Every finding on record at Medilodge of Wyoming

Based on observation and interview, the facility failed to maintain proper infection control practices for one of two Residents (R69) observed during clinical care activities. Findings include:Resident #69 (R69)On 7/23/25 at approximately 9:41 AM, RN C administered a prescribed nasal spray to R69. RN C prepared to give R69 their insulin injection via pen in the abdomen by cleansing the area with alcohol swab. RN C then waved her hand back and forth over the area swabbed by alcohol to get it dried prior to administering the insulin injection. According to the World Health Organization (WHO) 2020, injections are unsafe when administered with unsterile or improper techniques. The WHO recommends swabbing the injection site for 30 seconds and allowing the area to dry for 30 seconds. RN C waving their hand over the alcohol causes it to evaporate too quickly, disrupting the alcohol's action, while potentially introducing new microorganisms. RN C's actions can increase the risk for infection at the injection site. Upon return to the medication cart, RN C did not cleanse the nasal applicator that had visible residue on the tip prior to placing it back into the medication cart. RN C did not cleanse insulin pen prior to placing it in a plastic bag without sealing the bag and put it back in the medication cart. Not cleansing the nasal tip or the insulin pen increased the risk for cross contamination to other residents' medications.On 7/24/25 at 8:32 AM, during interview with Infection Prevention (IP) nurse, the IP nurse stated that all staff were expected to perform their duties including medication administration, hand washing, and environmental services per standards of care. The IP nurse stated that any education given to staff, regarding these duties was provided by the education department. The IP nurse could not state the standards regarding medication administration for insulin or nasal sprays.

Based on observation, interview, and record review, the facility failed to ensure the physician reviewed monthly drug regimen review recommendations for 1 resident (R70) of 5 residents reviewed for unnecessary medication. Findings include:Review of an admission Record revealed R70 admitted to the facility on [DATE] with pertinent diagnoses which included hypertension and gastro-esophageal reflux disease (GERD).Review of R70's drug regimen review Physician Recommendations dated 6/14/2025 revealed .This resident is receiving famotidine 20mg BID (twice daily) for GERD since 03/2023. Please evaluate for continued need/reduction. There was no indication that the physician had reviewed this recommendation.Review of R70's Physician's Orders on 7/14/2025 at 11:14 AM revealed an active order for famotidine 20mg to be taken by mouth twice a day. Further review of the electronic medical record revealed no documentation that the physician had reviewed the drug regimen review Physician Recommendations dated 6/14/2025.In an interview on 7/24/2025 at 12:42 PM, the Director of Nursing (DON) reported R70's drug regimen review Physician Recommendations dated 6/14/2025 had not been reviewed by the physician. The DON reported she was not sure how this was missed.Review of facility policy/procedure Addressing Medication Regimen Review Irregularities, reviewed 12/28/2023, revealed .Any irregularities noted by the pharmacist during this review must be documented on a separate, written report. The report will be sent to the attending physician. The attending physician must document in the resident medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. The report should be submitted to the DON within 10 working days of the review.

Based on interview and record review, the facility failed to obtain informed consent and offer information about formulating an Advanced Directive for 1 resident (R82) out of 5 residents reviewed for Advanced Directives. Findings include: Review of an admission Record reflected R82 admitted to the facility on [DATE] with diagnoses that included encephalopathy (a brain disease that can appear as confusion, memory loss, personality changes and/or coma), cognitive communication deficit, mild cognitive impairment, major depression, and generalized anxiety disorder. Review of a form Advanced Directives Acknowledgements/CPR (Cardiopulmonary Resuscitation) Consent reflected what CPR is; Acknowledgments, including spaces after each statement for initials to indicate understanding,I have been informed of my rights and all rules and regulations regarding decisions regarding medical care; I have been fully informed of my options when choosing CPR or Do Not Resuscitate (DNR) services; I understand I have the right to alter my decisions concerning CPR or DNR services and that any change must be communicated., a CPR Decision for resuscitation, no resuscitation or I do not wish to make a choice at this time and a section that pertained to requesting additional information about how to formulate an Advanced Directive (Medical POA, (power of attorney)) with boxes giving the signer of the form the option to check a box indicating Yes or No. Review of the Advanced Directives Acknowledgements/CPR Consent form signed by R82 on [DATE] (the date R82 admitted to the facility) reflected R82 specified their CPR decision but was incomplete pertaining to areas of informed consent and interest in additional information about formulating an Advanced Directive or establishing a Medical Power of Attorney. A facility representative (the Director of Nursing, DON) also signed the form on [DATE]. During an interview on [DATE] 9:42 AM, Social Services Director (SSD) F reported the Advanced Directives/CPR Consent form is new to the admission process in the last 6 months. According to SSD F the priority is to get the form signed by the resident in order to establish that resident's code status. Upon reviewing R82's form that was signed on [DATE], she could not tell if any follow-up had occurred to determine if R82 had a medical POA and/or was fully informed of their rights related to CPR. During an interview on [DATE] at 10:52 AM the DON reported she assisted with the admission of R82 and only got the signature R82's CPR decision. The DON reported the resident would stay a full code until the physician gets the two witnesses and order on the chart. The DON said that any additional information pertaining to the Advanced Directives Acknowledgements/CPR Consent may be available with SSD E who is assigned to R82 at the facility. The DON acknowledged that there is pertinent information missing from the form. Review of a Discharge Planning Evaluation form dated [DATE] indicated an admission Care Conference took place and did NOT include R82 and did not reflect a discussion about Advanced Directives or CPR Decisions had taken place. During an interview on [DATE] at 11:30 AM, SSD F reported that R82's Advanced Directives/CPR Consent form was incomplete and had been signed by the R82 and the DON. SSD F said that R82 had family involved with care conferences but did not have any documentation indicating they would have any authority to act on R82's behalf if her circumstances changed and she was no longer able to make medical decisions for herself. Review of a facility policy Residents' Rights Regarding Treatment and Advanced Directives dated [DATE] reflected, It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advanced directive. The policy specified 1. On admission, the facility will determine if the resident has executed an advanced directive, and if not, determine whether the resident would like to formulate an advanced directive. 2. The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advanced directive.

Based on observation, interview, and record review, the facility failed to follow professional standards regarding medication administration for 1 of 6 residents (Resident #57), reviewed for professional standards. Findings: Resident #57 (R57) Review of an Admission Record revealed R57 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses of stroke, legal blindness, repeated falls, and anxiety disorder. During an observation on 08/21/24 at 10:15 AM, R57 laid in bed resting with his eyes open and a small plastic cup containing multiple pills sat on the overbed table. R57 stated that sometimes the nurse would leave his morning medications for him to take when he wakes up. R57 also reported that he does not take his medications independently, nor store any of his medications in his room. Review of the Electronic Health Record (EHR) for R57 revealed there was not an assessment nor a physician order for R57 to self-administer medications. During an interview on 08/23/24 at 8:08 AM, the Director of Nursing indicated that if a resident was able to self-administer medications, there would be an assessment and an order for such. Review of the facility policy Medication Administration last reviewed 01/17/23, reflected: (15) Observe resident consumption of medication.

Based on interview, observation, and record review, the facility failed to ensure accurate skin assessments and timely responses to skin changes for 2 of 16 residents, (Resident #22 and Resident #54) reviewed for impaired skin. The deficient practice resulted in no follow-up assessments and treatment orders for identified skin conditions. Findings include: Resident #54 (R54) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R54 admitted to the facility on [DATE] with diagnosis of (but not limited to) stoke, chronic pain syndrome, and heart failure. Brief Interview for Mental Status (BIMS) reflected a score of 12 out of 15 which represented R54 was cognitively intact. During an interview and observation on 8/20/24 at approximately 3:53 PM, R54 was asked if she had any wounds the staff was monitoring and R54 stated she had no wound dressings. R54 stated that she was told she needed surgery for a skin issue on her right breast. R54 pulled her shirt up and showed this Surveyor a darked, raised area of skin that was larger than a half dollar to the right breast. R54 said she'd had the skin issue for a long time. The August 2024 Treatment Administration Record (TAR) was reviewed on 8/20/24 after interviewing R54. There were no monitoring or treatment orders noted for the skin issue to the right breast. The skin assessments from 7/18/24 - 8/20/24 were reviewed on 8/20/24. The assessment dated [DATE] reflected that R54 had an existing abnormal skin area and documented in the comments box reflected, Mole on the right breast. The weekly skin assessments dated 7/25/24, 8/5/24, 8/8/24 and 8/15/24 were reviewed. These 4 most recent assessments all reflected that No was checked for Are there any existing abnormal skin areas? The assessments did not accurately reflect the skin issue to the right breast that R54 showed this Surveyor on 8/21/24. During an interview on 8/21/24 at approximately 12:15 PM, the Director of Nursing (DON) was advised that R54 told this Surveyor that she needed surgery to remove an abnormal skin lesion on her right breast but was unable to find anything about this in the electronic health record. The DON was advised of the weekly skin assessments that did not reflect any ongoing abnormal skin conditions. The DON stated she would look into this. At approximately 2:15 PM, the DON stated R54 was not scheduled for any procedures for the right breast skin issue and provided the following documents for review: -The admission assessment dated [DATE], R54 had a Mole to the right breast that measured 4.1 cm x 4.3 cm. -An updated weekly skin assessment dated [DATE] at 2:12 PM that reflected, Right breast mole measuring 4.0 x 4.5. -A verbal physician order to refer resident to dermatology to evaluate mole on right breast dated 8/21/24 at 2:06 PM. These actions were all taken after it was brought to the attention of facility. A request for the most recent physician assessment of the right breast skin issue was made on 8/21/24 at 2:39 PM and the DON provided a copy of the Physician Assistant's note 1/19/22 that reflected, Patient states she has a bunch of moles of her back and chest that are itching her .Several seborrheic keratosis (a skin condition that appears as a waxy, brown, black, or tan growth) noted throughout back and chest .3. Seborrheic keratosis. Advised to keep lesions moist with daily moisturizing . There was no measurement or order to monitor characteristics noted. The orders were reviewed again for updates on 8/22/24 and noted a new order dated 8/22/24 to Assess mole to right breast. Monitor characteristics, measure length and width and document in progress notes, in the evening every 3 month(s) starting on the 1st for 30 day(s) Note characteristics and measurements in progress note. And as needed for resident concerns, noted changes document in nursing notes. There was no evidence the abnormal skin issue to the right breast was being assessed and monitored prior to the onsite survey. Resident #22 (R22) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R22 admitted to the facility on [DATE] with diagnosis of (but not limited to) peripheral vascular disease, heart failure, chronic kidney disease, diabetes, and pressure ulcer to the sacral area. Brief Interview for Mental Status (BIMS) reflected a score of 12 out of 15 which represented R22 was cognitively intact. During an interview and observation on 8/20/24 at 11:06 AM, R22 was observed resting on his bed with his feet on top of the blanket. The left great toe had a dressing with a date of 8/19/24 on it and a dressing to the top of his right foot that was dated 8/19/24. When asked about the wounds to the left toe and right foot, R22 could not recall how they happened but stated that he has poor circulation. The most recent weekly skin assessment dated [DATE] (11 days prior) reflected no new skin issues but reflected existing skin issues of right toes, right buttock and left buttock. No indication of a right foot wound to the top of the foot at the time of this assessment. The electronic progress notes from 8/1/24 - 8/21/24 were reviewed on 8/21/24 at approximately 11:30 AM and did not reveal any documentation of an open area to the right foot that required a dressing. The care plan for skin integrity in the electronic record was reviewed on 8/21/24 at 11:30 AM and did not reflect an issue to the right foot nor any interventions regarding it. The August 2024 TAR was reviewed on 8/21/24 at 11:30 AM and did not reflect a treatment order for the right foot. During an interview and record review on 8/21/24 at approximately 2:00 PM, the DON was advised of the presence of a dressing on R22's right foot that had the date of 8/19/24 documented on it. There was no indication of the skin issue documented in the progress notes, skin assessment nor the August TAR. The DON stated that Registered Nurse (RN) A does wound rounds every Monday and may have more information related to the right foot. During an interview on 8/22/24 at 10:45 AM, RN A stated that she was the first person to note a new skin tear to the top of the right foot. RN A stated normally she notifies the physician, obtains a treatment order, documents it in the progress notes and updates the care plan. RN A stated, There was a lot going on that day and I missed it.

Based on observation, interview and record review, the facility failed to honor resident choices and preferences based on the individualized plan of care for 1 resident (Resident #40) out of 16 residents reviewed for self-determination. Findings: Resident #40 (R40) Review of an Admission Record reflected R40 admitted to the facility with diagnoses that included muscle weakness, need for assistance with personal care, repeated falls, chronic post-traumatic stress disorder PTSD), dependence on enabling machines and devices and anxiety. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflects R40 is cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 13/15. Review of a Care Plan initiated on 7/20/2023 reflected R40 required assistance with Activities of Daily Living (ADL) related to his diagnoses. Interventions included: Transfers: 2 person assist with Hoyer (mechanical) lift (added to the care plan on 6/14/2024); I like to sit up in my recliner after breakfast (added to the care plan 7/12/2024). Further review of the Care Plan indicated R40 was At risk for impaired mood related to depression, anxiety, insomnia and PTSD. The goal of the care plan focus was (R40) will remain free of signs and symptoms of distress, depression, anxiety, or sad mood. Interventions included Encourage participation from resident to make own decisions; Offer resident choices whenever possible to in order to promote a feeling of self-worth and control over the environment. During an observation on 8/20/2024 beginning at 1:45 PM, R40 was seated in his wheelchair next to the nurse station on the unit where he lived. R40 reported he was waiting for staff to transfer him into his recliner chair because he was uncomfortable in his wheelchair. R40 explained that he often has to wait for a long time before 2 staff members can assist with a Hoyer transfer. R40 reported that sometimes he stays in bed longer than he would like to in the morning because he knows it will be a long time before staff will get him into his recliner again, and often staff will transfer him into bed rather than his recliner because staff don't want to transfer him any more than they have to. Certified Nursing Assistants were observed in the area and were aware R40 wanted to be transferred to his recliner and reported having other things to do and waters to pass. Registered Nurse (RN) A was seated at the nurse desk and was overheard instructing staff to transfer R40 into his recliner chair 3 times over the course of the observation. R40 said he was frustrated. RN B came to the nurse desk and agreed to assist Certified Nurse Aide (CNA) C with the two-person transfer. CNA C was overheard encouraging R40 to go to bed, rather than sit in his recliner and R40 said he preferred to sit in his recliner. R40 was transferred to his recliner at 2:25 PM, 40 minutes after the surveyor had become aware of R40's request. During an observation on 8/21/2024 at 11:30, R40 reported he was again wafting to be transferred into his recliner because his wheelchair was very uncomfortable. During a follow-up interview on 8/21/2024 at 3:51 PM, R40 said that he reports his concerns about how long it takes staff to transfer him to every staff who work with him.

Based on interview and record review, the facility failed to treat residents with dignity and respect and failed to provide an environment that promoted and enhanced resident quality of life for 1 resident (Resident #3) and residents attending monthly group meetings, reviewed for dignity, resulting in the potential for feelings of frustration, depression, and loss of self-worth and an overall deterioration of psychological well-being. Findings: Resident #3 (R3) Review of an Admission Record revealed R was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: multiple sclerosis. Review of a Minimum Data Set (MDS) assessment for R3, with a reference date of 5/8/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R3 was cognitively intact. During an interview on 07/25/23 at 12:15 PM, R3 reported that she felt it was disrespectful when the facility nursing staff wore earbuds while they provided care to residents. R3 reported it was not necessary to wear them while they were working. R3 reported staff wearing earbuds has been an ongoing issue at the facility. During an interview on 07/25/23 at 9:58 AM, Family Member (FM) I reported she did not appreciate facility nursing staff wearing earbuds while they were preparing and passing out medications to residents. FM I reported that she visits often and has observed staff wearing earbuds during most visits to the facility. Review of Resident Council meeting minutes dated 3/29/23 revealed, .some CNA (Certified Nursing Assistants) on 3rd shift on phones-being addressed not resolved .2nd + 3rd shift some on phone with ear buds . Review of Resident Council meeting minutes dated 4/24/23 revealed, .Old Business Review/Status Update .2nd + 3rd shift some on phone with ear buds .Discussed with DON (Director of Nursing) currently working on it . Review of Resident Council meeting minutes dated 5/31/23 revealed, .Old Business Review/Status Update .2nd/3rd shift some on phone with ear buds .DON came to last meeting to discuss .(in progress). Review of Resident Council meeting minutes dated 6/28/23 revealed that staff wearing ear buds was not addressed as Old Business Review and was not identified as a current concern.

Based on observation, interview, and record review, the facility to failed to ensure call lights were in reach and answered promptly for 3 residents (Resident #224, #8, and #63), reviewed for accommodation of needs, resulting in the potential for residents to not meet their highest practicable level of well-being. Findings include: Resident #224 (R224) Review of an Admission Record revealed R224 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: stroke and aphasia (difficulty speaking). R224 was able to make needs known but had difficulty speaking. During an observation and interview on 07/25/23 at 09:40 AM, R224's call light was on and he reported he had been waiting for assistance for over an hour. R224 pointed to his wheelchair and indicated he was waiting to be assisted out of bed. Review of the call light system located at the nurses station revealed R224's call light had been activated at 9:32 AM. At 9:48 AM, Certified Nursing Assistant (CNA) J went into R224's room, the call light was shut off, and CNA J exited the room. At 9:53 AM R224 was asked if he had been assisted at the time CNA J entered the room and shut off the call light. R224 reported she had not assisted him and CNA J shut off his light without explaining when she would return. R224 reported he did not know where his call light was. R224's call light was not in reach and was located hanging from the top of his bed where he was unable to see or reach the call light. 29073 Resident #8 (R8) Review of an Admission Record reflected R8 admitted to the facility on [DATE] with pertinent diagnoses of blindness of one eye, osteoarthritis, muscle weakness, need for assistance with personal care, gastrostomy status (feeding tube), low back pain and depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] reflected R8 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14/15 and needed extensive assistance from one person for dressing, toileting and bathing. During an interview on 07/25/23 at 1:51 PM, R8 reported he was frustrated with how long it takes staff to respond to his requests for help. R8 could not be specific about what he had to wait for or when he had to wait. R8 shook his head from side to side said it depends. R8 then waved the surveyor away. Resident #63 (R63) Review of an Admission Record reflected R63 admitted to the facility on [DATE] with diagnoses that included non-pressure chronic ulcer of skin of other sites with fat layer exposed, morbid obesity, type 2 diabetes, muscle weakness, need for assistance with personal care, generalized anxiety disorder and insomnia. Review of a quarterly MDS assessment dated [DATE] reflected R63 was cognitively intact as evidenced by a BIMS score of 10/15 and required extensive assistance from two people for bed mobility, dressing, toileting, and personal hygiene. R63 was totally dependent on two people for transfers and needed extensive assistance from one person for locomotion on and off the unit and bathing. During an interview on 7/25/23 at 11:01 AM, Resident # 63 reported staff will take an hour to answer the call light on the 3rd shift. R63 said she has skin breakdown that is worsened from urine exposure. R63 said she does attend the Resident Council meetings and has told staff about her concerns. R63 said call light response time will get better for a while then goes back to long wait times.

Based on observation, interview and record review, the facility failed to ensure residents were kept safe from accidents and hazards for 1 residents (Resident #8) when staff failed to maintain NPO (nothing by mouth) status, resulting in the potential for harm from complications related to the resident's inability to swallow safely. Findings: Resident #8 (R8) Review of an Admission Record reflected R8 admitted to the facility on [DATE] with pertinent diagnoses of blindness of one eye, osteoarthritis, muscle weakness, need for assistance with personal care, gastrostomy status (feeding tube), low back pain and depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] reflected R8 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14/15 and needed extensive assistance from one person for dressing, toileting and bathing. Review of a Speech Therapy SLP Evaluation and Plan of Treatment for certification period 6/30/2023 - 7/29/2023 reflected R8's treatment approaches included Treatment of swallowing dysfunction and/or oral function for feeding and Eval of oral and pharyngeal swallow function. The recommendations for R8 following the evaluation was that R8 remain NPO for liquids or solids. Review of a Care Plan initiated on 6/30/23 reflected The resident (R8) is at nutritional risk r/t past medical history of metabolic encephalopathy, emphysema, CHF (Congestive Heart Failure), ischemic cardiomyopathy .Resident is NPO . Interventions included: NPO, Provide and serve TF (tube feeding) as ordered, Water flushes as ordered. Review of a Diet Requisition Form dated 6/29/23 reflected R8 was NPO. Review of the most recent NP/PA (Nurse Practitioner/Physician Assistant) progress note dated 7/18/2023 at 1:00 PM indicated R8 was NPO. During an observation on 7/25/23 at 1:51 PM, R8 was noted to have water in a Styrofoam cup with a straw on the over the bed table within reach. During an observation on 7/26/23 at 9:33 AM, R8 was observed to have water in a Styrofoam cup with a straw on the over the bed table within reach. During an observation and interview on 7/26/23 at 2:31 PM, R8 was observed with water in a Styrofoam cup with a straw at the bedside. When asked, R8 reported he does drink the water. During an observation on 7/27/23 at 11:40 AM, R8 was observed with water in a Styrofoam cup with a straw at the bedside, the water was from the third shift on 7/26/23. During an interview on 7/27/23 at 11:45 am, Certified Nurse Aide (CNA) E reported that the water should not be in R8's room because he is NPO.

Based on observation, interview and record review, the facility failed to ensure systems were implemented to accurately account for controlled substances when licensed nurses were not conducting/signing off on shift to shift narcotic reconciliation and licensed nurses were not signing out controlled substances from narcotic sheets prior to administration of the controlled substances, resulting in the potential for the inability to reconcile narcotics and diversion. Findings: Review of a facility policy Controlled Substance Administration & Accountability reviewed/revised on 1/1/2022 reflected It is the policy of this facility to promote safe, high quality patient, care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure. The policy specified 8. The Charge Nurse on duty will maintain the keys to the controlled substance containers. The keys to this container should not be shared with other staff, including licensed staff without first conducting a complete controlled substance count. The Director of Nursing Services will maintain a set of back-up keys for all drug storage areas including keys to the controlled substance containers. 11. Nursing staff must count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services or His/Her designee immediately. Documentation should be made on the shift verification sheet. A complete controlled substance count of the 300 Unit medication cart was conducted with Licensed Practical Nurse (LPN) G on 7/27/23 at 8:35 AM. It was discovered during the process that the Controlled Substance Shift Inventory had not been verified by the outgoing and oncoming nurse as evidenced by the signature of the oncoming nurse was missing for 7/27/23 for the shift beginning at 6:00 AM. On 7/27/23 at 8:40 AM, the narcotic count for each prescription of a controlled substance in the 300 Unit Medication cart was conducted with LPN G. It was discovered during the count that there were discrepancies for controlled substance counts on the Controlled Substance Record for 4 controlled substance prescriptions. LPN G reported that she forgot to sign out the doses on the Controlled Substance Record when she prepared them for administration. During an interview on 7/27/23 at 8:50 AM, the Director of Nursing (DON) reported that it is the expectation that licensed nurses validate the controlled substance count on the Control Substance Record and record the withdrawal of a controlled substance each time a controlled substance medication is prepared for administration to the resident.

This citation pertains to intakes #: MI00129767, MI00130369, MI00130422, and MI00137768 Based on interview and record review, the facility failed to 1.) ensure residents received consistent and comprehensive physician ordered care, 2.) notify the physician of abnormal findings, and 3.) ensure residents received care in accordance with professional standards for medication administration, in 5 residents (Resident #22, #24, #25, #27, and #26) reviewed for quality of care, resulting in a delay in treatment and the potential for the worsening of a medical condition and residents not attaining or maintaining his or her highest practicable level of wellbeing. Findings: Resident #22 (R22) Review of an Admission Record revealed R22 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: hypotension (low blood pressure). Review of R22's Physician Order dated 3/26/23 revealed, Vital Signs every evening shift every Wed (Wednesday) for Vitals monitoring. Review of R22's Physician Order dated 9/29/22 revealed, Midodrine HCl Tablet 10 MG Give 1 tablet by mouth three times a day for orthostatic BP (low blood pressure that happens when standing up from sitting or lying down). Midodrine is prescribed for increasing blood pressure. Review of R22's Blood Pressure Summary revealed that on 5/24/23 a blood pressure result of 165/97. Normal blood pressure range less than 120 over less than 80 (120/80) per [NAME] and [NAME] 10th edition) confirming R22 was hypertensive (high blood pressure) at that time. Review of R22's May Medication Administration Record (MAR) revealed that on 5/24/23 R22's 9:00 PM dose of midodrine was withheld for 4-Vitals Outside of Parameters for Administration without ordered parameters or a physician order. The physician was not notified of R22's elevated blood pressure and an order was not received to hold the midodrine and/or an order to implement parameters. Review of R22's Nurses Notes dated 5/25/23 at 9:06 AM revealed, Patient had blood pressure of 165/97 on 5/24/23. Continued monitoring and med staff notified. No new orders at this time. Confirming R22's provider was not notified of the hypertensive result at the time the blood pressure was obtained, and a follow-up/re-assessment was not completed. Review of R22's May Treatment Administration Record (TAR) revealed no vital sign assessment on 5/31/23 and no documentation for the rationale it was not completed (TAR left blank). Review of R22's June Treatment Administration Record (TAR) revealed that on 6/7/23 R22 refused the vital sign assessment. No documentation found that an attempt was made to obtain vital signs at a later date and/or time. Review of R22's Blood Pressure Summary revealed the following: *On 5/24/23 at 6:36 PM a blood pressure result of 165/97 *On 6/14/23 at 8:06 PM a blood pressure result of 165/97 *On 6/14/23 at 9:26 PM a blood pressure result of 118/64 Review of R22's Electronic Health Record (blood pressure summary, progress notes, MAR, and TAR) revealed no documentation that R22's blood pressure was reassessed following the hypertensive reading on 5/24/23 until 6/14/23. Resident #24 (R24) Review of an Admission Record revealed R24 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: type 2 diabetes. Review of R24's Physician Order dated 5/23/23 revealed, Accucheck (blood sugar assessment) two times a day related to TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED. Notify physician if (less than) 70 or (greater than) 400. Review of R24's Blood Sugar Summary revealed the following: *On 5/2/23 at 4:07 PM a result of 424 *On 5/7/23 at 4:20 PM a result of 468 *On 5/8/23 at 4:28 PM a result of 420 *On 5/11/23 at 6:26 PM a result of 412 *On 5/24/23 at 6:27 PM a result of 405 *On 6/1/23 at 8:36 PM a result of 412 Review of R24's Order Administration Note dated 5/2/23 at 4:07 PM revealed, Accucheck .resident stated she had eaten a bag of doritos. There was no documentation verifying that the nurse notified R24's provider of the blood sugar result of 424. Review of R24's Nurses Note dated 5/12/23 at 3:05 PM, written by Unit Manager (UM) D revealed, Blood glucose read 412 on 5/11/23 at 18:26 (6:26 PM). Med staff notified and no new orders at that time. Confirming R24's provider was not notified of the elevated blood sugar result at the time of the assessment by Licensed Practical Nurse (LPN) E, the nurse that obtained the blood sugar on 5/11/23. Review of R24's Nurses Note dated 5/25/23 at 9:13 AM, written by UM D revealed, Patient had blood pressure of 154/82 on 5/24/23 and blood glucose of 405. Asymptomatic. Continued monitoring and med staff notified. No new orders at this time. Confirming R24's provider was not notified of the elevated blood sugar result at the time of the assessment by Registered Nurse (RN) S, the nurse that obtained the blood sugar on 5/24/23. Review of R24's Nurses Note dated 6/5/23 at 3:06 PM, written by UM D revealed, Patient had blood sugar of 412 on 6/3/23. Asymptomatic. Med staff aware. No new orders at this time. Will continue to monitor. Confirming R24's provider was not notified of the elevated blood sugar result at the time of the assessment by RN F, the nurse that obtained the blood sugar on 6/1/23. Review of R24's Blood Sugar Summary revealed the blood sugar result of 412 was documented on 6/1/23 with no elevated blood sugar result of 412 on 6/3/23. Review of R24's Electronic Health Record revealed no documentation that the provider was notified of R24's blood sugar results greater than 400 at the time of the assessments on 5/2/23, 5/7/23, 5/8/23, 5/11/23, 5/24/23, or 6/1/23. Resident #25 (R25) Review of an Admission Record revealed R25 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: orthostatic hypotension. Review of R25's Physician Order dated 3/27/23 revealed, Midodrine HCl Tablet 5 MG Give 10 mg by mouth every morning and at bedtime for ortho hypotension. (two 5mg tabs) HOLD if SBP >180mmHg (systolic blood pressure/top number greater than 180). Review of R25's May and June Medication Administration Record revealed midodrine was not administered on 5/6/23. R25 refused midodrine on 5/9/23 (PM dose), 5/15/23, 5/28/23 (AM dose), 5/29/23 (AM dose), 6/7/23 (AM dose), 6/9/23 (AM dose), 6/12/23 (AM dose), and 6/13/23 (PM dose) and therefore a blood pressure assessment would not be required. Midodrine was documented as administered on every other MAR entry. Review of R25's Blood Pressure Summary (May 1-June 14) revealed the following: *On 5/2/23 at 4:04 PM a result of 112/61 *On 5/10/23 at 10:14 AM a result of 120/78 *On 5/24/23 at 11:30 AM a result of 133/66 *On 5/27/23 at 1:03 PM a result of 135/65 *On 6/1/23 at 11:17 AM a result of 109/56 *On 6/6/23 at 9:22 AM a result of 79/55 *On 6/7/23 at 10:36 AM a result of 110/63 *On 6/11/23 at 1:13 PM a result of 114/73 Confirming licensed nurses were not obtaining a blood pressure assessment prior to the administration of the midodrine to ensure the medication was administered within the physician ordered parameters. Resident #27 (R27) Review of an Admission Record revealed R27 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: acute diastolic congestive heart failure. Review of R27's Physician Order dated 5/29/23 revealed, Daily Weight in the morning related to ACUTE DIASTOLIC (CONGESTIVE) HEART FAILURE. Review of R27's Weight Summary from 5/29/23-6/15/23 revealed R27's weight was not assessed from the date of the order until 6/7/23. *On 6/7/2023-123.8 pounds *On 6/11/2023-120.8 pounds Review of R27's May and June Treatment Administration Record revealed on 5/29/23 R27 was not in the facility. R27 refused her daily weight on 6/4/23 and 6/8/23. On 5/30/23, 5/31/23, 6/1/23, 6/2/23, 6/3/23, 6/9/23, and 6/10/23 the TAR was left blank indicating the weight was not obtained and without a rationale for the weight assessment not being completed. Review of R27's Electronic Health Record revealed no additional documentation related to R27's weights or rationale for the lack of weight assessments. During an interview on 06/14/23 at 3:39 PM, RN C reported that if blood sugars, vital signs, or weights are ordered the assessment should be documented in the residents MAR/TAR and should not be left blank. RN C reported that if an assessment is refused, the refusal would be documented in the Electronic Health Record. RN C reported if a blood sugar is greater than 400 and it's ordered to notify the provider, the provider would be called at the time of the assessment. RN C reported that provider notification of an abnormal result/vital sign would be documented in the resident's progress note. RN C reported if a resident's blood sugar was outside of the ordered parameters, it would require a phone call to the provider at the time of the assessment. RN C reported that if parameters are ordered for blood pressure medication, the expectation is for the nurse to obtain the blood pressure prior to the medication administration. 29073 Resident #26 (R26) Review of an Admission Record reflects R26 admitted to the facility on [DATE] with diagnosis that included end stage renal disease, dependence on renal Dialysis, type 2 diabetes, unspecified mood disorder and anxiety. Review of a Minimum Data Set (MDS) discharge assessment dated [DATE] reflected R26 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15/15. Review of a NP/PA (Nurse Practitioner/Physician Assistant) Progress Note dated 6/8/2023 at 10:29 AM reflected HISTORY OF PRESENT ILLNESS: Pt (patient) seen for initial evaluation. Staff reports that patient had a bad night last night, states that she is scared to stay at (name of facility) because someone tried to kill her last night. This is a [AGE] year-old female hospitalized for weakness, dyspnea and abdominal pain. She has a history of end-stage renal disease with hemodialysis, congestive heart failure with preserved ejection fraction, glaucoma, CVA (cerebral vascular accident/stroke) and hypertension. Patient is sitting on her bed. Patient is upset that a male nurse entered her room at 3:30 a.m. last night with a filled syringe. She states that she is planning to leave the facility today after dialysis. She denies pain, chest pain, shortness of breath or cough, nausea/vomiting, abdominal pain or diarrhea/constipation. She voices no medical concerns. Charts, meds and labs reviewed. During a telephone interview on 6/15/2023 at 10:59 AM, Licensed Practical Nurse (LPN) E confirmed he did attempt to administer a TB (tuburculosis) test to R26 at 3:20 AM on 6/8/2023. According to LPN E he gathered the supplies and went to R26's room where the resident was sleeping. LPN E said he knocked on R26's door and when he did not get a response, he announced himself again then entered the room, turned on the overhead light and began to draw the privacy curtain around R26's bed at which time R26 did wake up. LPN E said that R26 was clearly upset and began asking who LPN E was and insisted on looking at his name badge while asking what he was doing. LPN E said that R26 refused the injection and said she did not like to be woken up so early on a day she has dialysis. LPN E said he accepted R26's refusal and left the room. LPN E said that R26 continued to be very upset and after he left the room, R26 turned on her call light and loudly yelled for help and was very upset for the rest of the morning. LPN E said that it was not unusual for nurses to carry out TB testing in the middle of the night and said he did not stop to think that maybe it (TB testing at 3:20 AM) was not a good idea. Review of the June 2023 Medication Administration Record (MAR) revealed an order for Tuberculin PPD (purified protein derivative) Solution Inject 0.1 ml intradermally one time only for tuberculosis screening until 6/7/2023 at 23:59 (11:59 PM) Administer 0.1 ml intradermally - read/record results 48-72 hours in millimeters -Start Date- 06/07/2023 1400 (2:00 PM) The MAR indicated that the order had not been carried out on 6/7/2023 and that on 6/8/2023 at 3:27 AM, R26 refused the ordered intradermal test. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Daily weights are an important indicator of fluid status ([NAME], 2019c). Each kilogram (2.2 lb) of weight gained or lost overnight is equal to 1 L of fluid retained or lost. These fluid gains or losses indicate changes in the amount of total body fluid .Compare the weight of each day with that of the previous day to determine fluid gains or losses. Look at the weights over several days to recognize trends. Interpretation of daily weights guides medical therapy and nursing care. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 994). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Use vital sign measurements to determine indications for medication administration. For example, give certain cardiac drugs only within a range of pulse or BP (blood pressure) values .Know the acceptable vital sign ranges for your patients before administering medications .Verify and communicate significant changes in vital signs. Baseline measurements provide a starting point for identifying and accurately interpreting possible changes. When VS appear abnormal, have another nurse or health care provider repeat the measurement to verify readings. Inform the charge nurse or health care provider immediately, document findings in your patient's record, and report changes to nurses during hand-off communication (TJC, 2020). [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 468). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Responsibility and accountability are other critical thinking attitudes essential to safe medication administration. Accept full accountability and responsibility for all actions surrounding the administration of medications. Do not assume that a medication that is ordered for a patient is the correct medication or the correct dose. Be responsible for knowing that the medications and doses ordered are correct and appropriate. You are accountable if you give an ordered medication that is not appropriate for a patient. Therefore, be familiar with each medication, including its therapeutic effect, usual dosage, anticipated changes in laboratory data, and side effects. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 607). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, In a hospital or extended-care setting it is difficult to provide patients with the time needed to rest and sleep. The most effective treatment for sleep disturbances is to eliminate factors that disrupt the sleep pattern. You need to plan care to avoid waking patients for nonessential tasks. Do this by scheduling assessments, treatments, procedures, and routines for times when patients are awake. For example, if a patient's physical condition has been stable, avoid waking him or her to check vital signs, unless ordered. Allowing patients to determine the timing and methods of delivery of basic care measures promotes rest. Do not give baths and routine hygiene measures during the night for nursing convenience. Draw blood samples at a time when the patient is awake. Unless maintaining the therapeutic blood level of a drug is essential, give medications during waking hours. Work with the radiology department and other support services to schedule diagnostic studies and therapies at intervals that allow patients time for rest. Always try to provide the patient with 2 to 3 hours of uninterrupted sleep during the night. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (pp. 1054-1055). Elsevier Health Sciences. Kindle Edition.

