the bathroom door a little to check on Resident #601 while she was doing care for the resident in bed one in the adjacent room. CNA #17 reported that she explained to Resident #601 that she needed to keep her eyes on him at all times and he said "I can't poop if you are watching me".CNA #17 informed Resident #601 he must use the call light to get her before he gets off the toilet, shut the bathroom door, and continued to complete care on the resident in the adjacent room. CNA #17 reported that she heard Resident #601 yelling help and found him on his bottom on the floor in his room. CNA #17 reported Resident #601 had a skin tear on his arm, the nurse was called and completed an assessment, and CNA #17 was suspended immediately. CNA #17 reported that she was informed safety over-rides Resident Rights and she should not have left Resident #601 on the toilet alone. CNA #17 reported there is not enough on third shift for the resident activity. In an interview on 8/24/12 at 11:59 AM, LPN #11 reported that any resident with safety alarms is not to be left alone in the bathroom. In an interview on 8/28/12 at 4:33 PM, CNA #19 reported residents would be safer if we had more staff on third shift. In an interview on 8/29/12 at 8:11 AM, CNA #20 reported that since some halls have the majority of their residents classified as fall risk that cannot be left unattended, 3rd shift was not staffed well enough to answer all call lights and fall alarms in a timely manor. In an interview on 8/29/12 at 1:30 PM, CNA #21 reported that on her shift she usually has 20-23 residents and when she has to stay in the bathroom with a fall risk resident it is difficult to answer another alarm goes, but does the best she can to. CNA #21 reported Hall A has the most residents, about 30, and at times there is only one CNA assigned to that hall. Observations of Resident #601 on 8/23/12 at 8:30 AM and various time throughout the day, and on 8/24/12 between 10:00 AM and 4:00 PM revealed, Resident #601 up in a wheelchair in hallway and at meals, safety devices were noted in place and functioning. #

This citation pertains to intake number MI 229. Based on observation, interview, and record review the facility failed to supervise and prevent the elopement of 1 of 2 sampled residents (Resident #500) from a total sample of 9 residents, resulting in an Immediate Jeopardy for Resident #500 who was assessed to be an elopement risk, wore a WanderGuard bracelet, was observed opening the B Hall exit door approximately 30 minutes prior to his elopement, and who eloped from the facility via the B Hall exit door on 11/24/2011 at approximately 3:00 PM, unbeknownst to facility staff. This deficient practice places 11 other residents, who were assessed to be elopement risks, at high risk for harm, injury, and/or death. Findings include: Per the facility face sheet Resident #500 was a [AGE] year old male admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of a facility "Accident/Incident Report", dated 11/24/2011, revealed the B-Hall exit door alarm sounded at 3:00 PM. The report revealed that 3 Certified Nursing Assistants (CNA's) responded to the alarm and found Resident #500 outside. The report revealed Resident #500's vital signs were taken and were within normal limits. Review of the nurses' "Progress Notes", dated 11/24/2011, revealed that, at the time of Resident #500's elopement, the temperature outside was 46 degrees Fahrenheit. The note revealed Resident #500 was placed on 15 minute checks. Review of physician's orders, dated 11/22/2011, revealed an order to check placement and function of WanderGuard every shift, but did not indicate why a WanderGuard bracelet was placed on Resident #500. Review of "Nursing Comprehensive Admission Data Collection and Assessment's", dated 10/13, 10/20, and 11/21/2011, revealed that it was not documented that Resident #500 was at risk for elopement. Review of a care plan titled, "Elopement Plan of Care: Assessment, Prevention, and Management" with the earliest documented date of 10/13/2011, revealed under the assessment section, "11/21/2011-Attempted elopement out main doors/hall exits." There were no goals or interventions noted on the care plan. Further review of the care plan reflected that the care plan was initiated on 10/13/2011 but no notations were documented on the care plan until 11/21/2011. Review of another page of a care plan titled "Elopement Plan of Care: Assessment, Prevention, and Management", dated 11/22/2011, revealed Resident #500 had a cognitive impairment. Another assessment, dated 11/24/2011, revealed Resident #500 had an elopement history with a notation, dated 11/22/2011, that revealed Resident #500 had a desire to return home. Review of interventions included, "Initiate Wander Alert System" (dated 11/22/2011), and "Utilize signs to assist in managing unsafe wandering, stop signs at hall exit doors, (dated 11/23/2011). Further review of the care plan revealed, under the assessment section and dated 11/24/2011, "Resident exited B-Hall exit door without assist ...". An intervention was added on 11/25/2011 that revealed Resident #500 was put on 15 minute checks to monitor his whereabouts. Review of nurses' notes, dated 11/21/2011, revealed no indication as to why the WanderGuard bracelet was placed on Resident #500. Nurses' notes, dated 11/22/2011, reflected, "N.O. (new order) monitor WanderGuard check placement and fx (functioning)." In an interview on 12/16/2011 at 11:38 AM, Dietary Aid (DA) #1 said that on 11/24/2011 at the end of his shift, about 2:20 PM, he was leaving to go home. DA #1 said he went out the service hall exit door in the B-hall (a different exit door in the same the hall). DA #1 said when he got outside he noticed CNA #2 and CNA #5 looking around the dumpster. DA #1 said that he did not know what they were doing and stated that he did not ask. DA #1 said he got into his car and began to drive up the parking lot towards the road and that was when he saw Resident #500 by the dumpster heading towards the front parking lot. DA #1 said it was about 2:30 PM. DA #1 said he parked his car and assisted Resident #500 back into the facility through the service hall door. DA #1 said he told a nurse, but did not know the name of the nurse he told. Observation of the area where DA #1 found Resident #500 was conducted on 12/16/2011 during the interview with DA #1. DA #1 revealed that he found Resident #500 approximately 50 to 100 feet from the B-Hall exit door, by the dumpster. DA #1 said Resident #500 was in his wheelchair facing the downward slope in the driveway. In an interview on 12/16/2011 at 11:54 AM, Certified Nursing Assistant (CNA) #2 said that at approximately 2:30 PM on 11/24/11 he was caring for another resident when he heard the B-Hall exit door