Every finding on record at Medilodge of Yale

Based on observation, interview, and record review, the facility failed to implement care plan interventions for heel boots, for one resident (R25) of two reviewed for positioning needs. Findings include: On 07/07/25 at 9:25 AM, and 04:18 PM, R25 was observed sleeping supine in bed, no heel boots on and heels not elevated off surface of the bed. No extra pillows or heels boots were observed at bedside. Review of the record for R25 revealed: R25 was admitted into the facility on [DATE]. Diagnoses included Muscle Weakness, High Blood Pressure, and Difficulty in Walking. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed: a Brief Interview for Mental Status (BIMS) score of 15/15; the need for substantial/maximal assistance for chair to bed transfer and toilet transfer; R25 was dependent on staff for lower body dressing putting and taking off footwear and R25 required partial/moderate assistant to roll left and right while in bed. Review of the at risk for impaired skin integrity care plan dated 06/04/25 documented Prevalon style off-loading boots (heel boots) to (bilateral lower extremities) BLE while in bed as tolerated. On 07/08/25 at 8:49 AM, R25 was observed to be in bed, laying on their back, with the head of the bed up slightly, and dressed in a hospital style gown. R25's heels rested on the bed surface without a device under the lower legs or heel boots. On 07/08/25 at 10:18 AM, 11:06 AM, 12:27 PM, 1:26 PM and 2:12 PM R25 was dressed in a t-shirt and shorts and laying on their back in a recliner. R25's feet hung off the end of the footrest at the level of the heel. No heel boots were in place. On 07/09/25 at 8:06 AM, R25 reported they would wear the heel boots in bed. On 07/09/25 at 08:06 AM, 9:07 AM, and 10:20 AM, R25 was observed sitting up in bed eating breakfast with no heel boots on and heels resting on the bed. At 8:06 AM, the daughter reported she has not seen the boots on R25's feet in a long time and family is there daily. On 07/09/25 at 10:04 AM, care was reviewed with Licensed Practical Nurse (LPN) G. LPN G identified an order for heel boots dated 04/12/25. LPN G reported the nurse who entered the order would be responsible for entering it into the care plan and the Kardex (Certified Nurse Assistant (CNA) guide for resident care). LPN G was unable to locate the intervention for heel boots in the care plan. CNA H was asked about the care of R25 and reported they had asked about changing the t-shirt and elevating the heels but was not asked about wearing the heel boots. Further review of the progress notes with LPN G revealed no documentation of refusal of care related to heel boots. The heel boots were observed in a closet in a plastic bag. On 07/09/25 at 10:43 AM, the Interim Director of Nursing (IDON) reported the nurse who writes the order for heel boots is responsible for entering it into the care plan which will trigger the Kardex for the CNAs to implement the intervention. The IDON reported refusals would be documented by the CNA and the nurse would be notified. Review of the Kardex revealed no intervention for heel boots, and review of the tasks in the electronic medical record (EMR) revealed no documentation by the CNA of refusal to wear the heel boots. A review of the policy, Comprehensive Care Plans, revised 6/30/22, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment (Minimum Data Set) . 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment .

Based on observation, interview, and record review the facility failed to assess, monitor and control blood sugar levels (accu-cheks) for two residents (R54, R16) of three residents whose blood sugar monitoring was reviewed. Findings include: R54 On 07/07/2025 at 9:25 AM, R54 was observed walking in the hall. R54 indicated their blood sugars were out of control. R54 reported they did not discuss this with facility staff. A review of the medical record revealed R54 was admitted into the facility on [DATE] with readmissions after hospitalizations on 01/13/25, 01/17/25, and 03/14/25 secondary to complications from abdominal surgeries that included wound leaks, wound abscess, wound infection and ileus. Pertinent diagnoses include: Diabetes Mellitus and surgical complications. A Brief Interview for Mental Status (BIMS) dated 05/23/25 revealed a score of 13/15 which indicated little to no cognitive impairment. Further review of the medical record for R54 revealed sliding scale insulin coverage for blood sugar level checks were discontinued on 05/13/2025 based on pharmacy recommendations. Adjustments to long-acting insulin and short-acting insulin doses were made until 06/18/2025 based on glucose levels taken prior to meals. No adjustments were made to insulin doses after that date. Blood sugars taken after 06/18/25, continued to be high with the following results: 71 out of 82 blood glucose values were higher than 201(normal range 60-120). No sliding scale insulin was given or dosage adjustments in the long-acting dose or short- acting dose were not made. A review of the Physician Communication Book, revealed two communications related to R54. One was a note regarding a blood sugar of 400 on 06/02/2025, with no changes made. The second note dated 06/19/25 was related to blood work including a Hemoglobin A1C (an indication of blood sugar control over a 3 month period). The result for the A1C reported on 06/18/2025 was 11.1. (normal range equals less than 6.4), no changes were made to dosages of the long-acting or short-acting insulins. An interview with the Interim Director of Nursing (IDON) revealed the Nurse Practitioner was attempting to stop sliding scale coverage facility-wide based on a recommendation from the pharmacist and The Society for Post-Acute and Long-Term Care Medicine (AMDA). The IDON further revealed the expectationis that Nurse Practitioners and Physicians would be reviewing blood glucose levels and making adjustments in insulin orders as needed. The DON further indicated the expectation was that the nurse would report any trends of elevated blood sugars. A phone interview with Nurse Practitioner (NP) I revealed they could not recall whether the consistently elevated blood sugars were reported by the nurse. NP I further revealed they were not aware the blood sugar levels were still elevated. There was no indication of why blood sugar monitoring was discontinued. R16 On 07/07/25 at 8:08 AM, resident R16 was interviewed and indicated the nurses don't check my blood sugar or A1C. On 07/09/25 at 10:04 AM, Licensed Practical Nurse (LPN) G revealed they did not check R16's blood sugar this morning. LPN G revealed there was no order for it. LPN G reported blood sugars are not normally done on long-acting insulin. A review of the medical record for R16 revealed they were admitted to the facility on [DATE]. Pertinent diagnoses included Type 2 Diabetes, and Morbid Obesity . The Minimum Data Set (MDS) assessment dated [DATE] revealed intact cognition score of 15/15. A review of hospital discharge paperwork 04/15/25 revealed diabetes worsening, monitor glucose, tight glycemic control protocol. Discharge paperwork indicated to continue sliding scale insulin, and long-acting insulin. The discharge hospital note indicated R16's A1c on 4/10/25 was 8.2. The record review revealed on 04/15/25, the following diabetic orders were entered: by Nurse Practitioner (NP) I: Insulin Glargine Subcutaneous Solution (long-acting insulin) inject 5 units subcutaneously at bedtime. A review of the blood sugars from 04/15/25 through 4/30/25 were documented four times daily with the following summary of results: 42 blood sugars between 150-200 for an average of 184.78, seven blood sugars between 201-250 for an average of 225.71, there is one blood sugar at 253, and one blood sugar at 301, which indicated decreased blood sugar control. On 06/12/25 at 7:57 PM, a blood sugar was documented at 151. No other blood sugar readings were documented for the month of June. No blood sugars were documented for the months of May or July 2025. Review of the progress note for R16 dated 05/16/25, 05/19/25, 05/19/25, 06/09/25, and 06/16/25 revealed NP I documented the following: Uses Insulin Glargine 5 units at bedtime, sliding scale insulin coverage with meals. Continuing current therapy (blood sugar checks), will adjust dosage as needed to achieve optimal glycemic control monitor signs and symptoms hypo/hyperglycemia, notify provider of any acute changes. Review of the active physician orders revealed no accu-checks and no sliding scale insulin were ordered. Review of the active physician orders revealed no accu-checks and no sliding scale insulin were ordered Review of R16's impaired metabolic status related to diabetes care plan dated on 04/18/25 revealed the intervention to .monitor glucose levels . On 07/09/25 a policy was requested at 2:17 PM related to glucose monitoring. Administer replied via email at 3:01 PM, We do not have a policy for insulin sliding scale or diabetes/insulin order.

Based on observation, interview, and record review, the facility failed to honor resident's preference for incontinence products for one (R42) of five residents reviewed for resident rights. Findings include: Review of the facility record for R42 revealed an original admitted [DATE] and a most recent admitted [DATE] with diagnoses that included Cerebral Infarction with Left Hemiplegia, Congestive Heart Failure and Depression. The Brief Interview for Mental Status (BIMS) assessment dated [DATE] and scored 15/15 indicated no cognitive impairment. On 05/21/24 at 9:43 AM, R42 reported the facility would not allow them to use incontinence (blue) pads on the bed. R42 stated they preferred to use incontinence pads because of their severity of bladder incontinence and they purchased two of their own pads to use in addition to the facility-provided pads. R42 indicated late last year the facility staff took the pads away and will not allow the resident to use them saying, [the facility Administrator (NHA)] just told me that if they let me use them they have to let everyone use them. When asked if the facility offered them a choice to keep the pads or an alternative option to replace the pads R42 stated No, they just took them. Review of a facility Quality Assurance (Grievance/Concern) Form dated 12/12/23 revealed R42's concern description stating Resident purchased [their] own blue pads and they were removed with the rest (of the blue pads) in building. [They] state [they] need them. The Findings section of the form states Daughter ok with us keeping, doesn't want them. Further review of R42's facility record revealed the resident's daughter who signed the grievance form is not the resident's guardian and the resident is their own responsible party. On 05/23/24 at 12:14 PM, the facility Director of Nursing (DON) reported that R42's incontinence pads were removed because the facility's corporate ownership discontinued their use in their facilities due to evidence of increased skin breakdown and maceration (softening and breaking down of skin) related to their use. On 05/23/24 at 12:38 PM, the NHA reported the corporation did discontinue use of the incontinence pads. The NHA was asked to provide a policy or any documentation of the directive to institute the policy. The NHA reported they were not aware of any such documentation but they would investigate further. On 05/23/24 at 12:50 PM, the NHA indicated their was no documentation of the directive to discontinue use of the incontinence pads and said It's a standard of practice and indicated the resident would wear an incontinence brief and be changed rather than using a pad. The NHA further stated [R42's] daughter works here (at the facility) and she signed off on it. Review of the facility policy Resident Rights dated 10/30/23 includes the Policy statement The facility will inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility will also provide the resident with prompt notice of changes in any State or Federal laws relating to resident rights or facility rules during the resident's stay in the facility. Receipt of any such information must be acknowledged in writing.