This citation pertains to MI00133268 Based on interview and record review, the facility failed to operationalize the abuse policy and failed to formulate and implement measures to prevent recurrence of resident-to-resident abuse by one Resident (Resident #14 (R14)) with a known history of behaviors following an incident with another Resident (R13) resulting in the potential for avoidable resident to resident abuse. Findings: On 11/25/22 a Facility Reported Incident (FRI) was received by the state agency of a Resident-to-Resident abuse incident involving R13 and R14. R13 Review of the Minimum Data Set (MDS) dated [DATE], reflected R13 was admitted to the facility 7/12/22 with diagnoses than included: End Stage Renal Disease (on dialysis) and Leukemia. The MDS also reflected R13 was cognitively intact and had not exhibited any verbal or physical behaviors toward others. R14 Review of the Electronic Medical Record (EMR) reflected R14 admitted to the facility 2/5/21 with diagnoses that included Borderline Personality and Dementia with Behavior Disturbances. The EMR reflected R14 had a guardian. The MDS dated [DATE] revealed R14 had displayed verbal behaviors toward others such as cursing and screaming. Review of the FRI reported to the state agency by the facility reflected on 11/25/22 R14 made a derogatory comment to R13 then struck the Resident with an open hand. The FRI documentation substantiated that a resident to resident incident occurred but that R14 had reduced ability to fully comprehend or control her behavior due to her Borderline Personality Disorder combined with Dementia. The policy provided by the facility titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation last revised 10/24/22 was reviewed. The policy reflected 3. Prevention .The facility will identify, correct, and intervene in situations in which abuse, neglect, . is more likely to occur. The facility policy's definition of Abuse includes that Instances of abuse of all residents, irrespective of any mental, or physical condition causes physical harm, pain, or mental anguish, and includes verbal abuse and physical abuse. The facility policy's definition of verbal abuse includes disparaging and derogatory terms to residents . and the definition of physical abuse includes hitting and slapping. The facility policy reflected Reporting/Response: 8 all substantiated incidents . the facility will analyze the occurrences to determine what changes are needed . to prevent further occurrences. The facility policy reflected that The Licensed Nurse will . Notify the attending physician . and Medical Director. Monitor and document the resident's condition, including response to medical treatment or nursing interventions . Document actions taken in the medical record . Complete an incident report . And Revise the resident's care plan . The facility 5 Day investigation of the incident revealed a list of Actions Taken by the facility following the incident. These Actions Taken included 7. (R14)'s Care Plan was reviewed and updated as needed, 13. (R14)'s room was moved further away from (R14) to put some space between residents, 14. Facility requested (name of contracted psychiatric service) psychiatric team conduct a medication and treatment review, and 15. Guardian provided increased supervision after incident. The facility documented in the Conclusion of the 5-day investigation that R14 has difficulty with impulsivity. The facility documented that R14 receives ongoing treatment from a contracted social worker and psychiatrist to assist her with compensatory strategies to better handle interpersonal relationships with other residents. Review of the Care Plan for R14 revealed a Focus of The resident is physically aggressive with agitation and anger .Resident exhibits physical behaviors, ie) hitting, pulling hair of other residents initiated 12/10/21 and revised on 5/3/22. The Care Plan did not reveal any revisions were implemented following the resident-to-resident incident on 11/25/22 with R13. The Care Plan reflected interventions that included analyze and assess but included only one actual intervention that could be implemented to protect other residents from R14. This intervention reflected intervene before agitation escalates which suggests that R14 must be monitored and supervised for agitation. However, this Care Plan Focus does not provide staff direction on how this is to be implemented to protect other residents from escalating agitation or the impulsivity of R14. Additionally, since no new interventions were implemented following the incident of 11/25/22, the Care Plan does not indicate how the Guardian was to provide increased supervision after the incident or how R14 is to be supervised when the Guardian is not present. Further review of the Care Plan for R14 reflected an intervention of Resident moved to a room on a different unit than the resident targeted which was initiated 5/3/22 well before the incident on 11/25/22. However, review of the room history revealed R14 has resided in the same room since 4/1/22. This indicated the R14 was not relocated on 5/3/22 to separate from the resident targeted or that R14 was relocated following the incident of 11/25/22 as reported to the state agency. Further review of the EMR did not reveal the Licensed Nurse had documented the Resident-to-Resident incident of 11/25/22. No documentation was found in the EMR that an assessment was completed or that the physician was notified of the incident in accordance with the facility policy. On 6/14/23 at 12:37 PM an email request was sent to the Nursing Home Administrator (NHA) for Incident and Accident (I/A) Reports for R14 from 9/1/22 to 2/1/23. On 6/14/23 at 3:10 PM an interview was conducted with the NHA and Social Services Director (SSD) T in the office of the NHA. The NHA was informed that no documentation of the incident of 11/25/22 was found in the EMR. Also, that no documentation of vital signs, skin or other assessments following the incident were found in the EMR. SSD T was asked about timely mental health review of R14. SSD T reported that the Psychiatrist does talk to R14 every few months. The NHA was informed that the requested I/A reports have yet to be provided. The NHA acknowledged that I/A reports are not part of the medical record but that this document is available to facility staff in the EMR under a Risk tab. The NHA reported that any vital signs, assessments and notifications likely would have been documented on the I/A report. The NHA reported that coping methods for R14 would be documented in the Care Plan. The NHA was informed that the Care Plan did not reflect a review or revision of the Care Plan had been conducted following the incident or that any coping methods or new interventions had been initiated. The NHA was also informed that the EMR reflected that R14 had not been moved to a different room. The NHA reported that another room must not have been available. On 6/14/23 at 3:30 PM the Director of Nursing (DON) reported that an IA report had been completed for R13 and included the name of R14 but that no I/A report had been completed for R14. This indicated that no documentation of the incident, as directed by the facility Abuse policy was available in the medical record for healthcare providers. Review of the documentation of the contracted Social Worker encounter on 12/7/22 following the incident was reviewed. The documentation reflected, Recent behavioral challenges and acts of aggression are reviewed. (R14) does not take ownership of her role in these. Insight is poor. No further documentation was found regarding compensatory strategies to better handle interpersonal relationships with other residents as stated by the facility in the Action Taken section of the facility 5-day Investigation. The contracted Social Worker documentation also did not reflect any orders or recommendations to the facility staff on how to address future behavioral challenges and acts of aggression displayed by R14. The first encounter with the contracted Psychiatrist following the incident occurred on 1/11/23 approximately six weeks after the incident. The documentation by the contracted Psychiatrist reflected (R14) has had a couple of verbal altercations with residents over the past several months . The documentation did not reveal any instructions of compensatory strategies for the Resident or staff. By including, in the Actions Taken section of the facility investigation report that the mental health professionals develop compensatory strategies reflects that the facility was relying on these professionals for direction in preventing future Abuse incidents perpetrated by R14. The EMR does not reflect that the facility sought their advice when none was provided in the documentation of the resident encounters with Mental Health. The EMR, as a tool for communication between health care providers and record of the plan of care, does not include pertinent information about the incident on 11/25/22 or the Resident's behavior in accordance with the facility Abuse policy that the reported Actions Taken were devised, implemented, and placed to facilitate a systematic review to prevent recurrence of Abuse incidents and to ensure the safety and well-being of R14 and all residents that encounter R14.

This citation pertains to intake #MI 122 Based on interview and record review, the facility failed to immediately and thoroughly investigate a suspicious injury of unknown origin and prevent staff to resident sexual abuse for one resident (Resident #101). This deficient practice resulted in an Immediate Jeopardy when beginning on [DATE], and as a result of the facility's failure to implement the facility Abuse Policy and ensure resident safety, Resident #101 was subjected to sexual abuse by a facility employee. This deficient practice resulted in R101's sexual abuse to continue, the potential for an inappropriate staff to resident relationship to go uninvestigated (R104) and placed all residents at risk for serious injury, physical and psychosocial harm, impairment, and/or death. Findings: Review of the State Operations Manual revealed, Nursing home staff are entrusted with the responsibility to protect and care for the residents of that facility. Nursing home staff are expected to recognize that engaging in a sexual relationship with a resident, even an apparently willingly engaged and consensual relationship, is not consistent with the staff member's role as a caregiver and will be considered an abuse of power. Also, for some health care professionals, it is prohibited by licensure or certification requirements for professionals to have a relationship with a resident (or patient). Review of the facility policy Abuse, Neglect and Exploitation last revised [DATE] revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; b. Establish policies and procedures to investigate any such allegations . 2. The facility will designate an Abuse Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written . I. Screening A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff . III. Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse, such as the identify when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship; B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms . IV. Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse 2. Physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on a resident's body 3. Physical injury of a resident, of unknown source 4. Resident reports of theft of property, or missing property 5. Verbal abuse of a resident overheard 6. Physical abuse of a resident observed 7. Psychological abuse of a resident observed 8. Failure to provide care needs such as feeding, bathing, dressing, turning & positioning 9. Evidence of photographs or videos of a resident that are demeaning or humiliating in nature, regardless of whether the resident provided consent and regardless of the resident's cognitive status. 10. Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur . VI. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation; B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents; D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; E. Protection from retaliation; F. Providing emotional support and counseling to the resident during and after the investigation, as needed . Review of the facility policy Checking References on New Hires last revised [DATE] revealed, Individual reference checks should be checked on each employment candidate prior to any offer of employment being made .Procedure: 2. Perform reference checks after conducting a successful personal interview and before a final offer is made .4. Complete a minimum of two professional reference checks. 5. Determine if the candidate's current employer can be contacted for a reference check before an offer is made. If not, make an offer dependent upon the successful completion of a reference form from the current employer . Review of the facility Employee Conduct revealed, .In addition, listed below are examples of behavior The Company considers to be gross or serious misconduct which may result in disciplinary action up to and including immediate termination. This list is not all-inclusive and does not alter the at will status of your employment .19. Engaging in inappropriate or unprofessional personal relationships with residents . Resident #101 (R101) Review of an Admission Record revealed R101 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for R101, with a reference date of [DATE] and [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R101 was cognitively intact. Review of the Functional Status revealed that R101 required extensive 2-person physical assist for bed mobility and personal hygiene and 1-person physical assist for eating. During an interview on [DATE] at 11:57 AM, R101 reported that Certified Nursing Assistant (CNA) G had been her caregiver and had been assisting her with Activities of Daily Living (eating, personal hygiene, bed mobility, etc.) since he began working at the facility and we clicked. R101 reported that she and her husband had been going through some difficult times and she had been feeling vulnerable and missed the intimacy and companionship that she once shared with her husband. R101 reported that she and CNA G had discussed those feelings and she reported that CNA G knew a lot of personal information about R101 and her husbands relationship. R101 reported that CNA G knew when she was fighting with her husband and what the fights were about because he would assist her with using her iPad to communicate with her husband. R101 reported that CNA G was aware of her concerns that her husband was being unfaithful. R101 reported that CNA G knew she was emotionally in a bad place. R101 reported that because of her feelings of vulnerability she had consented to things I wouldn't have normally done. R101 reported that CNA G involved himself in personal fights (with her husband), it was weird. I took it as he was listening, but looking back now, he knew how sad I was. I let him get too close. R101 reported that on [DATE] she had made some sexual comments to CNA G and consented to oral sex while he was feeding her dinner. R101 reported that she did not report that incident to facility staff members. R101 reported that on [DATE], during dinner time, CNA G engaged in oral sex with R101. R101 reported that during that encounter he got more enthusiastic and cracked her tooth and gave her a fat lip. R101 reported that CNA G's penis was cut during that encounter, and he cleaned off the blood from his penis and used some of her bandages. R101 reported there was blood on her sheets from his penis. R101 reported that following the oral sex, Registered Nurse (RN) F noticed her chipped tooth and knew something was up. R101 reported that CNA I noticed the blood on the floor and sheet and had asked her about it while CNA G was present for cares. R101 reported that CNA I kept asking me what the blood was from and could tell R101 was too scared to answer. R101 stated, I couldn't say anything with him in there. R101 reported that RN T noticed bloodied dressings in R101's trashcan the following morning ([DATE]). R101 reported that there was no investigation into her broken tooth, bloodied sheets, bloodied dressing/paper towel in the trashcan, or swollen lip at that time. R101 was not comfortable reporting the oral sex at that time but reported that she felt like I had to speak up eventually. R101 reported that on [DATE], during dinner time, CNA G engaged in oral sex with R101. R101 reported that this incident was violent in nature and pushed R101 to report to facility staff. R101 reported that she said yes to the encounter but not to the way CNA G did it. R101 reported that she did not want to refuse because she did not want to be in the position to have him do it anyway. R101 stated she did not want to be a victim. R101 reported that her door was shut, she did not have access to her call light, her voice was not loud enough to yell, and the facility was short staffed. R101 reported that she had no ability to get help. R101 reported that CNA G moved her body to the edge of the bed, held her head, kept her on her side, and pulled her hair which left her unable to pull away. R101 reported that CNA G then pushed my face hard into his crotch and forced his (penis) down my throat. R101 reported that she couldn't breathe and that's what scared me. I really didn't feel like I could say no. I couldn't even breathe. R101 reported that CNA G's penis began bleeding again because the scabs from the previous encounter had opened. R101 reported that CNA G ejaculated down her throat, and she spontaneously swallowed and stated, he went too far. R101 reported that with each encounter it was getting more violent and she didn't know what the next week would bring. That's why I had to speak up. R101 reported that on [DATE] and [DATE] she was unable to push CNA G away, pull away from CNA G, or move herself independently away from CNA G. R101 reported that she had never made an allegation of inappropriate behavior against any staff or resident prior to [DATE]. R101 reported that on [DATE] she reported the 3 occurrences of oral sex with CNA G to Social Worker (SW) H and an investigation into the allegations was started. R101 reported that since the incident she was started on [MEDICATION(S)] (antianxiety medication) because of her feelings surrounding the sexual abuse. R101 reported at night I get weepy, especially after dinner, and when I think about everything. Review of R101's handwritten Witness Statement dated [DATE] at 9:30 AM revealed, Can you tell me what happened last week? (R101) Well, I initiated it (oral sex) but (CNA G) and I started getting flirty (with) each other. We became overly verbally sexual with each other, mostly during meals. He was calling off work a lot and I told him as an incentive to come to work I would give him a blow job. He said I'm going to remember you said that in a joking way. On Sunday (last week) he was helping me eat and I decided I was going to try to get him aroused verbally and it worked and then he asked me if we were going to do oral and I said yes. So he had the door closed and the curtain pulled. He would turn me on my side and put it (penis) in my mouth. He was too nervous to (ejaculate). On Monday ([DATE]) we were doing it orally again and while he was thrusting, my front tooth cracked (and) broke. My tooth cut his penis. He thought my mouth was bleeding but it was him. He used Kleenex and wash cloths to clean it up and a bandage from my drawer. On Thursday ([DATE]) he was with me again and the cut on his penis cut back open and blood got on my sheets and pillow. He was thrusting really deep. Had ahold of my hair and was pushing my head on his penis. He was deep in my throat and I think he (ejaculated) and I swallowed it. After that (on Friday) I asked for (SW H) and told her what happened because I was afraid I was in over my head .she stated she doesn't want to be the victim she just got worried (because) she can't move her arms/legs only her head . Review of R101's typed Witness Statement dated [DATE] at 9:30 AM revealed, .Wednesday (CNA G) came to work and was feeding me again and he wanted to do it again and I was happy to do it (oral sex). He was thrusting his penis in my mouth my front tooth chipped and I cut him. He thought it was my mouth but I told him not it was not. He cleaned it up with Kleenex and used some of my bandage to cover it. (RN T) the nurse noticed that some of the bandage was cut but I didn't say anything to her .On Thursday he wanted to do it again, and this time it was getting a little rough and had my hair in his hand and was pushing my head on his penis and it went deep in my throat and I think he (ejaculated) and I swallowed it. I re-broke the cut open. That's when I thought I might be in over my head . During an interview on [DATE] at 2:21 PM, CNA I reported that on Monday, [DATE] she worked the 3rd shift (from [DATE]-[DATE]). CNA I reported that she was assisting CNA G at shift change with care to R101 and had observed blood at the top of R101's sheets and was confused as to why blood would be there. CNA I reported that she asked R101 if she was okay and she kind of looked at me funny and said, never mind or don't worry about it. CNA I reported that she looked over R101's body at that time and didn't see any open areas and verified that R101 was not menstruating. CNA I reported that after assisting R101 with care she went to the trash to discard materials used and saw that there was bloodied tissue paper in the trashcan. CNA I reported that she notified 3rd shift nurse, Licensed Practical Nurse (LPN) S (worked [DATE]-[DATE]) of the additional concerns because 2nd shift nurse, LPN J had left for the night. CNA I reported that CNA I and LPN S assessed R101 to see where the blood on the sheets and the trash came from. CNA I reported that at that time she identified blood and swelling on the corner of R101's mouth and CNA I wiped it off. Review of CNA I's Witness Statement dated [DATE] at 4:10 PM revealed, What care/kind of care (R101) (require)? Total dependent .2 person (assist) .Feed-1 person assist .Has (CNA G) given 1 person (care)? Yes, he has (R101) allows it-only certain people she feels comfortable (with) allowing 1 person. CNA G is one of them .noted chipped tooth Mon ,d+[DATE] .Did you ask what happened? (CNA R) did-blood (at) top of head-Saw Kleenex in trash (possible) period (R101) nonchalant; (with) (CNA G) at time. CNA G (didn't) say anything .( CNA I) went and told (LPN J) (about) tooth .noted lip was swollen (can't remember day)(last week). (Note: R101's chipped/broken tooth was repaired by the dentist on [DATE] indicating CNA I's documented observation of chipped/broken tooth date is incorrect.) During an interview on [DATE] at 12:10 PM, LPN J reported that she was made aware that R101 had a chipped tooth. Review of LPN J's Witness Statement dated [DATE] at 4:25 PM revealed, .Chipped tooth? Told Monday-(CNA I) thought chipped. Did you ask (R101)? No . During an interview on [DATE] at 10:13 AM, LPN S reported that he was working with CNA I on 3rd shift for [DATE]-[DATE]. LPN S reported that he had observed some blood on R101's sheets when he was assisting CNA I. LPN S reported that he had assessed her skin and found no skin integrity concerns. LPN S reported he did not recall being notified of R101 having a bloody or swollen lip and stated, CNA I didn't mention that to me. Or if she did, I must have forgotten it. Review of facility investigation revealed no documentation of a Witness Statement from LPN S. During an interview on [DATE] at 12:53 PM, RN T reported that she had worked the morning of [DATE] and had observed smeared blood on R101's sheets near her face. RN T reported that she had also observed that R101 had a cut on the corner of her mouth. RN T reported that CNA I reported to her that she had found bloody paper towels in the garbage the night before. RN T reported that each individual concern didn't seem out of the ordinary, but everything together (bloodied paper towel in garbage, cut lip, blood on sheets) seemed strange. RN T reported that upper management was notified of her concerns. RN T reported that R101's demeaner has changed significantly since the incident. RN T reported that R101 is now quiet, withdrawn, and apologetic. RN T reported that on [DATE] she was asked to be a witness for the Director of Nursing to place CNA G on investigative leave because R101 had accused CNA G or sexual assault. RN T reported that she was never asked to give a witness statement regarding her observations on [DATE]. Review of facility investigation revealed no documentation of a Witness Statement from RN T. During an interview on [DATE] at 12:38 PM, RN F reported that on [DATE] the dietician approached RN F about R101 being seen by the dentist for a cracked tooth. RN F reported she went to R101 to find out how her tooth broke and R101 stated her tooth got bumped. RN F reported that she asked R101 if it was by the hoyer lift, if it was intentional, or what caused it to happen and R101 stated, just know my tooth got bumped. RN F reported that it felt as though R101 was trying to protect someone and that R101 was implying she had concerns. RN F reported that her interaction with R101 was unsettling, and she had concerns R101 was being abused. RN F reported that at that time she notified the Nursing Home Administrator of her concerns. Review of facility investigation revealed no documentation of a Witness Statement from RN F. During an interview on [DATE] at 10:20 AM, CNA R reported that she was not aware of what happened between CNA G and R101 but has noticed that R101 was different than normal now and is quiet, when previously she was talkative and interactive with staff. CNA R reported that R101 has never made allegations against staff before and has never behaved sexually inappropriate with CNA R. CNA R reported that CNA G was R101's primary CNA. During an interview on [DATE] at 11:29 AM, SW H reported that R101 had never made allegations against staff members until [DATE] when R101 reported the sexual abuse from CNA G. SW H reported that R101 had not been accused of being sexually inappropriate with staff or residents since her admission to the facility. SW H reported that R101 was recently started on [MEDICATION(S)] following the sexual abuse. Review of R101's Social Services Progress Note dated [DATE] revealed, .Had initially voiced feeling anxious with some difficulty sleeping during the past several nights r/t (related to) incident from last week . Review of R101's Social Services Progress Note dated [DATE] revealed, .Discussed some difficulty sleeping, ie) increased thinking at night when it is quiet .(Psych Provider) has indicated she may recommend [MEDICATION(S)] r/t increased anxiety. Review of R101's Social Services Progress Note dated [DATE] revealed, Resident in good spirits today. Appropriate in conversation. No comments r/t incident from 1 weeks ago. Does voice feeling that she is 'coming to terms with it and moving on. Voiced the [MEDICATION(S)] ([DATE]) has been helpful in minimizing distress and some tearfulness as she copes with consequences, own feelings and relationship with her spouse . (Indicating a change in R101's psychosocial wellbeing following the incident with CNA G) Review of R101's Progress Notes/Nursing Progress Notes revealed no documentation of chipped tooth, lip swelling/cut, or blood on sheets from [DATE]-[DATE]. Review of R101's Dental Summary Report dated [DATE] revealed, Emergency Exam-Patient presents for a limited exam with discomfort; Probable cause-broken tooth .NURSE WOUND UP BRINGING PATIENT TO CLINIC AREA. SMOOTHED SHARP EDGE OFF TOOTH . Review of the Facility Reported Investigation revealed, .Interviews: (CNA G) (Director of Nursing/DON) and (Nursing Home Administrator) (via phone) interviewed (CNA G) the first time when we were unsure of who the individual was that was involved in this situation with (R101). The DON and Administrator asked him if he had noticed anything unusual about (R101's) behavior. (CNA G) said no. DON and Admin asked him if he ever provided her care alone (CNA G) said no he did not. Admin asked him if he ever fed (R101) alone and (CNA G) stated yes. DON and Admin asked if he ever saw any males go in her room alone. (CNA G) stated there was one male resident that has visited but the door is was (sic) open. (CNA G) stated that her husband goes in there alone but they have not been getting along lately. Admin asked him, how do you know. (CNA G) stated resident has asked him to call her husband on her iPad because she can't dial herself. (CNA G) had been upset about being taken off (R101's Unit) earlier and at this time the (Admin) explained that it was due to this investigation. (CNA G) agreed. Later that evening when (DON) was told by (R101) who the individual was she engaged in oral sex with, (CNA G) was taken into an office. (DON) informed him that he was suspended pending investigation due to (R101) reporting that he had been the one to engage in oral sex with her on 3 occasions. (DON) asked him if he wanted to make a statement regarding allegation. (CNA G) responded that he did not know what to say. (DON) also informed (CNA G) that (R101) did indicate that it was consensual. (CNA G) stated that he still didn't know what to say .(R101) told (SW H) it was good to feel wanted because she and her husband have had issues since he had an amputation. (R101) went on to report that it (oral sex) happened again on Monday, [DATE] during the dinner meal. (R101) stated that this time it was a bit more aggressive and she broke a tooth. (R101) said the last time oral sex had taken place was on Thursday, [DATE] during the dinner meal. (R101) explained she approached (SW H) about this relationship because she felt 'things kind of got out of hand', became 'more aggressive' and I 'was in over my head' .(R101) also stated she 'I didn't want to make so much trouble for everyone .Conclusion .Resident (R101), reported three consensual sexual interactions that occurred with (CNA G) between the dates of [DATE] and [DATE]. (CNA G) has been interviewed and suspended. (CNA G) neither confirmed or denied the consensual sexual interactions with (R101) when interviewed during suspension. There have been multiple attempts to contact (CNA G) to cooperate with investigation .(Facility) is unable to substantiate abuse due to lack of cooperation and response from (CNA G) and the fact that the resident, who has full decision making capacity, initiated a consensual sexual interaction. (Indicating the facility did not identify Abuse of Power to substantiate the allegation of sexual abuse between CNA G and R101). Review of R101's Electronic Health Record revealed no documentation that R101 had been offered Sexually Transmitted Disease testing following the oral sex, with blood and seminal fluid present, with CNA G. Verified with Nursing Home Administrator via email on [DATE] at 10:50 AM that R101 had not been offered testing. Attempted to contact CNA G with no return call prior to survey exit. Verified via the employee schedule provided by the facility that LPN J worked 2nd shift [DATE], CNA G worked 2nd shift [DATE] and [DATE], CNA I worked 3rd shift [DATE]-[DATE], LPN S worked 3rd shift [DATE]-[DATE], and RN T worked [DATE] 1st shift. Resident #104 (R104) Review of an Admission Record revealed R104 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for R104, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R104 was cognitively intact. During an interview on [DATE] at 12:00 PM, R104 reported that CNA G had provided cares for her since he started working at the facility. R104 reported that she had communicated with CNA G outside of work on more than one occasion via social media. R104 reported that she had been talked to regarding communication outside of work with CNA G by SW H and the Nursing Home Administrator. R104 reported that she would message CNA G via social media if he called in sick to work to make sure he was okay. R104 reported that she has been devastated since hearing what happened between R101 and CNA G and does not believe the allegations and feels that CNA G was unjustly terminated (important to note that R104 knew/verbalized explicit details related to the investigation between R101 and CNA G and was able to list off specific staff, the resident, and details of the investigation). R104 reported that she has been messaging CNA G since he was terminated from the facility on [DATE] to let him know she supports him. R104 stated, I'm doing the best I can to get out of here to continue her relationship with CNA G. During the interview with R104, she was crying, and verbalized CNA G's termination had been difficult for her emotionally. During an interview on [DATE] at 2:21 PM, CNA I reported that CNA G and R104 had developed a relationship that required her to report it to the administrator. CNA I reported that R104 was in love with him (CNA G) and we (coworkers) told him to be careful of becoming too close or allowing the resident to cross a professional/caregiving boundary. CNA I reported that this was months prior to the incident with R101. During an interview on [DATE] at 10:13 AM, LPN S reported that he was aware that R104 took a liking to (CNA G). LPN S reported that at one point, R104 had attempted to get the employee communication book to obtain CNA G's telephone number. LPN S reported that at some point she was able to get his number and she would contact him. LPN S reported that CNA G was the primary caregiver for R101 and R104. LPN S reported that he was not aware if there was a sexual relationship between CNA G and R104, but at one point CNA G said he was going to quit and R104 was emotional about it. LPN S reported that there were rumors that the relationship between CNA G and R104 was sexual in nature, but he never asked R104 about their relationship. During an interview on [DATE] at 12:53 PM, RN T reported that she had concerns that R104 and CNA G had an inappropriate relationship. RN T reported that since CNA G's termination from the facility, R104 is having an extraordinarily hard time without having (CNA G) there. He was the only one she lets change her. During an interview on [DATE] 3:00 PM, Nursing Home Administrator reported that she had been made aware of R104 and CNA G's relationship and had spoken to CNA G. NHA reported that the incident was approximately 6 months ago. NHA reported that she had investigated the relationship and no concerns were noted and CNA G continued to provide care for R104. NHA reported that there were no incident reports, concern forms, or investigative documentation available related to the investigation. (No documentation was received prior to survey exit.) Review of R104's Electronic Health Record revealed no documentation of R104's relationship with CNA G. Review of R104's Care Plan revealed no documentation of behaviors related to inappropriate relationships with caregivers. Review of CNA G's Timecard revealed CNA G's punched in for orientation on [DATE] and the first shift working with residents was on [DATE]. Review of CNA G's Professional Reference Check #1 revealed no Business/Company Name. Dates of Employment (Begin Date and End Date) were blank 5 years ago not sure dates. Reference check completed on [DATE]. (Approximately 4 months after the beginning of employment). Review of CNA G's Beneficiary Designation Form and Emergency Information Form revealed that CNA G's Professional Reference #1 was CNA G's girlfriend/secondary contact/primary beneficiary. Indicating a thorough professional reference check was not completed. Review of CNA G's Professional Reference Check #2 revealed no Business/Company Name. Dates of Employment (Begin Date and End Date) were blank. Reference check completed on [DATE] (Approximately 4 months after the beginning of employment). On [DATE] the Administrator was verbally notified and received written notification of the Immediate Jeopardy that was identified on [DATE] due to the facility's failure to immediately and thoroughly investigate a suspicious injury of unknown origin and prevent staff to resident sexual abuse for R101. A written plan for removal for the Immediate Jeopardy was received on [DATE] and the following was verified on [DATE]: 1.Identification of Residents Affected or Likely to be Affected: The DON, Social Services Director, and designee(s) interviewed residents with BIMS scores of 10 and above for potential abuse. All residents, currently residing in the facility, had skin assessments to assess for signs of injuries of unknown origin that would require additional investigation started on [DATE]. (Completion Date: [DATE]) No additional concerns with abuse were identified based on these interviews. Social services has reviewed any residents within the last 30 days of new or increased antidepressants/antianxiety medications to ensure there were no signs or symptoms of abuse for those residents. (Completion Date: [DATE]) Resident # 101 has met with Psych Services Physician for a psychiatric evaluation on [DATE], and Psych services PA on [DATE]. The facility social worker has continued to make follow up supportive visits with the resident since the relationship was identified by the facility on

Based on observation, interview, and record review the facility failed to: 1. Properly date and discard food product; 2. Properly store ready to eat and raw animal product in a manner to reduce the risk of contamination; and 3. Thoroughly clean food contact surfaces to be clean to sight and touch. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 75 residents who consume food from the kitchen. Findings Include: 1. During an initial tour of the kitchen, starting at 9:10 AM on 5/10/22, observation of the walk in cooler found a bag of ham chunks dated 4/30 to 5/6, an unopened bag of cole slaw mix with a best by date of 5/7/22, and a container of cream corn dated with a discard date of 5/9. During a tour of the kitchen, at 9:17 AM on 5/10/22, it was observed that an open thawed box of strawberry shakes, 3/4s full, in the two door refrigeration unit were found with no date to indicate discard. A review of the manufactures instructions, found the shakes are good 14 days from thaw. During an interview with Dietary Manager CC, at 10:25 AM on 5/10/22, it was found that he normally goes through to check dates every morning. When asked about dating the strawberry shakes, DM CC stated that they were probably pulled last night. During a tour of the facility, at 2:25 PM on 5/10/22, with Maintenance Director EE, observation of the 300 hall storage room found 12 strawberry flavored nutritional drinks with a manufactures use by date of 1DEC2021. Further review of the storage room found three full boxes and 12 single containers of vanilla flavored nutritional drinks with a manufactures use by date of 1MAY2022. A revisit to the 400 Hall pantry area, at 2:41 PM on 5/10/22, found one strawberry flavored nutritional drink with a manufactures use by date of 1DEC2021. A revisit to the 100 Hall pantry area, at 2:54 PM on 5/10/22, found six strawberry flavored nutritional drinks with a manufactures use by date of 1DEC2021 and a facility date of 5/5/22 with a residents name on the containers. Further review of the 100 Hall pantry found 12 strawberry and two vanilla flavored nutritional drinks with a manufactures use by date of 1MAY2022. According to the 2013 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO -EAT, 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 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 . According to the 2013 FDA Food Code 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 appropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17(A) . 2. During the initial tour of the kitchen at 9:12 AM on 5/10/22, it was observed that ready to eat shredded chicken and ready to eat ham, was found on the bottom shelf of the walk in cooler stored next to raw chicken. During a revisit to the walk in cooler, at 10:30 AM on 5/10/22, an interview with DM CC and District Dietary Manager (DDM) DD, took place about reducing the risk of cross contamination, afterwards DDM DD changed out the storage location of the shredded chicken and the cooked ham to be above and away from the raw chicken. According to the 2013 FDA Food Code section 3-302.11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (1) Except as specified in (1)(c) below, separating raw animal FOODS during storage, preparation, holding, and display from: .(b) Cooked READY-TO-EAT FOOD .(b) Arranging each type of FOOD in EQUIPMENT so that cross contamination of one type with another is prevented . 3. During the initial tour of the facility, at 9:19 AM on 5/10/22, a review of the mechanical scoops drawer found two mechanical scoops with dried on food debris stored with clean mechanical scoops. Further review of the drawer found an accumulation of crumb debris in the drawer. During a tour of the kitchen, at 9:30 AM on 5/10/22, it was observed that two bins containing utensils were stored below the preparation table on the cook line. When asked if these were clean utensils bins, Cook GG stated Yes. The large bin was found to contain spoons and ladles with an accumulation of crumb debris inside of the bin. During a tour of the 400 hall pantry, at 10:00 AM on 5/10/22, it was observed that the bottom drawers of the unit were found with an accumulation of brown staining. An interview with DM CC, at 10:33 PM on 5/10/22, found that clean utensil drawers should be cleaned out once a week or as needed. According to the 2013 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