alarm. CNA #2 said he went to the door and found that Resident #500 had removed the stop sign and opened the door. CNA #2 said he assisted Resident #500 to the D-hall area and stated that he did not tell any other staff member that Resident #500 attempted to exit the facility. CNA #2 said a bit later (did not know the time) he had gone outside the B-Hall service door for about 2 minutes with CNA #5. CNA #2 said that when he and CNA #5 re-entered the facility, through the service door, the two of them heard a door alarm. CNA #2 said he did not know exactly when the door alarm began to sound. CNA #2 said that neither he nor CNA #5 heard an alarm while they were outside and stated that upon their entrance into the facility they looked down to the nurses' station and saw 4 nurses who all pointed towards the B-Hall door that was alarming. CNA #2 said that he and CNA #5 went to the B-Hall exit door and found the stop sign removed and the door closed. CNA #2 said that he and CNA #5 went outside but did not see anyone. CNA #2 said that he and CNA #5 checked by the road also but did not see any resident and stated that they also had looked towards the dumpster but saw no resident so the two of them returned inside the facility. CNA #2 said that he reported to 4 nurses, who were at the nurses' station, that they had found no resident outside. CNA #2 said no other staff initiated or assisted with an elopement search. CNA #2 said that by the time he and CNA #5 returned to the nurses' station DA #1 had brought Resident #500 back into the facility. CNA #2 said Resident #500 was placed on 15 minute checks for his whereabouts after his exit from the facility. In an interview on 12/16/2011 at 2:26 PM, CNA #5 said that he had gone outside with CNA #2 for a brief minute and upon their return into the facility heard a door alarm. CNA #5 said when he and CNA #2 re-entered the facility and heard the door alarm, they looked towards the nurses' station and the staff at the nurses' station (did not remember who) where just saying "door" and it was not until he and CNA #2 approached the nurses' station that the staff at the nurses' station pointed towards the B-Hall exit door. CNA #5 said that when he and CNA #2 approached the B-Hall exit door, the stop sign was off the door. CNA #5 said that he and CNA #2 went outside but did not see anyone and stated that he did not even know who it was that he was looking for. CNA #5 said that is was common that Resident #500 would look for his car and that Resident #500 may occasionally open the exit door in the rehab hall. CNA #5 said that when he and CNA #2 re-entered the facility, after looking outside, DA #1 had brought Resident #500 back into the facility. CNA #5 said that no other staff helped him and CNA #2 with the search, and stated that he and CNA #2 were the only two staff that searched for a missing resident. CNA #5 said that he remembered last seeing Resident #500 at approximately 2:30 PM and stated Resident #500 was brought back into the facility at approximately 3:00 PM. In an interview on 12/16/2011 at 10:14 AM, CNA #4 said she was in the break room in the service hall when she heard DA #1 tell Resident #500 that they were going to re-enter the facility through the service door. CNA #4 said she became curious as to whom DA #1 was speaking to, so she looked out the break room door and saw DA #1 bringing Resident #500 back into the facility. CNA #4 said someone (staff) was watching Resident #500 all the time and stated that she could not believe Resident #500 got out the door. CNA #4 said that Resident #500 had stated that he was going home and stated that Resident #500 was very confused. CNA #4 said Resident #500 always approached exit doors and would try to escape 5 times per day. CNA #4 said Resident #500 would constantly push open the rehab hall exit door. (Observation of this door on 12/15/2011 at 2:30 PM revealed this door exited the facility hall and led to a corridor to the rehab department with an exit door to the outside in front of the hall exit door). CNA #4 said Resident #500 always would say that he had to go get his car. CNA #4 said, after Resident #500 eloped on 11/24/2011, he was placed on 15 minute checks but no 1-on-1 observation was initiated. CNA #4 said that Resident #500 continued at his attempts to exit the facility after his elopement on 11/24/2011. In an interview on 12/16/2011 at 12:27 PM, RN #3 said that she was in another resident's room administering medications via a feeding tube on 11/24/11 when she heard the door alarm sounding. RN #3 stated that she could not put down what she was doing in order to respond to the door alarm. RN #3 reported that the resident she was with would not have been in any harm had she (RN #3) left her to respond to the door alarm. RN #3 said the alarm sounded for approximately 1 minute and had stopped upon her exit of the room. RN #3 said that when she left the room she learned that Resident #500 had exited the facility. RN #3 reported that Resident #500's exit was unusual for him and stated that Resident #500 did not usually sound door alarms, although stated that CNA #4 worked with Resident #500 frequently. RN #3 said that she was not made aware Resident #500 had attempted to exit out the B-Hall door 30 minutes prior to his elopement. RN #3 said she had placed Resident #500 on 15 minute checks but not 1-on-1 observation because Resident #500's CNA (CNA #5) had other residents to care for. In an interview on 12/20/2011 at 1:09 PM, Assistant Director of Nursing (ADON) #6 said Resident #500 had a WanderGuard on his person because Resident #500 displayed signs of exit-seeking behaviors. ADON #6 said Resident #500 would have exit-seeking behaviors after a visit from his family. In an interview on 12/20/2011 at 2:06 PM, LPN #7 said that he heard the door alarm, made an announcement that the B-Hall door alarm had sounded, but stated that he did not respond to the alarm. LPN #7 said he saw CNA's #2 and #5 respond and he thought that was enough. LPN #7 said that, after the fact, he found out that was not the correct approach to an exit door alarm per the facility policy and procedure. LPN #7 said that he just continued to do his own work and did not respond to the door alarm. LPN #7 said that he was aware Resident #500 had exit-seeking behavior and stated Resident #500 had days when he attempted to get out of the facility via any door. LPN #7 said Resident #500 would sound exit door alarms frequently, stating that he (Resident #500) wanted to go home and/or go get his car. In an interview on 12/21/2011 at 12:00 PM, RN #8 said that she did hear the door alarm sound, but stated that she did not respond to the alarm. RN #8 said the door alarms always sounded and staff was constantly turning the alarms