Based on observation, interview and record review, the facility failed to implement fall interventions per the plan of care for one resident (R38) out of six residents reviewed for care plan interventions. Findings include: On 05/21/24 at 2:30 PM, R38 was observed asleep lying in bed. There was no mat was on the floor by the bed. On 05/22/24 at 9:13 AM, R38 was observed lying in bed asleep. There was no mat on the floor by the bed. On 05/22/24 at 10:15 AM, R38 was observed lying in bed. There was no mat observed on the floor by the bed. A review of R38's medical record revealed that they were admitted into the facility on [DATE] with diagnoses of Huntington's Disease, Schizoaffective Disorder, Dementia, and Hypertension. A review of R38's Minimum Data Set (MDS) assessment dated [DATE] revealed, R38's Brief Interview for Mental Status assessment score was a 10 indicating moderate impaired cognition. Further review of R38's medical record revealed the following care plan: Focus: resident is at risk for falls / injury related to generalized weakness, needs assistance with Activities of Daily Living, opoid medication use, and psychoactive medication use. Interventions listed include mat to floor next to bed left side initiated 2/5/24. On 5/23/24 at 10:30 AM, the Director of Nursing (DON) was asked about the expectations for following the plan of care for resident at risk for falls. The DON stated, I expect the interventions to be used as needed for the necessary condition or reason needed for the resident. A review of the facility's policy titled Comprehensive Care Plan implemented 1/1/21 and revised 6/30/22 revealed the following, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Based on observation, interview, and record review, the facility failed to document and monitor a change in condition timely, and follow the care plan for one resident (R50) of one resident reviewed for change of condition. Findings include: On 5/21/24 at 10:05 AM, R50 was observed lying in bed pleasantly confused and unable to be interviewed due to their cognition. A review of R50's medical record revealed they were admitted into the facility on [DATE] with diagnoses of Unspecified Dementia, Type II Diabetes, and Hypertension. Further review of the medical record revealed that the resident was significantly cognitively impaired, and required extensive assistance with Activities of Daily Living. Further review of the medical record revealed the following care plan: Focus: Resident has episodes of bladder/bowel incontinence related to dementia, depression, diabetes. Date Initiated: 09/20/2023 .Interventions: .Observe for signs/symptoms of UTI (urinary tract infection) and report to Physician/PA (physician assistant)/NP(nurse practitioner) pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.) Date Initiated: 09/20/2023 . Further review of the medical record revealed the following progress notes: 5/14/2024 12:01 (12:01pm) Nurses Note Text: Resident refusing to get out of bed today. Hospice aide reports cloudy/mucous in urine. 5/17/2024 18:28 (6:28pm) Nurses Note Text: Hospice called nurse this shift and ordered a UA C&S (urinalysis and culture and sensitivity). Hospice aid in earlier this shift and reported to hospice nurse that resident was more combative than usual, and urine was darker than normal. Order placed in computer. 5/20/2024 08:05 (8:05am) Nurses Note Text: Resident straight cathed (catheterized- a drain to remove urine from the bladder) for UA, immediate return of tan, foul smelling urine. A review of the physician orders noted the order for the UA was created on 5/17/24, but was not started until 5/19/24. It was further noted the UA was not collected until 5/20/24. On 5/22/24 at 1:04 PM, after a request, the Director of Nursing (DON) provided lab results for R50, and indicated the resident's urinalysis was collected and sent to the lab on 5/20/24, with results being received via fax on 5/22/24. A review of R50's urinalysis results dated 5/20/24 revealed that there were eight tests completed on R50's urine sample indicating abnormal results, per a legend noted at the bottom of the document. On 5/22/24 at 2:09 PM, the DON was asked about the delay in R50 obtaining a UA, and the progress note indicating that on 5/14/24 the resident had cloudy/mucus in their urine. The DON explained that the resident's urine was not an indication of an infection, and her expectation of the facility staff would have been to monitor and push fluids. She further explained the resident's hospice nurse visited the resident on 5/16/24 and did not note any concerns with the resident. Regarding the timeliness of the lab and collections of results, she explained the order from the hospice company was received on a Friday, 5/17/24 after 6pm and the lab was not drawn until after the weekend, as the facility has access to the lab Monday through Friday. A review of R50's hospice progress note authored by the hospice nurse, and dated for 5/16/24 noted the following, .R50 is sitting up in the high fowler's position (laying on back with head of bed between 60-90 degrees), alert to self more withdrawn today. Does not want to converse with this writer which is new .Pt (patient) is having hallucinations . On 5/22/24 at 2:25 PM, the DON further explained the resident has a history of kidney stones, and a history of UTIs and the last time the resident was treated, they had to have 4-5 IVs (intravenous) placed because they kept ripping them out. On 5/23/24 at 10:29 AM, the DON and Corporate Employee A asked to speak to the surveyor and explained the resident's symptoms did not meet McGreer's criteria (criteria used to determine infections), and the symptoms the resident was displayed could have been from multiple things because the resident is incontinent and may have been an issue related to hydration as this has been an ongoing issue for the resident. The DON explained that she spoke to the nurse on R50's unit who hadn't noted any concerns related to the resident, and also questioned hospice management why an order for a UA was ordered when the resident did not display pain or suprapubic pain. On 5/23/24 at 11:00 AM, the Nursing Home Administrator (NHA) was asked about her expectations for nurses to monitor and assess changes in condition, and she explained it is her expectation that nurses are monitoring for changes of conditions. A review of the facility's Notification of Changes policy did not address monitoring a resident following a potential change in condition. A review of the facility's Comprehensive Care Plan policy did not address implementing care planned interventions.

This citation pertains to intake MI00143016 and MI00143086. Based on interview and record review, the facility failed to promptly identify and intervene for an acute change in condition for one resident (R700) out of one reviewed for change in condition, resulting in R700 experiencing pain and hospitalization . Findings Include: On [DATE] at 1:38 PM, an interview was conducted with Caregiver (CG) D. CG D stated that they were with R700 the entire night. CG D stated that R700 had been complaining of pain since 10:00PM. R700 stated that they had to keep going in the hallway to find someone. CG D stated that they R700 had emesis (vomiting) and was moving around because they could not find a comfortable position. CG D stated that they asked R700 what their pain level was and that they told them that it was an ,d+[DATE], sometimes a ,d+[DATE] depending on their position. CG D stated that the nurse said they had to call the on-call physician for orders but gave them a Tylenol around 5:00 AM in the meantime. CG D stated that R700 kept asking to go to the hospital. CG D stated that the nurse came in and stated the physician stated R700 could go to the hospital or have a stat (immediate) abdominal x-ray and R700 stated they wanted to go to the hospital. CG D stated they called R700's spouse around 5:30 AM, to let them know that R700 was going to the hospital. CG D stated shortly after the nurse came back in and stated they were putting the transfer on hold because the Director of Nursing (DON) wanted to come in and assess R700 first. CG D stated the next shift nurse came in and saw the emesis and how much pain R700 was in and called 911. CG D stated that the DON did not come into the facility until around 8:00 AM right before the ambulance came. CG D stated that R700 died while in the emergency room . CG D stated that they wish they knew they could call 911 themselves because they would have called. A review of the medical record revealed that R700 admitted into the facility on [DATE] with the following medical diagnoses, Congestive Heart Failure and Gastro-Esophageal Reflux Disease. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status assessment score of ,d+[DATE] indicating an intact cognition. R700 also required assistance with bed mobility and transfers. Further review of the progress notes revealed the following, Date: [DATE] at 5:30 AM .On call physician notified of resident's c/o (compliant of) discomfort, PRN (as needed) Tylenol given and not effective at this time. Resident was given option of a stat x-ray or to be sent to the hospital per on call [Physician Group]. Resident chose to be sent to the hospital. Paperwork for transfer was printed and signed. DON notified of transfer and ordered floor staff to hold off sending to ER and inform resident [DON] would be in shortly to evaluate and talk to [R700]. Staff informed resident DON would be arriving to discuss situation between 8:00 AM -8:30 AM, resident was emotional . Date:[DATE] at 7:30 AM .Resident's vital signs abnormal when checked in AM. This could be due to resident having an episode of emesis and possible dehydration due to that, as well as anxiety that resident stated [they] have. Date: [DATE] at 7:35 AM .Spoke to DON regarding residents and care givers concerns, complaints of ABD (Abdominal) pain r/t (related to) HX (History) of hernia. ABD 2 view x-ray was ordered and increased v/s (vital sign) monitoring to every 4 hours. Date:[DATE] at 4:23 PM .Spouse and caregiver arrived in facility to pickup resident's belongings. Resident passed (expired) upon arriving to (name of local hospital) this morning. Spouse stated unsure of what occurred, and autopsy has been ordered . Further review of R700's last recorded vital signs at 5:32 AM on [DATE] noted the following, Blood Pressure-,d+[DATE], Respirations-30, and Oxygen level-88% on room air. A review of the Medication Administration Record (MAR) revealed that R700 received 4 MG (Milligrams) of Zofran (Antiemetic) at 11:51 PM and 650 MG of Tylenol at 4:53 AM. On [DATE] at 10:54 AM, an interview was conducted with Certified Nursing Assistant (CNA) B. CNA B stated that they saw R700 the day they went to the hospital. CNA B stated that R700 was complaining about being in a lot of pain and they were given report at 6:00 AM that R700 was going to the hospital. CNA B stated that R700 ended up going to the hospital around 8:30AM-9:00AM. On [DATE] at 11:13 AM, an interview was conducted with Registered Nurse (RN) A. RN A stated that they never assessed the resident themselves. RN A stated that they just ordered an Abdominal x-ray and put the order in for increased vital signs. On [DATE] at 11:20 AM, an interview was conducted with RN C. RN C stated that they came in a little after 6:00 AM and was told by the two-night shift nurses that they obtained an order from the physician and R700 was going to the hospital but was later informed that they were told to hold the transfer by the DON. RN C stated they did not actually see R700 until around 7:40 AM and noted that R700 was anxious and kept saying they wanted to go to the hospital and wondering why they were not sending them out. RN C stated that they called 911 immediately and sent them out to the hospital. On [DATE] at 12:19 PM, an interview was conducted with the DON. The DON stated they were called by staff and informed them they were sending R700 to the hospital. The DON stated they chose to put the transfer on hold until they assessed based on the facilities return to hospital protocols. The DON stated they did not call the on-call physician and let them know they were not sending R700 to the hospital. The DON was queried as to why the abdominal x-ray was not entered until 7:35 AM, if R700 was not going to the hospital. The DON stated they did not know. The DON was queried about if they saw R700's last recorded vital signs. The DON stated they were not told R700's vital signs over the phone during the initial call from staff. The DON stated R700 was sent out due to family insistence, however when they assessed them, they did not appear to be in any distress. The DON stated that they were not sure what caused R700's death. A review of a facility policy titled, Transfer and Discharge (including AMA) noted the following, . 9. Anticipated Transfers or Discharges - initiated by the resident. a. Obtain physicians' orders for transfer or discharge and instructions or precautions for ongoing care.