This citation contains two deficient practice statements. DPS #1 Based on observation and interview the facility failed to properly store clean and sanitary items and maintain laundry equipment. These conditions resulted in the increased risk of clean and sanitary items to become contaminated before use, increasing the risk of negative outcomes for the resident population. During a tour of the facility, at 2:05 PM on 5/10/22, observation of the 100 hall clean linen closet found two wash cloths and a gown on the floor. During a tour of the facility, at 2:13 PM on 5/10/22, observation of the 200 hall spa room found eight towels and eight wash cloths laying on the shower bed open and exposed. During a tour of the facility, at 2:16 PM on 5/10/22, observation of the nursing supply closet found an assortment of spoons, paper trash, wrappers, elastic bandage gauze, a urinal, and a urine leg bag on the floor. An interview with Regional Housekeeping Manager (RHM) FF, at 2:18 PM on 5/10/22, found that staff should be cleaning storage rooms at least once a week. During a tour of the laundry room, at 2:20 PM on 5/10/22, it was observed that two clean laundry carts, used to move clean laundry from the dryer to the folding table, were found ripped and torn around the top perimeter of the carts. Further review of the carts found an accumulation of dirt and wrapper debris underneath the false bottoms of the carts. When the accumulation of debris was pointed out to RHM FF, she stated they would get the carts cleaned out. During a review of the 400 hall spa room, at 2:41 PM on 5/10/22, it was observed that a lift sling was found on the floor outside of the spa room. Further review of the spa room found four folded towels and eight wash cloths open and exposed, stored on top of the dirty linen basket, roughly five feet from the spa commode. DPS #2 Based on observation, interview, and record review the facility failed to: 1.) ensure tube feeding equipment was maintained in a sanitary manner between feedings for 1 (Resident #41) of 2 residents reviewed for tube feeding, 2.) disinfect/clean shared resident care equipment between uses, and 3.) ensure staff put on personal protective equipment correctly resulting in the potential for infection.Findings include: Improper Mask Use:During an observation on 05/10/22 at 11:04 AM, the transmission based precaution signage on Resident #270's door stated, Please see nurse before entering STOP and Transmission Based Precautions (Droplet/Contact/Airborne) - New Admissions, Covid + (positive), covid exposed . What you should be wearing before entering room: N95 Mask . During an observation on 05/11/22 at 07:50 AM, Certified Nurse Aide (CNA) J outside of Resident #270's room put on personal protective equipment before entering the resident room. CNA J put a new N95 (respirator; mask) over her surgical mask she had already been wearing previously, making the N95 unable to provide a good seal. Director of Nursing B and Registered Nurse Unit Manager I were present in the area with CNA J but did not address the incorrect use of the N95. At 07:55 AM, CNA J took off the N95 mask and the surgical mask remained on underneath. During an observation on 05/11/22 at 08:23 AM, before entering Resident #270's room CNA J put an N95 (respirator; mask) on over her surgical mask that she was already wearing previously. During an interview on 05/12/22 at 09:11 AM, Registered Nurse Regional Nurse Consultant C confirmed an N95 should not be worn over a surgical mask. During an observation and interview on 5/10/22 at 12:51 PM UM O answered a call-light for R270 while stating, I'll go in there to help her. Observed Transmission-Based Isolation Precautions signage posted on door. UM O stated, The resident is on transmission-based precautions because she is not fully vaccinated for Covid-19 and was just admitted to the facility. Observed UM O place a N95 mask over the surgical mask she was wearing in hall, then don gown and gloves without performing hand hygiene before entering resident room. During an interview on 5/11/2022 at 11:11 AM DON B stated, Signage for Transmission Based Precautions (TBP) does not say to place a N95 mask over a surgical mask. A N95 mask should be sufficient. I'll have to look at the CDC (Centers for Disease Control) and facility policy before I tell you wearing a surgical mask over a N95 is correct for infection control. I do not want to give my personal opinion on it. During an interview on 5/12/2022 at 9:48 AM, DON B stated, Staff should not be putting an N95 mask over surgical mask when going into a transmission-based precautions room as you cannot assure seal and a clean mask is being put over a dirty mask. Review of the Center's for Disease Control and Prevention's personal protective equipment material (https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/use-n95-respirator.html), updated 3/16/22, stated, Your N95 must form a seal to your face to work properly. Sanitary Tube Feeding Equipment: During an observation on 05/11/22 at 08:04 AM, Resident #41 was asleep in his bed with his tube feeding container hanging from the tube feeding pole next to the bed with approximately 825 milliliters of tube feeding formula remaining. The tube was hanging from the container and pole and the portion that connects to the resident was uncapped and resting on the back of the tube feeding pump. During an interview on 05/11/22 at 11:33 AM, Nursing Unit Manager LP confirmed tube feeding tubing should be capped between uses and stated, It (tube feeding tubing) should be capped for sanitary (sanitary reasons). During an interview on 05/11/22 at 12:31 PM, Director of Nursing B confirmed tube feeding tubing should be capped in between feedings. Review of Resident #41's physician order, dated 3/30/22, stated, one time a day for enteral feed (tube feeding). [Name Brand of Tube Feeding Formula] @ (at) 102ml/h (milliliters per hour) x15 hours on at 16:00 (4 PM) off at 0700am. 1530ml total volume . SHARED EQUIPMENT During an observation and interview on 5/10/22 at 12:02 PM a Reliant 450 mechanical Hoyer lift was outside room [ROOM NUMBER]. A partially filled disinfectant spray bottle was in a orange net bag attached to the lift. On the sling bar where resident sling straps are attached was a cloth cover covered with dust debris. The entire surface of the lift was covered in dust debris. CNA N was passing Surveyor in hall and stated, Lifts are to be cleaned after each resident use every day. During an observation and interview on 05/11/22 01:19 PM, R39 was in her room sitting in her wheelchair having her vital signs with a blood pressure cuff taken by CNA N. When done taking vital signs, CNA N left the vital machine unattended in the 400 hall by Case Manager office without disinfecting/cleaning it. At 1:24 PM, CNA R took vital sign machine into R23's room and placed same blood pressure cuff on resident. During an interview on 5/11/22 at 2:14 PM, CNA R stated, The vital sign machine and resident shared equipment should be cleaned after use on a person. I know you saw me not clean the vital sign machine. I'm sorry about that. I went to help with a call light and meant to get back to clean it. During an interview on 5/11/22 at 2:16 PM, CNA N stated, Shared equipment should be cleaned after it used on each resident. During an interview on 5/12/2022 at 9:25 AM, LPN H stated, Shared equipment should be cleaned after use on a resident for infection control. Review of facility policy Cleaning and disinfection of Resident-Care Equipment date implemented: 1/1/2021 revealed, Policy: Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with the current CDC recommendations in order to break the chain of infection .3. Staff shall follow established infection control principles for cleaning and disinfecting reusable, non-critical equipment. General guidelines include .b. Each user (staff) is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident .d. Multiple-resident use equipment shall be cleaned and disinfected after each use .

Based on interview, and record review, the facility failed to ensure completion of routine COVID-19 testing of staff who were not fully vaccinated, in 1 of 3 staff members reviewed for COVID-19 testing, resulting in the potential for delayed identification of COVID-19 infections. Findings include: In an interview on 5/10/22 at 8:45 a.m., Administrator A reported there were no COVID-19 positive staff or residents at the facility in the past four weeks. Review of a COVID-19 Staff Vaccination Matrix, provided by the facility on 5/10/22, revealed Waiver Care Aide (WCA) E was partially vaccinated for COVID-19. Review of a COVID-19 Vaccination Record Card for WCA E revealed the first dose of the COVID-19 vaccine (Moderna) was received on 12/9/21. In an interview on 5/11/22 at 2:01 p.m., with Director of Nursing (DON) B and Regional Nurse Consultant (RNC) C, DON B reported staff who were not fully vaccinated were tested for COVID-19 twice a week. In an interview on 5/12/22 at 9:19 a.m., Administrator A reported WCA E had tested positive for COVID-19 around the time the second dose of the vaccine was due (January 2022), and had to delay administration of the second dose. Administrator A reported WCA E was advised to delay the second dose of the COVID-19 vaccine for 90 days. Administrator A reported WCA E had the second dose of the COVID-19 vaccine on 5/11/22. In an interview on 5/12/22 at 10:44 a.m., Licensed Practical Nurse (LPN) BB reported staff who were not fully vaccinated were tested for COVID-19 twice a week. Review of a COVID-19 Vaccination Record Card for WCA E revealed the second dose of the COVID-19 vaccine (Moderna) was received on 5/11/22. In an interview on 5/12/22 at 12:31 p.m., Administrator A reported the facility started a new process for tracking staff COVID-19 vaccinations. Administrator A reported the new form identified which staff were eligible for the booster, which staff had not completed the primary vaccination series, and developed a list of staff members that are required to be tested for COVID-19. Administrator A stated .We just got this report at the end of last week . Administrator A reported WCA E was hired on 4/12/22 with the expectation that she obtain the second dose of the COVID-19 vaccine in a timely manner. Administrator A reported WCA E was required to wear additional PPE (Personal Protective Equipment) which included an N95 mask, and stated .She has been getting tested , but it looks like there has been some gaps . Review of the COVID-19 POC Test Results for WCA E revealed a COVID-19 test was performed on 4/12/22 (with negative results), and on 5/10/22 (with negative results). No other COVID-19 test results provided for WCA E. Note a four week gap between COVID-19 tests for WCA E (who was not fully vaccinated). In an interview on 5/12/22 at 1:46 p.m., Administrator A stated in regard to WCA E and the COVID-19 test completed on 5/10/22 .she was on the list this week (to be tested ) due to the new system . Administrator A reported staff who were not fully vaccinated should be tested twice a week. Administrator A reported twice a week testing for staff who were not fully vaccinated began in April 2022. Review of an email sent by Administrator A on 5/12/22 at 2:11 p.m., revealed the level of COVID-19 community transmission changed from moderate to substantial the week of 4/19/22. Review of the policy/procedure Coronavirus Testing, dated 4/26/22, revealed .The facility will implement testing of facility residents and staff, including individuals providing services under arrangement and volunteers, for COVID-19 .Fully Vaccinated refers to a person who is (greater than or equal to) 2 weeks following receipt of the second dose in a 2-dose series, or (greater than or equal to) 2 weeks following receipt of one dose of a single-dose vaccine .The facility will conduct testing through the use of rapid point-of-care (POC) diagnostic testing devices or through an arrangement with an offsite laboratory .Expanded screening testing of asymptomatic healthcare personnel should be as follows .a. HCP (Health Care Providers) who are up to date with all recommended COVID-19 vaccine doses may be exempt from expanded screening testing .b. HCP who are not up to date with all recommended COVID-19 vaccine doses should continue expanded screening testing based on the level of community transmission as follows .Moderate (yellow) .Once a week .Substantial (orange) .Twice a week .

Based on observation, interview, and record review, the facility failed to provide care and services to promote dignity in 1 of 2 residents (Resident #321) reviewed for dignity, resulting in feelings of isolation and disappointment and the potential for diminished self-worth, sadness, and frustration. Findings include: Review of an Admission Record revealed Resident #321 admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Brief Interview for Mental Status (BIMS) assessment for Resident #321, dated 5/12/2022, revealed a score of 15, out of a total possible score of 15, which indicated that the resident was cognitively intact. In an observation on 5/10/2022 at 11:39 a.m., an isolation cart was visible outside of Resident #321's room. Signage on the door directed staff to utilize a gown, gloves, eye protection, and an N-95 while in the room. Review of Resident #321's orders revealed an active order with a start date of 5/6/2022, Resident on Transmission-Based Precautions for 10 days- if no symptoms may discontinue after 10 days. In an observation on 5/12/2022 at 8:43 a.m., Resident #321's room was observed to no longer have an isolation care outside of the room or transmission based precautions signage on the door. In an interview on 5/12/2022 at 08:43 a.m., Licensed Practical Nurse (LPN) G reported that Resident #321's transmission based precaution order was no longer active. In an interview on 5/12/2022 at 08:45 a.m., RN Unit Manager I reported that Resident #321 only required 5 days of transmission based precautions and that she was planning to discontinue the order in the electronic medical record. In an interview on 5/12/2022 at 9:13 a.m., Regional Clinical Director C reported that the facility is following the CDC- New Admissions and Residents who Leave the Facility flowsheet to determine quarantine requirements for new admissions regarding COVID vaccination status. Regional Clinical Director C reported that Resident #321 is fully vaccinated and did not meet the requirement to quarantine. Regional Clinical Director C reported that there is no clinical indication to place vaccinated residents into quarantine for 5 days upon admission. Review of the CDC- New Admissions and Residents who Leave the Facility flowsheet, updated 11/17/2021, revealed .Vaccinated Residents Who are Up-to-Date Admission/readmissions . Do NOT require quarantine . In an interview on 5/12/2022 at 11:21 a.m., Resident #321 reported that being in quarantine upon admission to the facility made her feel disappointed because she was afraid that this would prolong her stay. Resident #321 reported that she felt that staff were drawing straws before entering her room, hesitant to enter because of the precautions. Resident #321 reported that this made her feel isolated. Review of the policy/procedure Promoting/Maintaining Resident Dignity, dated 1/1/2021, revealed .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life .

Based on observation, interview, and record review the facility failed to ensure consistent use/documentation of a hand orthotic device for 1 (Resident #41) of 4 residents reviewed for range of motion, resulting in lack of documentation addressing orthotic use for a hand contracture with the potential for worsening of a contracture and/or increased pain/discomfort.Findings include:During an observation on 05/11/22 at 08:08 AM, Resident #41 was laying in his bed in his room and the therapy carrot (hand orthotic device; placed in hand to keep hand more open rather than closed) was on his bedside table out of reach from the resident. Both of Resident #41's hands were clenched in a fist and resting on his chest. The therapy carrot had built up brown debris from the tip (narrow end of the device) to the number 2 on the numbering system listed along the device. During an observation on 05/11/22 at 11:38 AM, Resident #41 was asleep in his bed in his room and both hands were curled into fists. The therapy carrot was on the bedside table which was out of reach in the corner of the room from his right shoulder. The therapy carrot was still soiled as it was from the observation on 05/11/22 at 08:08 AM. During an observation on 05/11/22 at 02:34 PM, Resident #41's therapy carrot remained on the bedside table out of reach in the same place it did on 05/11/22 at 11:38 AM. During an observation on 05/12/22 at 07:58 AM, Resident #41's therapy carrot was on the bedside table outside of the resident's reach in his room. The therapy carrot was still visibly soiled. Both of Resident #41's hands were curled into fists resting on his chest. During an interview on 05/11/22 at 08:20 AM, Licensed Practical Nurse (LPN) BB reported there was no defined time frames to use the therapy carrot that she was aware of and it (the use of the therapy carrot) wasn't on any of the med (medication) sheets. LPN B reported Resident #41 didn't refuse to use the therapy carrot. During an interview on 05/11/22 at 09:59 AM, Director of Rehabilitation (DOR) X confirmed the facility's Occupational Therapist (OT) Y started Resident #41 on the therapy carrot for the right hand contracture. DOR X reported OT Y recommended the therapy carrot be used four a day. During an interview on 05/11/22 at 11:13 AM, Licensed Practical Nurse Unit Manager O reported the order to use the therapy carrot for Resident #41 was put in today (5/11/12) and the order was Therapy carrot in hands 3-4 hours daily as tolerated, monitor for irritation. LPNUM O confirmed there was no order previously. LPNUM O reported the therapist (Occupational Therapist) had verbally given the order previously to nursing so the order hadn't been put in. LPNUM O confirmed there was not any documentation to show the therapy carrot was being used previously. LPNUM O reported Resident #41 had contractures to both hands, but the right hand was worse and confirmed there was nothing in Resident #41's care plan to address his hand contractures. LPNUM O reviewed Resident #41's record and stated, I am not seeing anything in regards to documentation of the use of the therapy carrot. During an interview on 05/11/22 at 12:36 PM, Director of Nursing B, Registered Nurse Unit Manager I, and Registered Nurse Regional Nurse Consultant (RNRNC) C were asked for any and all documentation to show Resident #41 had been being offered/provided the therapy carrot since Occupational Therapy started it 4/5/22. RNRNC C confirmed the task section of Resident #41's record didn't address the therapy carrot/hand orthosis. By the end of the survey no further documentation was provided to show Resident #41 had been receiving his therapy carrot for his hand contracture. Review of Resident #41's care plan, print date 5/11/22, had no mentioning of a hand orthotic device/therapy carrot and did not mention the resident had a right hand contracture. Regarding contractures, the care plan stated, admitted with contractures to LE bilat (lower extremetities bilaterally (both legs)). The right hand contracture and the therapy carrot orthotic device were not in Resident #41's care plan. Review of Resident #41's physician order, start date 5/12/22, stated, Therapy Carrot in hands 3-4 hours daily as tolerated, monitor for irritation. The Occupational Therapy's discharge summary recommendation stated 4 hours. The order indicated hands, as in both hands, but only one therapy carrot was in Resident #41's room during observations. Review of Resident #41's occupational therapy discharge summary, dated 4/25/22, stated, Dates of Service: 3/8/2022-4/19/2022, Discharge Recommendations: 24 hour care. Caregivers/staff to continue placement of carrot orthosis while observing for signs of irritation., and Pt (patient) will tolerate wear of resting hand orthotic for 4 hours without signs and symptoms of pain or skin irritation. Review of Resident #41's Nursing Readmission Evaluation, dated 12/8/21, stated, Specify ROM (range of motion) limitation(s) .Right hand contracture . Review of Resident #41's occupational therapy notes, dated 4/12/22, stated, pt (patient) edu (educated) on importance of keeping maintaining ROM (range of motion) with carrots with further edu required but pt was receptive for the day. On 4/11/22 the therapy note stated, thearpist (therapist) provided pt (patient) with carrots to maintain new ROM with pt tolerating fair. On 4/5/22 the therapy note stated, Patient tolerated carrot orthosis placed to level 12 in right hand this session. Review of Resident #41's medical diagnoses, print date 5/11/22, included dementia, protein-calorie malnutrition, mild cognitive impairment, and intellectual disabilities. Review of Resident #41's most recent brief interview for mental status, dated 3/26/22, was scored 7 which reflected severe cognitive impairment.

Based on observation, interview, and record review, the facility failed to ensure appropriate catheter care including monitoring the patency of tubing and collection bag in two (2) residents (R220 and R13) of three (3) residents observed for indwelling catheter care, resulting in the potential for an urinary tract infection. Findings include: R220 Review of R220's Admission Record, indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to R220's Minimum Data Sheet (MDS) dated [DATE], R220 had not completed the BIMS (Brief Interview Mental Status). Upon observing and interviewing the resident, it was noted he could intermittently respond to simple questions with yes or no answers. The resident had an indwelling catheter and required extensive assistance for ADL (activities-of-daily living) cares. During an observation on 5/10/22 at 10:33 AM R220 was supine in his bed. Resident had a Foley catheter (indwelling catheter) attached to the left side of his bed. No stat lock was observed. Blood-tinged urine in catheter bag. During an observation on 5/11/2022 at 1:13 PM R220 was supine in bed eyes closed softly snoring. Foley catheter attached to bed frame with blood-tinged urine in catheter bag. No stat lock anchoring catheter. During an observation on 5/12/22 at 9:00 AM R220 was supine in bed. Blood-tinged urine in catheter bag with light colored sediment the entire length of tubing. No stat lock on resident. During an observation and interview on 5/12/22 at 9:15 AM Licensed Practical Nurse (LPN) H R220 had a catheter for urinary retention. R220 was supine in his bed awake. LPN stated, (R220's) catheter bag was changed 5/2 (2022). His urine is cloudy and blood-tinged with sediment in the tubing. This needs to be changed and I will follow up with the nurse practitioner. He does not have a skin lock (securing device). Observed LPN H look for a securing device on resident then find a rubber band with clip on tubing. She took the clip and attached it to the bed's fitted sheet. LPN H stated, The facility uses this (referring to the clip). I've not seen a skin lock used here. The resident's nurse should be assessing the catheter every shift. During an interview on 5/12/2022 at 9:48 AM with Nursing Home Administrator (NHA) A and Director of Nursing (DON) B, DON B stated, A resident with a urinary catheter should have a skin lock/anchor to prevent tugging. My expectations of a resident with sediment in the tubing and blood-tinged urine in a catheter bag would be to report it to the nurse who would then contact the nurse practitioner or doctor. I have not been told about (R220's) blood-tinged urine or sediment in catheter tubing. Review of R220's Order Summary revealed, Maintain indwelling catheter, ensure privacy cover and stat lock in place .order date 5/9/2022 . Review of R220's Order Summary revealed, Monitor urine from indwelling catheter for color, cloudiness, odor, and decreased output. Notify provider as needed of any change. Every shift .order date 5/9/2022 . Review of R220's Care Plans revealed, .has catheter or urinary diversion .will remain free from catheter-related trauma through review date .will show no signs/symptoms of urinary infection through review date .monitor and document output as per facility policy .Date Initiated 5/7/2022 . Review of R220's Progress Note 5/6/2022 22:54 (10:54 PM) revealed, .Has Foley catheter. Review of R220's Nursing Admission Evaluation dated 5/7/2022 06:54 (6:54 AM) revealed, .indwelling catheter patent, urine clear yellow . R13 According to the MDS dated [DATE], R13 scored 15/15 (cognitively intact) on his BIMS (Brief Interview Mental Status), had an indwelling catheter, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R13's Order Summary 2/21/2022 revealed, Place Foley catheter for pressure ulcers to buttock/assist with wound healing . Review of R13's Order Summary 3/29/2022 revealed, Place new Foley d/t (due to) current Foley not draining properly. Place 18fr (French) Foley to prevent obstruction r/t (related to) sediment in urine . Review of R13's Care Plan revision on 3/10/2022 revealed, .has an indwelling catheter related to buttock and coccyx wounds .will show no s/sx (signs/symptoms) of urinary infection through review date .will be/remain free from catheter-related trauma through review date (target date: 3/9/2022) .monitor/document for pain/discomfort due to catheter (date initiated: 2/18/2022) . During an observation and interview on 5/10/22 at 12:25 PM R13 was in his bed stating, I have a catheter because I cannot move my bladder. Observed catheter not in a privacy bag hanging on frame of bed on resident's right side visible from hallway. Privacy bag laying on floor across the room. No stat lock was observed securing the catheter. R13 stated he had never had a stat lock while at the facility. CNA N entered room to empty catheter bag stating she did not know why R13 did not have a securing device to anchor catheter. Observed on 5/11/22 at 10:20 AM R13 in his bed. No stat lock was observed to secure catheter tubing. Observed on 5/11/2022 at 2:20 PM R13 self-propelling in wheelchair in day room. Urinary catheter tubing visible coming out from under shorts. No stat lock to keep catheter tubing in place. During an observation and interview on 5/12/22 at 9:24 AM, Surveyor and LPN H hallway. The catheter bag was not in a privacy bag. The privacy bag was laying on the floor across the room in the same spot as day before (5/11/2022). Dark yellow urine was in the catheter bag. LPN H stated, (R13) should have a clip on here (referring to catheter tubing) to secure it and he doesn't. His urine is a little concentrated but clear. Review of R13's May 2022 Medication Administration Record/Treatment Administration Record (MAR/TAR) revealed, Straight cath every 4 hours as needed for nerve damage, unable to empty bladder Start Date 2/17/2022 D/C (discontinue) Date: 5/11/2022. It was noted R13 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R13's Progress Note 2/24/2022 at 11:03 AM revealed, .He requests Foley catheter placement, states that urine leaks when he is turned from side to side . Review of R13's Progress Note 2/24/2022 14:32 (4:32 PM) revealed, .currently has an order to straight cath every 4 hours. I did order Foley catheter placement . Review of R13's Progress Note 2/28/2022 07:13 (AM) revealed, .Foley cath 14 fr inserted for resident per orders. Urine return; yellow, clear, no odor . Review of R13's Progress Note 3/29/2022 15:25 (3:25 PM) revealed, .resident's abdomen to be distended and hard to the touch .assessed Foley and noticed minimal output .probably obstruction r/t sediment in urine .no new orders received at this time . Review of facility policy Catheter Care Procedure - Urinary date implemented: 1/1/2021 revealed, Policy .to provide catheter care to all residents that have an indwelling catheter in an effort to reduce bladder and kidney infections. Catheter care will be provided by the nursing assistant (CNA) and/or nurse. Details .3. Catheters should be secured to prevent pulling and damage to the urethral meatus. This may be accomplished by .a. utilizing the appropriate drainage device (leg bag or catheter bag) .b. leg strap, c. Velcro strap, d. Linen/clothing clamp, e. Adhesive securing device .

Based on observation, interview, and record review the facility failed to ensure adaptive dining equipment was provided consistently for 1 (Resident #30) of 4 residents reviewed for adaptive dining equipment, resulting in difficulty eating and the potential for weight loss and frustration.Findings include: During an observation and interview on 05/11/22 at 07:57 AM, Resident #30 was eating breakfast in bed in his room. The dining utensils that were provided to the resident were built up silverware but they weren't weighted utensils. Resident #30's meal ticket indicated to provide weighted utensils. Resident #30 reported the built up silverware that was not weighted was not easy to use and his hand was visibly shaking, appearing to be a tremor, as he held the dining utensil. The un-weighted dining utensil clanked repeatedly inside the bowl as his hand shook and had difficulty getting eggs on the utensil and to his mouth. Resident #30 reported the un-weighted build up silverware were the dining utensils he usually received from the facility. During an observation and interview on 05/11/22 at 08:31 AM, in the kitchen Dietary Manager CC had both built up silverware and weighted silverware available in a bin. Dietary Manager CC confirmed the build up silverware was different than the weighted utensils. During an interview on 05/11/22 at 11:32 AM, Licensed Practical Nurse Unit Manager O confirmed Resident #30 has had tremor like movement in his hands since she can remember and it wasn't a new condition. Review of Resident #30's progress note, dated 4/1/21, stated, Nursing Communication to Therapy: A therapy referral is required for the following reasons: Physical Therapy: .Occupational Therapy: Increased difficulty opening containers, packages, scooping food .Shakiness with feeding self. During an observation and interview on 05/12/22 at 07:45 AM, Resident #30 reported he has had shakes and tremors in his hands his entire life and the weighted utensils help him eat especially with soup. Resident #30's hands were both shaking during time of the interview. During an observation on 05/12/22 at 07:54 AM, Resident #30 was laying in bed in his room when staff delivered him his breakfast meal. Resident #30's meal ticket stated Weighted Utensils, but he was provided a non-weighted built up fork and knife. Only the spoon was weighted. Resident #30's hands were visibly shaking as he was eating. Review of Resident #30's progress note, dated 4/15/21, stated, Resident reports improved self-feeding with weighted utensils. Review of Resident #30's nutrition evaluation, dated 3/16/22, stated, The resident continues to use weighted utensils. Review of Resident #30's nutrition care plan, revised 3/16/22, included the intervention of Weighted utensils with meals which was initiated on 4/14/2021. Review of Resident #30's medical diagnoses included muscle weakness. Review of Resident #30's most recent brief interview for mental status, dated 3/14/22, was scored 15 which indicated intact cognition. Review of the facilities Assistive Devices (Adaptive Dining Equipment) policy, dated 5/2014, stated, It is the center (facility) policy to provide assistive devices/utensils as identified in the individualized plan of care to maintain or improve a resident's/patient's ability to eat independently.