off. Review of the facility policy and procedure entitled "Elopement Prevention and Management Program", last revised October 2008, revealed under the procedure for "Missing/Suspected Missing Resident" "Staff will respond to a sounding door alarm." On 12/20/2011 at 10:45 AM, the Administrator was notified of the Immediate Jeopardy that began on 11/24/2011, was identified on 12/16/2011 and removed on 12/6/2011, when the facility failed to prevent the elopement of Resident #500, who was assessed to be at risk for elopement, wore a WanderGuard bracelet on his person and who eloped from the facility when facility staff failed to respond properly to the B-hall exit door alarm on 11/24/2011 between 2:30 and 3:00 PM. This deficient practice places 11 other residents, who were identified to be an elopement risk, at a high risk for elopement that could result in injury, harm, and/or death. On 12/21/2011 the surveyor confirmed the facility implemented the following to remove the Immediate Jeopardy: 1). Resident #500 was discharged from the facility on 12/2/2011. 2). On 11/24/2011 all residents with increased wandering behaviors were assessed for elopement risk and one additional resident was identified. 3). On 12/2/2011 all residents in the facility were assessed for elopement risk by utilization of the "Quarterly Nursing Assessment" form. 4). On 11/28/2011 the elopement book was updated and deemed necessary. The one additional resident was added to the elopement book. 5). On 11/28/2011 additional door alarms, which needed to have the alarm volume increased, were identified. On 11/28/2011 additional alarms were added to all end-hall exit doors to provide increase in volume and staff awareness. 6). Beginning 11/25/2011 all staff received an in-service on the facility policy and procedure that included: A). How to handle a missing/suspected missing resident. B). Who to notify in the event of an elopement/attempted elopement. C). Initiation of "Missing Resident Action Plan", including a facility wide head count. D). All staff to respond to alarms. E). Searching the entire grounds and facility. F). Monitoring of WanderGuards. As of 12/20/2011, 7 of 141 employees had not received the in-service and staff who had not received the in-service will not be permitted to work until the in-service had been attended. 7). On 11/25/2011, LPN #7 was disciplined for failure to respond to a door alarm, on 11/24/2011, CNA #2 was disciplined for failure to report to a supervisor an attempted elopement, and on 12/6/2011, RN #8 was disciplined for not responding to a door alarm. 8). On 11/25/2011, "CareTracker Behavior Monitoring Reports" were reviewed and will be reviewed daily (Monday-Friday) by the IDT Team during the morning and Daily Clinical Review. 9). Beginning 11/25/2011 elopement drills began and will continue monthly unless determined otherwise by the Quality Assurance Process Committee (QPI). 10). Beginning 11/28/2011 residents with exit seeking behavior will be reviewed 5 days per week in clinical meeting and will continue. 11). On 11/28/2011 a QPI meeting was held. Although the Immediate Jeopardy was removed on 12/6/2011, the facility remained out of compliance at a scope and severity of pattern with no actual harm but potential for more than minimal harm, due all staff had not received the in-service on the facility policy and procedure for elopement, and sustained compliance had not been verified by the State Agency. ( )

THIS CITATION PERTAINS TO INTAKE MI 822 Based on observations, interviews, and records reviewed, the facility failed to provide supervision and assistive devices to prevent accidents (when interventions identified in care plans were absent or ineffective) resulting in harm to 1 of 3 sampled residents (resident #101 ) out of a total sample of 3, when Resident #101 fractured a rib as a result of a fall in her room. Findings: Record review of a "Face Sheet", dated 3/15/11, and an Admission Minimum Data Set ((MDS) dated [DATE], revealed Resident #101 was a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's functional status assessment revealed Resident #101 was not steady and could only stabilize with human assistance, and used a wheelchair or walker while mobile. The MDS also revealed Resident #101 had a history of [REDACTED]. Record review of a "Fall/Injury Assessment: Prevention and Management Plan of Care", dated 3-14-11, identified Resident #101 was at risk for falls and interventions were to include increased supervision, one person assist for transfers, a chair alarm and bed alarm were to be applied, with a mat to the floor next to the bed, with bed wheels locked and the bed positioned against the wall. The plan of care was also dated 4-4-11 but did not identify which interventions may have been added and none of the interventions were clearly identified as having been discontinued. Record review of a "Plan of Care" initiated 3-14-11 and signed again on 4/4/11 revealed Resident #101 had a potential for seizure activity and called for padded side rails. Observations of Resident #101's room were made during an interview conducted with Resident #101 on 5/31/11 at 3:30 PM. Resident #101 was resting in bed and a sensor alarm would sound briefly when the resident shifted her weight in the bed. The resident sat herself up on the side of the bed with her legs over the side of the mattress and triggered the alarm to sound continuously and the resident reached under the bed at the center of the mattress and disabled the alarm. No facility staff responded to the alarm that had been sounding. The side rails of the bed were not engaged and were not padded as care planed. Record review of an " Accident/Incident " report, dated 5/6/11, revealed a nurse aide (CNA) responded to a loud crash in Resident #101's room and discovered Resident #101 on the floor between the night stand and closet with her neck twisted. No bleeding was noted and due to the resident's positioning, no physical assessment was completed. The resident was sent to the hospital emergency room via ambulance. An interview, on 6/2/11 at 5:15 AM, with CNA #12 revealed she was the nurse aide who had responded to the loud crash in Resident #101's room. When asked if an alarm was sounding at the time of the fall she said no. When asked by the surveyor if an alarm was on the bed at all, CNA #12 stated, " I know there was no alarm on the bed at all because I looked for it myself and there was no alarm. " Record review of a hospital "Admission History and Physical" dated 5/6/2011, revealed Resident #101 was admitted to the hospital after a fall. "During her workup in the emergency room she was found to have a urinary tract infection and some mild rib pain ...She (Resident #101) complained of pain during examination of the right side of her chest as I (the physician) was auscultating her lungs ..." Record review of a hospital "CT Abdomen and Pelvis without contrast", dated 5/17/2011, conducted on Resident #101 for "Abdominal pain, generalized" revealed "Acute fracture of the right posterior rib with mild displacement". Record review of a hospital "Discharge Summary", dated 5/19/2011 revealed Resident #101 was admitted to the facility on [DATE] with secondary [DIAGNOSES REDACTED]. ( )