Based on observation, interview and record review the facility failed to ensure a 14 day end date and appropriate diagnosis was applied to as needed (PRN) psychotropic medications (Lorazepam/Ativan) and or (Quetiapine/Seroquel) for one (R424) resident of six reviewed for unnecessary medication use resulting in the potential for prolonged use of medication. Findings include: On 03/13/23 at 10:28 AM, R424 was observed to be dressed and standing outside their isolation room. Staff attempted to coax R424 to return to their room as R424 walked a short distance from their room. R424 with prompting by staff returned to their room. At 4:20 PM, R424 was observed to be standing in the doorway of the Director of Nursing (DON) office. On 03/15/23 at 9:46 AM, R424 was seated calmly in their room. R424 was dressed and had a mask. A review of the record for R424 revealed, R424 was admitted into the facility on [DATE]. Diagnoses included Dementia, Diabetes, and Kidney Disease. A physician order for Lorazepam dated 03/13/23 at 4:57 PM revealed, Lorazepam Tablet 0.5 (milligrams) mg, Give One tablet by mouth every eight hours as needed for anxiety. The end date was documented as indefinite. The audit detailed documented review by Unit Manager and Registered Nurse (RN) I. Further review of physician orders revealed psychotropic orders with start dates of 03/11/23 (discontinued 03/13/23) and 03/14/23 for Seroquel Oral 25 mg (milligram), Give .5 tablet by mouth every day shift for Dementia. An active physician order dated 03/10/23 for Seroquel Oral 25 mg, Give one tablet by mouth every evening for Dementia. The Black box warnings for the Seroquel indicated Seroquel was to be used with caution in elderly with Dementia. A review of the Seroquel medication at 'www.drugs.com' did not indicate Dementia as a diagnosis for administration. R424 also had an active order for the antidepressant Duloxetine. A review of the March 2023 Medication Administration Record (MAR) revealed an administration on 03/14/23 of the Lorazepam Tablet 0.5 mg, Give One tablet by mouth every eight hours as needed for anxiety. The March 2023 MAR further documented an administration on 03/12/23 of the Seroquel Oral 25 mg, Give one tablet by mouth every 24 hours as needed for agitation. This did not indicate a a 14 day stop date. The MAR indicated the order was started 03/10/23 and discontinued 03/13/23. On 03/15/23 at 10:23 AM and 12:10 PM, the concerns related to psychotropic medications were reviewed with the Director of Nursing (DON). The DON indicated they would modify the Lorazepam order and acknowledged the need for a 14 day stop date on as needed psychotropic medications. A review of the facility policy titled, Use of Psychotropic Drugs and Gradual Dose Reductions revised 01/01/22 revealed, Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident ' s response to the medication(s) . 1. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: antipsychotics,antidepressants, anti-anxiety, and hypnotics . 7. PRN orders for psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e.14 days) .

Based on observation, interview and record review, the facility failed to complete a comprehensive, individualized care plan for five residents (Resident #35, 45, 47, 64 and 123) of 18 reviewed for care planning, resulting in the potential for missed care needs. Findings include: Resident #45 On 01/03/2022 at 01:04 PM, Resident #45 was observed dressed and groomed in their wheelchair. Resident #45 was wearing oxygen tubing in their nose. Resident #45 stated that the oxygen was new to them since their most recent hospitalization . Resident #45 was asked about the care they received in the facility and stated, I am just waiting to go home now. They aren't doing anything here anymore; I don't do therapy. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #45 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #25 had a brief interview for Mental Status (BIMS) score of 13 out of 15, indicating an intact cognition, and needed extensive assistance with bed mobility and transfers. A record review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Spo2 (pulse oximetry) less than 90% ra (room air), apply o2 (oxygen) at 2 liters via n/c (nasal cannula). On 1/05/2022 at 08:22 AM, during an observation of medication administration, Resident #25 was observed to be lying flat in bed without their oxygen on. The Nurse applied the pulse oximeter on Resident #45's finger to check their oxygen level, which revealed 82% (normal is 90-100%). The Nurse then applied the oxygen, which brought Resident #45's oxygen level back up to 93%. Resident #45 was asked if they wear the oxygen all the time and stated, Sometimes I need it, sometimes I don't. On 01/05/22 at 11:55 AM, the Director of Therapy (DOR E) was interviewed in regard to Resident 45's therapy. DOR E explained that Resident #45 was making slow gains and the insurance felt the pace of the improvements was not enough to get Resident #45 where they needed to be to get to their prior level of functioning. The DOR stated, We were very frustrated. (Resident #45) has low endurance with fluctuating oxygen levels, with activity, they desats (oxygen level drops on exertion), and (Resident #45) doesn't like to wear the oxygen. With covid (a contagious and potentially serious respiratory infection), we have noticed it just takes time for the lungs and body to heal . A review of the plan of care for Resident #45 revealed no respiratory/oxygen care plan. On 01/05/2022 at 01:03 PM, MDS Nurse D was interviewed in regard to Resident #45 not having an oxygen or respiratory care plan. The MDS Nurse D explained that the care plan gets initiated upon admission and then updated over time. MDS Nurse D reviewed Resident #45's care plan at this time and also noted no care plan addressing the oxygen and/or respiratory status. MDS Nurse D stated, (Resident #45) should have had one (respiratory/oxygen care plan) if they came in (were admitted ) with it (oxygen order). On 01/05/2021 at 01:36 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were interviewed in regard to care planning, specifically with Resident #45's respiratory/oxygen status. The DON explained that the care plans are generated upon admission and then flows with the MDS schedule for review. The DON stated, Depending on the diagnosis, they pick out the problems. I do know that (Resident #45) does not want (to wear) their oxygen. R47 R47 was admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R47's Minimum Data Set (MDS) assessment dated [DATE] noted, R47 with an impaired cognition on the Brief Interview Mental Status (BIMS). R47's required assistance with activities of daily living. On 1/03/22 at 10:53 AM, R47 was observed in their room sitting in a wheelchair. R47 had oxygen on via nasal cannula, the tubing was observed tangled under R47's wheelchair and legs. R47 was observed trying to reach for the tubing, by pulling it from behind their head. The tubing was observed to be stuck and was unable to be moved. R47 made a request for assistance from this surveyor. A staff member came into the room and was observed to assist R47 to untangle the tubing. On 1/05/22 at 10:44 AM, R47 was observed in their room, sitting in the wheelchair. The oxygen concentrator was on, and the nasal cannula to the oxygen was observed on the floor tangled under the wheelchair. At 10:52 AM, a certified nursing assistant (CNA) came into R47's room, R47 stated, Do I need the oxygen. The CNA stated, Yes you do. The CNA was observed to untangle and to pick up the tubing off the floor and to tell R47 that she was going to get a new one because it had been on the floor. R47's medical record revealed an Order Oxygen: RUN @ (at) [2]L /MIN (liters/minute) VIA (by) N/C (nasal cannula) PRN (as needed) start date: 12/31/21. Progress Notes: 1/4/2022 15:00 Pertinent Charting-Infections/Signs Symptoms Note Text: Event Date: 12/27/2021. Site of originally identified infection: pneumonia resident is alert and able to make needs known, no Signs or Symptoms of acute distress noted, VSS (vital signs stable), updrafts are effective, ABT (antibiotic therapy) continues, o2 (oxygen) PRN at 2 liters will monitor. Assessments Pertinent Charting Follow-up Infections/Signs & Symptoms. Description: Follow up. Date: 1/4/2022. A: Event Information. 1. Follow up to infection & symptoms that occurred on: 12/27/2021. 2. Site of originally identified infection: pneumonia. 3. Comments: Res (resident) cont (continue) oral abt r/t (related to) pneumonia. Afebrile. No s/sx (signs or symptoms) of adverse reaction noted. O2 WNL (within normal limits). Will cont to monitor. Further review of R47's medical record revealed, R47 did not have a care plan that addressed respiratory care, oxygen use, and long tubing. R123 R123 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress Notes: 1/3/2022 23:24 (11:00 PM) Transcribed NP/PA (Nurse Practitioner/Physician Assistant) Progress Note Text . History Of Present Illness: This patient is being evaluated per nursing request due to controlled substance medications needed. The patient is a [AGE] year-old [gender] transferred from [local facility] on hospice. The patient requires [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] for her pain. The patient's daughter and family member present they have transported [R123] from another facility. They are unable to provide completed history [R123] does have dementia there are no records available as awaiting records from hospice . Further review of R123's medical record revealed, R123 did not have a care plan that addressed hospice care. On 1/05/22 at 1:09 PM, the MDS Nurse was asked the facility's procedure for care planning for residents for the use of oxygen and that was on hospice. The MDS Nurse stated, Yes if they initiated an order, yes it should be care planned. If they were admitted on hospice, yes it should be care planned. On 1/05/22 at 1:39 PM, the Director of Nursing (DON) was asked about care plans and stated, They are done upon admission, the admitting Nurse would trigger care plans, then at 14 days someone would look at it (care plans) again. For hospice we would do three-day conference, when we meet with them or family to follow up, make sure we have appropriate wishes, and match the hospice care plan with the facility's plan. R64 On 1/03/22 at 10:15 AM, during the initial tour of the memory unit, R64 was observed in bed with headphones on. R64 was positioned on their back. R64 was pleasantly confused and was able to answer basic questions. On 1/03/22 at 12:07 PM and 2:22 PM, R64 was observed from the doorway in bed, eyes closed, positioned on their back. On 1/04/22 at 9:10 AM, R64 was observed in bed, positioned on their back. R64 was interviewed and asked if they had gotten out of bed. R64 said, They just leave me in her by myself. On 1/04/22 at 10:55 AM, 1:40 PM, and 2:15 PM, R64 was observed from the doorway in bed, eyes closed, positioned on their back. On 1/05/22 at 9:20 AM, R64 was observed from the doorway in bed, eyes closed, positioned on their back. A review of R64 medical record noted an admission to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R64 has a Brief Mental Status (BIMS) of 4 out of 15 (Severe cognitive impact). A review of R64's care plan noted the following: Focus: The resident has pressure ulcers development to the following areas sacrum Date Initiated: 03/20/2021 .Revision on: 08/11/2021. The care plan did not indicate that R64 refused to get out of bed or address that the Resident received assistant to get out of bed. On 1/05/22 at 10:43 AM, Wound Care Nurse A was interviewed and questioned about R64 being out of bed. Wound Care Nurse A stated, (R64) does not tolerate being out of bed .(R64) refuses to get out of bed. On 1/05/22 at 1:50 PM, the Director of Nursing (DON) was Interviewed and queried about R64 not getting out of bed, refusing to get out of bed, and the care plan not indicating that R64 refused getting out of bed. The DON stated, (R64) refuses to get out of bed and repositioning . It absolutely should be in the care plan because (R64) does not like to get out of bed. should it be care plan absolutely. The DON was notified that there was not documentation noting R64's refusal to get out of bed. R35 On 01/05/2022 at 10:30 AM, this surveyor was informed that R35 tested positive for Covid-19. On 01/05/2021, a review of R35's medical record revealed that R35 was admitted into the facility on [DATE] with the following diagnoses, [CONDITION(S)] Disease, Anxiety Disorder, and Dementia with Behavioral Disturbance. A review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 5/15 indicating severely impaired cognition. R35 also required two-person total dependance for bed mobility and transfers. It was also noted that R35 was receiving hospice care. A review of R35's care plan did not note R35 being under hospice care. On 01/05/2022 at 11:33 AM, an interview was conducted with Social Worker (SW) C regarding R35 being under hospice and the hospice care plan. SW C stated that everyone puts the care plans in and that it is a collaborative effort. SW C stated that they currently have three hospice companies within the facility. SW C was queried as to the timeline as to when hospice care plans are usually put in for residents. SW C stated that they are usually entered within a week of them being put on hospice. On 01/05/2021 at 11:40 AM, an interview was conducted with Registered Nurse (RN) F regarding R35. RN F was queried as to who they would contact if R35 had a change in condition. RN F stated that they would contact the responsible party, as well as hospice. RN F was queried as to where they would find the contact information for R35's hospice provider and they replied, I would look in the care plan. On 01/05/2022 at 1:36 PM, an interview was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) regarding R35 not having a hospice care plan. The DON stated that the care plan should have been triggered upon admission, however they cannot recall why one was not put in for R35. A review of a policy titled; Hospice revealed the following: The facility and hospice provider will coordinate a plan of care and will implement interventions in accordance with the resident's needs, goals, and recognized standards of practice in consultation with the resident's attending physician/practitioner and resident's representative, to the extent possible.