This citation pertains to intake #MI 947 Based on observation, interview and record review the facility failed to prevent the physical and emotional abuse of one Resident (Resident #1), of 5 sampled residents, resulting in Immediate Jeopardy (IJ) when Resident #1 was forced to take a shower against her will by 2 Certified Nurse Aides (CNA D and CNA E), sustaining bruises to both hands, a red mark on her cheek and a scratch to her left arm; and neglect, when a Licensed Practical Nurse (LPN C) did not intervene immediately despite the resident's cries for help. This deficient practice placed all 64 residents living at the facility at risk for serious harm, injury and or death. Findings include: Review of a facility Admission Record indicated Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A Minimum Data Set assessment dated [DATE] reflected Resident #1 was severely cognitively impaired and needed extensive assistance from two people for transfers, dressing, toileting and was totally dependant on staff for personal hygiene and bathing. Review of a Care Plan last revised 8/13/18, reflected, (name of Resident #1) exhibited physically aggressive behaviors, hitting, swatting at staff, combativeness and agitation r/t Dementia with disturbances . The goal of the care plan was that the resident would not harm herself or others. Interventions included: When the resident becomes agitated: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. Review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) on 8/24/18 reflected that on 8/17/18 (Resident #1) was getting a shower and became resistive and combative with the aides. (Resident #1) flailed her arms, struck out and hit the staff and and the lift causing bruises (to the) back of her right hand, forearm and cheek .LPN C, heard (Resident #1) yell, learned that (Resident #1) had been resistive and combative with the shower and entered shower room and observed bruises. Staff providing the shower were suspended. (Resident #1) was found to have a 2.8 centimeter (cm) by 2.9 cm bruise to the back of right hand, a .9 cm by .5 cm bruise to her left hand, a 8.2 cm by .9 cm bruise to her right forearm and a 1 cm by 1 cm red spot on her right cheek. The FRI went on to detail that the Director of Nursing (DON) and Nursing Home Administrator (NHA) were notified of the incident. The (State Agency) was notified. The Police were not notified because there was no reasonable suspicion of a crime. The FRI reflected the Investigation Conclusion: The facility cannot substantiate that abuse occurred. On 8/29/18 at 3:30 p.m., Surveillance Video from 8/17/18 was viewed in the presence of NHA A. In the video, at approximately 3:30 p.m., Resident #1 was seen being positioned in front of the entrance of the shower room and left to wait for CNA D and CNA E who were getting ready to shower her. CNA D and CNA E took Resident #1 into the shower room at 3:34 p.m At 3:36 p.m., LPN C was observed looking toward the shower room responding to something then returning to her work. LPN C was observed looking toward the shower room again at 3:37 p.m., then returning her attention to what she was doing at the nurses's station. At 3:42 p.m., CNA D was observed in the video exiting the shower room, LPN C looked toward CNA D who was saying something to LPN D. In another view of the surveillance video, CNA D was observed gesturing with large movements, extending her forearms from her shoulders outward and back toward her head again quickly, then flinging open a brief and re-entering the shower room at 3:43 p.m. At 3:46 p.m., LPN C was observed getting up from the nurse's station and entering the shower room, exiting about forty-five seconds later. At 3:48 p.m., CNA E exited the Shower room with Resident #1, followed shortly after by CNA D. In another camera angle, Resident #1 is observed visibly upset, mouth agape, as CNA E took Resident #1 to her room. After finishing with cares in Resident #1's room, CNA D was observed taking Resident #1 out of her room and left her sitting in her wheelchair at the nurse's station. At 3:50 p.m., Resident #1 was observed crying, shoulders heaving. At 3:51 p.m., CNA J was observed consoling Resident #1, handing her facial tissues. Resident #1 was observed showing CNA J her visibly bruised hands. At 3:56 p.m., Social Services Director (SSD) G and Unit Manager, Registered Nurse (RN) F are seen entering the unit and taking Resident #1 toward her room. Resident #1 was again observed visibly upset. In the meantime, CNA D and CNA E were both observed on the unit, responding to Resident call lights. At 4:28 p.m., NHA A was observed in the video arriving on the unit (52 minutes after LPN C first responds to commotion in the shower room). NHA A was observed briefly interacting with Resident #1 who showed NHA A her bruised hands. NHA A then took a lengthy telephone call and did not seem to notice CNA E was still working on the unit. RN H, RN I, LPN C, SSD G and RN F were all in the area and did not seem to react to the fact that CNA E and D were not removed from all resident contact. At 4:43 p.m., NHA A finished his telephone call and was observed gesturing to CNA E to come with him. CNA E was observed on camera in the vicinity of Resident #1 and responding to resident call lights for over an hour after LPN C first noticed commotion in the shower room. During an interview on 8/30/18 at 8:30 a.m., NHA A reiterated his interview with Resident #1 on 8/17/18 after the shower. NHA A said You would have thought (CNA D) would have stopped (the shower) a long time ago. On 8/30/18 at 10:00 a.m., the surveillance video from 8/17/18 was reviewed again in the presence of NHA A and the Regional Director of Clinical Services (RDCS) P. When Resident #1 was observed in the video being brought back to her room after the shower on 8/17/18, NHA A said Yeah, she (Resident #1) is not happy. NHA A reported that he believed he was first made aware of the allegation of abuse when RN F came to the conference room after her interview with Resident #1. NHA A said he thought the aides had been removed from duty, noting that CNA D came off the unit first, but was not accompanied by CNA E. Review of a Statement of Witness documented by LPN C at 3:50 p.m. on 8/17/18, reflected the following: Heard (Resident #1) in the shower room. Saw (CNA D) come out to get a brief for resident. She stated (Resident #1) was combative in the shower. After she went back in heard (Resident #1) yelling again. I then went in and saw aides getting resident dressed and being put into wheelchair. During an interview on 8/29/18 at 4:41 p.m., LPN C said that she had been getting report at the nurse's station when Resident #1 was getting showered by CNA D and CNA E on 8/17/18. LPN C said she heard screaming coming from the shower room and recalled CNA D leaving the shower room saying Never again! I'm never doing this again!. LPN C reported she later entered the shower room, saw the resident was in a sit to stand lift and heard Resident #1 say Look what they've done! They were hitting me! LPN C said that she then left the shower room, had the aides fill out statements and measured the bruises on Resident #1's hands, arm and face. LPN C said she called the RN F and SSD G to the unit to check on Resident #1. LPN C said she did not do a full physical assessment on Resident #1. When asked, LPN C said she probably should have protected Resident #1 at the time of her first observation of Resident #1 in the shower room and probably should have had CNA D and CNA E leave while I was right there with the resident. LPN C admitted she did not remove CNA D or CNA E from duty immediately. Review of a Statement of Witness documented by CNA D at 3:45 p.m. on 8/17/18 reflected, (Resident #1) was very combative while we were preparing, giving, and redressing her during shower time. I was hit in the face three times, one time hard enough to knock my glasses across the shower room. (Resident #1) pulled my hair, spit at both of us, kicked both of us. Called us [***] es. We did our best to calm her down during the whole time. During an interview on 9/4/18 at 12:08 p.m., CNA D reported the facility had been short staffed on 8/17/18 so she agreed to stay an extra four hours beyond her normally scheduled shift which started at 6:00 a.m. CNA D reported that she is normally a restorative Aide and was not as familiar with the resident's and let CNA E take charge. CNA D said she got Resident #1's clothes from her room while CNA E took Resident #1 into the shower room. CNA D reported that when she entered the shower room, Resident #1 was holding onto the sink and saying something like I don't want . CNA D said she wasn't really listening to Resident #1 and said she should have wheeled her out of the shower room at that time. CNA D said Resident #1 was more irate than normal and was cursing and yelling the whole time. CNA D said she did leave the shower room to get a brief and told the nurses something like she was a little frustrated because Resident #1 had hit her glasses off her face. CNA D said that LPN C came into the shower after she had gone back in with a brief for Resident #1. CNA D said she never asked Resident #1 if she wanted to stop the shower. CNA D said We made a big fat mistake, we should have stopped. Review of a Statement of Witness documented at 3:45 p.m. on 8/17/18 by CNA E reflected, (Resident #1) was very combative when giving her a shower. Staff was preparing to get her ready and she was combative while we were undressing, showering and redressing her. She kicked staff, swore, spit at, pulled hair and grabbed my arm so hard. It took two of us to complete the shower. We did our very best to keep her calm, but she just kept increasing her behaviors. During an interview on 8/30/18 at 3:03 p.m., CNA E reported that she was on duty 8/17/18 and she and CNA D were giving showers because CNA D was leaving at 8:00 p.m. that evening. CNA E said she was pretty familiar with Resident #1 and noticed that on 8/17/18 Resident #1 was in a mood. CNA E said that Resident #1's mood could flip on a coin and that normally she would back off and give her space, but that day she was trying to get her showers done so she wouldn't get into trouble. CNA E said that Resident #1 said No! No! No! when she hooked her up to the mechanical lift to get her undressed but did not stop because she was so focused on the task at hand. CNA E said that Resident #1 was flailing around naked when sitting in the shower chair and said she still did not stop the shower. CNA E reported Resident #1 was confused about what they were doing and as soon as the water was turned on Resident #1 had an Epic Meltdown. CNA E said Resident #1 was showered as quickly as possible and recalled LPN C coming into the shower room at one point while they were drying off Resident #1 and asked What's going on? CNA E reported the whole event was very chaotic, with Resident #1 grabbing her arm, spitting on their faces, hitting off CNA D's glasses and that she put her hands out to block Resident #1's hits. CNA E reported that she had a feeling the shower would be seen as abuse because of Resident #1's reaction, describing Resident #1 as inconsolable, very angry and hostile toward she and CNA D. CNA E said she saw Resident #1 crying but wondered if she was fake crying or laugh crying. CNA E said I've realized since then, it should not have happened. I'm very remorseful. Review of a Statement of Witnessobtained by Unit Manager, RN F at 3:50 p.m. on 8/17/18 reflected Resident #1 stated the following: While she was getting a shower, the girls beat me with their hands and with a stick. They took that fancy thing (shower head) and hit/sprayed water in my face, hair and all over. Asked (Resident #1) if they were trying to give her a shower. She said that they were not, there was so much water that I couldn't see. They scratched my arm (showed scratch mark). I tried to defend myself, but they were too big. During an interview on 8/29/18 at 3:10 p.m., RN F said that LPN C called her on 8/17/18 and reported there had been an incident with Resident #1 in the shower room. RN F said she and SSD G went to the unit and interviewed Resident #1. RN F said that she found Resident #1 to be tearful and said Resident #1 felt like she was fighting for her life. RN F went on to report that she has been working in the Long Term Care industry for many years and had never seen a scratch like what was on Resident #1's arm from a lift, and that seeing it made her very uncomfortable. Review of a Statement of Witness obtained on behalf of Resident #1 by SSD G at 3:50 p.m. on 8/17/18, reflected the following: (Resident #1) voiced that she was in the shower and they (2 girls) had that fancy thing (removable shower head) and there was so much water. Resident said she asked them to stop and they didn't. She said she tried to defend herself (put her right hand up) but they (2 girls) were too strong and she hurt her hands and arm. Resident also voiced they hit her with a stick. Resident said she didn't know the girls names. Resident also pointed to a red spot on her right cheek. During an interview on 8/30/18 at 9:15 a.m., SSD G reported that on 8/17/18 at around 3:30 or 4:00 p.m. RN F got a call from LPN C that there had been an incident in the shower room with Resident #1. SSD G and RN F both went to interview Resident #1 and SSD G reported that Resident #1 was tearful and distraught but was able to consistently report what she thought had happened. SSD G said Resident #1 told her she tried to tell the girls No! No! No! but that they wouldn't listen. During an interview on 8/29/18 at 2:40 p.m., RN H reported that she had been on duty on 8/17/18 and was finishing up her shift when Resident #1 was showered. RN H said she heard Resident #1 raising her voice in the shower room but did not intervene or provide a witness statement because she had reported off to LPN C and was finishing up for the day. On 8/30/18 at 5:50 p.m., NHA A was informed of the Immediate Jeopardy that began on 8/17/18. On 9/4/18 the SA verified the facility implemented the following to remove the immediacy: 1. An attempt to interview the resident was completed by the Regional Director of Clinical on 08/30/18 and was unsuccessful related to the resident's cognition and mentation. 2. Resident #1 was assessed by (name of facility psychiatric services) on 8/22/18 with no new recommendations and no recollection of the incident occurring. 3. Social Services conducted assessments on Resident #1 and documented 8/18, 8/20 and 8/21 with no adverse effects noted to resident. 4. Resident #1's physician and representative were made aware of the incident on 8/17/18 and 8/31/18 when it was determined by the state survey team that abuse actually occurred. 5. A police report was filed on 08/30/18 and the police came to the facility on [DATE] for follow up. 6. All residents with a BIMS of 10 or above were interviewed by department managers to determine if they had any concerns with treatment during care. The interviews were completed on 8/30 and 8/31/18. 7. A skin sweep was conducted on 8/30/18 by licensed nurses to determine any new injuries of unknown origin. During the skin sweep, residents were observed for their reaction to staff to assure no presence of fear or change of behavior. 8. On 8/30/18 CNA D was suspended. CNA E resigned from the facility on 8/24/18. 9. Administrator A was placed on leave 8/30/18 during the investigation and RDO AA is acting in his place. 10. On 8/30/18, RDO AA and DON reviewed facility policies and procedures related to abuse reporting and investigating and found them to be appropriate. 11. DON, management staff and direct care staff were reeducated or will not be allowed to return to work after 8/30/18 until reeducation on abuse is completed. Although the Immediate Jeopardy was removed as of 8/31/18, the facility remained out of compliance at a scope of isolated and a severity of No actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to all staff had not been in-serviced on the abuse prohibition policy and procedures, and sustained compliance has not been verified by the state agency.

This citation pertains to intake #MI 947 Based on interview and record review, the facility failed to provide sufficient staffing levels for two residents (Resident #4 and #1) out of 5 sampled residents, resulting in (A) feelings of frustration when Resident #4 had to wait over an hour for assistance; (B) abuse when Resident #1 was showered against her will by CNA D and CNA E, and (C) patterns of absenteeism, staff turnover and feelings of burnout and stress expressed by multiple staff negatively impacting all residents. Resident #4 Review of a facility Admission Record reflected Resident #4 was a woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment dated [DATE] indicated that Resident #4 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 5/15 and needed extensive assistance from 2 people for transfers and extensive assistance from one person for toileting. During an interview on 9/5/18 at 9:45 a.m., the Power of Attorney (POA) DD of Resident #4 reported that he felt the facility was short staffed and explained that on 8/27/18 between 6:30 p.m. and 7:45 p.m. Resident #4 waited to be assisted to the bathroom because all but one aide was on break, including the nurse. POA DD said he lost his temper with the staff and reported the situation to the Nursing Home Administrator, but wasn't sure that anything was done about it. Resident #1 Review of a facility Admission Record indicated Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A Minimum Data Set assessment dated [DATE] reflected Resident #1 was severely cognitively impaired and needed extensive assistance from two people for transfers, dressing, toileting and was totally dependant on staff for personal hygiene and bathing. Review of a Care Plan last revised 8/13/18, reflected, (name of Resident #1) exhibited physically aggressive behaviors, hitting, swatting at staff, combativeness and agitation r/t Dementia with disturbances . The goal of the care plan was that the resident would not harm herself or others. Interventions included: When the resident becomes agitated: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. On 8/29/18 at 3:30 p.m., Surveillance Video from 8/17/18 was viewed in the presence of NHA A. In the video, at approximately 3:30 p.m., Resident #1 was seen being positioned in front of the entrance of the shower room and left to wait for CNA D and CNA E who were getting ready to shower her. CNA D and CNA E took Resident #1 into the shower room at 3:34 p.m At 3:36 p.m., LPN C was observed looking toward the shower room responding to something then returning to her work. LPN C was observed looking toward the shower room again at 3:37 p.m., then returning her attention to what she was doing at the nurses's station. At 3:42 p.m., CNA D was observed in the video exiting the shower room, LPN C looked toward CNA D who was saying something to LPN D. In another view of the surveillance video, CNA D was observed gesturing with large movements, extending her forearms from her shoulders outward and back toward her head again quickly, then flinging open a brief and re-entering the shower room at 3:43 p.m. At 3:46 p.m., LPN C was observed getting up from the nurse's station and entering the shower room, exiting about forty-five seconds later. At 3:48 p.m., CNA E exited the Shower room with Resident #1, followed shortly after by CNA D. In another camera angle, Resident #1 is observed visibly upset, mouth agape, as CNA E took Resident #1 to her room. After finishing with cares in Resident #1's room, CNA D was observed taking Resident #1 out of her room and left her sitting in her wheelchair at the nurse's station. At 3:50 p.m., Resident #1 was observed crying, shoulders heaving. At 3:51 p.m., CNA J was observed consoling Resident #1, handing her facial tissues. Resident #1 was observed showing CNA J her visibly bruised hands. At 3:56 p.m., Social Services Director (SSD) G and Unit Manager, Registered Nurse (RN) F are seen entering the unit and taking Resident #1 toward her room. Resident #1 was again observed visibly upset. In the meantime, CNA D and CNA E were both observed on the unit, responding to Resident call lights. At 4:28 p.m., NHA A was observed in the video arriving on the unit (52 minutes after LPN C first responds to commotion in the shower room). NHA A was observed briefly interacting with Resident #1 who showed NHA A her bruised hands. NHA A then took a lengthy telephone call and did not seem to notice CNA E was still working on the unit. RN H, RN I, LPN C, SSD G and RN F were all in the area and did not seem to react to the fact that CNA E and D were not removed from all resident contact. At 4:43 p.m., NHA A finished his telephone call and was observed gesturing to CNA E to come with him. CNA E was observed on camera in the vicinity of Resident #1 and responding to resident call lights for over an hour after LPN C first noticed commotion in the shower room. During an interview on 9/4/18 at 12:08 p.m., CNA D reported the facility had been short staffed on 8/17/18 so she agreed to stay an extra four hours beyond her normally scheduled shift which started at 6:00 a.m. CNA D reported that she is normally a restorative Aide and was not as familiar with the resident's and let CNA E take charge. CNA D said she got Resident #1's clothes from her room while CNA E took Resident #1 into the shower room. CNA D reported that when she entered the shower room, Resident #1 was holding onto the sink and saying something like I don't want . CNA D said she wasn't really listening to Resident #1 and said she should have wheeled her out of the shower room at that time. CNA D said Resident #1 was more irate than normal and was cursing and yelling the whole time. CNA D said she did leave the shower room to get a brief and told the nurses something like she was a little frustrated because Resident #1 had hit her glasses off her face. CNA D said that LPN C came into the shower after she had gone back in with a brief for Resident #1. CNA D said she never asked Resident #1 if she wanted to stop the shower. CNA D said We made a big fat mistake, we should have stopped. During an interview on 8/30/18 at 3:03 p.m., CNA E reported that she was on duty 8/17/18 and she and CNA D were giving showers because CNA D was leaving at 8:00 p.m. that evening. CNA E said she was pretty familiar with Resident #1 and noticed that on 8/17/18 Resident #1 was in a mood. CNA E said that Resident #1's mood could flip on a coin and that normally she would back off and give her space, but that day she was trying to get her showers done so she wouldn't get into trouble. CNA E said that Resident #1 said No! No! No! when she hooked her up to the mechanical lift to get her undressed but did not stop because she was so focused on the task at hand. CNA E said that Resident #1 was flailing around naked when sitting in the shower chair and said she still did not stop the shower. CNA E reported Resident #1 was confused about what they were doing and as soon as the water was turned on Resident #1 had an Epic Meltdown. CNA E said Resident #1 was showered as quickly as possible and recalled LPN C coming into the shower room at one point while they were drying off Resident #1 and asked What's going on? CNA E reported the whole event was very chaotic, with Resident #1 grabbing her arm, spitting on their faces, hitting off CNA D's glasses and that she put her hands out to block Resident #1's hits. CNA E reported that she had a feeling the shower would be seen as abuse because of Resident #1's reaction, describing Resident #1 as inconsolable, very angry and hostile toward she and CNA D. CNA E said she saw Resident #1 crying but wondered if she was fake crying or laugh crying. CNA E said I've realized since then, it should not have happened. I'm very remorseful. CNA E reported she resigned from the facility on 8/24/18 as a result of being mandated to work a double shift from the third time since (MONTH) (YEAR). Review of the undated mandation list provided by HR YY reflected CNA E was mandated to work a double shift on 7/27/18 and again on 8/10/18. On 8/30/18 at 5:50 p.m., NHA A was informed of an Immediate Jeopardy at F-600 (Abuse and Neglect) that began on 8/17/18 as a result of events that took place during and after Resident #1's shower given by CNA D and CNA E. Review of a Performance Improvement Form dated 8/27/18 reflected the following: On 8/24/18 (Registered Nurse F) received a call from (RN ZZ) at 8:56 p.m. stating that the building has call off for third shift and (CNA E) was on the list for mandation and she was refusing to stay. I asked to speak to her and asked her about staying. She refused and stated that she could refuse and would get a write up for the first refusal. I then offered her a monetary bonus and mentioned being a team player to her and she again refused becoming loud and I asked her to calm down. She then stated that she was not staying and she would not be returning tomorrow for her shift. I then stated that was her choice and I would accept her resignation. Review of a statement dated 8/29/18, documented by RN W reflected the following On Friday night 8/24/18 I was walking up to the double doors in the service hallway to enter into the facility for a 10:00 p.m.-6:30 a.m. shift I had picked up. Upon getting near the doors I hear someone saying loudly I will not be back here, I'm done. Upon the door opening I see that it is (CNA E) and she is on her cell phone talking with someone as she comes through the double doors into the service hallway. I asked her what was going on to cause such a reaction. She states that she is mandated and she is tired of it, she was leaving and not coming back. (CNA E) did speak with (Director of Nursing B) at one pint after this on the phone and then came to (nurses station) and states that (DON B) fired her. When I spoke with (DON B) it was not that she was fired, she has said she was quitting and her verbal resignation was accepted on the spot. (CNA E) began getting loud at (another nurses station) talking to other aides telling them what had taken place and I approached her and instructed her (to) leave the building due to the drama and loudness as well as that she no longer worked here. (CNA E) did leave the building at this time. Review of a facility guideline Absentee Control Program, undated, reflected Employee absenteeism negatively affects the ability of the facility to provide high-quality care to residents/patients on a consistent basis. All absences will be tracked; excessive absences (as defined by the guideline) will be documented on the Absenteeism notice. We have a no-fault attendance guideline in which there are no excused absences. All absences affect the center equally so all are treated equally. Rather than explore the reason for individual absences, we look at the pattern of absences. The guideline indicated that after Sixty (60) calendar days of perfect attendance, one (1) point will drop off the employee's record. Review of all Certified Nurse Aide employee files reviewed during a partial extended survey concluded on 9/5/18 revealed that between the months of (MONTH) (YEAR) and (MONTH) (YEAR), 27 out of 40 CNA's had been issued absenteeism notices. Review of an undated facility Points document provided by HR YY reflected that of all clinical and non-clinical staff that worked at the facility, 47 out of 61 employees were being monitored for absenteeism based on their date of hire. During an interview on 9/5/18 at 3:30 p.m., Human Resources Director (HR) YY reported that the facility had experienced a nearly 200% turnover in staff during the past year. As of (MONTH) (YEAR), the facility had instituted mandation (mandating staff to work extra hours in addition to their normally scheduled shift), something the facility had never had to do before. Review of an undated list provided by HR YY reflected that between 7/8/18 and 8/24/2018 14 staff members had been mandated to work beyond their scheduled shift. The list provided by HR YY did not reflect staff who volunteered to work extra shifts. Review of a Performance Improvement Form, dated 02/02/18, Certified Nurse Aid (CNA) VV received corrective action due to Telling them (residents) they are going to have to wait because the facility was short staffed .Making statements to residents to make them feel fear and disrespected .Making disparaging remarks about the organization. Review of a Performance Improvement Form, dated 07/20/18, CNA VV received corrective action for loud offensive, inappropriate behavior at nurses station in the middle of the hallway, when at the end of the shift, CNA VV was told that she was being mandated to work a double shift.

This citation pertains to intake #MI 947 Based on observation, interviews, and record review, the facility administration failed to use its resources to effectively and efficiently maintain the highest practicable physical, mental and psychosocial well-being for its residents, resulting in an immediate jeopardy, when the administrative staff failed to (A) identify, investigate and report allegations of abuse for 1 of 5 sampled residents (Resident #1) reviewed for abuse and (B) provide staffing levels to meet the needs of the residents, resulting in the substandard quality of care for all residents who reside in the facility. Findings include: (A) Review of an Abuse Prevention Program policy and procedure, last updated to 2/22/18, reflected the facility was committed to protecting residents from abused by anyone including but not necessarily limited to: facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to our residents, family members, resident representative, legal guardians, surrogate, Sponsors, friends, visitors, or any other individual. The policy specified that 19. Employees of the facility who have been accused of resident abuse shall be suspended from Duty immediately until the results of the investigation have been reviewed by the administrator .25. Any staff member or person affiliated with this facility who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense shall immediately report, or cause a report to be made of, the mistreatment or offense. Failure to report such incidents may result in legal/criminal action being filed against individual(s) with holding such information. 28. The facility will report to the Nurse Aide Registry or licensing authorities any knowledge of court actions against an employee that would make them unfit for service. Resident #1 Review of a facility Admission Record indicated Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. A Minimum Data Set assessment dated [DATE] reflected Resident #1 was severely cognitively impaired and needed extensive assistance from two people for transfers, dressing, toileting and was totally dependant on staff for personal hygiene and bathing. Review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) on 8/24/18 reflected that on 8/17/18 (Resident #1) was getting a shower and became resistive and combative with the aides. (Resident #1) flailed her arms, struck out and hit the staff and and the lift causing bruises (to the) back of her right hand, forearm and cheek .LPN C, heard (Resident #1) yell, learned that (Resident #1) had been resistive and combative with the shower and entered shower room and observed bruises. Staff providing the shower were suspended. (Resident #1) was found to have a 2.8 centimeter (cm) by 2.9 cm bruise to the back of right hand, a .9 cm by .5 cm bruise to her left hand, a 8.2 cm by .9 cm bruise to her right forearm and a 1 cm by 1 cm red spot on her right cheek. The FRI went on to detail that the Director of Nursing (DON) and Nursing Home Administrator (NHA) were notified of the incident. The (State Agency) was notified. The Police were not notified because there was no reasonable suspicion of a crime. The FRI reflected the Investigation Conclusion: The facility cannot substantiate that abuse occurred. On 8/29/18 at 3:30 p.m., Surveillance Video from 8/17/18 was viewed in the presence of NHA A. In the video, at approximately 3:30 p.m., Resident #1 was seen being positioned in front of the entrance of the shower room and left to wait for CNA D and CNA E who were getting ready to shower her. CNA D and CNA E took Resident #1 into the shower room at 3:34 p.m At 3:36 p.m., LPN C was observed looking toward the shower room responding to something then returning to her work. LPN C was observed looking toward the shower room again at 3:37 p.m., then returning her attention to what she was doing at the nurses's station. At 3:42 p.m., CNA D was observed in the video exiting the shower room, LPN C looked toward CNA D who was saying something to LPN D. In another view of the surveillance video, CNA D was observed gesturing with large movements, extending her forearms from her shoulders outward and back toward her head again quickly, then flinging open a brief and re-entering the shower room at 3:43 p.m. At 3:46 p.m., LPN C was observed getting up from the nurse's station and entering the shower room, exiting about forty-five seconds later. At 3:48 p.m., CNA E exited the Shower room with Resident #1, followed shortly after by CNA D. In another camera angle, Resident #1 is observed visibly upset, mouth agape, as CNA E took Resident #1 to her room. After finishing with cares in Resident #1's room, CNA D was observed taking Resident #1 out of her room and left her sitting in her wheelchair at the nurse's station. At 3:50 p.m., Resident #1 was observed crying, shoulders heaving. At 3:51 p.m., CNA J was observed consoling Resident #1, handing her facial tissues. Resident #1 was observed showing CNA J her visibly bruised hands. At 3:56 p.m., Social Services Director (SSD) G and Unit Manager, Registered Nurse (RN) F are seen entering the unit and taking Resident #1 toward her room. Resident #1 was again observed visibly upset. In the meantime, CNA D and CNA E were both observed on the unit, responding to Resident call lights. At 4:28 p.m., NHA A was observed in the video arriving on the unit (52 minutes after LPN C first responds to commotion in the shower room). NHA A was observed briefly interacting with Resident #1 who showed NHA A her bruised hands. NHA A then took a lengthy telephone call and did not seem to notice CNA E was still working on the unit. RN H, RN I, LPN C, SSD G and RN F were all in the area and did not seem to react to the fact that CNA E and D were not removed from all resident contact. At 4:43 p.m., NHA A finished his telephone call and was observed gesturing to CNA E to come with him. CNA E was observed on camera in the vicinity of Resident #1 and responding to resident call lights for over an hour after LPN C first noticed commotion in the shower room. During an interview on 8/30/18 at 8:30 a.m., NHA A described his interview with Resident #1 on 8/17/18 after the shower. NHA A said You would have thought (CNA D) would have stopped (the shower) a long time ago. On 8/30/18 at 10:00 a.m., the surveillance video from 8/17/18 was reviewed again in the presence of NHA A and the Regional Director of Clinical Services (RDCS) P. When Resident #1 was observed in the video being brought back to her room after the shower on 8/17/18, NHA A said Yeah, she (Resident #1) is not happy. NHA A reported that he believed he was first made aware of the allegation of abuse when RN F came to the conference room after her interview with Resident #1. NHA A said he thought the aides had been removed from duty, noting that CNA D came off the unit first, but was not accompanied by CNA E. Resident #2 Review of a facility Admission Record reflected Resident #2 was a woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set quarterly assessment dated [DATE] reflected Resident #2 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 12/15, was totally dependent on staff for transfers and needed extensive assistance from two people for toileting. Incident #1 for Resident #2 Review of an incident report dated 6/30/18 reflected that on 6/30/18 Resident #2 was calling out, seemed agitated. She had a skin tear to top of left hand . Review of a a Statement of Witness, undated, documented by Certified Nurse Aide (CNA) U, reflected the following: I was busy changing residents want (sic) (Resident #2's) light was going on many times, so I told the nurse on the charge (sic) to please go ask her for me because I already been there many time and give her everything she want and she said not she does not mean that she want them, so the nurse came back that she bleeding because she had a skin tear and I went back in her room check her, then I found that her has was cut. I asked (Resident #2) what happen, she said that I was the one who did it to her. Review of personnel records for CNA U reflected she was not suspended pending investigation as a result of the alleged staff to resident abuse. During an interview on 9/4/18 at 12:50 p.m., Regional Director of Clinical Services (RDCS) P reported the incident had not been reported to the State Agency, or handled as an allegation of staff to resident abuse. Incident #2 for Resident #2 Review of Progress Notes dated 7/21/18, documented by Licensed Practical Nurse (LPN) XX reflected the following,Resident verbalized that she needed protection that she felt that people were trying to hurt her. Resident seems more confused since this incident she continues to put on call light and when staff asked if she is ready to get off the toilet she says she's not ready but continues to push the light. Review of a Statement of witness dated 7/21/18 at 2:15 PM documented by Activity Director (AD) Z reflected the following before leaving facility, writer checked in with the nurses station, Registered Nurse (RN) W and LPN XX were at desk and stated they were having difficulties with Resident #2 due to her med change last night. (Resident #2) put call light on, writer answered, resident stated did you hear what they did to me? Writer stated No, resident stated they take me from the dining room to my room, get me alone and they hurt me. When asked how they hurt her resident said They did not so much physical but they say they will do things then won't follow through. (AD Z) asked for an example resident stated they take her from dining room into her room put her in left and arms are buckled in and can't move them and then leave her alone and in the lift. Resident stated a man in a black uniform in a woman in a green uniform hurt her. (Resident #2)stated she does not want to be left alone in her room. Writer (AD X) stated it will not happen again and Resident stated will you protect/defend me? Writer (AD X) stated yes resident replied thank you. The statement of witness continued to say that LPN XX and writer entered resident room to conduct interview resident said she was anxious and nervous but felt safe administrator contacted at 4:20 PM (over two hours after the allegation of staff to resident abuse was made) to follow up family and on call nurse notified. Review of employee files for both CNA EE and CNA FF did not reflect notice of suspension pending investigation into the alleged staff to resident abuse. During an interview on 9/5/18 at 10:10 a.m., the Regional Director of Operations (RDO) AA reported there was no evidence the alleged staff to resident abuse had been reported or thoroughly investigated in addition to failing to protect residents from the potential for ongoing abuse. (B) Resident #4 Review of a facility Admission Record reflected Resident #4 was a woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment dated [DATE] indicated that Resident #4 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 5/15 and needed extensive assistance from 2 people for transfers and extensive assistance from one person for toileting. During an interview on 9/5/18 at 9:45 a.m., the Power of Attorney (POA) DD of Resident #4 reported that he felt the facility was short staffed and explained that on 8/27/18 between 6:30 p.m. and 7:45 p.m. Resident #4 waited to be assisted to the bathroom because all but one aide was on break, including the nurse. POA DD said he lost his temper with the staff and reported the situation to the Nursing Home Administrator, but wasn't sure that anything was done about it. Review of a facility guideline Absentee Control Program, undated, reflected Employee absenteeism negatively affects the ability of the facility to provide high-quality care to residents/patients on a consistent basis. All absences will be tracked; excessive absences (as defined by the guideline) will be documented on the Absenteeism notice. We have a no-fault attendance guideline in which there are no excused absences. All absences affect the center equally so all are treated equally. Rather than explore the reason for individual absences, we look at the pattern of absences. The guideline indicated that after Sixty (60) calendar days of perfect attendance, one (1) point will drop off the employee's record. Review of all Certified Nurse Aide employee files reviewed during a partial extended survey concluded on 9/5/18 revealed that between the months of (MONTH) (YEAR) and (MONTH) (YEAR), 27 out of 40 CNA's had been issued absenteeism notices. Review of an undated facility Points document provided by HR YY reflected that of all clinical and non-clinical staff that worked at the facility, 47 out of 61 employees were being monitored for absenteeism based on their date of hire. During an interview on 9/5/18 at 3:30 p.m., Human Resources Director YY reported that the facility had experienced a nearly 200% turnover in staff during the past year. As of (MONTH) (YEAR), the facility had instituted mandation (mandating staff to work extra hours in addition to their normally scheduled shift), something the facility had never had to do before. Review of an undated list provided by HR YY reflected that between 7/8/18 and 8/24/2018 14 staff members had been mandated to work beyond their scheduled shift. The list provided by HR YY did not reflect staff who volunteered to work extra shifts.