Complaint Intake Number: MI 858 Based on observations, interviews, and records review the Facility failed to prevent significant medication error for 11 of 14 residents who were admitted or readmitted to the Facility in the past 6 weeks in the sample of 16 (#102, #106, #107, #108, #109, #110, #111, #112, #113, #114, #115 & #116) resulting in Immediate Jeopardy for Resident #102 who was readmitted to the hospital with [REDACTED]. Resident #106-diabetic coma, pain and inflammation, high blood pressure; Resident #107-blood clots, [MEDICAL CONDITION], uncontrolled blood pressure, exacerbation of mental illness ([MEDICAL CONDITION] and depression) Resident #108-overriding infection due to interruption of treatment of [REDACTED]. Resident #109-blood clots that could cause a [MEDICAL CONDITION] (stroke) or a [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]), pain, constipation Resident #110-depression, bladder instability, constipation, pain Resident #111- [MEDICAL CONDITION], exacerbation of dementia) and [MEDICAL CONDITION] Resident #112- high blood pressure, anxiety, exacerbation of fungal infection and bacterial infection Resident #113-nerve pain Resident #114-[MEDICAL CONDITION] and exacerbation of [MEDICAL CONDITION], depression, high blood pressure & dementia Resident #115-anxiety, [MEDICAL CONDITION], hypertension and the effects of potassium depletion. Resident #116-[MEDICAL CONDITION] and exacerbation of hypertension, [MEDICAL CONDITION] and [MEDICAL CONDITION]. Findings include: Resident #102 Per the hospital discharge orders dated [DATE] Resident #102 was prescribed 2 (two) intravenous antibiotics-[MEDICATION NAME] every 12 hours and [MEDICATION NAME] daily. Per the hospital medication administration records the [DATE] dose of [MEDICATION NAME] was given at the hospital. Review of Resident #102's Medication Administration Records revealed he did not receive the evening dose of [MEDICATION NAME] on [DATE] and did not receive either dose of [MEDICATION NAME] on [DATE] and he did not receive the daily dose of [MEDICATION NAME] on [DATE]. Per the Hospital Discharge Summary dated [DATE] Resident #102 was "recently discharged from the hospital on long-term antibiotics for osteo[DIAGNOSES REDACTED]. He apparently failed to receive his antibiotics, when he was discharged and his fever returned to a high degree. When he was brought back to the hospital (on [DATE]) and antibiotics were resumed, he promptly defervesced (fever subsided/temperature returned to normal) and was stable for discharge..." Per the Hospital Discharge Planner notes ([DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]) the hospital was in contact with the Facility and discussed that Resident #102 would require intravenous antibiotic therapy for an extended period of time after leaving the hospital. Per the Hospital Nurses' Notes dated [DATE] Resident #102 left the hospital for the Facility at 3:24 p.m. and "Report called to nurse at (Facility). Discharge papers faxed again to Facility to the Nurses' fax this time (it was faxed to the main office earlier)." Per the Hospital Physician's Note dated [DATE] Resident #102 was diagnosed with [REDACTED]. Review of the Face Sheet dated [DATE] found in Resident #102's closed clinical record revealed he was a [AGE] year-old male first admitted to the facility on [DATE]. Per the [DIAGNOSES REDACTED]. Per the Hospital Physician's Note dated [DATE] Resident #102 had fallen while intoxicated in [DATE] and was subsequently quadriplegic (paralyzed from the neck down); he had a Stage IV Pressure Ulcer on his sacrum with a Wound VAC (suction to remove debris) in place; he had an indwelling urinary catheter and multidrug resistant urinary tract infection; he had a feeding tube; he had osteo[DIAGNOSES REDACTED] (infection in the bone) in a toe on his left foot and in his left outer ankle; and he had a history of [REDACTED]. Per the Hospital Physician's Note dated [DATE] Resident #102 "presents to the emergency room with a fever today. The Patient was recently admitted (to the hospital) on [DATE] through [DATE]." A summary of the consultations and procedures during the hospital stay was given. "The Patient was sent from the nursing home today with a fever that started at 12:00 a.m. He had a T-max (temperature highest) of 104.7 at 5:00 a.m. ...Plan-we will admit..." Resident #102's hospital discharge orders dated [DATE] and the hand written Facility's Physician order [REDACTED].#102 from [DATE]-[DATE] were reviewed. There were several discrepancies between the two sets of orders and between the orders and the listing of medications/dose/frequency/route on the Medication Administration Records. There were two sets of Medication Administration Records (6 pages each) in different handwriting that appeared to be intended for use from Resident #102's admission on [DATE] through his return to the hospital on [DATE] as any entries of administration were made on [DATE] or [DATE]. One set-(Set #A)-was in the same handwriting as the Facility's physician's orders [REDACTED]. The other set-(Set #B)-had an empty space intended for the start date and the ending date "[DATE]" written on the bottom of 3 pages; the other 3 pages in Set #B were not dated. Not all medications were listed on both sets and some medication strengths or frequency of administration did not match from set-to-set. Some medications that were administered were documented as administered on Set #A while others were documented on Set #B (meaning one set was blank but the other set had an entry). Both the Hospital Discharge Orders dated [DATE] and the Facility's physician's orders [REDACTED].#102 which were not administered as follows: 1. [MEDICATION NAME] (antibiotic) 1000 mg IV (intravenous) every 12 hours 8:00 a.m. and 8:00 p.m.-next dose due [DATE] at 8:00 p.m.-MAR Set #A blank 8:00 p.m. [DATE] and blank on [DATE] at 8:00 a.m. and 8:00 p.m. MAR indicated [REDACTED]. 2. [MEDICATION NAME] (antibiotic)1000 mg/100 ml IVPB (intravenous) once a day-next dose due [DATE] at 8:00 a.m.-MAR Set #A was blank on [DATE] at 8:00 a.m. and MAR indicated [REDACTED]. Resident #102's Hospital Discharge Orders dated [DATE] and his Facility's physician's orders [REDACTED]. 