Based on observation, interview, and record review, the facility failed to provide visual privacy for one sampled resident (R57) out of four reviewed for privacy, resulting in the potential of exposure during care, and feelings of embarrassment. Findings Include: On 01/03/2022 at 11:30 AM, an interview was conducted with R57 regarding their stay in the facility. R57 stated that they don't have many complaints but would like a shade to be put on their window. R57 stated that although they like the view out of their window, it can get bright and there is also a chair sitting outside that makes them uncomfortable. R57 stated that they have not had a shade on the door since they moved into that room. Upon observation, R57's bed was pushed against the wall and a patio door. The door was looking out into the courtyard. There were no shades observed on the patio door, there was also no privacy curtain observed that would be able to cover the patio door. R57 was queried regarding how privacy was provided during their care by the staff. R57 stated that they pull the curtain on the other side of the bed, but the patio door does not get covered. A review of R57's medical record revealed that R57 admitted into the facility on [DATE] with the following diagnoses, [CONDITION(S)] of Right Lower Limb, Major Depressive Disorder, and Difficulty in Walking. A review of the Minimum Data Set, dated dated dated [DATE] noted a Brief Interview for Mental Status score of 15/15 indicating intact cognition. R57 also required limited to extensive assist with bed mobility and transfers. On 01/05/2022 at 11:30 AM, a medication observation was conducted with Registered Nurse (RN) F. During the observation RN F was queried regarding R57's not having a shade on the patio door, and how privacy during care was being provided. RN F stated that there should be a shade on the door and that they would let maintenance know by putting in a ticket. On 01/05/2021 at 12:15 PM, an interview was conducted with the Maintenance Director regarding the missing shade on R57's patio door. The Maintenance Director stated that they were unaware that R57 did not have a shade on their patio door and would get one put up immediately. The Maintenance Director stated that the floor staff can put in a ticket through TELS (an electronic system for work orders) and that they check the orders every 15-20 minutes. The Maintenance Director stated that they never received a work order for this but would take care of it. On 01/05/2022 at 1:36 PM, an interview was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) regarding R57 not having a shade on their patio door. The DON states that the nurses or nurse aides should have put in a request in TELS stating that R57 needed a shade. The DON stated that it should have been dealt with before R57 had to bring it to someone's attention. A review of a policy titled; Activities of Daily Living did not address providing privacy.

Based on observation, interview and record review, the facility failed to monitor and consistently document the food acceptance for one resident (Resident #25) of two residents reviewed for weight loss, resulting in the likelihood of continued unexplained weight loss and malnutrition. Findings include: On 01/03/2022 at 10:42 AM, Resident #25 was observed dressed and groomed in their wheelchair. Resident #25 was asked about how the food was in the facility and stated, Sometimes it's bad. Resident #25 did not elaborate. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #25's most recent admission to the facility was on 12/27/2019 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #25 needed limited assistance with transfers and bed mobility, was independent with eating, and had a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognition. A review of the weights for Resident #25 revealed the following: 12/30/2021 134.0 (pounds/Lbs) 12/21/2021 132.2 Lbs 12/16/2021 128.8 Lbs 12/07/2021 131.3 Lbs 12/03/2021 128.7 Lbs 11/23/2021 131.7 Lbs 11/15/2021 135.5 Lbs 11/09/2021 134.6 Lbs 11/04/2021 132.0 Lbs 10/25/2021 135.9 Lbs 10/21/2021 134.3 Lbs 10/15/2021 143.0 Lbs 10/13/2021 144.3 Lbs 10/05/2021 138.6 Lbs 10/01/2021 136.0 Lbs 09/20/2021 138.3 Lbs 09/12/2021 138.0 Lbs 09/08/2021 137.1 Lbs 09/01/2021 137.4 Lbs 08/23/2021 140.8 Lbs 08/20/2021 143.7 Lbs 08/10/2021 138.6 Lbs 08/03/2021 139.0 Lbs 07/21/2021 138.4 Lbs 07/12/2021 138.1 Lbs 07/11/2021 138.5 Lbs 07/04/2021 151.2 Lbs A record review of the Physician Orders for Resident #25 revealed the following: HEALTHSHAKE-two times a day for supplement (ordered 06/14/2021). Magic Cup-every day and evening shift for supplement (ordered 02/12/2021). A record review of the Progress Notes for Resident #25 revealed the following: 12/30/2021 15:15 (03:15 PM) .Nutrition/Hydration Weight gain/loss; Hydration concern: CBW (current body weight) 132.2 lbs- up 3.4 lbs History/Precipitating factors: PO (by mouth) intake is excellent at 100% of meals consumed per FAR (Food Acceptance Report) Mitigating factors (wounds, diarrhea, infections, other): (left blank) Interventions: Continue supplements, snacks, high calorie drinks . 12/24/2021 13:51 (01:51 PM) .Nutrition/Hydration Weight gain/loss; Hydration concern: CBW 128.8 lbs- down 2.5 lbs History/Precipitating factors: PO intake is down this week at 85% of meals consumed on average per FAR Mitigating factors (wounds, diarrhea, infections, other): (left blank) Interventions: Continue supplements, snacks, high calorie drinks. Review of advanced directives/code status: Full code . 12/22/2021 08:49 (AM) Dietary Progress Notes Note WEIGHT WARNING: Value: 132.2 . -7.5% change [ 8.4% , 12.1 ] -10.0% change [ 12.2% , 18.4 ] The resident has been identified with significant weight loss x 180 days. Etiology unknown- potentially r/t (related to) underlying catabolic disease process such as cancer. Ht (height) 72 (inches) , CBW 12/21 132.2 lbs/ IBW (ideal body weight) 178 lbs +/- 10% .100% intake of facility diet necessary to meet minimum estimated nutritional needs; PO intake at 82% of meals consumed per FAR. Magic cup BID (twice per day), health shake BID, snacks BID, whole milk TID (three times per day) in place for nutrition support. Was trialing an appetite stimulant; the resident may benefit from this again. Resident to be reviewed in next .meeting. Advanced directives reflect full code and includes life sustaining treatments, not excluding artificial nutrition support. Physician aware, will continue to follow on weekly weights. Care plan reviewed. 12/10/2021 16:25 (04:25 PM) .Nutrition/Hydration Weight gain/loss; Hydration concern: CBW 131.3 lbs- down 3.3 lbs x 30 days History/Precipitating factors: PO intake remains good at 94% of meals consumed on average per FAR Mitigating factors (wounds, diarrhea, infections, other): (left blank) Interventions: [MEDICATION(S)] completed. Continue supplements, snacks, high calorie drinks . On 01/04/2022 at 12:42 PM, Resident #25 was observed dressed and groomed sitting in their room with their lunch tray in front of them. Resident #25 was moving their food around on their tray to set the tray up. Resident #25 was asked about the lunch and stated, It is good, I like tacos, we have them on Tuesdays. A record review of the Nutrition Care Plan (initiated 01/08/2018) for Resident #25 revealed the following: Focus: The resident has potential for nutritional deficits r/t diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident has hx (history of) PEG (Percutaneous Endoscopic Gastrostomy-a tube insertion through the abdominal wall for artificial nutrition administration) tube use but has been on an oral diet since 2018. Triggers for 180 day significant weight loss . Goal: The resident will maintain adequate nutritional status and tolerate the least restrictive diet, with goal to restore weight towards IBW as tolerated through review date. Interventions: Administer medications as ordered. Monitor/Document for side effects and effectiveness. Monitor FAR and fluid intake and offer alternative choices for refused food and fluids PRN (as needed). Dislikes squash, broccoli, spinach, cornbread, oatmeal. Monitor weights per policy for significant changes. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Prefers to eat meals in his room. Encourage him to eat in the main dining room. Provide and serve diet as ordered. Provide and serve supplements as ordered: Magic cup BID, health shake BID. Send scheduled PM and HS (hour of sleep) snack to provide additional cals. A review of the FAR (from 12/06/2021-01/04/2022) for Resident #25 revealed no documentation of meal intake for the following meals: 12/06/2021-no dinner intake documented. 12/07/2021-no breakfast or lunch intake documented. 12/08/2021-no lunch intake documented. 12/09/2021-12/13/2021-no meal intake documented. 12/14/2021-no breakfast or lunch intake documented. 12/15/2021-12/17/2021-no meal intake documented. 12/18/2021-no dinner intake documented. 12/19/2021-no meal intake documented. 12/20/2021-12/23/2021-no dinner intake documented. 12/24/2021-12/25/2021-no meal intake documented. 12/26/2021-12/27/2021-no breakfast or lunch intake documented. 01/01/2022-no lunch or dinner intake documented. 01/02/2022-no dinner intake documented. 01/03/2022-01/04/2022-no meal intake documented. On 01/05/2022 at 11:50 AM, Registered Dietician (RD B) was interviewed via phone in regard to Resident #25's weight loss. RD B stated, (Resident #25's weight loss) is tricky, I tried different angles. I have talked to the Doctor, the Nurse Practitioner, I have asked for cancer tests, a colonoscopy .If the weight did not improve, (Resident #25) was on a PEG tube before, they may need it again. (Resident #25) gets health shakes and magic cup twice per day. Their weight has slowly been trending up. RD B was asked if the completion of FARs has been an issue in the building and stated, Yes, I have addressed this with [Director of Nursing/DON] and [Inservice Coordinator], to educate the new staff to document the FARs. On 01/05/2022 at 01:36 PM, the DON and Nursing Home Administrator (NHA) were interviewed in regard to Resident #25's weight loss. The DON stated, [RD B] works closely with (Resident #25). She sees (Resident #25) twice per week. I know at one point (Resident #25) was on a medication (to stimulate appetite), but I am not sure if (Resident #25) still is. The DON was asked if there was a problem within the facility of completing FARs. The DON stated, I am not aware of FAR documentation being problem. The DON and NHA were asked how they could effectively monitor Resident #25's appetite if the FARS were not completely filled out. The DON stated, (Resident #25) is stable. I know (Resident #25) eats. No further explanation was provided by the end of the survey. A review of the facility policy titled Weight Monitoring dated 01/01/2021 revealed the following: .7. Documentation .c. Meal consumption information should be recorded and may be referenced by the interdisciplinary care team as needed.