This citation pertains to intake MI 568 Based on observation, interviews, and record review, the facility failed to prevent the elopement of 1 resident (Resident #100), out of 3 residents reviewed for elopement, from a total sample of 12 residents, resulting in an Immediate Jeopardy when Resident #100, who had been assessed as an elopement risk and was to have a WanderGuard (RFT brand Wander Management Transmitter) on her wheelchair, eloped from the facility, unbeknownst to staff, after the WanderGuard was no longer secured to her wheelchair. A visitor assisted Resident #100 outside, allowing Resident #100 to elope from the facility on 5/7/17 at approximately 1:30 pm. Resident #100 was found approximately 10 minutes later in the driveway, 30 yards from the facility front door, without her WanderGuard present on her wheelchair. This deficient practice placed Resident #100 and 2 other residents who were assessed as being at risk for elopement at risk for serious harm, injury and/or death from hazards outside the facility. Findings include: A review of facility policy titled Unsafe Wandering and Elopement Prevention Protocol Missing Resident Protocol with a revision date of 2016 revealed the facility's policy statement: Every effort will be made to prevent unsafe wandering and elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. Nursing personnel must report and investigate all reports of missing residents. Further review of the policy reflected the following: 1. All residents who are at risk for harm because of unsafe wandering will be assessed by the interdisciplinary care planning team. 2. The resident's current MDS (Minimum Data Set, an assessment tool) will be reviewed to determine what changes have occurred that would trigger elopement episodes. 3. The resident's care plan will be modified to indicate the resident is at risk for elopement episodes. Staff will be informed at shift change of the modifications to the resident's care plan. 4. Interventions for unsafe wandering and elopement attempts will be entered onto the resident's care plan and medical record. 5. Should an elopement episode occur, the contributing factors, as well as the interventions tried will be documented on the nurses' notes. 6. If a resident is discovered to be missing a search shall begin immediately, per the missing person/s protocol The policy also indicated It is the responsibility of all personnel to report any resident attempting to leave the premises or suspected of being missing to the licensed nurse in charge as soon as practical. A review of the RFT brand Wander Management Transmitters User Guide, released 2/2017 revealed the following: USER TRAINING-only users who have received adequate training on the use of the system, as outlined in this manual, should use the system. It is the responsibility of the facility to ensure all users have been trained. Failure to adequately train employees may cause system failure due to user error. In addition, incorrect use of the equipment may also result in system failure. A review of the facility's Elopement Book (contained pertinent resident information, used to identify residents who are at risk for elopement) on 6/2/2017 at 12:00 p.m., identified Resident #100, #105 and #106 as currently at risk for elopement. Nursing Home Administrator (NHA) A stated these books are located at the reception desk and each nurses station. Resident #100 A review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #100 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) score indicated Resident #100 was moderately cognitively impaired and required extensive assistance from 1 person for locomotion on and off the unit. Review of a Nurse's Note dated 5/1/17 at 3:03 PM, reflected Resident presented signs of delirium and agitation starting early in the AM as reported by nursing staff. As the day has went on resident started to exit seek. UM (Unit Manager) .put a WanderGuard on residents chair as a preventative measure. A review of the current Care Plan revealed Resident #100 was identified as being at increased risk of elopement by the facility on 05/01/2017 with interventions initiated that same day that included, WANDER ALERT: Wanderguard to back of w/c (wheelchair); check placement and function q (every) shift. Review of the Treatment Administration Record (TAR) indicated beginning 5/1/17 various nursing staff had documented they checked placement and function of the wanderguard device for Resident #100 every shift as ordered. Review of the 5/1/17 Risk of Elopement/Wandering Review assessment for Resident #100 notes she is at risk for elopement due to Currently being treated for [REDACTED]. Family is aware of exit seeking and new orders for WanderGuard; will re-evaluate necessity after acute condition is resolved. An additional assessment was completed on 5/7/17 at 5:00 PM and noted Attempts to leave facility unattended and change in mentl (sic) status. Review the elopement incident investigation documents provided by the facility reflected that on 5/5/2017 Resident #100 removed the WanderGuard device from the chair as identified by staff. It was reapplied to the chair but because WanderGuard bands were not accessible to the nurses the WanderGuard was not properly secured to the chair. Witness statements included in the investigation conducted by the facility revealed that on 5/7/2017, Licensed Practical Nurse (LPN) K reported that Resident #100 had a WanderGuard on the back handle of her w/c @ (wheelchair at) breakfast which was taped in place. Activities Aide (AA) L reported Resident #100 didn't have a wanderguard on (wheelchair) due to switch of chairs earlier that wk (week). A written statement by Activities Director (AD) N also confirms a WanderGuard was not on the back of Resident #100 wheelchair at the time of elopement on 5/7/17. Further review of the incident investigation documents revealed On 5/7/17 sometime after lunch, Resident #100 was observed by AD N to be talking to AA L about wanting to go outside. AD N's statement revealed .staff redirected resident by telling her that the road out front was a 45 mph road and that it was cold out. AA L's written statement confirmed she was the staff who had the discussion with Resident #100 that AD N reported. AA L's statement revealed after this exchange with Resident #100, she reported she asked AD N if she should be on WanderGuard and she said they were looking into it. AA L reported that she directed Resident #100 to follow her roommate to her room away from the lobby. AD N reported that at approximately 1:30 PM, she viewed Resident #100 self-propelling wheel chair toward the hall way that leads to the lobby while they walked to a printer. On the way back AD N noted Resident #100 was not in the lobby. A Code Amber (a protocol used when a resident is missing) was called between 1:30 and 1:35 PM. At some point after the Code Amber was called, a visitor reported to AA L that a resident was in front of the building. AA L went outside to attempt to return the resident to the facility. Resident #100 was noted to be approximately 30 yards from the building and resistant to re-entry. Resident #100 was returned to the facility with the assistance of other staff members at approximately 1:40 PM. Upon returning Resident #100 to the building AA L states LPN K checked new wander guard to make sure it work and then left alarm going while going back to unit. I turned off alarm and found a yellow sticky note next to alarm -c (with) code on it. Further review of the facility investigation revealed that a visitor to the facility, M, had assisted Resident #100 out of the building. Visitor M was interviewed as part of the facility's internal investigation and was noted to report that upon entry into the facility he viewed Resident #100 talking to a man in a yellow shirt. They appeared to be together and he opened the door for them as they exited the building. A nurse's note on the electronic medical record authored by LPN K from 5/7/17 at 4:47 PM reflected Resident exited the building unassisted, she did not leave the facility grounds. She was escorted back into the facility by staff. No harm noted. Administrator, Director of Nursing, Dr, and family all notified. On 6/2/2017 at approximately 12:30 PM, function and placement was confirmed Regarding Resident #100's WanderGuard. There was a WanderGuard observed on her wheel chair with expiration date 11/17/17 and one on her left arm with expiration date 6/2017 (no day noted). Resident #105 A review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #105 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) score indicated Resident #105 was severely cognitively impaired and needed supervision from one person for locomotion on the unit and required extensive assistance from 1 person with locomotion off the unit. A review of the current care plan revealed Resident #105 was identified as being at increased risk of elopement by the facility on 05/25/2017. The care plan notes Wander guard to the left ankle. Check placement and function q (every) shift. A review of Nurses note from 5/24/17 at 6:00 PM in the electronic medical record states Staff reported in the afternoon that (Resident #105) had made statement about wanting to go outside. She currently has an acute condition .and has had an increase in confusion with hallucinations .Wander guard placed to the left lower leg and is functioning properly. New order to check placement and function of wander guard every shift. A review of Resident #105's Treatment Administration Record (TAR) The TAR for Resident #105 was not observed to have an order regarding a wanderguard. A review of incident reports regarding Resident #105 revealed she had experienced an unobserved fall in her room on 4/3/17 at 1:00 AM. Resident #105 was noted to be confused at the time of the incident was being treated for [REDACTED].#105 was not assessed to be at risk for elopement at that time. Review of the 5/25/17 Risk of Elopement/Wandering Review assessment for Resident #105 notes she is at risk for elopement due to Resident noted to have been sitting at the front door with her feet pushing on the door. Staff responded to the door alarm. Resident redirected and assisted to her room. An additional assessment was signed on 6/2/2017 and noted an effective date of 5/31/17 Resident #105 was not noted at risk for wandering due to Residents condition has improved. Resident #106 A review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #106 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) score indicated Resident #106 was moderately cognitively impaired and was a 1 person extensive assist in locomotion on and off the unit. A review of the current care plan revealed Resident #106 was identified as being at increased risk of elopement by the facility on 03/22/16. Care plan interventions note WANDER ALERT: Wander Guard initiated on 3/22/16 and last revised 5/8/17. A review of Resident #106's treatment administration record (TAR) notes Check placement and function of wanderguard every shift. The TAR for Resident #106 notes confirmation of regular function and placement checks by various nursing staff. A review of progress notes from 5/24/17 at 12:05 PM, in the electronic medical record, reveals Resident stated that she was 'leaving this place,' and that she is moving to Kalamazoo .Resident has a hx (history) of telling staff that she is leaving to go to another facility when she is entering a manic stage r/t (related to) her bipolar dx (diagnosis). Unit manager was notified. Review of the 5/9/17 Risk of Elopement/Wandering Review assessment for Resident #106 notes she is at risk for elopement with the following comment resident is bipolar, and has a WanderGuard in place. On 6/2/2017 at 11:45 AM, a facility tour was completed with Maintenance Supervisor (MS) E and Nursing Home administrator (NHA) A. A map of the facility with doors numbered was provided as a tool used by the facility to audit the function and security of exits. Door alarm functions were observed at this time and concerns for accidents and hazard were noted with door number 10 and 11. Door number 11 is located near the Sunrise Dining Room and enters into a closed courtyard. The door alarm was observed to go off only when the door closed after being opened. MS E adjusted the settings to the alarm, which was located in the upper door frame. The alarm was opened again and the door alarmed immediately when opened. The alarm continued until disabled by MS E. Door number 10 is located near the Sunset Dining Room and enters into a closed courtyard. The door alarm was observed to go off only when the door closed after being opened. The alarm noise was a chime rather than a loud beeping noise. MS E adjusted the settings to the alarm, which was located in the upper door frame, and then opened the door again. The door alarmed when opened, again with a chime sound. The chiming sound was observed to shut off on its own instead of continuing to alarm until disabled. MS E adjusted the alarm again and opened the door. It was observed to make a loud beeping noise instead of the chime sound. The alarm continued until disabled by MS E. MS E stated, and NHA A confirmed that sometimes activity staff will set the door alarm to the chime noise if they are using the courtyard for an activity. NHA A was questioned if the door alarm was checked at the end of activities or in the evening to ensure it was back to the alarm sound rather than the chime sound. NHA A stated it was checked one time a day. When asked what that time was, NHA A stated, It varies. MS E was questioned as to when audits were completed of the door alarms. He stated he has always completed a daily audit of all doors. Upon further questioning he stated that he only checked outer exit doors prior to 5/7/17, but now checked all exit doors including doors to the courtyard. MS E further stated that he works Monday through Friday and that weekend managers would be doing door alarm audits on the weekend. A review of Logbook Documentation records printed on 6/2/2017 revealed that an audit of door alarms prior to 5/7/17 included only 7 of 13 egress doors in the facility. The document notes Doors, Locks & Alarms: Test operation of door and locks daily. There was no verified checks in the Logbook Documentation on 4/29/17, 4/30/17, or 5/6/17. On 5/7/2017-6/2/2017 the door audits were recorded on a facility map with 13 egress doors noted. An interview and observation was started with LPN C at approximately 12:15 PM on 6/2/2017. LPN C stated she checks placement of the WanderGuards but does not test the functionality. LPN C guessed maybe 3rd shift checks functionality. A review Resident #105's Electronic Medical Record (EMR) was completed with LPN C who was standing by her medication cart. There was no order in the EMR for a WanderGuard. LPN C stated the unit manager informed her about a week ago that Resident #105 was to have a WanderGuard due to a urinary tract infection. A review of Resident #106's EMR was completed with LPN C, the EMR contained an order to check placement and function of a WanderGuard. LPN C confirmed she had checked placement earlier that day, but not function, however, she had documented she checked function (calling into question the accuracy of the medical record). When questioned how function would be checked, LPN C stated that she had not checked function of WanderGuards since she was employed at the facility. After searching the medication cart, LPN C was able to locate the WanderGuard function tester in her cart. An interview and observation was started with RN D at approximately 12:20 PM on 6/2/2017. RN D reviewed Resident #100's EMR and revealed an order for [REDACTED].#100's wheelchair was initiated on 5/1/2017. The order was to check placement and function of the WanderGuard each shift. RN D stated that Resident #100 also has a WanderGuard on her arm, but she could not find the order. RN D reported that she checks placement and functionality of the WanderGuards per resident care plans. RN D was asked to demonstrate checking placement and functionality of WanderGuards. RN D located the WanderGuard function tester and pressed a button on the side of the device while standing at the medication cart resulting in one beep, then let go of the button. RN D then approached Resident #100 who was in the dining room and repeated the procedure while holding the function tester near the WanderGuard at the back of Resident #100's wheelchair, resulting in one beep, then let go of the button. RN D was asked to explain how this was an indication the transmitter in the WanderGuard was functioning, given the fact that the one beep was also demonstrated in a hallway several feet away from Resident #100. RN D could not explain the observation. At approximately 12:25 PM on 6/20/17, DON B joined the interviews with RN D and LPN C regarding the WanderGuard testing. Initially, DON B said the function tester was working because she could hear it beeping. DON B was asked to demonstrate use of the WanderGuard function tester. DON B could not immediately display knowledge of the process. While standing in the hall several feet away from Resident #100, DON B pressed the button on the side of the device and one beep was heard. DON B then wondered if the battery needed to be replaced and went to a mail room to get a fresh battery. DON B then changed her mind, didn't replace the battery and was then observed to refer to the instructions located on the WanderGuard function tester. After reading the instructions, DON B went to Resident #100 in the dining room and was able to validate the WanderGuard was working when she placed the function tester directly on top of the WanderGuard and held down the button on the side of the device and an intermittent beep was heard, after several beeps, DON B released the button on the side of the testing device and said that is the proper way to test function. On 6/2/2017 at approximately 1:35 PM, an interview was completed with NHA A and Regional Clinical Coordinator (RCC) RA. NHA A and RCC RA were questioned regarding the root cause of Resident #100's elopement. NHA A stated it was due to the resident being helped out of the building by a visitor. NHA A was asked again if there were any other concerns and NHA A stated that the alarm did not sound when Resident #100 left the building. It was again asked if there were any further reasons for the elopement of Resident #100 and RCC RA responded that Resident #100 had removed her wander guard herself previously and it had been taped on her wheelchair after this. RCC RA stated that Resident #100 must have removed her WanderGuard again because Resident #100 was checked at the beginning of the shift and the WanderGuard was present. RCC RA admitted that the WanderGuard was not present when Resident #100 was located outside the facility. On 6/2/2017 at 3:35 PM, the Nursing Home Administrator (NHA) A, Director of Nursing (DON) B, Regional Clinical Coordinator (RCC) RA and Senior Regional Director of Operations (SRDO) I were informed Immediate Jeopardy (IJ) had been identified at F-323 starting on 5/7/2017 at 1:30 PM for the facility's failure to prevent the elopement of 1 resident (Resident #100), who was a known elopement risk and wore a WanderGuard bracelet and still, unbeknownst to staff, eloped from the facility after her WanderGuard was removed and she was assisted out of the building by a visitor, allowing Resident #100 to elope from the facility on 5/7/2017 at 1:30 PM. This deficient practice has the potential to affect all 3 residents who are assessed as being at risk for elopement at risk for serious harm, injury and or death from hazards outside the facility. On 6/6/2017 the surveyor verified the following interventions had been put into place and were effective to remove the immediacy: 6/2/217 5:40 PM The regional clinical consultant validated transmitters were properly placed and functioning on the 2 residents who are at risk for elopement and the care plans have been updated. Placement of transmitters was verified to be on their person, not on their wheelchairs. 6/2/17 6:46 PM The orders were clarified for placement and function for (Resident #100) to include transmitter on her person and the transmitter to the wheelchair has been removed 6/2/17 5:15 PM The director of nursing validated the transmitter was removed from (Resident #105) as per order on 5/31/17. (Resident #105)'s information was removed from the Elopement Books as she is no longer and elopement risk. 6/2/17 6:00 PM Five Elopement books were validated to be corrected by the Director of Nursing. 6/2/17 6:20 PM Eight out of nineteen nurses received reeducation by 6/2/17 and the remaining has been re-educated prior to working their next shift. Re-education of nurses on checking transmitters for placement, function and expiration as well as how to check transmitters for functionality, Unsafe Wandering & Elopement Prevention Protocol Missing Resident Protocol Policy. Current staff will be re-educated on the Unsafe Wandering and Elopement protocol 6/2/17 6:30 PM Medical director designee was notified of the immediate jeopardy and plan. 6/6/17 A letter was sent on May 8 to all family members to remind them to consult with the nurse supervisor before assisting residents outdoors. 6/6/17 For Resident #100, she was placed on every 15 minute checks starting on May 7, then graduated to everyone our checks on May 18. And has continued to remain safe with no further attempts at elopement. Although the Immediate Jeopardy (IJ) was removed on 6/2/17, the facility remained out of compliance at a scope of isolated and a severity of No actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to all staff had not been in-serviced on the corrective action implemented to remove the immediacy and sustained compliance has not been verified by the state agency.

This citation pertains to MI 764 Based on interview and record review, the facility failed to properly assess skin alterations, and then notify the physician of Resident #2's acute change in skin condition in 1 resident (#2) of 2 total sampled residents reviewed for pressures ulcers, after Resident #2 was noted to have alteration in skin integrity, resulting in delayed treatment, and the worsening of Resident #'2's coccyx pressure ulcer. Findings include: Review of the face sheet and most recent Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #2 was an [AGE] year old male resident re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed that Resident #2 required extensive assistance with activities of daily living (ADLs). Review of the wound clinic note dated 3/29/17 revealed that Resident #2 had multiple pressure ulcers, Pressure ulcer of sacral region, stage 3; pressure ulcer of left heel, unstageable; pressure ulcer of right heel, unstageable; pressure ulcer of unspecified cite, unstageable .Wound #1 status is open. Original cause of wound was Pressure Injury. The wound is currently classified as a Category/Stage III (deep wound with loss of skin, usually exposes some fat) wound and is located on the Medial Coccyx. The wound measures 4 cm (centimeters) length x 2 cm width x 0.3 cm depth. There is fat exposed .Wound #2 status is Open. Original cause of wound was Pressure Injury .located on the Left Lower Leg .The wound is currently classified as Unable to visualize wound bed .The wound measures 1.2 cm length x 1.2 cm width x 0.1 cm depth .Wound #3 status is Open. Original cause of wound is Pressure Injury. The wound is currently classified as Unable to visualize wound bed .The wound measures 0.7 cm length x 1 cm width x 0.1 cm depth; Wound #4 status is Open. Original cause of wound was Pressure Injury. The wound is currently classified as a Unable to visualize wound bed .The wound measures 1.2 cm length x 0.7 cm width x 0.1 cm depth .Overall the patient's health status, as reported by the patient, has been complicated by a hospital admission from 3/20-3/25 for UTI (Urinary Tract Infection), patient accompanied to clinic today by daughter. Daughter states that nursing home has not been consistent with offloading buttock or legs . Review of the facility's Pressure Ulcers/Skin Breakdown - Clinical Protocol revised 3/23/2011 revealed, The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcer( s ) .In addition, the nurse shall assess and document/report the following: a. Vital signs b. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue Pain assessment d. Resident's mobility status e. Current treatments, including support surfaces .The physician will help the staff define the type (for example, arterial or stasis ulcer) and characteristics (necrotic tissue, status of wound bed, etc.) of an ulceration .The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents .During resident visits, the physician will evaluate and document the progress of wound healing especially for those with complicated, extensive, or non-healing wounds . During an observation on 3/29/17 at 9:30 a.m., Resident #2 was observed in his room lying in his bed. Resident did not have any pants on and was wearing a brief. The pad underneath the resident was folded up, and the resident was laying on the crease. The resident had two blue boots on, the boot on the right foot was twisted and and not properly floating his heel. There was a pillow on the floor at the foot of his bed. Surveyor spoke to the nurse on duty and stated that Resident #2 needed some assistance. During an interview on 3/29/17 at 1:45 p.m., when asked what the expectation was for skin and wound documentation, DON B stated that head to toe skin assessments are to be completed by licensed nurse once a week. If they find something they are to notify the physician for follow up treatment and to document their findings. When asked how often wounds should be documented on, DON B stated that they should be measured and assessed once a week, the staging should be be included in the documentation. While looking at Resident #2's complete medical chart, DON B was asked if she revealed any documentation that Resident #2's wounds had been communicated to Resident #2's physician, DON stated, Nothing other than a dietary note that the physician signed. Review of this note revealed the only thing documented pertaining go Resident #2's pressure ulcers was on 1/26/17, increase cal/pro (calorie/protein) needs 2nd pressure injury, and the physician simply signed this note. With DON B present, a review of Resident #2's medical chart revealed the following documentation of Resident #2's wounds: -BATHTIME SKIN ANATOMY DIAGRAM sheets dated 12/31/16 only mentioned, the left heel is hard review of further sheets dated 1/4/17, 1/11/17, 2/8/17, 2/11/17 and 2/15/17 failed to mention any alterations to Resident #2's skin. -Review of the facility's Weekly Wound Tracking Worksheet dated 1/2/17 revealed, coccyx 0.5 raw Allevyn q 3 (indicating an alteration to Resident #2's coccyx and was to be treated with Allevyn every 3 days). Review of Resident #2's medical chart failed to reveal that an order for [REDACTED]. -Review of the hospital admission record dated 1/20/17 revealed Resident #2 was admitted to the hospital on [DATE]. Further review of this record failed to mention any alteration to Resident #2's skin. Resident #2 was discharged from the hospital on [DATE] back to the facility -Review of the facility's Admission Evaluation form dated 1/24/17 revealed, that Resident #2 was at high risk for pressure ulcers. Further review of the form revealed the skin condition of Coccyx Stage I red blanchable area .Coccyx 0.5 cm x 0.4 cm open area. -Review of the facility's (Name of the computer system that the facility uses to document wounds) note dated 2/1/17 revealed a open stage I coccyx wound measuring 0.5 length x 0.5 width was present. Treatment was cleanse with soap and water, pat dry Allevyn change q (every) 3 days. Review of the medical record failed to reveal where this order was documented. Further review of the chart failed to reveal where this treatment was carried out by nursing staff. -Review of the facility's Weekly Wound Tracking Worksheet dated 2/9/17 revealed, coccyx red nothing else was documented. -Review of the hospital discharge summary dated 3/5/17 revealed that resident #2 was admitted to the hospital on [DATE] with, Pressure ulcer on the coccyx, unstageable; Pressure ulcer of the right heel, unstageable; Pressure ulcer of the left lateral lower leg, unstageable; Pressure ulcer of the left lateal malleolus (ankle), unstageable; Pressure ulcer of the left lateral heel, unstageable; DTI (deep tissue injury) of the left lateral 5th metatarsal (foot) head, 5th metatarsal base and left posterior heel. Further review of the discharge summary revealed, Wound clinic was consulted for wound on the coccyx and bilateral (both) lower extremities. -Review of the facility's Nursing Evaluation Data assessment dated [DATE] reveled that the only Skin Condition had upon re-admission to the facility was Sacrum Pressure Stage II 5 cm length 5 mc width and no depth documented. --Review of the facility's (Name of the computer system that the facility uses to document wounds) note dated 3/6/17 revealed, Stage II pressure ulcer 2.2 length 2.2 width and no depth this is contradictory to the previous note dated 3/5/17. Review of the physician progress notes [REDACTED].#2's skin alterations. There was no assessments or plans for Resident #2's wound(s). Review of the facility's documentation failed to reveal that all of Resident 2's pressure ulcers were consistently documented on, and did not include all required documentation, according to the facility's policy. Further review of the medical record failed to reveal where Resident #2's physician was notified of any of Resident #2's pressure ulcers.

This citation pertains to MI 764. Based on interview and record review, the facility failed to update a care plan for 1 resident (Resident #2), out of a total sample of 5 residents reviewed for care plans, resulting in Resident #2 being admitted to the hospital for [MEDICAL CONDITION] (a life-threatening condition that arises when the body's response to infection injures its own tissues an organs) related to urinary tract infection [MEDICAL CONDITION] and the developing and worsening of multiple pressure ulcers. Findings include: Review of the face sheet and most recent Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #2 was an [AGE] year old male resident re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed that Resident #2 required extensive assistance with activities of daily living (ADLs). Review of the hospital admission history and physical dated 3/20/17 revealed Resident #2, .is being admitted on [DATE] after being found to have increased confusion and decreased mentation by his facility .Of note, (Resident #2) was recently seen here at (name of hospital) from 2/22/17-3/5/17 [MEDICAL CONDITION] secondary to (pneumonia). Patient was discharged home with [MEDICATION NAME] (antibiotic). Per facility, the instructions were lost and patient has continued to be on [MEDICATION NAME] BID (twice a day) until today, which I have discontinued. The Foley that is also present has also been in place since that hospitalization . This will be discontinued and replaced .ASSESSMENT/PLAN: [MEDICAL CONDITION] secondary to UTI . Review of the hospital discharge summary dated 3/5/17 revealed, Continue indwelling Catheter: yes change Foley every two weeks. Review of the facility's Catheter Care, Urinary policy revised 3/23/11 revealed, The purpose of this procedure is to prevent infection of the resident's urinary tract .1. Review the resident's care plan to assess for any special needs of the resident .Maintain an accurate record of the resident's daily output, per facility policy and procedure .Be sure the catheter tubing and drainage bag are kept off the floor .The following information should be recorded in the resident's medical record: The date and time that catheter care was given .The name and title of the individual(s) giving the catheter care .All assessment data obtained when giving catheter care .Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor .Any problems noted at the catheter-urethral junction during perinea! care such as drainage, redness, bleeding, irritation, crusting, or pain .Any problems or complaints made by the resident related to the procedure .How the resident tolerated the procedure .If the resident refused the procedure, the reason(s) why and the intervention taken .The signature and title of the person recording the data .Notify the supervisor if the resident refuses the procedure . Review of the complete medical record failed to reveal that any type of catheter care was ordered or completed for Resident #2's indwelling catheter, to include the catheter being changed every two weeks. Review of Resident #2's care plan failed to reveal that any type of catheter care interventions were put into place until 3/30/17. During an interview on 3/29/17 at 12:00 p.m., while reviewing Resident #2's medical record, and when asked if there were any orders for catheter care, or any cares completed to Resident #2's catheter, Director of Nursing (DON) B stated, Not that I am seeing .I am not seeing anything in the treatments. Review of the Treatment Administration Record for the month of March 2017, failed to reveal any type of treatments to Resident #2's catheter. Furthermore, it failed to reveal that Resident #2's catheter was every changed after being re-admitted to the facility on [DATE]. Review of the wound clinic note dated 3/29/17 revealed that Resident #2 had multiple pressure ulcers, Pressure ulcer of sacral region, stage 3; pressure ulcer of left heel, unstageable; pressure ulcer of right heel, unstageable; pressure ulcer of unspecified cite, unstageable .Wound #1 status is open. Original cause of wound was Pressure Injury. The wound is currently classified as a Category/Stage III (deep wound with loss of skin, usually exposes some fat) wound and is located on the Medial Coccyx. The wound measures 4 cm (centimeters) length x 2 cm width x 0.3 cm depth. There is fat exposed .Wound #2 status is Open. Original cause of would was Pressure Injury .located on the Left Lower Leg .The wound is currently classified as Unable to visualize wound bed .The wound measures 1.2 cm length x 1.2 cm width x 0.1 cm depth .Wound #3 status is Open. Original cause of wound is Pressure Injury. The wound is currently classified as Unable to visualize wound bed .The wound measures 0.7 cm length x 1 cm width x 0.1 cm depth; Wound #4 status is Open. Original cause of wound was Pressure Injury. The wound is currently classified as a Unable to visualize wound bed .The wound measures 1.2 cm length x 0.7 cm width x 0.1 cm depth .Overall the patient's health status, as reported by the patient, has been complicated by a hospital admission from 3/20-3/25 for UTI (Urinary Tract Infection), patient accompanied to clinic today by daughter. Daughter states that nursing home has not been consistent with offloading buttock or legs . Review of the facility's Pressure Ulcers/Skin Breakdown - Clinical Protocol revised 3/23/2011 revealed, The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcer( s ) .In addition, the nurse shall assess and document/report the following: a. Vital signs b. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue Pain assessment d. Resident's mobility status e. Current treatments, including support surfaces .The physician will help the staff define the type (for example, arterial or stasis ulcer) and characteristics (necrotic tissue, status of wound bed, etc.) of an ulceration .The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents .During resident visits, the physician will evaluate and document the progress of wound healing especially for those with complicated, extensive, or non-healing wounds . During a telephone interview on 3/27/17 at 9:50 a.m., Resident #2's daughter stated she visits her father 2-3 times per week. Resident #2's daughter further stated, They are supposed to rotate him every two hours and they don't .He is supposed to have those air boots on, when I come in they are never on. One day we asked about the aide about the boots and he just left and never came back. During an observation on 3/29/17 at 9:30 a.m., Resident #2 was observed in his room lying in his bed. Resident did not have any pants on and was wearing a brief. The pad underneath the resident was folded up, and the resident was laying on the crease. The resident had two blue boots on, the boot on the right foot was twisted and and not properly floating his heel. There was a pillow on the floor at the foot of his bed. Surveyor spoke to the nurse on duty and stated that Resident #2 needed some assistance. During an interview on 3/29/17 at 1:45 p.m., when asked what the expectation was for skin and wound documentation, DON B stated that head to toe skin assessments are to be completed by licensed nurse once a week. If they find something they are to notify the physician for follow up treatment and to document their findings. When asked how often wounds should be documented on, DON B stated that they should be measured and assessed once a week, the staging should be be included in the documentation. While looking at Resident #2's complete medical chart, DON B was asked if she revealed any documentation that Resident #2's wounds had been communicated to Resident #2's physician, DON stated, Nothing other than a dietary note that the physician signed. Review of this note revealed the only thing documented pertaining go Resident #2's pressure ulcers was on 1/26/17, increase cal/pro (calorie/protein) needs 2nd pressure injury. With DON B present, a review of Resident #2's medical chart revealed the following documentation of Resident #2's wounds: -BATHTIME SKIN ANATOMY DIAGRAM sheets dated 12/31/16 only mentioned, the left heel is hard review of further sheets dated 1/4/17, 1/11/17, 2/8/17, 2/11/17 and 2/15/17 failed to mention any alterations to Resident #2's skin. -Review of the facility's Weekly Wound Tracking Worksheet dated 1/2/17 revealed, coccyx 0.5 raw Allevyn q 3 (indicating an alteration to Resident #2's coccyx and was to be treated with Allevyn every 3 days). Review of Resident #2's medical chart failed to reveal that an order for [REDACTED]. -Review of the hospital admission record dated 1/20/17 revealed Resident #2 was admitted to the hospital on [DATE]. Further review of this record failed to mention any alteration to Resident #2's skin. Resident #2 was discharged from the hospital on [DATE] back to the facility -Review of the facility's Admission Evaluation form dated 1/24/17 revealed, that Resident #2 was at high risk for pressure ulcers. Further review of the form revealed the skin condition of Coccyx Stage I red blanchable area .Coccyx 0.5 cm x 0.4 cm open area. -Review of the facility's (Name of the computer system that the facility uses to document wounds) note dated 2/1/17 revealed a open stage I coccyx wound measuring 0.5 length x 0.5 width was present. Treatment was cleanse with soap and water, pat dry Allevyn change q (every) 3 days. Review of the medical record failed to reveal where this order was documented. Further review of the chart failed to reveal where this treatment was carried out by nursing staff. -Review of the facility's Weekly Wound Tracking Worksheet dated 2/9/17 revealed, coccyx red nothing else was documented. -Review of the physician progress notes [REDACTED].#2's skin alterations. There was no assessments or plans for Resident #2's wound(s). -Review of the hospital discharge summary dated 3/5/17 revealed that resident #2 was admitted to the hospital on [DATE] with, Pressure ulcer on the coccyx, unstageable; Pressure ulcer of the right heel, unstageable; Pressure ulcer of the left lateral lower leg, unstageable; Pressure ulcer of the left lateal malleolus (ankle), unstageable; Pressure ulcer of the left lateral heel, unstageable; DTI (deep tissue injury) of the left lateral 5th metatarsal (foot) head, 5th metatarsal base and left posterior heel. Further review of the discharge summary revealed, Wound clinic was consulted for wound on the coccyx and bilateral (both) lower extremities. -Review of the facility's Nursing Evaluation Data assessment dated [DATE] reveled that the only Skin Condition had upon re-admission to the facility was Sacrum Pressure Stage II 5 cm length 5 mc width and no depth documented. --Review of the facility's (Name of the computer system that the facility uses to document wounds) note dated 3/6/17 revealed, Stage II pressure ulcer 2.2 length 2.2 width and no depth this is contradictory to the previous note dated 3/5/17. Review of the facility's documentation failed to reveal that all of Resident 2's pressure ulcers were consistently documented on, and did not include all required documentation, according to the facility's policy. Review of the hospital discharge instruction sheet dated 3/5/17 revealed the following interventions to prevent the worsening of Resident #2's wounds, Assure no contact of wound with surfaces .Limit side lying to 30 degree tilt. Limit head of bed elevation to 30 degrees .use seat lifts or shift position in chair every 15 minutes when up, limit time in chair. Review of Resident #2's The resident has a diabetic/pressure ulcer on coccyx, L ankle, and R Heel care plan dated 1/25/17 and updated 3/30/17, revealed these interventions were not put into place until 3/30/17. Further review of Resident #2's care plan revealed, Evaluate dressing q (every) shift to ensure it is intact and adhering. Report loose dressing to treatment nurse. This intervention fails to indicate which dressing, and which location. During an observation on 3/29/17 at 11:25 a.m., with Unit Manager, RN G, Resident #2 was observed lying in bed. Resident was wearing a brief, when the brief was taken off, the Stage III pressure ulcer on Resident #2's coccyx was observed to be without any type of dressing.

This citation pertains to MI 764 Based on observation, interview, and record review, the facility failed to prevent the formation and worsening of pressure ulcers for 1 of 2 sampled residents (Resident #2) reviewed for pressure ulcers, from a total of 5 residents, resulting in the formation of and worsening of pressure ulcers for Resident #2. Findings include: Review of the face sheet and most recent Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #2 was an [AGE] year old male resident re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed that Resident #2 required extensive assistance with activities of daily living (ADLs). Review of the wound clinic note dated 3/29/17 revealed that Resident #2 had multiple pressure ulcers, Pressure ulcer of sacral region, stage 3; pressure ulcer of left heel, unstageable; pressure ulcer of right heel, unstageable; pressure ulcer of unspecified cite, unstageable .Wound #1 status is open. Original cause of wound was Pressure Injury. The wound is currently classified as a Category/Stage III (deep wound with loss of skin, usually exposes some fat) wound and is located on the Medial Coccyx. The wound measures 4 cm (centimeters) length x 2 cm width x 0.3 cm depth. There is fat exposed .Wound #2 status is Open. Original cause of would was Pressure Injury .located on the Left Lower Leg .The wound is currently classified as Unable to visualize wound bed .The wound measures 1.2 cm length x 1.2 cm width x 0.1 cm depth .Wound #3 status is Open. Original cause of wound is Pressure Injury. The wound is currently classified as Unable to visualize wound bed .The wound measures 0.7 cm length x 1 cm width x 0.1 cm depth; Wound #4 status is Open. Original cause of wound was Pressure Injury. The wound is currently classified as a Unable to visualize wound bed .The wound measures 1.2 cm length x 0.7 cm width x 0.1 cm depth .Overall the patient's health status, as reported by the patient, has been complicated by a hospital admission from 3/20-3/25 for UTI (Urinary Tract Infection), patient accompanied to clinic today by daughter. Daughter states that nursing home has not been consistent with offloading buttock or legs . Review of the facility's Pressure Ulcers/Skin Breakdown - Clinical Protocol revised 3/23/2011 revealed, The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcer( s ) .In addition, the nurse shall assess and document/report the following: a. Vital signs b. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue Pain assessment d. Resident's mobility status e. Current treatments, including support surfaces .The physician will help the staff define the type (for example, arterial or stasis ulcer) and characteristics (necrotic tissue, status of wound bed, etc.) of an ulceration .The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents .During resident visits, the physician will evaluate and document the progress of wound healing especially for those with complicated, extensive, or non-healing wounds . During a telephone interview on 3/27/17 at 9:50 a.m., Resident #2's daughter stated she visits her father 2-3 times per week. Resident #2's daughter further stated, They are supposed to rotate him every two hours and they don't .He is supposed to have those air boots on, when I come in they are never on. One day we asked about the aide about the boots and he just left and never came back. During an observation on 3/29/17 at 9:30 a.m., Resident #2 was observed in his room lying in his bed. Resident did not have any pants on and was wearing a brief. The pad underneath the resident was folded up, and the resident was laying on the crease. The resident had two blue boots on, the boot on the right foot was twisted and and not properly floating his heel. There was a pillow on the floor at the foot of his bed. Surveyor spoke to the nurse on duty and stated that Resident #2 needed some assistance. During an interview on 3/29/17 at 1:45 p.m., when asked what the expectation was for skin and wound documentation, DON B stated that head to toe skin assessments are to be completed by licensed nurse once a week. If they find something they are to notify the physician for follow up treatment and to document their findings. When asked how often wounds should be documented on, DON B stated that they should be measured and assessed once a week, the staging should be be included in the documentation. While looking at Resident #2's complete medical chart, DON B was asked if she revealed any documentation that Resident #2's wounds had been communicated to Resident #2's physician, DON stated, Nothing other than a dietary note that the physician signed. Review of this note revealed the only thing documented pertaining go Resident #2's pressure ulcers was on 1/26/17, increase cal/pro (calorie/protein) needs 2nd pressure injury. With DON B present, a review of Resident #2's medical chart revealed the following documentation of Resident #2's wounds: -BATHTIME SKIN ANATOMY DIAGRAM sheets dated 12/31/16 only mentioned, the left heel is hard review of further sheets dated 1/4/17, 1/11/17, 2/8/17, 2/11/17 and 2/15/17 failed to mention any alterations to Resident #2's skin. -Review of the facility's Weekly Wound Tracking Worksheet dated 1/2/17 revealed, coccyx 0.5 raw Allevyn q 3 (indicating an alteration to Resident #2's coccyx and was to be treated with Allevyn every 3 days). Review of Resident #2's medical chart failed to reveal that an order for [REDACTED]. -Review of the hospital admission record dated 1/20/17 revealed Resident #2 was admitted to the hospital on [DATE]. Further review of this record failed to mention any alteration to Resident #2's skin. Resident #2 was discharged from the hospital on [DATE] back to the facility -Review of the facility's Admission Evaluation form dated 1/24/17 revealed, that Resident #2 was at high risk for pressure ulcers. Further review of the form revealed the skin condition of Coccyx Stage I red blanchable area .Coccyx 0.5 cm x 0.4 cm open area. -Review of the facility's (Name of the computer system that the facility uses to document wounds) note dated 2/1/17 revealed a open stage I coccyx wound measuring 0.5 length x 0.5 width was present. Treatment was cleanse with soap and water, pat dry Allevyn change q (every) 3 days. Review of the medical record failed to reveal where this order was documented. Further review of the chart failed to reveal where this treatment was carried out by nursing staff. -Review of the facility's Weekly Wound Tracking Worksheet dated 2/9/17 revealed, coccyx red nothing else was documented. -Review of the physician progress notes [REDACTED].#2's skin alterations. There was no assessments or plans for Resident #2's wound(s). -Review of the hospital discharge summary dated 3/5/17 revealed that resident #2 was admitted to the hospital on [DATE] with, Pressure ulcer on the coccyx, unstageable; Pressure ulcer of the right heel, unstageable; Pressure ulcer of the left lateral lower leg, unstageable; Pressure ulcer of the left lateal malleolus (ankle), unstageable; Pressure ulcer of the left lateral heel, unstageable; DTI (deep tissue injury) of the left lateral 5th metatarsal (foot) head, 5th metatarsal base and left posterior heel. Further review of the discharge summary revealed, Wound clinic was consulted for wound on the coccyx and bilateral (both) lower extremities. -Review of the facility's Nursing Evaluation Data assessment dated [DATE] reveled that the only Skin Condition had upon re-admission to the facility was Sacrum Pressure Stage II 5 cm length 5 mc width and no depth documented. --Review of the facility's (Name of the computer system that the facility uses to document wounds) note dated 3/6/17 revealed, Stage II pressure ulcer 2.2 length 2.2 width and no depth this is contradictory to the previous note dated 3/5/17. Review of the facility's documentation failed to reveal that all of Resident 2's pressure ulcers were consistently documented on, and did not include all required documentation, according to the facility's policy. Review of the hospital discharge instruction sheet dated 3/5/17 revealed the following interventions to prevent the worsening of Resident #2's wounds, Assure no contact of wound with surfaces .Limit side lying to 30 degree tilt. Limit head of bed elevation to 30 degrees .use seat lifts or shift position in chair every 15 minutes when up, limit time in chair. Review of Resident #2's The resident has a diabetic/pressure ulcer on coccyx, L anke, and R Heel care plan dated 1/25/17 and updated 3/30/17, revealed these interventions were not put into place until 3/30/17. Further review of Resident #2's care plan revealed, Evaluate dressing q (every) shift to ensure it is intact and adhering. Report loose dressing to treatment nurse. This intervention fails to indicate which dressing, and which location. During an observation on 3/29/17 at 11:25 a.m., with Unit Manager, RN G, Resident #2 was observed lying in bed. Resident was wearing a brief, when the brief was taken off, the Stage III pressure ulcer on Resident #2's coccyx was observed to be without any type of dressing.