1. [MEDICATION NAME] (anti-coagulant to prevent blood clots) 5 mg daily 8:00 p.m.; 2. [MEDICATION NAME] (nutritional supplement) 9.2 gm 1 packet twice a day 8:00 a.m. and 8:00 p.m. 3. [MEDICATION NAME] (treatment of [REDACTED]. 4. [MEDICATION NAME] (urinary tract) 10 mg four times daily 6:00 a.m.-noon-6:00 p.m.-midnight; 5. [MEDICATION NAME] (anti-depressant) 20 mg at bedtime; 6. [MEDICATION NAME] ointment three times a day-8:00 a.m., 4:00 p.m. & 8:00 p.m.; 7. Protein Powder (supplement) 8 tsp. three times a day 8:00 a.m., 12:00 noon and 4:00 p.m.; 8. [MEDICATION NAME] inhaler daily at 8:00 a.m.; 9. [MEDICATION NAME] ([MEDICAL CONDITION] hormone) 25 mcg daily at 8:00 a.m.; 10. Calcium 500 mg with Vitamin D 200 IU twice a day 8:00 a.m. & 4:00 p.m.; 11. [MEDICATION NAME] eye drops every 6 hours (ordered "as needed" on the hospital discharge orders but the Facility physician's orders [REDACTED]. 12. [MEDICATION NAME] Santyl ointment daily 8:00 a.m. Review of both sets of MARs revealed no documented evidence that the following medications were administered to Resident #102 on [DATE]: [MEDICATION NAME], [MEDICATION NAME] Ointment, and [MEDICATION NAME] eye drops. Review of both sets of MARs revealed no documented evidence that the following medications were administered to Resident #102 on [DATE]: [MEDICATION NAME] (6:00 p.m. dose), [MEDICATION NAME] (all doses), [MEDICATION NAME] (all doses), Protein Powder (noon dose), [MEDICATION NAME] inhaler, [MEDICATION NAME] eye drops (all doses), [MEDICATION NAME] Santyl & Calcium with Vitamin D. The Hospital Discharge Orders prescribed the laxative/stimulant for Resident #102 as follows: 1. Senna 8.6 mg/[MEDICATION NAME] 50 mg ([MEDICATION NAME]-S) twice a day as needed. 2. Sennosides ([MEDICATION NAME]) 8.8 mg/5 ml syrup daily. The Facility's physician's orders [REDACTED]. 1. Senna 8.6 mg [MEDICATION NAME] 50 mg one tablet two times a day (dropped the "as needed") 2. Sennosides 8.5 mg (sic) /5 ml one time daily. MAR Set #A (did not match either set of orders): 1. Senna 8.6 mg [MEDICATION NAME] 50 mg was missing from the MAR 2. "Senna 8.8 mg/5 ml 1 spray (sic) as needed" MAR Set #B (included an order not found): 1. Senna 8.6 mg [MEDICATION NAME] 50 mg-one-twice a day 8:00 a.m. and 8:00 p.m. 2. Senna 8.6 mg [MEDICATION NAME] 50 mg-one-twice a day as needed 3. Senna 8.8 mg /5 ml syrup daily (via) [DEVICE] at 6:00 a.m. Review of the 2 sets of MAR indicated [REDACTED] The Hospital Discharge Orders for Resident #102's tube feeding was [MEDICATION NAME] 1.5 cal/1000 ml continuous. The Facility's physician's orders [REDACTED]. MAR Set #A-[MEDICATION NAME] 1.5 [MEDICATION NAME] feedings 360 cc per shift. MAR Set #B-[MEDICATION NAME] 1.5 cal/1000 ml continuous. A Telephone Order dated [DATE] at 18:20 (6:20 p.m.) stated [MEDICATION NAME] tube feeding 360 cc every 8 hours per shift till pump arrives. MAR Set #A documented Resident #102 received [MEDICATION NAME] feedings on the night shift of [DATE] and the day shift of [DATE]. MAR Set #B documented Resident #102 received nothing on [DATE] and on [DATE]. Review of Resident #102's Nurses' Notes revealed no documented evidence that the physician was notified that the medications were not administered as ordered on [DATE] and [DATE]. In an interview on [DATE] at 1:55 p.m. RN #14 said the "IV was supposed to be drop shipped" and offered no other explanation why medications were not administered on [DATE] and [DATE] to Resident #102. Review of the Transfer records revealed Resident #102 returned to the facility on [DATE] and was sent back to the hospital on [DATE]. He was readmitted to the facility on [DATE] and became unresponsive and was sent to the hospital on [DATE] where he expired. Resident #106 Per the Hospital History and Physical dated [DATE] Resident #106 was found that day by family unable to rise from the toilet. She had been unable to get up for more than 24 hours. Resident #106's [DIAGNOSES REDACTED]. Per the Admission Nursing assessment dated [DATE] Resident #106 was alert and oriented to person, time and place. Per the Admission Nurses' Notes dated [DATE] Resident #106 arrived from the hospital via ambulance at "18:00" (6:00 p.m.). Per Resident #106's Physician admission orders [REDACTED]. Review of Resident #106's [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Review of the content list for the Facility's emergency drug back-up box revealed it contained five tablets of [MEDICATION NAME] 5 mg. Review of Resident #106's Nurses' Notes revealed no documented evidence that the physician was notified that the medications were not administered as ordered on [DATE]. In an interview on [DATE] at 1:55 p.m. RN #14 said she administered the medications to Resident #106 on the evening of [DATE]. RN #14 said she "probably" obtained the needed medications "from back-up." RN #14 said, "I know she got her [MEDICATION NAME]." When asked where she obtained the [MEDICATION NAME] as it was not available in he emergency drug back-up box RN #14 did not answer. RN #14 said she "didn't remember" if she notified the physician that medications were not administered. At this Surveyor's request the Facility checked the charge slips for the emergency drug back-up medications. LPN #22 said in an interview on [DATE] at 3:28 p.m. that no drugs taken from the emergency drug back-up box on [DATE] were charged to Resident #106. Resident #106 was observed on [DATE] at 12:50 p.m. seated in a chair in her room. Resident #106 said she received her medications on the day after she was admitted to the facility. Resident #107 Per the Hospital Physician's Note dated [DATE] Resident #107 was a [AGE] year-old male who presented to the emergency room with a history of [MEDICAL CONDITION] and [MEDICAL CONDITION] mental illness, uncontrolled high blood pressure and severe leg pain. Blood clots were discovered in his legs and tests revealed aneurysmal dilatation of the common iliac artery with multiple ulcers involving the abdominal aorta. Resident #107 had emergency surgery to remove the blood clots on [DATE] and he had surgery on [DATE] to repair the right common iliac artery aneurysm that was "more than 2.0 cm" in size and replacement of the abdominal aorta with a bypass graft and removal of a clot behind his knee. Resident #107's physician's orders [REDACTED]. [MEDICATION NAME] (anti-psychotic) 12.5 mg twice a day, [MEDICATION NAME] (treatment to control [MEDICAL CONDITION]) 0.5 mg twice a day, [MEDICATION NAME] (treatment of [REDACTED]. [MEDICATION NAME] (treatment to control/prevent [MEDICAL CONDITION]) 100 mg four times a day, [MEDICATION NAME] (treatment to control/prevent [MEDICAL CONDITION]) 50 mg at bedtime, [MEDICATION NAME] (treatment of [REDACTED]. [MEDICATION NAME] (treatment of [REDACTED]. and [MEDICATION NAME] injections (anticoagulant to prevent formation of blood clots) 5000 Units every 12 hours sub-q (injection). Review of Resident #107's [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the content list for the Facility's emergency drug back-up box revealed it contained 1 vial of [MEDICATION NAME] 5000 Units for injection and 5 tablets of [MEDICATION NAME] 100 mg. Review of Resident #107's Nurses' Notes revealed no documented evidence that the Physician was notified that the prescribed medications were not given. In an interview on [DATE] at 1:55 p.m. RN #14 admitted she was Resident #107's nurse on the evening of [DATE] and offered no explanation for failing to administer his medications and for not notifying the physician. Resident #107 was observed on [DATE] at 12:52 p.m. eating his noon meal in his room. Resident #107 stated he did not get his medications on the day he was admitted to the facility because "they had to have it shipped." Resident #108 Per the "[DIAGNOSES REDACTED].