Based on observation, interview, and record review, the facility failed to provide showers and assistance with Activities of Daily Living (ADL's) for one sampled resident (R57) out of four reviewed for ADL Care, resulting in matted hair, feelings of frustration, and dissatisfaction with care. Findings include: On 01/03/2022 at 1:00 PM, R57 was seen in bed brushing their hair. R57 stated that they were applying detangling spray in their hair. R57 stated that they do what they can but is unable to reach the back of their head. Upon further observation R57 hair was noted to be matted and tangled in the back of their head. Registered Nurse (RN) G also observed R57 brushing their hair and stated they would have someone come in to help them brush their hair. On 01/04/2022 at 10:26 AM, R57 was queried as to whether they received help to comb their hair as requested. R57 stated that they had not received help and their hair was still matted. On 01/05/2022 at 11:24 AM, R57 stated that they still had not received help. R57 stated that somebody stated they were going to come back and help two days ago, but they never did. R57 stated that, they weren't going to worry about it, because the facility is understaffed and has bigger things to worry about. R57 was queried about the last time they had a shower that included getting their hair washed and R57 stated that they could not remember. A review of R57's point of care charting related to showers for the last 30 days revealed the following: 12/8,12/12,12/19, and 12/26 documented a response that R57 refused their shower. 12/31 documented a response of not applicable. A review of R57's care plan did not note a behavior or refusing showers. A review of R57's medical record revealed that R57 admitted into the facility on [DATE] with the following diagnoses, [CONDITION(S)] of Right Lower Limb, Major Depressive Disorder, and Difficulty in Walking. A review of the Minimum Data Set, dated dated dated [DATE] noted a Brief Interview for Mental Status score of 15/15 indicating intact cognition. R57 also required limited to extensive assist with bed mobility and transfers. On 01/05/2022 at 1:36 PM, an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) regarding ADL Care. The DON stated that R57 often refuses care, including showers. The DON stated that, it should definitely be documented, and care planned if someone refuses a shower. The DON stated that the nurse should be following up with documentation and they should be following up with the resident multiple times. A review of a policy titled, Activities of Daily Living revealed the following, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

This citation pertains to intake # MI 362. Based on interview and record review, the facility failed to bridge (provide protection underneath the tubing so it does not press against the skin) the tubing of a wound vac (a pump utilized on wounds to remove excess drainage) for one (Resident #701) of two residents reviewed for pressure ulcer care, resulting in the worsening of a pressure wound and pain. Findings include: On 08/02/2021 at 08:35 AM, Confidential Witness A was interviewed regarding Resident #701's wound care while at the facility. Confidential Witness A explained that the Resident was admitted to the facility on [DATE] with a wound on their buttocks area. Confidential Witness A stated, (Resident #701) went to the wound clinic on 06/29/2021, I was there. They (the facility) had forgot to put padding under the wound vac tubing, and the wound got worse! (Resident #701) was screaming in agony because of the pain. The following week we went back to the wound clinic, and they (the facility) forgot the wound vac! The Doctor took one look at the wound and said to send (Resident #701) to the hospital. A record review of the pictures of the wound provided with the intake revealed the following: 06/21/2021-A paper ruler with the date was against the wound indicated the wound was about eight inches in length. The wound was oval-like in shape and had clean edges that were pink, with red, epithelial (viable tissue growth) tissue noted at 9 o'clock, and black, necrotic (nonviable) tissue at 3 o'clock. The skin surrounding the wound had no redness, swelling or breakdown. 06/29/2021-The picture revealed a larger wound (unable to determine approximate measurement), with a large amount of yellow, slough (nonviable) tissue. There was a red, linear laceration extending out from the original wound. The skin around the wound was bright red and macerated (caused from prolonged exposure to moisture). The redness extended across the whole buttock region. A record review of the Treatment Administration Record (TAR) for June 2021 revealed the following wound order for Resident #701: Wound vac to sacral wound .continuous. Cleanse with wound cleanser. Tuck puracol in undermining then black foam to wound, skin prep to peri-wound and then cover with drape. Change 3 x/week .every Mon, Wed, Fri for wound. Start date 06/25/2021. The treatment to the wound was signed out as completed on 06/25/2021 and 06/28/2021. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #701 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating an intact cognition, and needed extensive two-person assistance with bed mobility. Resident #701 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/02/2021 at 02:18 PM, Wound Care Nurse B was interviewed via telephone regarding Resident #701's wound. Wound Care Nurse B stated, When I seen (Resident #701 on 06/28/2021), it looked like they had some pressure areas where the (wound vac) tubing was. There was not a bridge there (under the tubing), so I bridged it. The next day, (Resident #701) went to the wound clinic, and it was put on hold. Wound Care Nurse B explained that she had not done the first treatment change on 06/25/2021. A review of the wound care notes authored by Wound Care Nurse B revealed the following: 06/28/2021- res (resident) has noted non blanchable (skin does not change back to normal color when pressed on lightly, indicating poor blood flow to the area related to prolonged pressure) pressure, dark purple area where which appears to be from tubing from wound vac noted at 9 o'clock, 3 cm (centimeter) in length from wound edge. Res also has loss of skin tissue/excoriation that s 2/5 cm in length between 5 and 7 o'clock on outer edge of wound . A review of the progress notes for Resident #701 revealed the following: 06/24/2021 11:39 (AM) .physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .status post [MEDICAL RECORD OR PHYSICIAN ORDER] .Patient will have antibiotic therapy with IV (intravenous) [MEDICATION(S)] (antibiotic) .through 7/22/2021 and [MEDICATION(S)] (antibiotic) every 8 hours through 7/15/2021 steroid taper [MEDICATION(S)] .daily through 6/30/2021 . Pain control will be with oxycodone-acetaminophen .tabs every 4 hours as needed for pain control. Patient has wound VAC to sacral wound . 06/25/2021 10:10 (AM) Transcribed NP/PA (Nurse Practitioner/Physician's Assistant) Progress Note .Chief Complaint / Nature of Presenting Problem: Generalized pain/wound/refill patient's [MEDICATION(S)] This patient is being evaluated per nursing request due to the above concerns. Patient has generalized pain including on .left buttock . Continue patient's wound VAC for .left buttock coccygeal wound. Consult wound care nurse to evaluate make recommendations . 07/07/2021 14:03 (02:03 PM) Nurses' Notes .Res to be admitted to [Local Hospital] per family and PCP (Primary Care Physician) .request after appointment at WCC (wound care clinic) A record review of the skin assessments for Resident #701 revealed the following: 06/23/2021 (Admission)-Sacrum 4 (length in centimeters) x 3.5 (width) x 1.5 (depth). Stage 4 (wounds staged from 1-4, 4 with the most extensive damage through the muscle to the bone). 07/05/2021-Sacrum 6.9 (centimeters) x 5 x 2. On 08/02/2021 at 2:00 PM, an interview was completed with the Director of Nursing (DON) and Nursing Home Administrator (NHA). The DON was asked about the training that the nurses receive on wound vacs and explained that the facility gets frequent residents on wound vacs and that the nurses were very familiar with how to utilize wound vacs properly. The DON was asked about the bridging not being applied to the wound of Resident #701. The DON did not offer an explanation but explained that the wound itself was in a fragile state. A review of the facility policy titled Pressure Injury Prevention and Management dated 01/01/2021 revealed the following: .4. Interventions for Prevention and to Promote Healing .c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to .Redistribute pressure (such as repositioning, protecting and/or offloading heels .Minimize exposure to moisture and keep skin clean .Provide appropriate, pressure-redistributing, support surfaces .

Based on observation, interview and record review, the facility failed to ensure ongoing assessment and monitoring of nutritional status and implement planned interventions for one (#5) of six Residents reviewed for nutrition, resulting in lack of timely monitoring, assessment, reassessment, and implementation of planned interventions and Resident #5 experiencing a significant weight loss and the likelihood for decline in overall health status. Findings include: On 9/15/20 at 9:56 AM, an observation of Resident #5 occurred. From the hallway, Resident #5 was noted to be in bed, positioned on their back. A full cup of a clear colored liquid was present on the table in the Resident's room. The cup was not within the Resident's reach. An interview was attempted to be completed at this time. When asked questions, Resident #5 stated, There are needles in my legs and asked for assistance to adjust the pressure reduction boots in place indicating they were having pain. When asked additional specific questions, Resident #5 did not provide meaningful responses. Record review revealed Resident #5 was most recently admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired, was independent with set-up assistance for eating, and required limited to extensive assistance with all other Activities of Daily Living (ADLs). Review of Resident #5's care plans revealed a care plan titled, The resident is at risk for nutritional declines r/t (related to) nutritionally-pertinent [DIAGNOSES REDACTED]. The care plan included the interventions: -Monitor FAR (Food Acceptance Record) and fluid intake and offer alternative choices for refused food and fluids PRN (as needed) (Initiated: 9/15/20) -Offer HS (bedtime) snacks and additional snacks as desired (Initiated: 3/19/20) -Provide diet as ordered: Controlled Carb, Mechanical soft, ground meats (Initiated: 3/19/20; Revised: 6/19/20) -Provide supplements as ordered: Health shakes (Initiated: 3/30/20; Revised: 7/2/20 and 8/24/20) Detailed review of this care plan revealed it was revised after survey entrance on 9/15/20. The intervention, Monitor FAR (Food Acceptance Record) and fluid intake and offer alternative choices for refused food and fluids PRN (as needed) was initiated and the intervention Monitor weekly weights for significant changes (Initiated: 3/19/20) was resolved on 9/15/20. On 9/16/20 at 12:10 PM, Resident #5 was observed in their room in bed. A food tray was in place in front of the Resident. The Resident appeared easily distracted and was not actively eating their meal. When asked if they liked the food, the Resident did not respond. No staff were present to assist the Resident to eat. Review of Resident #5's documented weights revealed a significant weight loss of 11.96% between 3/26/20 and 9/13/20, an 7.74% weight loss between 6/7/20 and 9/6/20, and a 5.48 % weight loss between 8/2/20 and 9/6/20. Detailed review of Resident #5's documented weights displayed the following: -9/13/20 at 5:28 PM: 159.0 pounds (lbs.) . Chair -9/6/20 at 7:47 AM: 162.0 lbs . Chair -8/17/20 at 1:59 PM: 168.0 lbs . Hoyer -8/16/20 at 1:35 PM: 166.0 lbs . Wheelchair -8/9/20 at 7:12 AM: 172.0 lbs . Sitting -8/2/20 at 6:52 AM: 171.4 lbs . Hoyer -7/26/20 at 11:23 AM: 176.0 lbs . Sitting -7/19/20 at 11:22 AM: 175.0 lbs . Sitting -7/12/20 at 10:08 AM: 177.0 lbs . Hoyer -6/28/20 at 9:08 PM: 180.0 lbs . Wheelchair -6/21/20 at 9:28 PM: 182.0 lbs . Hoyer -6/14/20 at 9:46 PM: 175.2 lbs . Sitting -6/14/20 at 8:30 PM: 174.2 lbs . Sitting -6/7/20 at 8:01 PM: 175.6 lbs . Hoyer -5/17/20 at 8:28 PM: 175.8 lbs . Hoyer -4/19/20 at 8:05 PM: 190.2 lbs . Hoyer -3/26/20 at 2:39 PM: 180.6 lbs . Chair Review further revealed Resident #5's weight upon readmission to the facility from the hospital was 172.1 on 3/18/20 at 5:25 PM and they had weighed 178.0 lbs during their previous stay in the facility. Review of nutritional assessment and status documentation in Resident #5's medical record revealed the most recent nutritional assessment progress note was dated 7/2/20. Prior to 7/2/20, weekly progress note documentation was present from 3/23/20 to 7/2/20. Review of progress note documentation revealed the following: -3/23/20: SOC (Standards of Care) Nutrition/Hydration Weight gain/loss; Hydration concern: New to SOC d/t (due to) pressure ulcer. History/Precipitating factors . pressure ulcer on right buttock, varied intake, often sleeps in, confusion. Interventions: Prostat AWC . Will continue to monitor weekly . -4/2/20: SOC Nutrition/Hydration Weight gain/loss; Hydration concern: Weight is 180.6#, up from 