This citation pertains to MI 764. Based on observation, interview, and record review, the facility failed to provide appropriate cares and services for indwelling catheter use in 1 of 1 residents reviewed with indwelling catheters (Resident #2), in a total sample of 5 residents, resulting in Resident #2 being admitted to the hospital for [MEDICAL CONDITION] (a life-threatening condition that arises when the body's response to infection injures its own tissues an organs) related to urinary tract infection [MEDICAL CONDITION]. Findings include: Review of the face sheet and most recent Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #2 was an [AGE] year old male resident re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed that Resident #2 required extensive assistance with activities of daily living (ADLs). Review of the hospital admission history and physical dated 3/20/17 revealed Resident #2, .is being admitted on [DATE] after being found to have increased confusion and decreased mentation by his facility .Of note, (Resident #2) was recently seen here at (name of hospital) from 2/22/17-3/5/17 [MEDICAL CONDITION] secondary to (pneumonia). Patient was discharged home with [MEDICATION NAME] (antibiotic). Per facility, the instructions were lost and patient has continued to be on [MEDICATION NAME] BID (twice a day) until today, which I have discontinued. The Foley that is also present has also been in place since that hospitalization . This will be discontinued and replaced .ASSESSMENT/PLAN: [MEDICAL CONDITION] secondary to UTI . Review of the Hospital Discharge Summary dated 1/24/17 revealed, Urology Discharge Instructions: When you are discharged , please call the urology office to schedule an appointment with (Name of Doctor) in 1 week . Review of the medical record revealed Resident #2 was not seen by a urologist until 2/17/17. Further review of the medical record failed to reveal any reason why Resident #2 was not seen until over 3 weeks after being discharged from the hospital. Review of the hospital discharge summary dated 3/5/17 revealed, Continue indwelling Catheter: yes change Foley every two weeks. Review of the facility's Catheter Care, Urinary policy revised 3/23/11 revealed, The purpose of this procedure is to prevent infection of the resident's urinary tract .1. Review the resident's care plan to assess for any special needs of the resident .Maintain an accurate record of the resident's daily output, per facility policy and procedure .Be sure the catheter tubing and drainage bag are kept off the floor .The following information should be recorded in the resident's medical record: The date and time that catheter care was given .The name and title of the individual(s) giving the catheter care .All assessment data obtained when giving catheter care .Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor .Any problems noted at the catheter-urethral junction during perinea! care such as drainage, redness, bleeding, irritation, crusting, or pain .Any problems or complaints made by the resident related to the procedure .How the resident tolerated the procedure .If the resident refused the procedure, the reason(s) why and the intervention taken .The signature and title of the person recording the data .Notify the supervisor if the resident refuses the procedure . Review of the complete medical record failed to reveal that any type of catheter care was ordered or completed for Resident #2's indwelling catheter, to include the catheter being changed every two weeks. Review of Resident #2's care plan failed to reveal that any type of catheter care interventions were put into place until 3/30/17. During an interview on 3/29/17 at 12:00 p.m., while reviewing Resident #2's medical record, and when asked if there were any orders for catheter care, or any cares completed to Resident #2's catheter, Director of Nursing (DON) B stated, Not that I am seeing .I am not seeing anything in the treatments. Review of the Treatment Administration Record for the month of March 2017, failed to reveal any type of treatments to Resident #2's catheter. Furthermore, it failed to reveal that Resident #2's catheter was every changed after being re-admitted to the facility on [DATE]. During an observation on 3/27/17 at 9:30 a.m., Resident #2 was found to be laying in his bed. Resident #2's foley bag was laying on the floor. During an observation on 3/29/17 at 9:30 a.m., Resident #2 was found to be laying in his bed. Resident #2's foley bag was laying on the floor.

This citation pertains to MI 625 and MI 785. Based on observation, interview, and record review, the facility failed to follow resident care plans for two Residents (#2 and #4), failed to assess resident #2 for fall risk, failed to follow manufacturer's instruction and facility policy on proper use of a mechanical lift, resulting in Resident #2 falling, sustaining a [MEDICAL CONDITION] and Resident #4 falling and sustaining a skin tear. Findings include: Review of the facility's Mechanical Lift policy revised 8/2016 reveals, Two nursing assistants will be required to perform any mechanical lift procedure .2 staff are required for all transfers utilizing any type of mechanical lift. Review of the facility's Falls - Clinical Procedure revised April 2016 revealed, Admission Evaluation Data Form, which includes the falls risk evaluation .This form is completed upon admission, quarterly, and with significant change in status. Review of the (name of the mechanical lift) Instructions for Use, dated 11/2014, revealed, Carefully push the (name of the mechanical lift) in closer to make full lower leg contact with the knee support .When raising with the transfer sling, the resident's lower body will also be supported. During an observation made on 12/6/16 at 11:40 a.m., Certified Nursing Assistants (CNAs) N and O were observed transferring a supplemental resident from the bed to the wheelchair. During this observation, as the supplemental resident was raised from the bed, her lower body was not being supported by the knee support, rather the lower body was approximately 4-5 inches from this knee support. After CNA N and O completed transferring the supplemental resident, they were asked if they realized that the supplemental resident's lower body was not being supported by the knee support, both CNA N and O responded no, they did not realize that. Resident #2 Review of the Admission Record and most recent Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #2 was an [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed that Resident #2 required extensive assistance of 2 staff for transfers. Review of the complete medical record failed to reveal that a fall risk assessment had been completed since 5/28/16. During an interview on 12/6/16 at 12:36 p.m., Unit Manager, Registered Nurse (RN) M confirmed that the chart failed to reveal an updated fall risk assessment. Review of the facility's Fall Resulting in Injury investigation dated 12/2/16, revealed that, On 11/24/16 resident (#2) was assisted by CENA (Certified Nursing Assistant (CNA P)) for HS (before bed) cares. While using the mechanical lift, resident (#2) had to be assisted to the floor by (CNA P) .On 12/1/16 the resident (#2) had an x-ray of her right shoulder due to her expressing pain; this x-ray showed a [MEDICAL CONDITION] clavicle .Interviews with (CNA P) revealed that she had been trained during orientation to sue the mechanical lift .The interview also revealed that (CNA P) was operating the mechanical lift inappropriately with no second CENA present during its use . Review of the Radiology Report dated 11/26/17 revealed that Resident #2 had a, Recent mid shaft left clavicle fracture, nondisplaced. Review of Resident #2's ADL (Activities of Daily Living) care plan, revised 10/16/16 revealed, TRANSFER: The resident requires x1 assist with gait belt. Review of the (name of the mechanical lift) Instructions for Use, dated 11/2014, revealed, WARNING: Before attempting to use (name of mechanical lift), a full clinical assessment of the resident his/her condition, and suitability must be carried out by a qualified person. Review of the complete medical chart failed to reveal a full clinical assessment of the resident had been completed prior to using the mechanical lift. During an interview on 12/7/16 at 12:15 p.m., when asked if nursing staff should be the first to determine the use of a mechanical lift for transfers of residents, Occupational Therapist (OT V) stated, That should come from therapy, we have gotten screen request before to assess the ability to use a lift. OT V reviewed Resident #2's therapy record and was not able to find that any such assessment had been completed for Resident #2. Resident #4 Review of the Admission Record and most recent Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #4 was a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed that Resident #4 required extensive assistance of 2 staff for transfers. Review of the facility's incident report dated 12/3/16 revealed that Resident #4 was .on floor on back with feet straight out at end of bed - 0.50 skin tear (right) elbow .incorrect transfer. Further review of the report revealed that Licensed Practical Nurse (LPN) Q was the staff member that attempted to transfer Resident #4 with the mechanical lift, and that there was not a second staff member present during this transfer. Review of Resident #4's ADL care plan dated 11/23/16 revealed, Transfers: (name of mechanical lift) with x2 assist (indicating assist of 2 staff members). During an interview on 12/7/16 at 12:36 p.m., when asked if there were two staff members present with Resident #4 was transferred using the mechanical lift, Unit Manager RN M stated, She (LPN Q) did this by herself. During an interview on 12/7/16 at 10:20 a.m., when asked if there was a second person present during the transfer of Resident #4 on 12/3/16, LPN Q stated no, We only had 3 CNAs, one of them was on break, and the other 2 were helping other residents. When asked if she had used the lift before with only one person, LPN Q responded, yes. ( )

This citation pertains to MI 625 and MI 785. Based on interview, and record review, the facility failed to ensure two residents (Resident # 2 and # 4) of 3 residents reviewed for transfers were properly assessed for fall risk and were transferred safely, from a total sample of 5 Residents, resulting in Resident #2 falling, sustaining fracture of the clavicle and Resident #4 falling, sustaining a skin tear. Findings include: Review of the facility's Mechanical Lift policy revised 8/2016 reveals, Two nursing assistants will be required to perform any mechanical lift procedure .2 staff are required for all transfers utilizing any type of mechanical lift. Review of the facility's Falls - Clinical Procedure revised April 2016 revealed, Admission Evaluation Data Form, which includes the falls risk evaluation .This form is completed upon admission, quarterly, and with significant change in status. Review of the (name of the mechanical lift) Instructions for Use, dated 11/2014, revealed, Carefully push the (name of the mechanical lift) in closer to make full lower leg contact with the knee support .When raising with the transfer sling, the resident's lower body will also be supported. During an observation made on 12/6/16 at 11:40 a.m., Certified Nursing Assistants (CNAs) N and O were observed transferring a supplemental resident from the bed to the wheelchair. During this observation, as the supplemental resident was raised from the bed, her lower body was not being supported by the knee support, rather the lower body was approximately 4-5 inches from this knee support. After CNA N and O completed transferring the supplemental resident, they were asked if they realized that the supplemental resident's lower body was not being supported by the knee support, both CNA N and O responded no, they did not realize that. Resident #2 Review of the Admission Record and most recent Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #2 was an [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed that Resident #2 required extensive assistance of 2 staff for transfers. Review of the complete medical record failed to reveal that a fall risk assessment had been completed since 5/28/16. During an interview on 12/6/16 at 12:36 p.m., Unit Manager, Registered Nurse (RN) M confirmed that the chart failed to reveal an updated fall risk assessment. Review of the facility's Fall Resulting in Injury investigation dated 12/2/16, revealed that, On 11/24/16 resident (#2) was assisted by CENA (Certified Nursing Assistant (CNA P)) for HS (before bed) cares. While using the mechanical lift, resident (#2) had to be assisted to the floor by (CNA P) .On 12/1/16 the resident (#2) had an x-ray of her right shoulder due to her expressing pain; this x-ray showed a fracture of the right clavicle .Interviews with (CNA P) revealed that she had been trained during orientation to use the mechanical lift .The interview also revealed that (CNA P) was operating the mechanical lift inappropriately with no second CENA present during its use . Review of the Radiology Report dated 11/26/17 revealed that Resident #2 had a, Recent mid shaft left clavicle fracture, nondisplaced. Review of Resident #2's ADL (Activities of Daily Living) care plan, revised 10/16/16 revealed, TRANSFER: The resident requires x1 assist with gait belt. Review of the (name of the mechanical lift) Instructions for Use, dated 11/2014, revealed, WARNING: Before attempting to use (name of mechanical lift), a full clinical assessment of the resident his/her condition, and suitability must be carried out by a qualified person. Review of the complete medical chart failed to reveal a full clinical assessment of the resident had been completed prior to using the mechanical lift. During an interview on 12/7/16 at 12:15 p.m., when asked if nursing staff should be the first to determine the use of a mechanical lift for transfers of residents, Occupational Therapist (OT V) stated, That should come from therapy, we have gotten screen request before to assess the ability of residents to use a lift. OT V reviewed Resident #2's therapy record and was not able to find that any such assessment had been completed for Resident #2. Resident #4 Review of the Admission Record and most recent Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #4 was a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed that Resident #4 required extensive assistance of 2 staff for transfers. Review of the facility's incident report dated 12/3/16 revealed that Resident #4 was .on floor on back with feet straight out at end of bed - 0.50 skin tear (right) elbow .incorrect transfer. Further review of the report revealed that Licensed Practical Nurse (LPN) Q was the staff member that attempted to transfer Resident #4 with the mechanical lift, and did not have a second staff member assisting the transfer. Review of Resident #4's ADL care plan dated 11/23/16 revealed, Transfers: (name of mechanical lift) with x2 assist (indicating assist of 2 staff members). During an interview on 12/7/16 at 12:36 p.m., when asked if there were two staff members present when Resident #4 was transferred using the mechanical lift, Unit Manager RN M stated, She (LPN Q) did this by herself. During an interview on 12/7/16 at 10:20 a.m., when asked if there was a second person present during the transfer of Resident #4 on 12/3/16, LPN Q stated no, We only had 3 CNAs, one of them was on break, and the other 2 were helping other residents. When asked if she had used the lift before with only one person, LPN Q responded, yes. ( )

Based on observation, interview and record review the facility failed to provide treatment to prevent and heal pressure ulcers in 2 of 2 residents (Resident #4 and Resident #6) reviewed for pressure ulcers from a total of 13 residents, resulting in a worsening stage 2 pressure ulcer for Resident #6 and the development of pressure ulcers for Resident #4. Findings include: Resident #6: Review of the Face Sheet revealed Resident #6 was an [AGE] year old female admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #6 had a Brief Interview for Mental Status (BIMS) which indicated she had moderate cognitive impairment. Review of the Care Plan Skin Integrity Assessment:Prevention and Treatment Plan of Care dated 12/8/14 revealed Resident #6 was very high risk for developing a pressure ulcer. The Care Plan was updated 10/2/15 and further revealed Resident #6 was to Turn and Reposition .q (every) 2 hours and updated 8/8/15 to include Resident #6 wearing Prevalon boots (pressure relieving heel protector boot worn on feet) while up in wheelchair to prevent skin breakdown. Review of the Nursing Assistant Assignment Sheet revealed Resident #6 was to have Heels up at all times .reposition q 2 hours and Prevalon boots on when in wheelchair. In an observation on 8/21/15 at 9:00 am, Resident #6 was noted to be seated in her wheelchair in the hallway and without Prevalon boots on her feet. In an observation and interview on 8/21/15 at 9:28 am, Resident #6 was noted to be seated in her wheelchair in her room and without Prevalon boots on her feet. Resident #6 was asked by the surveyor if the nursing staff put the Prevalon boots on her feet. Resident #6 stated, we have them (Prevalon boots) but seldom use them. Resident #6 was asked by the surveyor if the nursing staff turned and repositioned every 2 hours. Resident #6 stated, they (nursing staff) don't really turn me. In an observation on 8/21/15 at 11:04 am, Resident #6 was noted to be seated in her wheelchair and without Prevalon boots on her feet. In an observation on 8/21/15 at 12:10 pm, Resident #6 was noted to be seated in her wheelchair in the dining room and without Prevalon boots on her feet. In an observation on 8/21/15 at 1:20 pm, Resident #6 was noted to be seated in her wheelchair in the hallway and without Prevalon boots on her feet (observations indicated Resident #6 had been seated in her wheelchair for more than 4 hours without repositioning). In an interview on 8/21/15 at 1:25 pm, Licensed Practical Nurse (LPN) C stated Resident #6 has pressure ulcers on her (Resident #6) right buttocks and the pressure ulcers have gotten bigger. Review of the Skin Grid- Pressure/[MEDICAL CONDITION] Ulcer/Other dated 7/1/15 revealed Resident #6 had a stage 2 (partial thickness pressure ulcer) pressure ulcer on her sacrum (buttocks) which measured 0.8 centimeter (cm) long by 0.4 cm wide and 0.1 cm deep. Review of the Skin Grid- Pressure/[MEDICAL CONDITION] Ulcer/Other dated 8/4/15 revealed Resident #6 had a stage 2 pressure ulcer on her sacrum which measured 1.2 cm long by 0.6 cm wide and 0.3 cm deep (indicated sacrum pressure ulcer was larger from previous measurement on 7/1/15). ( ) According to the 7/1/15 significant change and 4/30/15 quarterly MDS (minimum data set, an assessment tool), Resident #4 was a [AGE] year old female originally admitted to the facility 1/25/12 and readmitted on [DATE]. [DIAGNOSES REDACTED]. Her MDS reflected difficulty understanding and being understood, had short and long term memory deficits and was moderately impaired to make decisions. Resident #4's MDS also reflected that she required extensive assistance of two (2) for bed mobility, transfers, dressing and mobility around the unit / building. The significant change MDS (dated 7/1/15, when Hospice began) reflected the development of a Stage II pressure ulcer on 6/17/15. Review of Resident #4's Skin Grid - Pressure/[MEDICAL CONDITION] Ulcer / Other (Skin Grids) reflected 2 Skin Grids dated 6/17/15 one indicated she had developed a Stage I pressure ulcer to bilateral buttock which measured 8 cm (centimeters/in length) by (X) 11 cm (in width), without depth which was resolved (healed) 6/23/15. The other Skin Grid dated 6/17/15 documented a Stage II, which measured 0.5 cm X 1 cm with a depth of 0.025 cm. and reflected it had healed on 7/15/15. On 7/28/15 another Skin Grid recorded a 1 X 1 cm Stage II pressure ulcer to the left upper buttock. The weekly skin measurements recorded on that document reflected on 8/18/15 a Stage I ulcer with no additional documentation. Under Comments at the bottom of the page the following was recorded; Red, -0- (no) open areas Buttocks continues to heal. Blanchable. The Skin Integrity Assessment Prevention And Treatment Care Plan, with original interventions implemented on 10/13/13 reflected no Areas of Impairment (under the Assessment/Problem section of the care plan) until 8/11/15 when a Stage II pressure ulcer was recorded as present on the left buttock. Resident #4's Braden (skin) Risk Assessment Scale scores dated 11/19/14 and 2/10/15 reflected a score of a 12 which indicated a High Risk (10-12). Scores dated 4/18/15 and 8/11/15 reflected a Moderate Risk (13-14) with a 13 recorded. Resident #4's treatment sheets reflected at the beginning of the month of August 2015 the open area to Resident #4's left buttock was resolved. Another treatment page (for August 2015) reflected in the boxes to Measure open area to left buttock weekly and document on Skin Grid, that it had Healed on 8/18/15, with measurements initialed as performed on 8/4/15 and 8/11/15. The Skin Grid measurements reflected .5 X .5 cm(s) on both days. The Skin Grid on 8/18/15 reflected that the buttock remained red, was blanchable, but was no longer open. On 8/19/15 Resident #4 was observed up in her wheelchair at the following times: At approximately 1 p.m., Resident #4 was observed in her wheelchair being fed her lunch by a CNA. At approximately 1:30 p.m., she was observed, still up in her wheelchair in the lounge area on her unit, having her nails done by her hospice aide. At approximately 2:30 p.m., 3 p.m. and 4:50 p.m. Resident #4 was observed still up in her wheelchair by the desk on her unit. Again at approximately 4:50 p.m., Resident #4 was still observed seated in her wheelchair by the desk on her unit. At approximately 5:30 p.m., Resident #4 was observed being fed her dinner in the dining room. The Nursing Assistant Assignment Sheet, a care guide for the Certified Nursing Assistants(CNAs) in care of their assigned residents, reflected no directive to frequently change Resident #4's position or amount of time spent up in her wheelchair. ( )

This citation pertains to intakes MI & MI Based on interviews and record review the facility failed to provide supervision and monitoring of WanderGuard equipment to prevent the elopement and ensure the safety of 1 resident (#602) of 6 sampled residents reviewed for elopement risk, out of a total sample of 11 residents, resulting in Immediate Jeopardy for Resident #602 who was cognitively impaired and had a history of [REDACTED].#602 exited the facility on [DATE] between approximately 8:00 PM and 8:30 PM, without the WanderGuard alarming and unbeknownst to facility staff, via the front door as she followed another resident and the resident's family to their vehicle and attempted to get into the vehicle. Resident #602 was assisted back inside the facility by the other resident and the resident's family member. This deficient practice placed 6 other residents identified as elopement risks at risk for serious harm, injury and/or death. Resident #602 Review of Resident #602's Minimum Data Set (MDS), dated [DATE], indicated Resident #602 had a Brief Interview for Memory Status (BIMS) score of ,[DATE] (severe cognitive impairment). Review of Resident #602's Elopement Care Plan, initiated [DATE], reflected under Assessment,Exit seeking Behavior (describe): Has attempted to self-propel to Facility door and had an intervention, dated [DATE], for a WanderGuard to be applied. A WanderGuard is a transmitter bracelet that initiates an alarm to alert the staff if a resident attempts to exit the facility. Review of the [DATE] physician's orders [REDACTED]. During an interview on [DATE] at 2:20 PM, Witness C stated that at approximately 8:00 or 8:30 PM on [DATE], Resident #602 followed Witness C out the front doors of the facility to Witness C's car. Witness C stated she and her mother (another resident) had returned from a day out. Witness C stated she had left her mother's wheelchair inside the facility earlier in the day and had gone inside the facility to get the wheel chair so she could assist her mother from the car back into the facility. Witness C stated when she returned to her vehicle with the wheelchair, Resident #602 followed her out of the facility doors. Witness C stated she did not hear any alarms. Witness C stated that Resident #602 said Hello, I don't know you, but I'd like to go with you and attempted to climb into Witness C's vehicle. Witness C stated when she finished assisting her mother from the car; she assisted Resident #602 inside the facility. Witness C stated her mother told Resident #602 C'mon, (Resident #602's name) and that Resident #602 followed her mother like a little lost puppy. Interviews with Nurse D on [DATE] at 10:50 am, Unit Manager E on [DATE] at 11:00 am and Nurse B on [DATE] at 1:35 PM, revealed that nurses were visually checking the WanderGuard placement every shift, but were checking functionality only weekly by taking the residents by the exit doors to see if the alarm sounded. Both Nurse D and Nurse B stated they did not know how to use the transmitter tester to check the functionality of the WanderGuard. Review of the Elopement Prevention: Center Practices, effective [DATE] and last revised in [DATE], indicated Maintain door alarms and wander control systems in proper working order according to manufacturer's recommendation. Review of the Wandering Management Transmitters Users Guide, dated 2013, under Required Transmitter Testing page 12, indicated Required weekly testing for transmitters in use on residents. The following testing is required for transmitters in use weekly. All steps are mandatory. NOTE: Transmitters in use must be tested at least weekly. 1. Test the operation of the transmitters in use weekly using the transmitter tester. 2. Visually inspect transmitters in use weekly for damage or loose parts. 3. Verify on a weekly basis that the warranty expiration date stamped on transmitters in use has not expired. If the warranty period has expired, discard and replace the transmitter immediately. 4. Your facility must keep records of test and transmitter inspection. NOTE: Never take a resident to a door to test their transmitter. Review of the Treatment Administration Record for [DATE] reflects the last time Resident #602 was taken to a door to test the functionality of the WanderGuard was on [DATE], six days prior to Resident #602 exiting the facility on [DATE]. An interview with the Director of Nursing on [DATE] at 11:45 am revealed that her expectation was the WanderGuard .should be checked with a WanderGuard transmitter testing device, which will light up and turn green which means that the WanderGuard is functional. This should be done every shift. An interview with Nurse B on [DATE] at 1:35 PM revealed that she directed Certified Nursing Assistant (CNA) A to .take (Resident #602's name) by the front and the back doors and see if the 'WanderGuard' was working on [DATE]. Nurse B stated that CNA A returned and stated the 'WanderGuard' was not functioning as the alarms did not sound. Nurse B stated she did not know that Resident #602 had exited the facility until Witness C's mother came to her, with Resident #602 following, stating that Resident #602 had been outside trying to go with Witness C. The Administrator stated on [DATE] at 4:10 PM that the facility did not have any documentation related to education of the staff nurses on how to use the transmitter tester to check functionality of the WanderGuard transmitter. On [DATE] at 5:01 PM the Nursing Home Administrator (NHA) was notified of Immediate Jeopardy that began on [DATE] and identified on [DATE] due to the facility's failure to supervise and monitor Resident #602 when she eloped from the facility. A written plan of removal was requested at that time. On [DATE] 4:00 PM the surveyor verified the following: -Resident #602 had a reassessment for elopement risk and the medical record updated based on current assessment. -Resident #602's Code Alert (Wanderguard) transmitter was placed as ordered by the physician and was functional. -On [DATE] all residents were reassessed for elopement risk and 7 residents were identified as requiring a Code Alert device. -The Code Alert devices on the 7 residents identified as high elopement risk were correctly placed and functional. - On [DATE], the Licensed nurses received education regarding completion of Missing Resident Action Plan. -On [DATE], the facility had began educating all current staff members on testing and documenting the Code Alert devices functionality and placement. No staff member will be allowed to work past [DATE] without receiving all education. -The facility will forward racking and trending of audits to the NHA for presentation at facility QAPI at least monthly for review and further recommendations. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance with a scope of pattern and a severity of No actual harm with a potential for more than minimal harm that is not immediate jeopardy due to all staff had not received the inservice education for Code Alert functionality testing and documentation and the Missing Person Action Plan and sustained compliance had not been verified by the State Agency.