#108's [DIAGNOSES REDACTED]. Per the Admission Nursing assessment dated [DATE] Resident #108 was alert and oriented to person, time and place. Per the Nurses' Notes dated [DATE] at 17:20 (5:20 p.m.) Resident #108 was admitted via ambulance from the hospital. Resident #108's Physician's admission orders [REDACTED] [MEDICATION NAME] 500 mg IV (antibiotic) daily for 1 week for the treatment of [REDACTED]. [MEDICATION NAME] (antibiotic) every 6 hours (for treatment of [REDACTED]. [MEDICATION NAME] (treatment of [REDACTED]. Lactobacillus twice a day (treatment of [REDACTED]. [MEDICATION NAME] (treatment for [REDACTED]. [MEDICATION NAME] (treatment for [REDACTED]. Review of Resident #108's [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the Hospital MAR indicated daily" prior to discharge from the hospital-the dose was due at 5:00 p.m. Per the Hospital MAR indicated 12:31" thus his next dose was due at 6:00 p.m. on [DATE]. Per the Hospital MAR indicated 10:06" thus Resident #108's next dose was due at 6:00 p.m. on [DATE]. Review of the content list of the Facility's emergency drug back-up box revealed it contained 10 tablets of [MEDICATION NAME] 250 mg. Review of Resident #108's Nurses' Notes revealed no documented evidence that the physician was notified that the medications were not administered as ordered on [DATE]. In an interview on [DATE] at 3:15 p.m. RN #17 said she did not administer the medications to Resident #108 on the evening of [DATE] "thinking I needed to wait" for delivery from the pharmacy which was expected after 10:00 p.m. that night. RN #17 said she did not notify the physician that she did not administer the medications as ordered. In an observation on [DATE] at 12:56 p.m. Resident #108 said he did not receive his medications on his first day at the Facility. Resident #108 said, "I think they had a mix-up at first. Then they got it straightened out and oh boy! Here I come." Resident #108 gestured to indicate that beginning on his second day at the facility he received many medications every day. Resident #109 Per the Hospital Discharge Summary dated [DATE] Resident #109 was admitted to the hospital on [DATE] with an acute stroke; she was also diagnosed with [REDACTED]. Per the Admission Nursing assessment dated [DATE] (no time documented) Resident #109 was confused. Per Resident #109's Nurses' Notes dated [DATE] at "17:15" (5:15 p.m.) the physician was notified of the hospital transfer medication orders and the pharmacy was faxed the physician's orders [REDACTED]. Per the Admission Physician order [REDACTED].[REDACTED] [MEDICATION NAME] 0.5 mg (anticoagulant prescribed to prevent blood clots) [MEDICATION NAME] 50 mg (treatment of [REDACTED]. Magnesium Oxide 400 mg (antacid/laxative) [MEDICATION NAME] 50 mg (pain reliever). Review of Resident #109's [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s initials were circled (standard of practice for documentation that an ordered medication was not given). Review of the Nurses' Notes dated [DATE] and [DATE] revealed no documented evidence that the Physician was notified that Resident #109 did not receive the 8:00 p.m. medications on [DATE] as ordered by the Physician. In an interview on [DATE] at 2:52 p.m. RN #17 said she "did not know the extent of the contents of the back-up box" on [DATE] and admitted she did not administer the medications to Resident #109 at bedtime on [DATE]. Resident #109 was observed on [DATE] at 3:38 p.m. seated in her wheelchair in her room. A man who introduced himself as her grandson was visiting. Resident #109 said she was "not happy to be here" and did not want to engage in conversation with this Surveyor. Resident #110 Per the Hospital Discharge Summary dated [DATE] Resident #110 was admitted on [DATE] to the hospital after experiencing nausea, vomiting and diarrhea for ,[DATE] days. Per the Admission Nursing assessment dated [DATE] Resident #110 was confused. Per the Nurses' Notes dated [DATE] at "17:35" (5:35 p.m.) Resident #115 was admitted via medical transport. The time of arrival was not mentioned. Per the admission physician's orders [REDACTED]. [MEDICATION NAME] (treatment of [REDACTED]. [MEDICATION NAME] Chloride XL (relief of bladder instability) at bedtime, [MEDICATION NAME] S (laxative/stimulant) one daily (listed on the [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"2000" (8:00 p.m.), and Tylenol #3 (pain relief) every 6 hours (listed on the MAR indicated [REDACTED]. There was no documented evidence the Resident #110 received the Tylenol #3 at 6:00 p.m. or the [MEDICATION NAME] Chloride and [MEDICATION NAME] at bedtime as the boxes intended to document medication administration on the [DATE] MAR indicated [REDACTED] Review of the Nurses' Notes dated [DATE] and [DATE] revealed no documented evidence that the Physician was notified that the medications were not administered as ordered to Resident #110 on the evening of [DATE]. In an interview on [DATE] at 2:52 p.m. RN #17 admitted she did not administer the medications to Resident #110 on the evening of the day of her admission. RN #17 said she did not notify the physician. RN #17 said, "The pharmacy delivers at 10:00 p.m." and thus the medications needed at 6:00 p.m. and at 8:00 p.m. for Resident #110 were not available. RN #17 stated at that time she was unaware that she could have called the pharmacy for a "drop shipment" (early delivery) and she did not administer the [MEDICATION NAME] even though she was aware that [MEDICATION NAME] was a "stock med" (meaning a supply available for any resident's use was readily available in the medication cart). Resident #110 was observed on [DATE] in her room at 4:00 p.m. Resident #110 was rolling back and forth on the bed and said she had to go to the bathroom. Resident #110 said, "I've had my call light on for ,[DATE] hour." This Surveyor found a Nurse Aide and asked her to go to Resident #110 