172.1#. History/Precipitating factors .right buttock wound, healing well. Interventions: good intake . Comments: Weight is trending back up. Will continue to monitor in Nutrition . -5/18/20: SOC Nutrition/Hydration Weight gain/loss; Hydration concern: Weight is 175.8#, down from 177.6# History/Precipitating factors . wound almost healed, refused dinner on 5/16. Interventions: continue supps (supplement), eats 75- 100% most meals, Controlled Carb, Pureed diet . Will continue to monitor weekly in SOC . -6/22/20: SOC Nutrition/Hydration Weight gain/loss; Hydration concern: Weight is 182#, up from 175.2. History/Precipitating factors . right buttock wound improved. Interventions: diet upgraded from Pureed to Mechanical Soft per PA (Physician Assistant) (insurance did not cover SLT (Speech Language Therapist)); will continue Prostat AWC another week . Will continue to monitor weekly in SOC . -7/2/20: SOC Nutrition/ Hydration Weight gain/loss; Hydration concern: Weight is 180#, down from 182# History/Precipitating factors: Mitigating factors . wound is now closed per Wound Care Nurse. Interventions: varied intake; will continue Prostat for now. Comments: Will d/c (discontinue) from weekly SOC . An interview was conducted with Registered Dietician B on 9/17/20 at 7:49 AM. When queried regarding Resident #5's weight loss, Registered Dietician B indicated they were aware of the Resident's weight loss. When asked what interventions had been implemented to address the weight loss, Registered Dietician B stated, (Resident #5) was started on health shakes (nutritional supplement) about three weeks ago. Registered Dietician B was then queried regarding the Resident's weight loss trend and interventions and stated, (Resident #5) had some weight fluctuations. They were on Prostat AWC (nutritional supplement indicated for use in individuals with pressure ulcers- wounds caused by pressure) in June and July. When asked why Resident #5 was receiving Prostat AWC, Registered Dietician B replied, (Resident #5) had a wound at that time which had since healed. With further inquiry, Registered Dietician B stated, It (Prostat AWC) was discontinued on 8/3 (2020) and the health shake was started on 8/24 (2020). Registered Dietician B was queried why there was not an intervention in place prior to the health shake related to the Resident's weight loss and replied, The Doctor actually ordered the health shake so I was happy about that. When queried regarding the frequency in which they had assessed Resident #5's nutritional status, Registered Dietician B stated, I do an assessment anytime (a Resident) comes in and out of the hospital. Resident #5's medical record documentation was reviewed with Registered Dietician B at this time. Review revealed a complete Nutritional Data Collection/Evaluation was completed for Resident #5 on 3/19/20 and on 6/18/20. When asked if they complete additional assessment and documentation pertaining to Resident's nutritional status, Registered Dietician B indicated they also document in the Progress Note section of the medical record. Resident #5's documentation was reviewed with Registered Dietician B at this time. When asked why they last assessed and documented a progress note for the Resident occurred on 7/2/20, Registered Dietician B indicated Resident #5 was removed from the SOC Nutrition monitoring after their pressure ulcer had healed. Registered Dietician B was then asked how they assessed Resident #5's nutritional status and weight and stated, I check weights every morning. Registered Dietician further indicated they review Resident's Food Acceptance Record (FAR) documentation in the medical record. When queried regarding the frequency of weight monitoring, per facility policy/procedure, for Residents with weight loss or fluctuations in weights, Registered Dietician B replied, Weekly or more. When asked if Resident #5 should have been weighed weekly, Registered Dietician B indicated they should have been. Resident #5's documented weights were reviewed with Registered Dietician B at this time. When queried why Resident #5 had not been weighed weekly, Registered Dietician B stated, They must have changed it back. Registered Dietician B then stated, (Resident #5) was discharged from SOC weights on July 2. When asked, Registered Dietician B elaborated that SOC weights are completed weekly per facility policy/procedure. Resident #5's calculated weight loss percentages were reviewed with Registered Dietician B at this time. When queried regarding weekly weights being an active intervention on the Resident's care plan at that time, Registered Dietician B did not provide an explanation. When queried regarding the calculated weight loss and facility assessment and monitoring, Registered Dietician B stated, The way I do it is week to week and month to month. Registered Dietician B was then queried regarding the Resident's weight on 9/6/20 and why they had not documented an assessment and or implemented an intervention. Registered Dietician replied, On 9/8, I reviewed the 9/6 weight and requested a re-weight. I didn't get the reweight until 9/13. When asked why the re-weight was not completed until a week after it was requested, Registered Dietician B stated, It wasn't done promptly. When queried regarding interventions including staff assistance during meals for Resident #5, Registered Dietician B indicated facility staff assist Residents with dining as needed. When queried regarding assistance during meals not being included on the Resident's care plan, Registered Dietician B did not provide a response. When asked if Resident #5's planned intervention of weekly weight monitoring would have assisted in timely recognition and implementation of additional interventions to prevent/mitigate further weight loss and/or decline, Registered Dietician B replied, I don't know. It doesn't make sense. Review of Resident #5's Food Acceptance Record (FAR) for 8/19/20 to 9/16/20 revealed missing documentation of the Resident's meal percentage intake. Review revealed the Resident commonly consumed between 25 to 50 percent of their meals. Review revealed multiple dates with missing intake percentage documentation including: -Intake percentage documentation for only two meals on: 8/20/20, 8/31/20, 9/2/20, 9/5/20, 9/10/20, 9/11/20, and 9/14/20 -Intake percentage documentation for only one meal on: 8/21/20, 8/27/20, 8/28/20, 8/29/20, 8/30/20, 9/1/20, 9/3/20, 9/4/20, 9/8/20, 9/9/20, and 9/15/20 On 9/17/20 at 11:35 AM, an interview was conducted with Registered Dietician B. At this time, Registered Dietician B indicated they utilized different dates when calculating Resident #5's weight loss percentage which had indicated a four percent loss over a month timeframe. An interview was completed with the Director of Nursing (DON) on 9/17/20 at 12:14 PM. When queried regarding Resident #5's weight loss and lack of interventions, the DON indicated they were aware of the weight loss but did not provide further explanation. Review of facility policy/procedure entitled, Weight Assessment and Intervention (Revised 11/18), revealed, The nursing staff and the Dietitian will collaborate to prevent, monitor, and intervene for undesirable weight loss for our residents . 3. Any weight change of greater than or less than 5 pounds since the prior weight will be retaken within 24 hours for confirmation with licensed nurse confirming the reweigh. If the weight is verified, nursing will notify the physician, make a referral to the dietician, and notate on the 24-hour report for follow-up . 4. The Dietitian will respond within 24 hours of receipt of written notification. 5. The Dietitian will also review the weights for significant changes and insidious weight trends, negative trends will be assessed and addressed by the Dietitian whether or not the definition of Significant Weight Change is met . 9. Care Plan interventions will consider: a. Severity of change; b. Medical diagnosis (e.g., condition, prognosis, and stability); c. ADL status; d. Medications . 10. Interventions for undesirable weight loss should focus first on food (e.g., extra food, snacks, calorie-dense food, etc). Liquid nutritional supplements, per facility formulary, may be considered if resident caloric intake remains inadequate to stabilize or increase weight . The physician may order tests, appetite stimulants, or medications as appropriate .

Based on observation, interview, and record review, the facility failed to maintain the hand sink plumbing, the garbage grinder atmospheric vacuum breaker, the seal on the(NAME)cooler, and failed to ensure adequate lighting levels in the walk-in cooler, resulting in standing water on the floor, the potential for backflow of contaminants into the potable water supply, and the increased potential for improper food storage temperatures. These deficient practices had the potential to affect all residents in the facility. Findings include: On 9/15/20 between 8:30 AM and 9:30 AM, during an inspection of the kitchen with Dietary Manager (DM) O, the following items were observed: 1. The drain pipe for the hand washing sink was observed to be actively dripping water onto the floor. There was a small bucket underneath to catch the water, and there was water pooled on the flooring underneath. According to the 2013 FDA Food Code section 5-205.15 System Maintained in Good Repair, A plumbing system shall be: .(B) Maintained in good repair. 2. The atmospheric vacuum breaker (backflow prevention device) for the garbage grinder side sprayers, was observed to be missing the cap, leaving the inner workings of the device exposed. According to the 2013 FDA Food Code section 5-202.14 Backflow Prevention Device, Design Standard. A backflow or backsiphonage prevention device installed on a water supply system shall meet American Society of Sanitary Engineering (A.S.S.E.) standards for construction, installation, maintenance, inspection, and testing for that specific application and type of device. 3. The door on the left side of the(NAME)cooler was observed with a faulty seal. When closed, there were gaps between the door gasket and the front of the cooler. When queried, DM O stated, They just replaced the seal. He told me I have to hold it in for 10 seconds, and then it will seal. DM O tried to hold the door closed to ensure a seal, but the gasket still provided no seal against the unit. According to the 2013 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment, .(B) Equipment components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. 4. The lighting levels inside the walk-in cooler were observed to be extremely dim. The bulbs inside the fluorescent light fixtures were observed to be dim and flickering, and there was a bulb missing in one of the light fixtures. DM O confirmed that the lighting levels were dim, and stated, I'll let maintenance know. According to the 2013 FDA Food Code, section 6-303.11 Intensity, The light intensity shall be: (A) At least 108 lux (10 foot candles) at a distance of 75 cm (30 inches) above the floor, in walk-in refrigeration units and dry food storage areas and in other areas and rooms during periods of cleaning;

Based on observation, interview and record review, the facility failed to operationalize policies and procedures to implement a comprehensive infection control program including assessment and application of infection control and isolation procedures per Centers for Disease Control (CDC) recommendations and standards of practice for newly admitted Residents and Residents with new onset respiratory infection symptoms and failed to implement comprehensive surveillance and tracking of signs/symptoms of infections for five sampled (#'s 18, 34, 57, 60, and 187) and one unsampled Resident of two Residents reviewed for respiratory infections resulting in lack of readily accessible hand hygiene equipment, inadequate utilization of Personal Protection Equipment (PPE), lack of dedicated equipment for Residents in the isolation unit, and the likelihood for spread of infection to all Residents within the facility. Findings include: An interview was conducted with the facility Administrator on 9/15/20 at 9:15 AM. When queried regarding facility policy/procedure pertaining to Residents admitted /re-admission related to current Covid-19 recommendations, the Administrator revealed Residents who are admitted or readmitted to the facility are placed in designation isolation unit (E Hall) for 14 days. When asked what PPE is utilized, the Administrator indicated gowns, gloves, an N-95 (respirator mask that is worn snuggly to the face to filter 95% of 0.3 microns sized airborne particles) covered by a blue droplet mask, and eye protection (face shield or goggles). The Administrator further specified that PPE is donned (applied) before entering each Resident room and doffed (removed) before exiting the room. When asked, the Administrator detailed that facility Staff change the blue mask covering their N95 mask between each Resident and must clean googles/face shield prior to exiting the Resident's room. On 9/15/20 at 9:09 AM, Resident #18 was observed in their room in bed. An interview was conducted at this time. When asked how they were feeling, Resident #19 revealed they were still having a rash. With further discussion, the Resident was confused and unable to provide meaningful responses when asked direct questions. A tour of the new admission isolation unit (E hall) of