This citation pertains to intake # MI 034 Based on observation, interview and record review the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental and psychosocial well-being of 3 Residents (#1, #3 and #5) of 3 Residents sampled for adequate pain relief of a total of 8 Residents sampled resulting in all 3 residents having continuing pain. Findings include: Resident #1 Review of Resident #1's Minimum Data Set (MDS) assessment tool, dated 2/20/15, revealed Resident #1 was a [AGE] year old male, admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #1 scored 3/15 on his Brief Interview for Mental Status on 2/20/15, which is severely cognitively impaired. Review of a physician progress notes [REDACTED].#1 was transferred to the skilled nursing facility after having surgery to [MEDICAL CONDITION] from his colon (bowels). Resident #1 had a prolonged bowel obstruction after the surgery and nursing reported Resident #1 is confused and refusing therapy. Resident #1 said his belly is bloated, no pain, eating and drinking fine and just wants to get out of here. Review of Resident #1's physician orders [REDACTED].#1 was to get [MEDICATION NAME] 50 mg every 4 hours as needed for moderate pain. Review of nursing note dated 2/15/15 at 2:00 PM, revealed family requested Resident #1 get [MEDICATION NAME] (narcotic pain medication) because Resident #1 forgets he had surgery. Nursing contacted the physician and pharmacy to get a drop shipment of the [MEDICATION NAME]. (This information does not match the physician note dated 2/16/15 indicating Resident #1 does not have pain) See physician orders [REDACTED]. Review of a dietary progress note dated 2/17/15 revealed Resident #1's family met with the Registered Dietitian (RD) and reported Resident #1 was not eating well and did not like his current diet and when the RD observed Resident #1 eating in the dinning room he was only eating bites of rice and said he did not like ground meats. Resident #1 declined other foods offered at that time. The RD took food to Resident #1's room after he left the dining room and the family informed the RD Resident #1 had vomited and ginger ale was offered and Resident #1 accepted. (This information does not match the nurse report in the physician progress notes [REDACTED]. Review of intake #MI 034 revealed the complainant reported Resident #1 was not getting his pain medication as ordered on [DATE] and 2/15/15. The complainant said Resident #1 was only getting Tylenol. Review of the Medication Observation Record for Resident #1, no date revealed Resident #1 was given the first dose of [MEDICATION NAME] on 2/16/15 at 14:30 (2:30 PM) and [MEDICATION NAME] was ordered to be given around the clock (not as needed) on 2/17/15. Tylenol 500 mg was to be given every 6 hours as needed but was only given one time on 2/15/15 at 12:00 noon. (This documentation confirms the complainants report of not receiving his [MEDICATION NAME] for pain on 2/14/15 and 2/15/15. Review of a Resident Concern Report for Resident #1 dated 2/17/15 completed by Resident #1's family member D revealed, On Sunday 2/15/15 when we arrived on 7-3 shift, my dad told me that his stomach hurt and that he was hungry. When I spoke with the nurse she stated that he received Tylenol for pain and when I asked her about giving him the [MEDICATION NAME] prescribed she stated that it had not come yet and she would call the pharmacy to have it delivered. I asked if they had a back up supply that he could take some [MEDICATION NAME] and not have to wait for the pharmacy to have it delivered and she said she was instructed to give him Tylenol first then give [MEDICATION NAME] if it did not work from the Doctor (no orders to match giving Tylenol first). I stated that she had just given him Tylenol so he would have to wait (for) the the [MEDICATION NAME]. I stated to her that they could be given in combination and if he could have some. She stated she would give him some. (See the Medication Observation Recorded, [MEDICATION NAME] which is the same as [MEDICATION NAME] was not given until 2/26/15 at 2:30 PM) On Monday, 2/16/15 D documented, I arrived at 1:00 PM and my dad was lying in bed and was unable to reach his water at his bedside table and he was unable to reach his call light, which was on his night stand. He complained of pain in his abdomen. I went to the nurses station to speak with the nurse or an update and she stated that he was doing well except that he was not participating in therapy as much as they wanted him to, I asked her if they were medicating him prior to therapy and she stated he was getting Tylenol. (only one dose of Tylenol was documented on the Medication Observation Record and was given on 2/15/15 at noon, Resident #1 was admitted on [DATE] and physical and occupational therapy evaluations ordered on [DATE]) I told her that Tylenol has not been effective in controlling his pain and that was probably the reason that he wasn't participation as much. I asked her if they were giving him [MEDICATION NAME] as they had been in the hospital and at was effective and she stated that it was prn (as needed) and he has to asked for it. I stated that he has an Alzheimer Dementia [DIAGNOSES REDACTED]. I asked to speak the the Social Worker regarding a transfer to another facility. On Monday at 3:30 PM, my dad complained of abdominal pain after receiving [MEDICATION NAME] rating it 9 out of 10 (pain scale with a score of '10' indicating the highest level of pain imaginable by the resident) and I informed the nurse and she stated that she would have to call the doctor. At 4:40 PM I asked the nurse if the doctor had responded yet, because my dad was still complaining of pain and she stated she did not even call yet because she has narcotics to pass to other residents. (The medication Observation Recorded documented [MEDICATION NAME] was finally given at 17:30 (5:30 PM) which was 2 hours after Resident #1 said his pain was 9/10). During an interview with Social Worker C on 3/9/15 at 9:10 AM, C said he met with Resident #1's daughter on Monday 2/16/15 and completed paper work to request a transfer to another nursing home. SW C stated Resident #1's daughter complained of Resident #1 not getting pain medications and a drink being left in Resident #1's room for over 24 hours. C said he referred Resident #1's daughter to the unit manager, Licensed Practical Nurse (LPN) E for the nursing concerns. SW C said he was not Resident #1's assigned Social Worker and only met with Resident #1's daughter that day because Resident #1 assigned Social Worker was off. SW C was not sure how Resident #1's care concerns were addressed. During an interview with Unit Manager, LPN E on 9:15 AM, E confirmed that Resident #1's daughter had care concerns and had filled out Resident Concern Report. E provided a copy of a 4 1/2 page hand written report signed by Resident #1's daughter. The report was dated 2/17/15 and E said she became aware of the report on 2/18/15. E said she talked to the staff about the concerns including the pain concerns. E was asked if she had any documentation of discipline or education to staff regarding the concerns and E said she did not document any thing but did speak to LPN F about the pain medication concerns and provided her with education. During a telephone interview with LPN F on 3/9/15 at 10:25 AM, LPN F, denied knowing any thing about Resident #1's daughter's concerns about not providing Resident #1 with the pain medications he needed. and denied being provided any education by LPN E regarding Resident #1 not getting pain medication as he needed. Review of a progress note dated 2/18/15 documented that Resident #1's daughter was informed that Medicare coverage was going to end on 2/20/15. The writer explained that Resident #1 was not engaging in therapy due to his dementia and the daughter said she would go to therapy with Resident #1 and help him accept it. Family explained in the concern from dated 2/17/15 that they felt Resident #1 was not participating in therapy because he was not given pain medication in combination with his therapy and this was confirmed by the Medication Observation Record, dated 2/15/15. Review of the Interdisciplinary Resident Discharge Note dated 2/20/15 revealed the daughter was taking Resident #1 home and had the medications he needed at home. Referrals were made for home physical therapy, occupational therapy and nursing. During a telephone interview with family member D on 3/5/15 at 8:45 AM, D said the she was very upset with care Resident #1 was receiving at the facility, and had specific complains about he lack of pain control and nursing concerns. D said she could not get the care she need for Resident #1 at the facility so she took him home. ( ) Resident #3 Review of Resident #3's undated face sheet revealed he was a [AGE] year old male admitted to the facility on [DATE] and readmitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #3 was observed in bed on 3//5/15 at 11:00 AM. Resident #3 had a medical boot on his left foot/ankle and there were visible surgical scars on both knees. Resident #3 said his pain was a 4/5 out of 10 right now but could be zero if the nurses would give his break through pain medication on time. Resident #3 said he had asked for the night shift nurses to wake him up to give him his break through pain medication so he did not wake up in severe pain but only a couple nurses would wake him up for his pain medication. Resident #3 had a list of his pain medications in his hand and said he puts on his call light to ask for pain medication but it takes the nurse an hour to 1- 1/2 hours to get him the pain medication so he ends up taking his break through medication at the same time as his scheduled medication. Resident #3 said he has had to wait the longest for pain medication at night and has had to call in his girl friend to make sure he will get his pain medications. Resident #3 said the orthopedic physician order [REDACTED]. Resident #3 felt his pain would have been decreased today in his left knee if the CPM machine was working. During an interview with Resident #3 in his room on 3/5/15 at 12:00 noon, Resident #3 said nurse, Registered Nurse (RN) A refused to tell him what medications she was giving him, yelled at him, has laughed at him when he asked for Tylenol. Resident #3 said another nurse (RN) B had told him he was going to be a drug addict like her son if he kept taking narcotic pain medication. Resident #3 said these nurses made him feel like crap, and I have to call my family and girlfriend for support. I do not know if I will get the medication I need. Resident #3 said he has told several nurses and caregivers about these nurses. During an interview with the Nursing Home Administrator (NHA) on 3/5/14 at 1:10 PM the Surveyor Informed the NHA of Resident #3 concerns with RN A and B. The NHA said this was the first she was aware of these concerns and requested that this Surveyor discuss this information with the facility Social Worker (SW) C. During an interview with SW C on 2/5/15 at 1:30 PM the Surveyor informed SW C of the concerns Resident #3 had with RN A and B and SW C said he was not aware of these concerns but would go talk with Resident #3. On 3/6/15 RN A was observed working on Resident #3's nursing unit. RN A had worked the night shift and was counting narcotic pain medication with the oncoming nurse. The Surveyor asked RN A if she cared for Resident #3 last night and she said, no another nurse came in to pass his medication and help out on the unit. When asked why she did not give Resident #3 mediations she said, I really don't know I have been hearing rumors about another nurse but maybe he doesn't think I give him his medication. When asked if she ever refused to give him medication or had any difficulty with Resident #3, RN A denied any problems or ever with holding medications. During an interview with Resident #3 in his room with the NHA and SW C present the Surveyor asked Resident #3 if he had reported to the Surveyor yesterday that Registered Nurse (RN) A refused to tell him what medications she was giving him, yelled at him, has laughed at him when he asked for Tylenol, has waited 1 ½ hours for his 'as needed' pain medication and has refused to give him pain medications when he asked. Resident #3 confirmed he had given the Surveyor this information yesterday. Resident #3 said nurse (RN) B had told him he was going be a drug addict like her son if he kept taking narcotic pain medication. Resident #3 said these nurses made him feel like crap, cry and at one point he was even so depressed he was suicidal. During an interview the NHA and SW C in a private room on 3/6/15 at 11:08 AM the Surveyor asked the NHA and SW C if they had directly asked Resident #3 about the information the Surveyor provided 3/5/15 and they responded they did not and he gave them more information today. The NHA said she would suspend RN A and B today and start the abuse investigation based on this information. Review of Resident #3's orthopedic physician note dated 2/27/15, and FAX date 2/27/15 at 5:17 PM revealed the orthopedic physician order [REDACTED].#3 and it was to be set between 0-40 degrees and run 2-6 hour during a 24 hour period. Review of Resident #3's Physical Therapy Note date 3/3/15 revealed the physical therapist set up a CPM machine for Resident #3 and Resident #3 was educated that the CPM machine orders were for 0-30 degrees and that Resident #3 increased the CPM machine to 15 degrees of flexion. (machine not set up for 3 days after order) During an interview with the Nursing Home Administrator (NHA) on 3/5/15 at 4:50 PM the Surveyor asked why the CPM machine was not set up until 3 days after the order and the NHA said they did not get the order off the FAX machine until 3/1/15 and it did not arrive until 3/2/15 and the therapist did not set up the machine until 3/3/15. The NHA said the CPM machine was not broken, but they just learned today the machine they ordered would not work for Resident #3 because he did not tolerate very much motion. The NHA said they had to get a different machine from another company that would met Resident #3's motion needs. Review of the 24 hour status reports for Resident #3 revealed Resident #3 complained on 2/8/15 on the night shift of his [MEDICATION NAME] 10/325 ordered every 4 hours was not adequately controlling his pain and he was also complaining of muscle spasms and [MEDICAL CONDITION]. On 2/22/15 Resident #3 complained of his pain medications not be effective and he was observed crying one hour after his [MEDICATION NAME] ER was given. On 2/25/15 it was documented that he continues to have pain issues on this shift. Review of Resident #3's pain medication orders revealed he had orders dated 2/5/15 for [MEDICATION NAME]/[MEDICATION NAME] 5/325 (same as [MEDICATION NAME] which is a narcotic pain medication), two tablets every 4 hours as needed. Resident #3 received a new order for [MEDICATION NAME] 7.5/325 one tablet every 8 hours on 2/10/15 (two days after the 24 hour report indicated that the [MEDICATION NAME] was not effective pain relief). On 2/20/15 [MEDICATION NAME] IR 5 mg one tablet every 4 hours as needed, [MEDICATION NAME] 40 mgER on e tablet twice a day and [MEDICATION NAME] 50 mg one tablet every 4 hours as needed were ordered. No new pain medication order were found on 2/22/15 when Resident #3 was observed crying in pain or on 2/25/15 when Resident #3 again reported his pain medication was not effective. Review of the Medication Observation Record (MOR) for Resident #3, admitted [DATE] revealed [MEDICATION NAME] 40 ER for to be give twice a day at 8:00 AM and 20:00 (10:00 PM) and was provided 2/20/15 through 2/28/15. Review of Resident #3's as needed pain medication documentation revealed from 2/21/15 at 11:05 PM to 2/22/15 at 11:00 AM Resident #3 did not receive any pain medication. On 2/22/15 received as needed pain medication at 1:30 PM, 3:00 PM, and 9:00 PM and on 2/23/15 he received as needed pain medication at 1:00 AM, and 7:00 AM. (this confirms Resident #3 is not getting as needed pain medication at night and Resident #3 said he wanted to be woke up at night for pain mediation) ( ) Resident #5 Review of Resident #5's face sheet revealed she was a [AGE] year old female admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. During an interview with Resident #5 on 3/5/15 at 3:50 PM, Resident #5 said she was having problems getting one of her night shift nurses to give her pain medication and she finally reported the nurse and the facility moved that nurse to another unit. During an interview with the NHA on 3/5/15 the Surveyor asked the NHA about Resident #5 concern about not getting her pain medication and the NHA said a nurse made a medication error and was educated. Review of the Resident Concern Report for Resident #5 dated 3/3/15 revealed Resident #5 reported she did not get her midnight pain medication until 3:00 AM, which was 3 hours late. The nurse then wanted to give her the 6:00 AM pain medication at 6:00 (only 3 hours since last pain medication. Resident #5 said she just wants her pain pill at the scheduled times. Review of Resident #5 pain medication orders dated 2/25/15 revealed she had orders for Tylenol 325 mg every 4 hours as needed, [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg (same as [MEDICATION NAME] 5/325 mg). On 2/6/15 [MEDICATION NAME] was changed to [MEDICATION NAME] 5/325 two tablets every 6 hours around the clock. Review of the medication error report for Resident #5 dated 3/3/15 revealed Resident #5 only received one tablet of the [MEDICATION NAME] 5/325 at 6:00 AM and should have received 2 tablets of [MEDICATION NAME]. There was no indication that the medication was not given at the ordered times as Resident #5 reported. Review of the Medication Observation Record (MOR) dated 3/1/15 through 3/31/15 documented [MEDICATION NAME] 5-325 give 2 tablets at Midnight, 6:00 AM, 12:00 noon and 6:00 PM. It was documented that Resident #5 got her medications as ordered on [DATE] which does not match what the Resident reported. ( )

This citation pertains to intake # Based on observation, interview and record review the facility failed to provide an effective bowel regimen treatment for 5 (#1, 2, 3, 4 and 5) of 5 residents reviewed for bowel care from a total sample of 6 residents resulting in harm for preventable fecal impaction with pain and discomfort for Residents #1, 2 and 3; and constipation with accompanying pain with bowel movements for Residents #4 and 5. Additionally, Resident #2 had a knee pain that was not treated effectively or timely. Findings: Resident #1 Review of Resident #1's undated face sheet revealed he was an [AGE] year old male admitted to the facility on [DATE] after hospitalization due to surgical repair of a [MEDICAL CONDITION]. The facility did not complete a mental assessment for Resident #1, however during a telephone interview with Resident #1's Emergency Contact "C" on 12-12-14 a 8:57 a.m., Emergency Contact "C" said Resident #1 was his own responsible party. Review of the Physician Emergency Department Report for Resident #1, dated 12-2-14 documented under History of Present Illness, "The patient is an 88 -year-old male who comes to the emergency department reporting ongoing constipation. It sounds as though he has been having painful rectal spasms throughout the day and is known to be constipated." Review of the Hospital History and Physical Reports for Resident #1 dated 12-2-14 documented under History of Present Illness, "He presented to the "name of hospital" ED (emergency department) secondary to rectal spasms. He had been seen on 12-1-14 in the ED secondary to difficulty urinating and constipation. He had been straight catheterized frequent times at the subacute rehab, so they place (sic) a Foley catheter in the ED. He was given [MEDICATION NAME] to help with his constipation, and told to avoid his [MEDICATION NAME]. He returned to the ED on 12-2-14 secondary to rectal spasms. He had continued constipation. He had a slightly more positive UA (urinary analysis) then (sic) the prior one on 12-1-14. That one had a negative urine culture. The ED felt that the most likely [DIAGNOSES REDACTED]. The patient was also given [MEDICATION NAME] (given to assist in muscle relaxation) prior to disimpaction (removal of fecal material from Resident #1's rectum by a medical caregiver using a finger inserted into Resident #1's rectum to remove the fecal material). They were able to disimpact him in the ED. The patient was confused after he received the [MEDICATION NAME]. This was significant confusion. He appears to be improving and heading more towards his baseline at this time. Assessment/Plan: 1. [MEDICAL CONDITION] of an unclear source. Urinalysis was negative on 12-1-14, only minimally positive today after Foley placement. Possible pneumonia versus atelectasis on chest x-ray, 2. Recent [MEDICAL CONDITION], with Foley placement on 12-1-14, 6. Acute [MEDICAL CONDITION] (confusion) post [MEDICATION NAME] given prior to fecal disimpaction. Also fever may have contributed. 7. Fecal impaction, likely narcotics and decreased activity were complicating factors." Review of the Hospital Discharge Documentation for Resident #1 dated 12-6-14 (4 days after being admitted with a fecal impaction and complications related to constipation) documented, "The patient has been straight catheterizing frequently in the subacute rehabilitation center, Given ongoing concerns for rectal spasms and difficulty voiding, he was sent to the emergency department on the 1st where an abdominal x-ray obtained did show evidence of a significant amount of stool in the rectal region was noted. The patient had a Foley catheter placed in the emergency department. He was then prescribed [MEDICATION NAME] to help with constipation and was told to avoid his [MEDICATION NAME]. He was sent back to subacute rehabilitation. The patient returned to the emergency department on the 2nd secondary to worsening rectal spasms and continuing constipation. He was alert and interactive at that point in time. However, in the emergency department the patient did receive [MEDICATION NAME] for rectal disimpaction and became confused. The patient was also noted to be febrile (had temperature) in the emergency department at 39.3. He was tachyonic (fast heart rate) and had an elevated white count of 14.0. Urinalysis was somewhat more suggestive of a urinary tract infection than that obtained on 12/1, and he was admitted to "name of hospital group" with a provisional [DIAGNOSES REDACTED]. In regard to [MEDICAL CONDITION], it was felt this was likely due to the rectal impaction. The Foley has been removed, and he appears to be voiding adequately at this point in time." During a telephone interview with Resident #1's Emergency Contact "C" on 12-12-14 at 8:57 a.m., Emergency Contact"C" said Resident #1 told her he had complained multiple times while sitting on the toilet in the facility that he was plugged up and asked multiple staff to put on gloves and help him pass his bowel movement. Emergency Contact "C" said Resident #1 complained that he felt like he was sitting on a block of wood and complained of severe pain on 12-2-14 and staff would not do anything for Resident #1's pain. Emergency Contact "C" said they had to beg to have Resident #1 sent to the hospital. Emergency Contact "C" said Licensed Practical Nurse (LPN) D had been helpful sending Resident #1 to the hospital on 12-1-14 but on 12-2-14 Emergency Contact "C" felt that LPN "D" did not want to send Resident #1 to the hospital. Emergency Contact "C" said it took several hours to get the facility to send Resident #1 out to the hospital on 12-2-14 and he had severe pain when he had spasms and LPN "D" did not offer anything for pain" When the emergency room technicians came in the room they asked Resident #1 why he wanted to go to the hospital and Resident #1 told the emergency technicians it was due to pain and when he spasmed his pain was a "10". Review of Resident #1's medical record revealed there was no documentation that any nurse or the physician evaluated or treated Resident #1 for severe constipation during his 6 day stay at the facility. There was no documented change in physician orders for Residents #1's bowel care medications from admission. The only change in bowel medication was found in Resident #1's Medication Observation Record and documented Resident #1 received Milk of Magnesia Suspension on 12-1-14 at 4:00 a.m. with results. Physician orders did not reveal an order for [REDACTED]. Review of the Ambulance run sheet for Resident #1 dated 12-2-14 with arrival time of 2:21 p.m. revealed Resident #1 was complaining of severe pain and had been hospitalized on [DATE] for [MEDICAL CONDITION] and a Foley catheter was placed. Nursing staff reported Resident #1 was passing the expected amount of urine. Resident #1 was going back to the emergency room for evaluation due to persistent abdominal pain. Review of the "Nursing Home to Hospital Transfer Form" for Resident #1 dated 12-2-14 documented that Resident #1 was alert, oriented, followed instructions, was given Oxy 5 mg for pain at 12:30. No reason for transfer or vital signs were documented. During an interview with the Director of Nursing (DON) on 12-11-14 at 9:25 a.m. the Surveyor asked the DON why Resident #1 was sent to the hospital on 12-2-14. The DON reviewed Resident #1's chart and could not locate a reason in the chart or on the hospital transfer form. The DON said the family had called with multiple complaints and the facility had done an investigation. The DON provided the Surveyor with a copy of the facility investigation. The Surveyor asked the DON if Resident #1 had a problem with constipation because it was reported that Resident #1 had a fecal impaction when he arrived at the hospital on 12-2-14. The DON provided a bowel tracking record for Resident #1 that showed Resident #1 had a bowel movement 5 of the 6 days he was in the facility and denied any problem with constipation was found in the facility investigation. Review of the written statements in the facility investigation revealed no comments that the facility was aware of any constipation. Review of Resident #1's Bowel and Bladder Chart Detail Report from 11-27-14 through 12-2-14 revealed Resident #1 had an x-large bowel movement (BM) on 11-27-14, no BM on 11-28-14, a small BM on 11-29-14, a large, medium and small BM on 11-30-14, two small BM's on 12-1-14 and no BM on 12-2-14. The charting only allows the Certified Nurses Aide (CNA) to chart the consistency of the BM if it is loose. This Surveyor attempted to contact the CNA's that charted BM's for Resident #1 from 11-27-14 through 12-1-14 and the CNA's did not return the phone calls. There was a discrepancy between the facility information from 11/27 through 12/1/14 and the Emergency Department's admission [DIAGNOSES REDACTED]. During an interview with LPN "D" on 12-11-14 at 9:30 a.m. in the conference room LPN "D" said she sent Resident #1 to the hospital on 12-1-14 and 12-2-14. The Surveyor asked LPN "D" if she assessed Resident #1 prior to sending him to the hospital on 12-2-14. LPN "D" reviewed Resident #1's transfer form and medical record and could not locate any assessment or vital signs being completed on 12-2-14. LPN "D" said Resident #1 was complaining of pain and sent Resident #1 to the hospital on 12-1-14 due to [MEDICAL CONDITION] and again on 12-2-14 due to pain. Review of Resident #1's Minimum Data Set ((MDS) dated [DATE] revealed the Brief Interview for Mental Status (BIMS) was not completed. During an interview with the facility Social Worker (SW) "E", the Surveyor asked why the BIMS was not completed on Resident #1's MDS and SW "E" said he never met with Resident #1 during his say so he could not complete the BIMS and was not aware how Resident #1's cognitive status was during his stay in the facility. Review of the facility Procedure for Constipation dated effective September 2005 revealed "Policy: (Name of Nursing Facility) recognizes constipation is the most frequent complaint of older people regarding bowel function. Actual constipation is defined as three or more days without defecation. Constipation is a state in which a resident experiences a change in bowel habits characterized by a decrease in frequency and/or passage of hard dry stools. Standard bowel care to relieve constipation (in the absence of a bowel obstruction) with a provider order may include the following: Milk of Magnesia 30 ml PO (by mouth) HS (at night) after 8 shifts of no BM, [MEDICATION NAME] Suppository rectally if no results from the Milk of Magnesia, Fleets Enema rectally if no results from the [MEDICATION NAME] Suppository. Review of Resident #1's doctors orders revealed Resident #1 was admitted with orders for the stool soften Senna 8.6 mg twice and day and the Medication Observation Record documented Resident #1 received the Senna as ordered. The Medication Observation Record documented Resident #1 received Milk of Magnesia Suspension on 12-1-14 at 4:00 a.m. with results. Physician orders did not reveal an order for [REDACTED]. It was unclear if the facility staff monitored and reassessed the results of the bowel medication administration which resulted in a second hospitalization and disimpaction for Resident #1 Resident #2 Review of Resident #2's (undated) face sheet revealed she was a [AGE] year old female admitted the the facility on 12-4-14 with a [DIAGNOSES REDACTED]. During an interview with Resident #2 on 12-10-14 at 11:20 a.m. in Resident #2's room with Unit Manager (UM)"F" present, Resident #2 complained of severe pain with inadequate pain relief since admission and severe constipation for days "only able to pass small hard balls with pain". Resident #2 reported to (UM) "F" she had not seen the doctor since her admission and requested to see the doctor related to her pain and constipation. UM "F" reported Resident #2's concern to charge nurse LPN "G". LPN "G" called Resident #2's physician "H" on the telephone and reported Resident #2 was not getting adequate pain control and wanted to see the physician today. LPN "G" reported physician "G" would not order any pain medication over the telephone but would be in to see Resident #2 in two hours. During an interview with Resident #2 on 12-12-13 at 9:50 a.m. Resident #2 said she was still struggling to move her bowels and had pain of 9.5 on a scale of 1-10. Resident #2 said she had not seen the physician since admission. (Resident #2 was told she would see the physician on 12-10-14 around 11:30 am., two day ago). The Surveyor reported Resident #2's concerns to the charge nurse LPN "G" on 12-12-14 at 9:55 a.m. and to the Director of Nursing on 12-12-14 at 10:15 a.m. Review of nursing notes for Resident #2, dated 12-10-14 at 12:00 noon, documented, "right knee red, warm, swelling and increased pain. Call made to doctor "H" and he will come in today to see resident and determine if change in pain medication is indicated. Resident aware." (no mention of severe constipation) Review of Resident #2's medical record revealed no physician visit on 12-10-14 (Resident #2 was told she would see the physician within two hours on 12-10-14 around 11:30 a.m. when she reported inadequate pain control and severe constipation. During an interview with the DON, on 12-12-14 at 10:15 a.m. the DON did not know why Resident #2 was not seen by physician "H" on 12-10-14 as she was told she would be. The DON said physician "I" had consulted on Resident #2's pain on 12-11-14 but referred the pain control to Resident #2's orthopedic physician. The orthopedic physician had ordered a pain medication but it was not delivered by the pharmacy because Resident #2 was allergic to that pain medication. The DON said staff are calling physician "I" now to see what they can give Resident #2 for pain (more than 2 days after Resident #2 complained of inadequate pain control). Review of Resident #2's physician orders revealed no change in pain medication orders on 12-10-14 or for constipation. 12-11-14 Physician orders documented "[MEDICATION NAME] 500 mg bid" (twice a day pain medication) No Physician orders for medication for constipation were located for 12-12-14. . Physician order "12-12-14 no time "d/c (discontinue) Oxy IR order (pain medication), give [MEDICATION NAME] 30 mg IM q 6 hours (pain medication to be given every 6 hours in a shot form in the muscle)" Another Physician order was written 12-12-14 no time "d/c (discontinue) [MEDICATION NAME] 30 mg IM q 6 hours, start [MEDICATION NAME] 30 mg IM q 12 hours pain." Another physician order was written 12-12-14 no time for "[MEDICATION NAME] 50 mg 1-2 tabs every 4 hours prn (as needed) (1 tab for pain 1-5 and 2 tabs for pain 6-10 per Dr. "I"." No new orders were found for constipation. Review of Resident #2's "PRN (as needed) Administration Record revealed the last time a prn (as need) pain medication was given was on 12-10-14 for Tylenol 650 mg and the pain was rated at a 7 when given and results was a pain level at 6. During an interview, with Physician "I" on 12-12-14 at 1:30 p.m. Physician "I" said he was covering for Physician "H" and he did not know why Physician "H" did not see Resident #2 on 12-10-14 as he had told nursing he would see Resident #2 that day. Physician "I" said he reviewed Resident #2's pain medications on 12-11-14 but felt the orthopedic physician should address the pain because the knee was red and swollen. Physician "I" said he was not aware that Resident #2 wanted to talk to a physician and was not aware that the orthopedic doctor had ordered a pain medication that Resident #2 had an allergy to until today. Physician "I" said he was not aware Resident #2 had any problem with constipation. Physician "I" said he would see Resident #2 today and address the pain and constipation concerns. Resident #3 Review of Resident #3's (undated) face sheet revealed he was an [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. During an interview with Resident #3 on 12-11-14, at 12:15 p.m., with his family "N" and "O" present in the room, Resident #3 complained of the need to go to the bathroom, putting his call light on 1 hour ago and no one was helping him to the bathroom. The Surveyor asked Resident #3 to put on his call light again and Resident #3 pushed the call light button and the call light did not alarm. The Surveyor notified CNA "J" that Resident #3's call light was not working and he had been waiting an hour to use the bathroom. Resident #3 was observed in the bathroom with CNA "J" present on 12-11-14 at 12:40 p.m. Resident #3 told CNA "J" he had been having problems passing his bowel since he was admitted and complained of grunting to try to pass the BM and severe pain. CNA "J" went to get LPN "G" !2-11-14 at 12:42 LPN "G" came into Resident #3's bathroom and Resident #3 complained of severe pain all over and having a BM stuck in his rectum. Resident #3 asked for LPN "G" to help him pass the hard stool in his rectum and said he had hard stools for the last 3 days that were (demonstrated with finger approximately 3 inches in length). 12-11-14, at 1:00 p.m., Resident #3 was still in the bathroom attempting to pass his BM and LPN "G" said she had to leave to give someone pain medication. At 1:05 p.m. LPN "G" came back to Resident #3's bathroom and with a gloved hand said she could feel the hard stool but was not allowed to do a digital removal. Resident #3 complained of feeling like he was going to pass out and cried out in pain. 12-11-14 at 1:10 p.m. LPN "G" left Resident #3's bathroom to call the physician. 12-11-14 at 1:12 p.m. LPN "G" returned to Resident #3's bathroom and said she was not able to talk to Resident #3 physician. Resident #3 complained of nausea and pain "so bad he could not stand it." Resident #3 attempted to stand up and finally passed a hard dark 2 inch long stool. (first requested to use toilet at approximately 11:15 a.m. and strained for 30 minutes to have this BM) Resident #3 said he had been telling staff for days it hurt to pass his bowels. During an interview with Resident #3's, family member "N" on 12-11-14 at 12:20 p.m. "N" said Resident #3 takes 2 vegetable based stool softeners daily at home. Review of Resident #3's physician orders revealed he did not have any stool softener ordered. Review of Resident #3's Medication Observation Record since admission revealed the only bowel medication order was for Gavilax Powder 17 grams once daily as needed and it had not been given since admission. Resident #4 Review of Resident #4's (undated) face sheet revealed she was an [AGE] year od female admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #4 was not her own responsible party. During a telephone interview with CNA "K" on 12-11-14, at 1:30 p.m. CNA "K" said Resident #4 had a medium size hard stool on 12-10-14 and cried out in pain when she passed the BM. CNA"K" said she can not chart hard stools but always reports things like this to the nurse. Review of Resident #4's "Bowel and Bladder Detailed Entry Report documented Resident #4 had a BM at 9:13 a.m. on 12-7-14, no BM 12-8-14 all 3 shifts, no BM 12-9-14 all 3 shifts. (facility bowel protocol is for Milk of Magnesia if no BM for 8 shifts and [MEDICATION NAME] Suppository rectally if no results from the Milk of Magnesia, no documentation was in the Resident #4's medical record that showed the facility constipation protocol was followed) Review of Resident #4's "Bowel and Bladder Detailed Entry Report" revealed Resident #4 had a medium BM on 12-10-14 at 9:50 a.m., there was no documentation of hard/painful BM found in the medical record. Review of Resident #4's Medication Observation Record revealed a [MEDICATION NAME] Suppository was scheduled to be given on 12-10-14 between 6-2 and the box was not marked as given. Review of Resident #4's PRN Administration Record revealed she had Milk of Magnesia (MOM) Suspension available as needed and should be given if no BM for 3 days, there was no indication that MOM was giving in December of 2014. (Resident #4 had documentation of 8 shifts of no BM in December and facility protocol called for MOM to be given at that time). Resident #5 Review of Resident #5's (undated) face sheet revealed she was an [AGE] year old female that was readmitted to the facility on [DATE] with an original admitted [DATE]. Resident #5 is her own responsible party Review of Resident #5's Hospital Discharge Summary dated 12-8-14, page 7 documented, "NO BM since admit on 12-5." (facility bowel protocol is for Milk of Magnesia if no BM for 8 shifts and [MEDICATION NAME] Suppository rectally if no results from the Milk of Magnesia, no documentation was in the Resident #5's medical record to indicate the the facility protocol was followed) Review of Resident #5's "Nursing Comprehensive Admission Data Collection and Assessment, no date or time, signed by Registered Nurse (RN) "M" documented, "last BM 12-10-14, large. During an interview with RN "M" on 12-11-14 at 3:00 p.m. RN "M" said she assisted with the hospital readmission paper work on Resident #5. RN "M" said she did not see the hospital documentation that Resident #5's last BM was on 12-5-14. RN "M" said the nurse that started the readmission process should have seen the hospital report of no BM since 12-5-14 and she documented 12-10-14 because she interviewed the CNA. RN "M" denied getting a report from the CNA that the BM was hard and painful. RN "M" said if she had been aware of the lack of BM on 12-8-14 she would have started the bowel protocol and if she knew Resident #5 was having hard painful BM's she would have called the physician. During a telephone interview with CNA "K" on 12-11-14 at 1:30 p.m., "K" said Resident #5 had 3-4 large meat ball sizes BM's on 12-10-14 and cried in pain with each BM. CNA "K" said she told the nurse about Resident #5 having severe pain with hard BM's but was only able to chart the size not the consistency. During an interview with Resident #5 on 12-11-14 at 2:00 p.m. This Surveyor asked Resident #5 if she had a problem with her bowel movement yesterday (12-10-14) and she said she had pain passing her BM yesterday and still felt like she needed to go today but was not able to move her bowels. During a telephone interview with LPN "L" on 12-11-14 at 2:25 p.m. LPN "L" said the CNA told her 12-10-14 while she was working in the dinning that Resident #5 was having pain. LPN "L"said she did not recall the pain had anything to do with Resident #5's BM. LPN "L" said she went to see Resident #5 when she was done in the dinning room and asked Resident #5 about her pain and Resident #5 denied having any pain. ( )

This citation pertains to intake #MI 958 Based on observation, interview and record review, the Facility failed to prevent staff to Resident physical and mental abuse in 2 of 8 sampled residents (#104 and #106), from a total sample of 8 residents, resulting in: 1) Resident #104 being scrubbed so hard on her coccyx she sustained a skin ulcer, 2) the potential for a dislocation of a hip due to a rough transfer by facility staff of Resident #104, and 3) Resident #106 being fearful of Certified Nurse Assistant (CNA) #15 after being treated roughly. Findings include: Resident #104 Review of the closed, clinical record revealed Resident #104 was a [AGE] year old woman, admitted to the facility on [DATE]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status score of 13 out of 15 which indicated Resident #104 had minimal cognitive deficits and had [DIAGNOSES REDACTED]. Review of the Incident and Investigation report dated for an incident that occurred on 10/2/12 at 3:14 PM, revealed Resident #104 had gone to an Orthopedic (follow-up) appointment where an x-ray was performed and Resident #104's left hip was discovered to be displaced. Resident #104 reported to the surgeon that during a transfer from the wheelchair to the toilet, her leg buckled and she heard two clunks which may have been when the dislocation of her hip occurred. Resident #104 was immediately sent, by the Orthopedic Surgeon, to the emergency room to have her hip relocated. Review of the Orthopedic Surgeon progress note dated 10/2/12 revealed Resident #104 was sent to ER due to a Left Hip Dislocation. During a telephone interview on 1/24/13 at 12:00 PM, RN #5 said she was the Charge Nurse for Resident #104 and said Resident #104 reported to her that CNA #15 was "too rough" with her during care. In an interview on 1/24/13 at 1:20 PM, RN #6 said Resident #104 told her family, while she was in the hospital on [DATE], that she did not want to return to the facility. When her Family inquired Resident #104 said because of one CNA (CNA#15) who was too rough. Resident #104's family informed Resident #104 that she had a right to tell the facility she did not want CNA #15 to take care of her and Resident #104 returned to the facility on [DATE]. RN #6 reported that Resident #104 was assigned to be cared for by CNA#15, however, she instructed CNA#15 not to enter her room and to find someone else to care of her. RN #6 said CNA #15 worked the midnight shift on 10/1/13 and was assigned to care for Resident #104. RN #6 said, "this was the night (named CNA#15), scrubbed her so hard she caused a stage II pressure sore" RN #6 said Resident #104 was incontinent of stool and checked the Bowel Movement Documentation and said Resident #104 had loose stools on 10/1/12 . RN #6 said RN #5 charted on 10/1/12 at 11:00 PM, that Resident #104 developed a stage II pressure sore. RN #6 said CNA #15 worked from 2:00-10:00 PM on 10/1/12 and then through the 3rd shift, 10:00 PM until 6:00 AM the morning of 10/2/12 and had taken care of Resident #104. RN #6 said Resident #104 told her that was the night CNA #15 scrubbed her so hard it hurt. Review of the Facility's Skin Grid sheet dated 10/1/12 revealed Resident #104 had a wound on her coccyx that measured 1.6 CM length by 1.4 CM width, documented by RN #5. Review of the nurse's notes dated 1/3/12 (no time), revealed Resident #104 was discharged home. Resident #106 Review of the clinical record revealed Resident #106 was a [AGE] year old woman, admitted to the facility on [DATE]. Review of the MDS dated [DATE] revealed Resident #106 had [DIAGNOSES REDACTED]. Review of the facility's witness statement dated 10/3/12 at 4:00 PM and signed by Registered Nurse (RN) #5 revealed "(named Resident #106) came to me and asked to speak with me. She stated a girl who helps her to the bathroom at night is rough 'slamming and shoving' her around. She identified the staff member as (named CNA #15), by name. She also said (named CNA #15), yells at her. She does not want (named CNA #15) to care for her anymore or even come into her room. She stated, 'I am afraid of her'." Review of the Facility's witness statement dated 10/3/12 at 5:25 PM and signed by RN #6 was written "This clinician was alerted by staff that (named Resident #106 ), had verbalized fear of a CNA and had named (CNA #15) as that CNA. Upon interview (named Resident #106 ), stated she was cold last night and (CNA #15) came in her room. (named Resident #106 ), said she was mean to her. She 'shook her and pulled her curtain shut and closed her door'. When asked to demonstrate the shaking (named Resident #106 ), grabbed this clinician's arm and shoulder and shook vigorously. (named Resident #106 ), verbalized CNA #15 was mad and she was afraid of her...she does not want to see her again." An observation on 1/24/13 at 3:20 PM, revealed Resident #106, alone in her room, sitting in a wheelchair, with her head looking down. During an interview on 1/24/13 at 3:25 PM, when asked how she was treated by the staff, Resident #106 said, "Sometimes I'm treated like a moron." Resident #106 reported she did not remember CNA#15 and did not want to talk about it anymore. In an interview on 1/24/13 at 1:50 PM, RN #6 said Resident #106 complained about CNA #15 being rough with her and demonstrated by shaking RN #6's arm/shoulder vigorously. RN #6 said she did not doubt Resident #106's allegation because CNA #15, "could be forceful." RN #6 said she also had another complaint about CNA #15 from a daughter of a Resident (not on the sample), who was discharged to a Hospice Facility. During a telephone interview on 1/24/13 at 12:00 PM, RN #5 said she was the Charge Nurse for Resident #106 and said Resident #106 wheeled herself into RN #5's office on 10/3/12 and reported to her CNA #15 was "too rough" and did not want her to take care of her anymore. Review of the employee disciplinary action record dated 10/8/12, written by Registered Nurse (RN) #6, revealed CNA #15 was suspended then terminated from employment after an investigation substantiated staff to Resident abuse. Under the section titled, "Violation" was written, "(named CNA #15) helped (initialed Resident #104), who was a recent total hip arthroplasty patient, to the bathroom. When the resident complained her affected leg was buckling under her and "hearing two clunks, (CNA #15) responded by yelling at Resident #104 to stand up..." Resident #104 also reported (CNA #15) "was very rough with her during incontinent care, scrubbing so hard on her coccyx, the outer layer of the skin was damaged and an ulceration resulted. Another Resident (Resident #106) stated (CNA #15) was very mean to her and shook her by the shoulder. This resident (Resident #106), verbalized she was afraid of her and did not want her to come back into her room. She was able to identify (CNA #15) by name." The report indicated that CNA #15 refused to sign and refused to accept a copy of the termination for resident abuse. #