as soon as possible. Resident #111 Per the Hospital History and Physical dated [DATE] Resident #111 was admitted due to an eye infection; her other [DIAGNOSES REDACTED]. Per the Admission Nursing assessment dated [DATE] Resident #111 was confused. Per the Nurses' Notes dated [DATE] at 18:15 (6:15 p.m.) Resident #111 was readmitted , the physician was notified of the hospital transfer medication orders and the pharmacy was faxed the physician's orders [REDACTED]. Per the physician's orders [REDACTED]. [MEDICATION NAME] 40 mg (treatment for [REDACTED]. [MEDICATION NAME] 500 mg (treatment for [REDACTED]. [MEDICATION NAME] 10 mg (treatment for [REDACTED]. and [MEDICATION NAME] 100 mg 0.5 tab (treatment for [REDACTED]. None of these drugs were documented as given on the evening of [DATE] (boxes on the MAR indicated [REDACTED] In an interview on [DATE] at 2:52 p.m. RN #17 said she did not administer the evening medications to Resident #111 on [DATE] and she did not notify the physician. Resident #111 was observed on [DATE] at 3:40 p.m. asleep in her bed with supplemental oxygen being delivered via nasal canula. Resident #112 Per the Hospital History and Physical dated [DATE] Resident #112 was admitted to the hospital on [DATE] with uncontrolled blood pressure and a change in mental status. Per the Face Sheet Resident #112 was admitted to the facility on [DATE] at 10:30 a.m. Per the Nurse's Notes dated [DATE] Resident #112's the physician was notified of the hospital transfer medication orders and the pharmacy was faxed the physician's orders [REDACTED].) Per the physician's orders [REDACTED].[REDACTED]. Review of the Nurses' Notes revealed no documented evidence that the Physician was notified that the two medications were not administered on [DATE]. Review of the Physician's Telephone Orders dated [DATE] and the Nurses' Notes dated [DATE] at 15:15 (3:15 p.m.) revealed an order for [REDACTED]. There was no documented evidence in the Nurses' Notes that the nurse notified the Physician that the [MEDICATION NAME] was not administered on [DATE] at bedtime as ordered. Review of the Physician's Telephone Orders dated [DATE] at 10:30 a.m. revealed Resident #112 was prescribed [MEDICATION NAME] with [MEDICATION NAME] (vitamin supplement) daily at 8:00 a.m. Review of the [DATE] MAR indicated [REDACTED]. There was no documented evidence in the Nurses' Notes that the Physician was notified that the [MEDICATION NAME] with [MEDICATION NAME] was not administered at 8:00 a.m. on [DATE] as ordered. Review of the physician's orders [REDACTED].#112. Review of Resident #112's [DATE] MAR indicated [REDACTED]. Review of the Nurses' Notes revealed no documented evidence that the Physician was notified the [MEDICATION NAME] was not administered as ordered on [DATE]. Review of Resident #112's physician's orders [REDACTED]. Review of Resident #112's [DATE] MAR indicated [REDACTED]. There was no documented evidence in the Nurses' Notes that the Physician was notified that the first dose of Keflex was not administered on the day it was ordered. Review of the list of contents of the Facility's emergency back-up drug box revealed it contained 10 capsules of Keflex 250 mg. Resident #112 was observed on [DATE] at 3:50 p.m. reading in her husband's room. Resident #112 stated her concern with her medications was that she had used [MEDICATION NAME] for years and it was not prescribed by the Facility's Physician. Resident #112 said "when I bend over I regurgitate acid." Resident #113 Per the Hospital Discharge Summary dated [DATE] Resident #113 was admitted on [DATE] with pain in his legs and diagnosed with [REDACTED]. He was determined to not be a candidate for surgery and was treated with intravenous antibiotics. Per the Nurses' Notes dated [DATE] Resident #113 was admitted at 12:00 noon, the physician was notified of the hospital transfer medication orders and the pharmacy was faxed the physician's orders [REDACTED]. Per the Admission Physician order [REDACTED]. [MEDICATION NAME] (treatment of [REDACTED]. [MEDICATION NAME] (treatment of [REDACTED]. and [MEDICATION NAME] (treatment of [REDACTED]. There was no documented evidence that Resident #113 received the [MEDICATION NAME] or [MEDICATION NAME] as the boxes intended to document medication administration on Resident #113's [DATE] MAR indicated [REDACTED] Review of the Nurses' Notes dated [DATE] revealed no documented evidence that the nurse notified the Physician that Resident #113's medications were not administered as ordered on the evening of [DATE]. In an interview on [DATE] at 2:40 p.m. RN #20 admitted she did not administer the medications as ordered to Resident #113 on [DATE] and did not notify the physician. RN #20 said she expected the medications to be delivered between 10:00 p.m. and 11:00 p.m. that night and did not check the emergency drug backup box contents (per the content list the box held five [MEDICATION NAME] 100 mg capsules). Resident #113 was observed on [DATE] at 3:55 p.m. seated in his wheelchair in the doorway of his room. Resident #113 said he did not remember anything from the day of admission to the facility. Resident #114 Per the Hospital Discharge Summary dated [DATE] Resident #114 was admitted on [DATE] and diagnosed with [REDACTED]. Per the chest x-ray dated [DATE] Resident #114 had a new slightly displaced [MEDICAL CONDITION] rib on her left side. Per the Nursing assessment dated [DATE] Resident #114 was confused. Per the Minimum (MDS) data set [DATE] Resident #114 had identified short and long term memory deficits. Per the Nurses' Notes dated [DATE] Resident #114 arrived at the Facility at "15:00" (3:00 p.m.). Per the Admission Physician order [REDACTED]. [MEDICATION NAME] (treatment of [REDACTED]. [MEDICATION NAME] SR (antidepressant) 100 mg twice a day at 8:00 a.m. and 8:00 p.m., Candesartan (treatment of [REDACTED]. [MEDICATION NAME] Sprinkles ([MEDICAL CONDITION] prevention) 125 mg at noon and 250 mg at bedtime, [MEDICATION NAME] (treatment for [REDACTED]. [MEDICATION NAME] (anti-depressant) 20 mg at 8:00 p.m. and [MEDICATION NAME] (treatment for [REDACTED]. Based on review of the boxes intended to document medication administration on the [DATE] MAR indicated [REDACTED] [MEDICATION NAME] eye drops on [DATE] at 6:00 p.m. or on [DATE] at 6:00 a.m. and at 6:00 p.m. (boxes blank); [MEDICATION NAME] SR [DATE] and [DATE] at 8:00 p.m. (boxes blank) and [DATE] at 8:00 a.m. (box had a line drawn through it); Candesartan [DATE] 8:00 a.m. (box had a line drawn through it); [MEDICATION NAME] Sprinkles 125 mg [DATE] noon (box had a line drawn through it); [MEDICATION NAME] Sprinkles 250 mg 8:00 p.m. [DATE](box blank) and [DATE] (nurse's initials circled-standard of practice to document medication not given); [MEDICATION NAME] 8:00 p.m.