the facility began on 9/15/20 at 10:18 AM. The isolation unit was separated from the other hall of the facility by a moveable wall petition that was open on the top and bottom. Upon entering the unit, all the doors of occupied Resident rooms were noted to be open. Coughing from within several Resident rooms could be heard from the hallway and no staff were present in the hallway. A wrist style blood pressure monitor and an oral thermometer where noted sitting on the nurses' medication cart and on a table in the hall. Each Resident room door had a hanging PPE station in place on the room door. Two hand sanitizer dispensers were present on the walls in the isolation unit, both dispensers were located near the movable petition wall. On 9/15/20 at 10:23 AM, Unsampled Resident A was observed in their room in bed and a hanging PPE station was noted on the outside of their open room door. After donning PPE and entering the room, an interview was completed. When asked what PPE staff wear when they enter their room to provide care, Unsampled Resident A replied, Don't always wear it. At this time, Unsampled Resident A began coughing. Their cough was moist and harsh sounding. When asked, Unsampled Resident A revealed they had been coughing for a couple days but was unable to recall the specific date when the cough started. When asked if they had been tested for Covid-19 infection, Unsampled Resident A indicated they had not been tested recently. Unsampled Resident A was then asked what equipment staff use to monitor their vital signs, including temperature, and replied, They (staff) bring it (vital sign monitoring equipment) in. When asked, Unsampled Resident A revealed the door to their room is always left open. No dedicated vital sign monitoring equipment was observed in the Resident's room. A container of cleaning wipes was noted in the Resident's bathroom. After doffing PPE to exit the Resident's room, hand hygiene equipment was not readily accessible. A hand sanitizer dispenser was not present in the Residents room and it was necessary to walk back into the room, without PPE and within six feet of the Resident, to utilize the sink in the Resident's room which the Resident also uses. At 10:36 AM on 9/15/20, Resident #187 was observed in their room in the isolation unit of the facility and an interview was completed. When asked, Resident #187 revealed they had recently returned to the facility from the hospital. When asked the reason they were in the hospital, Resident #187 stated, Infections. When asked, Resident #187 revealed they were coughing occasionally. When queried if staff wore PPE when they entered their room, Resident #187 revealed staff do not consistently wear PPE. Observation of Resident #187's room and storage areas within their room revealed there was no dedicated vital sign monitoring equipment present. A container of cleaning wipes was noted in the Resident's bathroom. When asked how staff monitor their temperature and other vital signs, Resident #187 replied, They (staff) bring in a thermometer, wrist blood pressure, and finger thing (portable oxygen saturation monitor). Record review revealed Resident #187 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive to total assistance to perform Activities of Daily Living, except for eating. Review of Resident #187's laboratory diagnostic testing results in the medical record revealed the Resident was most recently tested in the facility for Covid-19 infection on 8/19/20. On 9/15/20 at 10:46 AM, an observation of Resident #57 and their roommate occurred in the isolation unit of facility. A hanging isolation PPE cart was present on the open door of the room. Resident #57's roommate was sitting in a reclining chair with their eyes closed, directly next to the open door of the room. The Resident was within two feet proximately of the open door and hallway. In order to don PPE, with the room door open, physical distancing of six feet was unable to be maintained. Resident #57 was observed sitting in a chair next to their bed and an interview was conducted. When asked how they were feeling and if they had any signs and/or symptoms of Covid-19, Resident #57 revealed they had a cough. A container of cleaning wipes was noted in the Resident's bathroom and dedicated vital sign monitoring equipment was not noted in the room. Record review revealed Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required extensive assistance to perform Activities of Daily Living (ADLs). On 9/15/20 at 11:48 AM, an interview was conducted with Physician Assistant L and LPN C in the hallway of the facility isolation unit. When queried regarding facility policy/procedure pertaining to Covid-19 screening and Resident admissions/re-admissions, Physician Assistant L stated, They (Residents) have to have a negative test from the hospital. When asked if Residents are admitted if they do not have a negative Covid-19 test, Physician Assistant L replied, I don't think so. Physician Assistant L elaborated further and stated, If it has been over a week (since tested at the hospital), they test them (Residents) here. When asked if Residents are tested routinely for Covid-19, Physician Assistant L replied, No, not unless there are symptoms. LPN C was then asked how they know if Residents are having symptoms, such as coughing, when they are not present on the isolation unit all the time due to also being assigned Residents not on the isolation unit, LPN C replied, Ask the CNA (Nursing Assistant). When asked if the Nursing Assistant was on the isolation unit all the time, LPN C stated, No, they (Nursing Assistant) float between halls. LPN C was then asked if Residents on the isolation unit of the facility exit their rooms and replied, Some do. On 9/16/20 at 8:00 AM, Resident #18 was observed in their room in bed. The Resident was focused on having a rash when speaking to them and did not provide responses to questions when asked. An interview was completed with Nursing Assistant F on 9/16/20 at 8:03 AM. When queried regarding Resident #18, Nursing Assistant F replied, (Resident #18's) real problem is the rash thing. It's like scabs. At 8:05 AM on 9/16/20, an interview was conducted with LPN K. When queried regarding Resident #18, LPN K stated, (Resident #18) just went to dermatology (appointment). When asked the date of Resident #18's appointment, LPN K replied, I am not sure what the date was, but I know the nurse got a call about the biopsy report. When asked if a Dermatology provider came to the facility or if Resident #18 left the facility to go to the appointment, LPN K stated, (Resident #18) went out to the appointment. When asked, LPN K indicated the Resident went to the appointment within the past two weeks. With further inquiry, LPN K revealed they would find the date the Resident went to the dermatologist and would follow up as the note was not scanned into the Electronic Medical Record (EMR). LPN K was then asked if Resident #18 was placed in isolation precautions after leaving the facility to go to the external dermatology appointment and replied, No. Record review of Resident #18's medical record revealed the Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required limited to extensive assistance to perform Activities of Daily Living (ADLs). Additional review of Resident #18's medical record revealed Resident #18 had been in their current room in the facility since 11/4/19. On 9/16/20 at 11:41 AM, an oral thermometer and a wrist blood pressure measurement device were observed on the medication cart in the isolation unit of the facility. An interview was conducted with Licensed Practical Nurse (LPN) C at this time. When queried regarding facility policy/procedure for obtaining vital signs, LPN C replied, Nurses and CNAs (Nursing Assistants) do vital signs. LPN C was then asked the frequency in which blood pressure is measured and replied, Midnights do every day. I only do them if I need it for meds (medication administration). When asked what equipment is utilized to obtain Resident vital sign measurements, LPN C indicated there should be dedicated equipment in each Resident's room. When queried why there was a thermometer and a wrist blood pressure monitoring device on the top of the medication cart, if there is dedicated equipment in each Resident room, LPN C revealed staff also use the vital sign monitoring devices on the medication cart. When queried how frequently Resident temperatures are taken, LPN C replied, Every shift. LPN C was then asked what device is utilized by staff to obtain Resident temperature and stated, We have a no contact thermometer in the med cart. At 11:54 AM on 9/16/20, Nursing Assistant G was pushing Resident #57 out of the shower room of the facility and down the hallway of the isolation unit in a wheelchair to the Resident's room. The shower room was located at the opposite end of the hall from the Resident's room. Nursing Assistant G did not have on gloves or a gown and the only PPE in place was a KN-95 mask without a droplet/procedural mask over the KN-95 mask. Resident #57 was wearing a hospital gown and had a droplet/procedural mask over their mouth. Upon reaching the Resident's room, Nursing Assistant G proceeded to enter the open doorway of the room while pushing the Resident in the wheelchair. After the Resident was just past the open door of the room (approximately three feet), Nursing Assistant G began donning PPE located in the hanging PPE cart on the door of the room. Nursing Assistant G did not perform hand hygiene prior to beginning to don PPE. An interview was conducted with Nursing Assistant G at this time. When queried, Nursing Assistant G revealed Resident #57 requires assistance with ADL care and that they had just provided a shower to the Resident. Nursing Assistant G was then asked what PPE was worn when assisting the Resident to shower and replied, Just a mask and pointed at the KN-95 mask they were currently wearing. When asked if they have to wear a gown or other PPE, per facility policy/procedure, due to the Resident currently being on isolation precautions related to admission and Covid-19, Nursing Assistant G stated, The Resident wears a blue (droplet/procedural) mask so we don't have to wear anything else. When queried if gloves were worn while showering the Resident, Nursing Assistant G replied, Well yeah. Nursing Assistant G was then asked if the wheelchair used to transport the Resident remained in their room and they indicated it did. With further inquiry regarding touching the Resident's wheelchair when pushing them in the hall without gloves, Nursing Assistant G indicated they did not think about touching the wheelchair. Nursing Assistant G was then asked about donning PPE without performing hand hygiene and revealed hand sanitizer and/or a sink were nearby to utilize. When queried regarding facility policy/procedure related to obtained Resident's vital signs on the isolation unit of the facility, Nursing Assistant G revealed both nursing and nursing assistants obtain Resident vital sign measurements. Nursing Assistant G stated, We do and sometimes nurses. We do on shower days. Nursing Assistant G was then asked what monitoring equipment is utilized to obtain vitals signs for Residents on the isolation unit and replied, They (Residents) should have vital sign equipment in their room. When asked if Resident #57 had vital sign monitoring equipment in their room, Nursing Assistant G entered the Resident's room, looked in various places, and stated, No, not in here. When queried if Resident #57's roommate had dedicated vital sign equipment in their room, Nursing Assistant G looked in the room and revealed there was also no dedicated vital sign equipment for Resident #57's roommate in the room. At 12:00 PM on 9/16/20, LPN C was observed exiting a Resident room on the isolation unit of the facility carrying a glucometer (medical device utilized to obtain Point of Care (POC) blood glucose levels). LPN C placed the glucometer directly on the top of the medication cart while unlocking the cart and then into a drawer in the medication cart without cleaning the device. An interview was completed at this time. When queried regarding disinfection and cleaning of the glucometer after using for a Resident on isolation precautions, LPN C stated, I used the peroxide wipes in the Resident's bathroom. LPN C was then asked if they had walked back through the Resident's room past the Resident without PPE and with the uncovered glucometer after cleaning it with a peroxide wipe in the Resident's bathroom and replied, Well, yes. When queried regarding facility policy/procedure pertaining to storing cleaning wipes in Resident bathrooms and cleaning reusable medical equipment in isolation rooms where PPE is supposed to be worn, LPN C did not provide further explanation. A review of the facilities Infection Control (IC) program was scheduled to be completed on 9/16/20 at 1:30 PM and transpired at 1:34 PM with the facility IC LPN D, Unit Manager Registered Nurse (RN) E and the Director of Nursing (DON). When asked to review facility IC surveillance and tracking including Covid-19 infections, IC LPN D stated, We don't have no Covid. When asked if they had ever had any Residents with Covid-19, IC LPN D replied, We put them on isolation on E-wing. When queried regarding facility staff, including contracted staff who had tested positive for Covid, IC LPN D revealed a therapy