THIS CITATION PERTAINS TO MI 417 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO: 1) PROVIDE CARE ACCORDING TO PROFESSIONAL STANDARDS OF QUALITY AND 2) ENSURE STAFF MEMBERS WERE EDUCATED AND PROFICIENT IN EMERGENCY PROCEDURES IN 1 (RESIDENT #501) OF 10 SAMPLED RESIDENTS FROM A TOTAL SAMPLE OF 10 RESIDENTS, RESULTING IN AN IMMEDIATE JEOPARDY (IJ) WHEN RESIDENT #501 WAS FOUND BLUE AND COLD TO THE TOUCH AND STAFF FAILED TO INITIATE CARDIOPULMONARY RESUSCITATION (CPR) OR ACTIVATE EMERGENCY MEDICAL SERVICES (EMS), DESPITE RESIDENT#501 BEING A FULL CODE. THESE DEFICIENT PRACTICES PLACE ALL RESIDENTS WHO MAY EXPERIENCE A LIFE THREATENING INJURY OR EVENT AND REQUIRE EMERGENT CARE AT RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH. FINDINGS INCLUDE: ACCORDING TO THE FUNDAMENTALS OF NURSING (POTTER AND PERRY, 6 th EDITION, 2005), "[MEDICAL CONDITION] IS CHARACTERIZED BY AN ABSENCE OF PULSE AND RESPIRATION. IF THE NURSE DETERMINES THAT THE CLIENT HAS [MEDICAL CONDITION], CARDIOPULMONARY RESUSCITATION (CPR) MUST BE INITIATED. CPR IS A BASIC EMERGENCY PROCEDURE OF ARTIFICIAL RESPIRATION AND MANUAL EXTERNAL CARDIAC MASSAGE." ACCORDING TO THE LEGAL AND ETHICAL ISSUES IN NURSING, FOURTH EDITION, BY GUIDO (2006), "STANDARDS OF CARE MUST HAVE AND USE THE KNOWLEDGE AND SKILL ORDINARILY POSSESSED AND USED BY NURSES ACTIVELY [MEDICATION NAME] IN THE NURSE'S SPECIALTY AREA." ACCORDING TO THE NURSE'S PROBLEM SOLVER (1995), "BY PROVIDING EMERGENCY RESUSCITATIVE SUPPORT, THESE PROCEDURES RESTORE SPONTANEOUS HEART RATE AND RESPIRATIONS AND PREVENT HYPOXIC DAMAGE TO THE BRAIN AND OTHER VITAL ORGANS. RESPONDING TO A CODE SWIFTLY AND EFFECTIVELY IS ESSENTIAL TO SAVING A PATIENTS LIFE." PER THE AMERICAN RED CROSS FIRST AID AND SAFETY HANDBOOK (2011), "A PERSON IN [MEDICAL CONDITION] IS UNCONSCIOUS, NOT BREATHING AND HAS NO HEARTBEAT." THE HANDBOOK REVEALED THAT A PERSON IN [MEDICAL CONDITION] WILL HAVE THE GREATEST CHANCE OF SURVIVAL IF THERE IS 1) EARLY ACCESS TO THE EMERGENCY MEDICAL SERVICES (EMS) SYSTEM, 2) EARLY CPR, 3) EARLY DEFIBRILLATION, AND 4) EARLY ADVANCED MEDICAL CARE. THE HANDBOOK ALSO REVEALED THAT "WITHOUT EARLY CPR AND DEFIBRILLATION, THE CHANCE FOR SURVIVAL IS GREATLY REDUCED." THE HANDBOOK MENTIONED THAT "ONCE YOU BEGIN CPR, DO NOT STOP EXCEPT IN ONE OF THESE SITUATIONS....ANOTHER TRAINED RESPONDER OR EMS PERSONNEL TAKE OVER." REVIEW OF THE INCIDENT/ACCIDENT REPORT WRITTEN BY LICENSED PRACTICAL NURSE (LPN) #3, DATED [DATE], REVEALED RESIDENT #501 WAS FOUND UNRESPONSIVE IN HER ROOM AT 7:00 AM AND "CODE BLUE" (IMMEDIATE RESUSCITATION) WAS NOT INITIATED. REVIEW OF THE "CPR CONSENT FORM", DATED [DATE], REVEALED RESIDENT #501 WANTED CPR PERFORMED IN THE EVENT OF AN OBSERVED OR UNOBSERVED [MEDICAL CONDITION] (HEART STOPPED) AND THAT NURSING STAFF WOULD INITIATE CPR, USE THE AUTOMATIC EXTERNAL DEFIBRILLATOR (AED), WHICH IS USED TO RESTART THE HEART AND EMERGENCY MEDICAL PERSONNEL WOULD BE CALLED. REVIEW OF THE FACILITY'S "RECORD AND RECEIPT OF BODY", DOCUMENT DATED [DATE], REVEALED RESIDENT #501 EXPIRED AT THE FACILITY ON [DATE] AT 9:30 AM. REVIEW OF THE FACE SHEET, DATED [DATE], REVEALED RESIDENT #501 WAS A [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE]. REVIEW OF THE [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET (MDS), dated [DATE], REVEALED RESIDENT #501 HAD MODERATE COGNITIVE IMPAIRMENTS, BUT WAS ABLE TO MAKE HERSELF UNDERSTOOD. RESIDENT #501 REQUIRED STAFF ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING. IN AN INTERVIEW ON [DATE] AT 2:27 PM, CERTIFIED NURSING ASSISTANT (CNA) #6 REPORTED SHE HAD PROVIDED INCONTINENCE CARE FOR RESIDENT #501 ON [DATE] AT 4:50 AM AND THAT RESIDENT #501 WAS BREATHING AND ABLE TO FOLLOW COMMANDS AT THAT TIME. IN AN INTERVIEW ON [DATE] AT 11:00 AM, CNA #4 SAID ON [DATE] AT 7:00 AM, SHE ENTERED RESIDENT #501'S ROOM TO GET HER READY FOR BREAKFAST AND FOUND RESIDENT #501 LYING IN BED, BLUE, AND COLD TO THE TOUCH. CNA #4 STATED SHE WAS "IN SHOCK AND PANICKED" AND DID NOT KNOW WHAT TO DO BECAUSE IT WAS HER FIRST DEATH. CNA #4 STATED SHE NOTIFIED LPN #3 ABOUT RESIDENT #501'S CONDITION AND ASKED CNA #5 FOR ASSISTANCE WITH RESIDENT #501. CNA #4 SAID THAT ON [DATE] AROUND 7:00 AM, SHE, LPN #3 AND CNA #5 WENT TO RESIDENT #501'S ROOM AND THAT LPN #3 ASSESSED RESIDENT #501 FOR PULSES AND LUNG SOUNDS AND NONE WERE PRESENT. IN AN INTERVIEW ON [DATE] AT 2:00 PM, CNA #5 REPORTED THAT ON [DATE] AROUND 7:00 AM, SHE WENT TO ASSIST CNA #4 AND LPN #3 WITH RESIDENT #501. CNA #5 STATED RESIDENT #501'S SKIN WAS "BLUE" IN COLOR AND THAT "NO ONE KNEW IF SHE WAS A FULL CODE" AND "THOUGHT SHE HAD PASSED AWAY." IN AN INTERVIEW ON [DATE] AT 10:25 AM, LPN #3 REPORTED THAT ON [DATE] AROUND 7:00 AM, CNA #4 NOTIFIED HER THAT RESIDENT #501'S SKIN WAS BLUE AND COLD TO THE TOUCH. LPN #3 STATED THAT SHE CHECKED RESIDENT #501'S APICAL (AT THE BASE OF THE HEART) PULSE AND LUNG SOUNDS WITH A STETHOSCOPE AND NONE WERE AUSCULTATED. LPN #3 STATED THAT SHE WAS UNAWARE OF RESIDENT #501'S CODE STATUS, DID NOT PERFORM CPR, AND DID NOT INITIATE EMS AFTER FINDING RESIDENT #501 WITHOUT RESPIRATIONS OR HEART SOUNDS. LPN #3 STATED SHE CALLED LPN #14 FROM ANOTHER UNIT ON [DATE] AT 7:10 AM FOR ASSISTANCE. ACCORDING TO LPN #3, LPN #14 TOLD HER TO CHECK FOR HEART AND LUNG SOUNDS, TO NOTIFY THE PHYSICIAN, FAMILY, AND THE ON-CALL NURSE MANAGER. REVIEW OF A WRITTEN STATEMENT DATED [DATE] REVEALED LPN #14 THOUGHT RESIDENT #501 WAS A DO NOT RESUSCITATE (DNR) BECAUSE THERE WAS NOT A "CODE BLUE" CALLED. LPN #14 DOCUMENTED SHE ASSISTED LPN #3 WITH RESIDENT #501 AND TOLD LPN #3 TO CHECK FOR HEART AND LUNG SOUNDS, AND TO NOTIFY THE PHYSICIAN, FAMILY, AND THE ON-CALL NURSE MANAGER. LPN #14 DOCUMENTED SHE WENT BACK TO HER UNIT TO FINISH HER MEDICATION PASS, GIVING NO FURTHER ASSISTANCE. IN AN INTERVIEW ON [DATE] AT 10:25 AM, LPN #3 STATED SHE PAGED THE PHYSICIAN THEN CALLED REGISTERED NURSE (RN) #12 (THE ON-CALL NURSE MANAGER/EDUCATIONAL COORDINATOR) AND LEFT A MESSAGE ON [DATE] AT 7:20 AM. LPN #3 REPORTED RN #12 RETURNED HER CALL ON [DATE] AT 7:30 AM AND THAT SHE TOLD RN #12 RESIDENT #501 HAD died . LPN #3 STATED RN #12 INSTRUCTED HER TO FIND OUT WHICH FUNERAL HOME THE FAMILY DESIRES AND TO CONTACT THE PHYSICIAN AND FAMILY. LPN #3 SAID RN #12 DID NOT ASK ABOUT RESIDENT #501'S CODE STATUS AT THAT TIME. LPN #3 STATED RN #12 CALLED BACK AT 7:40 AM AND ASKED WHAT RESIDENT #501'S CODE STATUS WAS. LPN #3 STATED SHE THEN REVIEWED RESIDENT #501'S CHART AND INFORMED RN #12 THAT RESIDENT #501 WAS A FULL CODE. IN AN INTERVIEW ON [DATE] AT 12:53 PM, RN #12 CONFIRMED SHE WAS THE ON-CALL NURSE MANAGER ON [DATE]. RN #12 SAID SHE RECEIVED A CALL ON ON [DATE] AND AT 7:18 AM BUT WAS UNABLE TO GET TO THE TELEPHONE. RN #12 STATED AT 7:23 AM, SHE CALLED THE FACILITY AND SPOKE TO LPN #3 AND WAS TOLD RESIDENT #501 HAD PASSED AWAY. RN #12 STATED SHE DID NOT TELL LPN #3 TO CHECK RESIDENT #501'S CODE STATUS, ASK WHAT HER CODE STATUS WAS, OR INSTRUCT LPN #3 TO INITIATE "CODE BLUE" AT THAT TIME. RN #12 SAID SHE TOLD LPN #3 TO FIND OUT WHEN CARE WAS LAST GIVEN AND TO CALL THE PHYSICIAN AND FAMILY. RN #12 STATED AROUND 7:25 AM ON [DATE], SHE CALLED ADMINISTRATOR #1 AND THAT ADMINISTRATOR #1 ASKED IF "CODE BLUE" HAD BEEN INITIATED; RN #12 STATED SHE DID NOT KNOW. RN #12 REPORTED SHE CALLED THE DON#2 AROUND 7:30 AM, WHO ASKED WHAT RESIDENT #501'S CODE STATUS WAS. RN #12 STATED SHE DID NOT KNOW. RN #12 STATED SHE CALLED LPN #3 AGAIN TO INQUIRE ABOUT RESIDENT #501'S CODE STATUS AND WAS TOLD THAT RESIDENT #501 WAS A FULL CODE. RN #12 STATED SHE CALLED THE ADMINISTRATOR #1 AND THE DON #2 AGAIN TO INFORM THEM RESIDENT #501 WAS A FULL CODE AND THAT "CODE BLUE" HAD NOT BEEN INITIATED. IN AN INTERVIEW ON [DATE] AT 10:25 AM, LPN #3 REPORTED THAT ON [DATE] AT 8:35 AM (1 HOUR AND 35 MINUTES AFTER RESIDENT #501 WAS FOUND BLUE AND COLD TO THE TOUCH), LPN #7 CAME AND INFORMED HER THAT BECAUSE RESIDENT #501 WAS A FULL CODE, CPR SHOULD BE INITIATED. LPN #3 REPORTED THAT CNA #4 WENT TO GET THE CRASH CART AND THE AED BUT RETURNED THEM TO THE CLOSET WHEN SHE FOUND RESIDENT #501'S FAMILY IN THE ROOM. IN AN INTERVIEW ON [DATE] AT 10:25 AM, LPN #3 REPORTED THAT SHE WAS HIRED INto the facility on [DATE] AND DID NOT RECEIVE TRAINING ON THE POLICIES AND PROCEDURES REGARDING ADVANCE DIRECTIVES OR "CODE BLUE" PRIOR TO THE INCIDENT THAT OCCURRED ON [DATE]. REVIEW OF THE EMPLOYEE FILE REVEALED THAT LPN #3 WAS HIRED BY THE FACILITY ON [DATE]. THE EMPLOYEE FILE ALSO REVEALED THAT LPN #3 RECEIVED HER CPR CERTIFICATION ON [DATE]. THE EMPLOYEE FILE REVEALED THAT LPN #3 HAD NO DOCUMENTED EVIDENCE SHE RECEIVED TRAINING REGARDING THE FACILITY'S POLICIES AND PROCEDURES FOR ADVANCE DIRECTIVES, "CODE BLUE", OR EMERGENT CARE. IN AN INTERVIEW ON [DATE] AT 12:53 PM, RN #12 REPORTED THAT SHE WAS HIRED INto the facility on [DATE] AS THE EDUCATIONAL COORDINATOR AND DID NOT INCLUDE EDUCATION ON CPR, ADVANCE DIRECTIVES, OR CODE STATUS DURING NEW HIRE ORIENTATION. RN #12 STATED SHE WAS UNFAMILIAR WITH THE FACILITY'S POLICIES AND PROCEDURES REGARDING ADVANCE DIRECTIVES AND CODE STATUS. ON [DATE] AT 2:30 PM, THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON [DATE] WHEN THE FACILITY FAILED TO 1) PROVIDE CARE ACCORDING TO PROFESSIONAL STANDARDS OF QUALITY AND 2) ENSURE STAFF MEMBERS WERE EDUCATED AND PROFICIENT IN EMERGENCY PROCEDURES IN 1 (RESIDENT #501) OF 10 SAMPLED RESIDENTS FROM A TOTAL SAMPLE OF 10 RESIDENTS, RESULTING IN AN IMMEDIATE JEOPARDY (IJ) WHEN RESIDENT #501 WAS FOUND BLUE AND COLD TO THE TOUCH AND STAFF FAILED TO INITIATE CARDIOPULMONARY RESUSCITATION (CPR) OR ACTIVATE EMERGENCY MEDICAL SERVICES (EMS), DESPITE RESIDENT#501 BEING A FULL CODE. THESE DEFICIENT PRACTICES PLACE ALL RESIDENTS WHO MAY EXPERIENCE A LIFE THREATENING INJURY OR EVENT AND REQUIRE EMERGENT CARE AT RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH. ON [DATE], THE SURVEYOR CONFIRMED THAT THE FACILITY STAFF IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON [DATE], THE FACILITY INITIATED EDUCATION IN PERSON FOR 32 LICENSED NURSES REGARDING ADVANCED MEDICAL DIRECTIVES, DO NOT RESUSCITATE (DNR) ORDER, INCIDENT/ACCIDENT REPORT COMPLETION, POST-CODE BLUE, CPR, BASIC LIFE SUPPORT, AED, EPISODIC DOCUMENTATION AND THE ABUSE/NEGLECT POLICY. AS OF [DATE], 28 OUT OF 32 LICENSED NURSES HAD RECEIVED THE IN-SERVICE TRAINING ON ADVANCE DIRECTIVES THAT BEGAN ON [DATE]. ANY LICENSED NURSE, NOT IN-SERVICED, WILL NOT BE ALLOWED TO WORK UNTIL IN-SERVICING IS COMPLETED. ALL NEWLY HIRED EMPLOYEES WILL BE EDUCATED ON THE ABOVE. 2. ON [DATE], 32 LICENSED NURSES WERE REVIEWED FOR CURRENT TRAINING/CERTIFICATION ON CPR. LICENSED NURSING STAFF NOT TRAINED/CERTIFIED HAVE BEEN SCHEDULED. ALL NEWLY HIRED EMPLOYEES WILL PROVIDE THE FACILITY CURRENT TRAINING/CERTIFICATION AND CANNOT BEGIN EMPLOYMENT UNTIL CPR TRAINING/CERTIFICATION IS COMPLETED. 3. ON [DATE], RECORDS FOR ALL 76 RESIDENTS WERE REVIEWED FOR CODE STATUS. PER CORPORATE POLICY, RESIDENTS' ADVANCED DIRECTIVES AND CODE STATUS ARE FOUND IN THE RESIDENTS' CHARTS. 4. IMMEDIATE INITIATION OF THE CENTER'S QUALITY ASSURANCE PROCESS WAS COMPLETED ON [DATE]. NEW EMPLOYEE ORIENTATION WAS UPDATED TO INCLUDE THE PROCEDURE FOR DETERMINING CODE STATUS AND FOLLOW THROUGH. MOCK CODES WERE INITIATED ON [DATE] AND DONE WEEKLY TIMES FOUR, THEN MONTHLY FOR EACH SHIFT FOR 3 MONTHS. THE FACILITY WILL DO FURTHER EDUCATION AS NEEDED. 5. BEGINNING [DATE], LICENSED NURSING STAFF WERE EDUCATED ON POLICIES AND PROCEDURES REGARDING EMERGENT CARE REGARDLESS OF A RESIDENTS ADVANCED DIRECTIVE THAT INCLUDED ASSESSING AND TREATING THE RESIDENT FOR INJURY, MAINTAINING THE ABC'S (AIRWAY, BREATHING, AND CIRCULATION) OF EMERGENT CARE, INITIATING AND ACTIVATING THE EMS RESPONSE SYSTEM, STABILIZATION OF THE RESIDENT AND NOT MOVING A RESIDENT UNTIL EMS ARRIVES, AND NOTIFICATION OF THE PHYSICIAN, NURSING MANAGER ON-CALL, THE DIRECTOR OF NURSING, THE ADMINISTRATOR, AND FAMILY ACCORDINGLY. ALTHOUGH IMMEDIATE JEOPARDY WAS REMOVED ON [DATE] AT 4:00 PM, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF ISOLATED AND A SEVERITY OF NO ACTUAL HARM BUT POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY, DUE TO EDUCATION NOT BEING COMPLETED AND THAT SUSTAINED COMPLIANCE HAS NOT BEEN VERIFIED BY THE STATE AGENCY. ( )

THIS CITATION PERTAINS TO MI 417 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE CARE AND SERVICES TO ATTAIN THE HIGHEST PRACTICABLE PHYSICAL WELL-BEING (PERFORM CARDIOPULMONARY RESUSCITATION (CPR) AND INITIATE EMERGENCY MEDICAL SERVICES (EMS) ON A FULL CODE RESIDENT) IN 1 (RESIDENT #501) OF 10 SAMPLED RESIDENTS WHO HAD ADVANCED DIRECTIVES IN PLACE, FROM A TOTAL OF 10 SAMPLED RESIDENTS, RESULTING IN AN IMMEDIATE JEOPARDY WHEN RESIDENT #501 WAS FOUND BLUE AND COLD TO THE TOUCH ON [DATE] AT 7:00 AM. THESE DEFICIENT PRACTICES PLACED ALL RESIDENTS WHO MAY EXPERIENCE A LIFE THREATENING INJURY OR EVENT AND REQUIRE EMERGENT CARE AT RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH. FINDINGS INCLUDE: A REVIEW OF AN INCIDENT/ACCIDENT REPORT WRITTEN BY PRACTICAL NURSE (LPN) #3, DATED [DATE], REVEALED RESIDENT #501 WAS FOUND UNRESPONSIVE IN HER ROOM AT 7:00 AM AND A "CODE BLUE" (IMMEDIATE RESUSCITATION) WAS NOT INITIATED DESPITE RESIDENT #501'S DESIRE FOR RESUSCITATION PER SIGNED ADVANCED DIRECTIVES, DATED [DATE]. A REVIEW OF A CPR CONSENT FORM, DATED [DATE], REVEALED RESIDENT #501 EXPRESSED HER DESIRE TO HAVE CPR PERFORMED IN THE EVENT OF AN OBSERVED OR UNOBSERVED [MEDICAL CONDITION] (HEART STOPPAGE) AND THAT NURSING STAFF WOULD INITIATE CPR, USE OF THE AUTOMATIC EXTERNAL DEFIBRILLATOR (AED, WHICH IS USED TO RESTART THE HEART) AND EMERGENCY MEDICAL PERSONNEL WOULD BE CALLED. A REVIEW OF THE FACILITY'S "RECORD AND RECEIPT OF BODY" DOCUMENT, DATED [DATE], REVEALED RESIDENT #501 EXPIRED AT THE FACILITY ON [DATE] AT 9:30 AM. A REVIEW OF THE FACE SHEET, THE [DIAGNOSES REDACTED].#501 WAS A [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MDS INDICATED RESIDENT #501 HAD MODERATE COGNITIVE IMPAIRMENTS, WAS ABLE TO MAKE HERSELF UNDERSTOOD, AND REQUIRED STAFF ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING. IN AN INTERVIEW ON [DATE] AT 2:27 PM, CERTIFIED NURSING ASSISTANT (CNA) #6 STATED SHE PROVIDED INCONTINENCE CARE FOR RESIDENT #501 ON [DATE] AT 4:50 AM AND THAT RESIDENT #501 WAS BREATHING AND ABLE TO FOLLOW COMMANDS AT THAT TIME. IN AN INTERVIEW ON [DATE] AT 11:00 AM, CNA #4 REPORTED THAT ON [DATE] AT 7:00 AM, SHE WENT IN TO RESIDENT #501'S ROOM TO GET RESIDENT #501 READY FOR BREAKFAST AND FOUND RESIDENT #501 LYING IN BED, BLUE AND COLD TO THE TOUCH. CNA #4 STATED SHE IMMEDIATELY NOTIFIED LPN #3 ABOUT RESIDENT #501'S CONDITION AND ASKED CNA #5 FOR ASSISTANCE WITH RESIDENT #501. CNA #4 REPORTED THAT ON [DATE] AT ABOUT 7:00 AM, SHE, LPN #3 AND CNA #5 WENT TO RESIDENT #501'S ROOM WHERE LPN #3 ASSESSED RESIDENT #501 FOR PULSES AND LUNG SOUNDS AND NONE WERE PRESENT. IN AN INTERVIEW ON [DATE] AT 10:25 AM, LPN #3 REPORTED THAT ON [DATE] AROUND 7:00 AM, CNA #4 INFORMED HER THAT RESIDENT #501 WAS BLUE AND COLD TO THE TOUCH. LPN #3 REPORTED GOING INTO RESIDENT #501'S ROOM TO CHECK RESIDENT #501'S RADIAL AND CAROTID PULSES AND NONE WERE PALPATED. LPN #3 STATED THAT SHE CHECKED RESIDENT #501'S APICAL PULSE AND LUNG SOUNDS WITH A STETHOSCOPE AND NONE WERE AUSCULTATED. LPN #3 STATED THAT SHE WAS UNAWARE OF RESIDENT #501'S CODE STATUS, DID NOT PERFORM CPR AND DID NOT INITIATE EMS AT THE TIME OF ASSESSMENT. LPN #3 REPORTED THAT ON [DATE] AT 7:10 AM, SHE CALLED LPN #14 AT ANOTHER UNIT IN THE FACILITY TO ASSIST HER WITH RESIDENT #501. LPN #3 STATED THAT LPN #14 TOLD HER TO CHECK FOR HEART AND LUNG SOUNDS, CALL THE PHYSICIAN, CALL THE FAMILY, AND CALL THE ON-CALL NURSE MANAGER. ACCORDING TO A HANDWRITTEN STATEMENT, DATED [DATE], LPN #14 THOUGHT THAT RESIDENT #501 WAS A DO NOT RESUSCITATE (DNR) BECAUSE THERE WAS NO "CODE BLUE" CALLED. LPN #14 DOCUMENTED THAT SHE WENT TO HELP LPN #3 WITH RESIDENT #501 AND TOLD LPN #3 TO CHECK FOR HEART AND LUNG SOUNDS, AND TO CALL THE NURSING ON-CALL MANAGER, PHYSICIAN, AND FAMILY. IN AN INTERVIEW ON [DATE] AT 10:25 AM, LPN #3 REPORTED THAT ON [DATE] AT 7:20 AM, SHE PAGED THE PHYSICIAN AND CALLED REGISTERED NURSE (RN) #12 (ON-CALL NURSE MANAGER AND EDUCATIONAL COORDINATOR) AND LEFT A MESSAGE FOR RN #12. LPN #3 REPORTED THAT ON [DATE] AT 7:30 AM, RN #12 RETURNED HER CALL AND SHE INFORMED RN #12 THAT RESIDENT #501 HAD PASSED AWAY. LPN #3 STATED THAT RN #12 TOLD HER TO FIND OUT WHICH FUNERAL HOME THE FAMILY DESIRED AND TO CONTACT THE PHYSICIAN AND FAMILY. LPN #3 REPORTED THAT RN #12 DID NOT ASK ABOUT RESIDENT #501'S CODE STATUS WHEN SHE FIRST SPOKE WITH HER. LPN #3 STATED RN #12 CALLED HER BACK AT 7:40 AM AND ASKED WHAT THE CODE STATUS FOR RESIDENT #501. LPN #3 STATED SHE LOOKED IN RESIDENT #501'S CHART AND TOLD RN #12 THAT RESIDENT #501 WAS A FULL CODE. IN AN INTERVIEW ON [DATE] AT 12:53 PM, RN #12 REPORTED SHE WAS THE ON-CALL NURSE MANAGER FOR [DATE]. RN #12 REPORTED SHE WAS AT HOME ON [DATE] AND AT 7:18 AM WHEN THE PHONE RANG, BUT SHE WAS UNABLE TO GET TO IT. RN #12 STATED ON [DATE] AT 7:23 AM SHE CALLED THE FACILITY AND SPOKE TO LPN #3. RN #12 STATED THAT LPN #3 INFORMED HER THAT RESIDENT #501 HAD PASSED AWAY. RN #12 REPORTED SHE GAVE INSTRUCTION FOR LPN#3 TO SEE WHEN CARE WAS LAST GIVEN AND TO CALL THE PHYSICIAN AND FAMILY. RN #12 REPORTED THAT SHE DID NOT INFORM LPN #3 TO CHECK RESIDENT #501'S CODE STATUS OR INITIATE "CODE BLUE" THE FIRST TIME SHE SPOKE WITH LPN #3. RN #12 STATED THAT ON [DATE] AROUND 7:25 AM, SHE CALLED ADMINISTRATOR #1 AND THE ADMINISTRATOR #1 ASKED IF CODE BLUE WAS INITIATED. RN #12 STATED SHE DID NOT KNOW IF CODE BLUE WAS INITIATED. RN #12 REPORTED SHE CALLED THE DON#2 AROUND 7:30 AM, WHO ASKED WHAT RESIDENT #501'S CODE STATUS WAS. RN #12 STATED SHE DID NOT KNOW. RN #12 STATED SHE THEN CALLED LPN #3 TO INQUIRE ABOUT RESIDENT #501'S CODE STATUS AND WAS TOLD BY LPN#3 THAT RESIDENT #501 WAS A FULL CODE. RN #12 AGAIN CALLED ADMINISTRATOR #1 AND THE DON #2 TO INFORM THEM RESIDENT #501 WAS A FULL CODE AND THAT "CODE BLUE" HAD NO BEEN INITIATED. IN AN INTERVIEW ON [DATE] AT 10:25 AM, LPN #3 REPORTED THAT ON [DATE] AT 8:35 AM (1 HOUR AND 35 MINUTES AFTER RESIDENT #501 WAS FOUND BLUE AND COLD TO THE TOUCH), LPN #7 INFORMED HER THAT BECAUSE RESIDENT #501 WAS A FULL CODE, CPR SHOULD BE INITIATED. ON [DATE] AT 2:30 PM, THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON [DATE] WHEN THE FACILITY FAILED TO PROVIDE THE NECESSARY CARE AND SERVICES TO MAINTAIN THE HIGHEST PRACTICABLE PHYSICAL WELL BEING FOR 1 (RESIDENT #501) OF 10 SAMPLED RESIDENTS FROM A TOTAL OF 10 SAMPLED RESIDENTS, RESULTING IN AN IMMEDIATE JEOPARDY (IJ) WHEN RESIDENT #501 WAS FOUND BLUE AND COLD TO THE TOUCH AND STAFF FAILED TO INITIATE CARDIOPULMONARY RESUSCITATION (CPR) AND EMERGENCY MEDICAL SERVICES (EMS), DESPITE RESIDENT #501 BEING A FULL CODE. THESE DEFICIENT PRACTICES PLACE ALL RESIDENTS WHO MAY EXPERIENCE A LIFE THREATENING INJURY OR EVENT AND REQUIRE EMERGENT CARE AT RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH. ON [DATE], THE SURVEYOR CONFIRMED THAT THE FACILITY STAFF IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON [DATE], INITIATION OF EDUCATION IN PERSON FOR 32 LICENSED NURSES REGARDING ADVANCED MEDICAL DIRECTIVES, DO NOT RESUSCITATE (DNR) ORDER, INCIDENT/ACCIDENT REPORT COMPLETION, POST-CODE BLUE, CPR, BASIC LIFE SUPPORT, AED, EPISODIC DOCUMENTATION , AND THE ABUSE/NEGLECT POLICY. AS OF [DATE], 28 OUT OF 32 LICENSED NURSES HAD RECEIVED THE IN-SERVICE TRAINING ON ADVANCE DIRECTIVES THAT BEGAN ON [DATE]. ANY LICENSED NURSE NOT IN-SERVICED WILL NOT BE ALLOWED TO WORK UNTIL IN-SERVICING IS COMPLETED. ALL NEWLY HIRED EMPLOYEES WILL BE EDUCATED ON THE ABOVE. 2. ON [DATE], 32 LICENSED NURSES WERE REVIEWED FOR CURRENT TRAINING/CERTIFICATION ON CPR. LICENSED NURSING STAFF NOT TRAINED/CERTIFIED HAVE BEEN SCHEDULED. ALL NEWLY HIRED EMPLOYEES WILL PROVIDE THE FACILITY CURRENT TRAINING/CERTIFICATION AND CANNOT BEGIN EMPLOYMENT UNTIL TRAINING/CERTIFICATION IS COMPLETED. 3. ON [DATE], RECORDS FOR ALL 76 RESIDENTS WERE REVIEWED FOR CODE STATUS. PER CORPORATE POLICY, RESIDENT ADVANCED DIRECTIVES AND CODE STATUS IS FOUND IN THE RESIDENT'S CHART. 4. IMMEDIATE INITIATION OF THE CENTER'S QUALITY ASSURANCE PROCESS WAS COMPLETED ON [DATE]. NEW EMPLOYEE ORIENTATION WAS UPDATED TO INCLUDE THE PROCEDURE FOR DETERMINING CODE STATUS AND FOLLOW THROUGH. MOCK CODES WERE INITIATED ON [DATE] AND DONE WEEKLY TIMES FOUR, THEN MONTHLY FOR EACH SHIFT FOR 3 MONTHS. THE FACILITY WILL DO FURTHER EDUCATION AS NEEDED. 5. BEGINNING [DATE], LICENSED NURSING STAFF WERE EDUCATED ON POLICIES AND PROCEDURES REGARDING EMERGENT CARE REGARDLESS OF A RESIDENTS ADVANCED DIRECTIVE THAT INCLUDED ASSESSING AND TREATING THE RESIDENT FOR INJURY, MAINTAINING THE ABC'S (AIRWAY, BREATHING, AND CIRCULATION) OF EMERGENT CARE, INITIATING AND ACTIVATING THE EMS RESPONSE SYSTEM, STABILIZATION OF THE RESIDENT AND NOT MOVING A RESIDENT UNTIL EMS ARRIVES, AND NOTIFICATION OF THE PHYSICIAN, NURSING MANAGER ON-CALL, THE DIRECTOR OF NURSING, THE ADMINISTRATOR, AND FAMILY ACCORDINGLY. ALTHOUGH IMMEDIATE JEOPARDY WAS REMOVED ON [DATE] AT 4:00 PM, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF ISOLATED AND A SEVERITY OF NO ACTUAL HARM BUT POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY DUE TO ALL EDUCATION HAD NOT YET BEEN COMPLETED AND SUSTAINED COMPLIANCE HAS NOT BEEN VERIFIED BY THE STATE AGENCY. ( )