This citation pertains to intake numbers MI 552, MI 555, MI 736, MI 766. Based on observations, interviews, and records review, the facility failed to provide a safe environment and adequate supervision for 1 of 7 sampled residents (Resident #101), resulting in a fall from a mechanical lift with the potential for serious harm. Findings Include: Resident #101 Per Resident #101's face sheet, she was admitted to the facility on [DATE]. Per a physician "Progress Note", dated 9/15/10, Resident #101's [DIAGNOSES REDACTED]. Per an "Accident /Incident Report", written by nurse #18, regarding Resident #101, dated 10/28/10 at 2:20 PM, "(Nurse aide #16) called (nurse #19) to room and resident was observed on the floor lying on her back with the sling (from the Arjo Maxi Move/ mechanical lift) underneath her and the hanger (spreader) bar was attached to the sling. The hanger bar was not attached to the lift. (Nurse #19) was at bedside with (Resident #101) and (nurse aide #16)". In an interview with Resident #101, on 11/10/10 at 1:20 PM, she told Surveyor the mechanical lift (Arjo Maxi Move) fell on her while nurse aide #16 was transferring her. Resident #101 stated the she experienced back pain due to the fall she "had to get x-rays and everything ... " Resident #101 stated she had fallen out of the lift a couple of times, that sometimes two nurse aides assisted with her transfers with the mechanical lift but not always and the day the lift broke, nurse aide #16 was performing the transfer without assistance of another staff member. Resident #101 was alert and oriented. In an interview with nurse #18, on 12/01/10 at 12:30 PM, nurse #18 told Surveyor she was one of the first nurses to respond when she heard nurse aide #16 call for assistance and remembered nurse aide #16 telling her that she heard a popping or snapping noise when she was turning the Arjo Maxi Move lift to put the legs of the machine under the bed. Per an "Accident/Incident Report", written by nurse #17, regarding Resident #101, dated 10/28/10 at 2:45 PM, "(Resident #101) and (nurse aide #16) reported to #17) that resident was being transferred from wheel chair to bed with total lift (Arjo Maxi Move). While transferring to bed, while turning machine, connecting part of machine broke. Resident fell to floor, falling 3-4 feet. Resident in bed when assessment completed". Per "Progress Notes", written by nurse #17 on 10/28/10, regarding Resident #101, "...Resident son (son #22) called at (5:00 PM). Explained to (son #22) (Resident #101) was being transferred from wheel chair to bed with total lift (Arjo Maxi Move). While transferring to bed, wheel chair was one foot from bed. While turning machine, machine (broke). (Resident fell to floor falling 3-4 feet. Family member upset asking how no one could have caught her to keep her from hitting floor...". In a telephone interview with nurse #17, on 12/02/10 at 11:05, she stated she made 2 calls to the on call physician the evening of 10/28/10. She said, in the first call, he told her to monitor Resident #101. Nurse #17 added, when Resident #101 began to complain of back pain, nurse #17 called the on call doctor again, and he ordered x-rays to be taken. Nurse #17 said Resident #101's daughter came around 6:30-7:00 PM on 10/29/10, after the x-rays had already been ordered. Per an imaging report, dated 10/28/10, an x-ray was ordered at 5:58 PM, "Findings: Examination of the sacrum & coccyx in two views reveals ...within normal limits". Per an imaging report, dated 10/29/10, an x-ray ordered at 1:34 PM, "Findings: Examination of the right wrist in three views reveals ...No evidence of fracture, dislocation ... " Per an "Accident/Incident Report", dated 8/08/10, regarding Resident #101, "Had been transferred to wheel chair by (nurse aide #23) and (Arjo Maxi Move) was being pulled away by (nurse aide #23). (Resident #101) tipped over backwards in wheel chair ...Action taken to prevent further incidents: ...have another (nurse aide) present during transfer ..." Per Resident #101's " Fall/Injury Assessment: Prevention and management Plan of Care ...Transfer (with) 2 A (assist) (dated 8/19/10) ...Device: with total lift (dated 8/04/10)". On 11/23/10 at 10:30 AM, in the administrator #20's office, Surveyor observed an Arjo Maxi Move mechanical lift. Per the administrator #20, the Arjo Maxi Move had been removed from service because it was involved in an incident on 10/28/10, resulting in a fall to the floor for Resident #101. In the presence of administrator #20 and the maintenance director #21, Surveyor observed worn and broken plastic gray bushings. Part of one bushing was in the machine and the pieces of another bushing were in a plastic bag attached to the machine. The administrator #2 stated, the parts were found on the floor after Resident #101 was placed in bed following the incident and presented photographs of the same parts. When maintenance director #21 put pressure on the spreader bar to simulate the pressure exerted if a resident were sitting in the sling, the spreader bar remained in position on the jib of the Arjo Maxi Move. When maintenance director #21 put (abnormal) upward and outward pressure on the spreader bar, it easily popped off the jib. Maintenance director #21 presented service records, showing that the lift had been inspected on 9/30/10,by the Arjo representative, and found to be free of bushing defects. In the presence of maintenance director #21, on 12/02/10 at 9:00 AM, the two additional Arjo Maxi Move lifts in the facility were inspected and observed to be free of bushing defects. Per a "Nursing Assistant Orientation Checklist", nurse aide #16 was hired on 9/28/09. LPN Nurse Educator #32 signed the checklist indicating that nurse aide #16 had received and completed training on "Use of Mechanical Lift", "Assisting a Resident to Sit on the Side of the Bed, Transferring a Weak/[DIAGNOSES REDACTED] (paralyzed) resident to Chair/Wheelchair" and "Transferring a resident from wheelchair to Commode" on 10/01/09. In an interview with nurse aide #16, on 12/01/10 at 11:10 AM, she told Surveyor someone else had probably used the machine before her and she had not inspected the spreader bar connection to the jib before or during the transfer of Resident #101 on 10/29/10. She also said, "...I learned my lesson ...one person is supposed to assist you when operating the machine ...but everyone was very busy". Per the Arjo Maxi Move "Operating and Product Care Instructions", "Ensure the spreader bar is securely connected to the jib before starting to lift". The operator's manual for the Arjo Maxi Move was presented for review on 12/02/10. In an interview with maintenance director #21, on 12/02/10 at 9:00 AM, he stated the Arjo representative was in the building earlier in the morning and may have brought the operator's manual. On 12/01/10 at 10:05 AM in a telephone interview with Arjo representative #59, he stated he did the inspection on the Arjo lift after the incident on 10/28/10, filled out an incident report. Arjo representative #59 stated, "It wasn't our (Arjo company) equipment's fault ...pins were not broken ...It is not the bushings ...looks like (bushing) was peeled off and bushings were in at the time of the incident ....I would say the hanger (spreader) was not on there properly ... (Nurse aide #16) did not look at hanger (spreader) to make sure it's in there correctly". Per the administrator #20, on 12/01/10 at 12:20 PM, she stated nurse aide #16 went against company policy that requires two staff members present during Arjo Maxi Move transfers.