staff had recently tested positive. Facility staff were then queried regarding surveillance and tracking of Residents with signs/symptoms of Covid-19 and indicated all newly admitted Residents are placed in isolation to monitor Covid-19. When queried regarding testing for Covid-19, the DON stated, Staff are being tested weekly. When asked if Residents were also tested weekly, the DON replied, No, not unless they have something on their Covid screen. The DON was then queried regarding the facility policy/procedure pertaining to new admissions and replied, They (new admits) to unit on isolation. We do a Covid test if they have not had a test within 72 hours (of admission). When asked about facility policy/procedure if a Resident did have a test within 72 hours of admission, the DON stated, If they have had a test, then we do not. When asked if the facility is using the testing or symptom method to monitor for Covid-19 infection, the DON stated, A combo really. Symptom method, we will decide on testing based on the symptoms. The staff were then queried regarding facility policy/protocol for new onset respiratory symptoms. IC LPN D stated, If it is Covid related then we test but it is individualized. With further inquiry, IC LPN D expanded, If there is a positive Covid screen then we talk to the Doctor. With further inquiry regarding the Covid screen completed for Residents in the Medication Administration Record [REDACTED]. When queried how comprehensive screening for signs and symptoms of Covid-19 is completed by facility nursing staff when they are not on the isolation unit consistently throughout their shift due to having a Resident assignment in a different hall (no dedicated staff for isolation unit) and Residents with decreased cognitive and physical function on the isolation unit, the DON replied, Well, this is not an acute care. With further inquiry related to not having dedicated staff assigned to the isolation unit, the DON stated, We base our nurses and nurses' aides (staffing) on acuity. The DON was queried regarding the Centers for Disease Control (CDC) recommendations pertaining to staff on an isolation unit and replied, The CDC does recommend dedicated staff. When questioned if all Residents who are admitted , readmitted , and/or leave the facility for an appointment are placed in isolation precautions in the dedicated isolation unit upon their return to the facility, IC LPN D replied, Yes. Facility staff were then asked about facility policy/procedure related to PPE use in the isolation unit. IC LPN D stated, PPE is changed for each room. When asked about staff face shields or goggles, IC LPN D stated, Wash in the room (with soap and water). When queried regarding PPE removal at the door of the room and staff having to reenter Resident rooms to utilize the sink to wash their face shield or goggles, IC LPN D did not provide an explanation. The DON then added, Or use a bleach wipe and indicated bleach wipes are maintained in the locked medication cart on the hall. When asked about the peroxide wipes observed in Resident bathrooms and observation of LPN C with the glucometer, both the DON and Unit Manager RN E replied, No and revealed cleaning wipes should not be kept in Resident bathrooms. The DON then stated, I can't believe it. That is not acceptable. Staff were then queried regarding the location of hand sanitizer in the unit including Resident rooms not having sanitizer dispensers and lack of easily accessible sanitizer in the hall of the facility. Unit Manager RN E indicated they were aware of the lack of readily available sanitizer and stated, I know they talked about it. When asked what PPE is required to be worn by staff when providing showering assistance to Residents on the isolation unit of the facility, Unit Manager RN E and IC LPN D both revealed all PPE (gloves, N95 mask, procedural/droplet mask), gown, and eye protection) should be worn. When asked what PPE staff should wear when taking a Resident back to their room after a shower in the hallway of the isolation unit, IC LPN D and RN E indicated gloves and a N95 mask with a droplet/procedural mask should be utilized. The DON stated, (Staff should) Wear all PPE in the shower and then in the hall. Remove when get back to room. When asked about vital sign monitoring equipment for Residents in isolation, all three staff revealed Residents on isolation precautions should have dedicated vital sign monitoring equipment in their room. When queried regarding observations of rooms not having dedicated equipment, RN E stated, I put one (vital sign equipment) in (Unsampled Resident A's) room yesterday. No further explanation was provided. When queried regarding all the Resident doors in the isolation unit being observed open and facility policy/procedure, the DON revealed the Resident room doors can be open per the Regional Nurse. With further inquiry regarding CDC recommendations regarding Resident room doors being open, the DON did not provide further explanation. Review of facility infection control surveillance and tracking data reviewed an undated and unsigned document for each month, except May 2020, related to process surveillance. Review of the document indicated process surveillance was completed once per month. The process surveillance form for June 2020 included a section, Transmission precautions are followed according to policy and procedures . The form included handwritten documentation of Nurse/CNA verbal education and further had a section PPE is used as required with See above written. When asked what occurred in June related to PPE, including location within the facility and if any infections resulted from improper PPE procedures, IC LPN D replied, I'm not sure. Review of line listing documentation revealed documentation of facility tracking of Residents who had received antibiotic therapy (medication treatment) for infections. When queried regarding tracking and documentation of Residents with infections prior to or who did not receive antibiotic treatment, IC LPN D revealed they do not track and monitor infection status of Residents who do not receive treatment. When asked how they are able to identify infections early and comprehensively when they are not actively tracking signs and symptoms of potential/actual infections, IC Nurse LPN D was unable to provide an explanation and/or documentation of surveillance. Further review of line listing documentation revealed Resident #60 was listed as having a respiratory infection with treatment in April 2020. When queried if Resident #60 had Covid testing, IC LPN D replied, Yes on 4/20 and reported on 4/24 (2020). When asked why the Resident was not tested for Covid until 4/20/20 when medical record documentation revealed the Resident had a temperature of 100.5 degrees Fahrenheit, coughing, sore throat, a decreased oxygen saturation of 93%, and shortness of breath when lying flat on 4/17/20, IC LPN D was unable to provide an explanation. When asked if the Resident was placed in isolation precautions and/or moved to a private room, IC LPN D revealed they were not sure and would have to look to determine if and when the Resident was moved/isolation was implemented. An interview was completed with the facility Administrator and RN N on 9/16/20 at 4:28 PM. When queried regarding facility policy/procedure regarding implementation of isolation precautions related to potential Covid-19 exposure for Residents, the Administration and RN N indicated newly admitted Residents are placed in the isolation unit of the facility for monitoring. When queried if Resident #18 had left the facility for an appointment outside, the Administrator indicated they had. When queried why the Resident was not placed in the Isolation unit upon their return to the facility, the Administrator revealed the Resident had worn a droplet/procedural mask when they left the facility. When queried if the Resident was in a private room and/or placed in isolation precautions upon their return to the facility, RN N reviewed the Resident's medical record and stated, No. A second interview was conducted with IC Nurse LPN D on 9/17/20 at 3:09 PM. When queried regarding the employee who had tested positive for Covid-19, IC LPN D revealed the employee was Speech Therapist M. When asked how the staff was identified as having Covid-19, IC LPN D revealed the employee tested positive but did not have symptoms. When queried regarding documentation of surveillance and tracking of employee call-ins and illness, IC LPN D revealed Therapy staff are contracted and the Therapy manager notified them of any staff call ins during their morning meetings. When asked where and how employee call ins are tracked in order to correlate trends of infection, IC LPN D revealed they get the call-in forms and presented a large pile of paper call in forms. When asked if the illness data from the call-ins was compiled for tracking and surveillance, IC LPN D stated, I like that and revealed they just reviewed the forms and remembered. With further inquiry regarding surveillance of the facility Residents treated by Speech Therapist M, IC LPN D revealed they did not have any surveillance/tracking data related to the Covid exposure. IC LPN D then revealed four Residents were placed on increased monitoring to every 4 hours. When asked how they knew what Residents to place on increased monitoring, IC LPN D stated, They (therapy) gave me a list. No further explanation was provided. On 9/15/20 at 10:42 AM, R34 was observed in their room. R34 was occupying the middle bed of three in the room and was observed to be forcefully coughing. When queried regarding the cough, the resident stated, I might have pneumonia. The resident did not have on a face mask, and both the resident's roommates did not have on face masks. On 9/15/20 at 1:55 PM, Licensed Practical Nurse (LPN) C was queried regarding R34's cough. LPN C stated, (R34) is awaiting a chest x-ray to rule out pneumonia. I wasn't here yesterday when the cough started. When queried if residents in the facility had been tested for COVID-19 recently, LPN C stated, They haven't been COVID tested in a while. R34 was heard and seen coughing in their room at this time. R34's roommates were still in the room and none of the residents were observed to have on face masks. On 9/16/20 at 10:16 AM, LPN K was queried regarding R34's chest x-ray that had been ordered. LPN K indicated the resident was still coughing and, has that back and forth. The x-ray was ordered on 9/14, done on 9/15, and LPN K pulled up the results on 9/16 which read Right middle lobe infiltrate. LPN K then stated the resident was on [MEDICATION NAME] (antibiotic) on 8/27 for pneumonia. Review of R34's progress notes revealed: 9/3/2020 13:23 SOC-Infection Type of infections/Signs & symptoms: Resident presented on 8-23-2020 with T (temperature) 102.3 (degrees Fahrenheit), confusion, cough, rhonchi, 02 sats of 88%. CXR (chest x-ray) ordered that showed modest right lobe infiltrates. 9/13/2020 05:14 Nurses' Notes Note Text: Add to note. O2 sat 91%. Respirations 18. Will continue to monitor. 9/13/2020 04:49 Nurses' Notes Note Text: Resident coughing still. Lungs sounds auscultated. Crackles heard in the right posterior, lower and upper lung. Will continue to monitor and place on doctor's log. Resident afebrile. 9/14/2020 08:33, Transcribed NP/PA Progress Note History Of Present Illness: This patient is being evaluated per nursing request due to crackles in lung bases with episodes of [MEDICAL CONDITION]. The patient currently is resting without O2 (oxygen) and pulse oximetry is greater than 90% .does have occasional cough but nonproductive per nursing .Will order a chest x-ray 2 views do the patient's crackles await results prior to changing any medications. The patient does not appear short of breath although did have episode of low SPO2 (blood oxygen level) .current SPO2 is greater than 90%. The patient is medically complex with multiple comorbidities and will require frequent monitoring, follow-up, and intervention for adequate symptom management. 9/15/2020 08:02, Transcribed physician progress notes [REDACTED]. Patient currently on room air sitting in wheelchair without respiratory distress. Patient is coughing frequently per roommates reports. Patient denies chest pain, fevers and no reported diarrhea. Patient past medical and social histories are reviewed .Will add additional [MEDICATION NAME] (water pill) 40 mg (milligrams) daily at 3 PM for 3 days. Await results of chest x-ray is given patient's diffuse crackles may be a component of fluid overload. Patient currently stable respiratory wise that (they are) off supplemental oxygen. Patient will require close followup to monitor results of chest x-ray. R34's progress notes did not mention COVID-19 and explanation of not testing the resident for COVID-19 was not mentioned in the documentation. On 9/17/20 at 9:08 AM, R34 was observed in the same room with two roommates present. The resident was standing up and getting ready to walk with therapy. R34 was observed to not have a mask on. A review of R34's vital signs revealed that the resident's SPO2 was 90.0% (ideally should be above 92%) on room air on 9/17/2020 at 10:29 AM. No SPO2 was recorded on 9/15 or 9/16. On 9/17/20 at 12:29 PM, the Infection Control Nurse (ICN) was queried regarding R34 and their respiratory symptoms. The ICN stated, The doctor looked at (R34's) history, that's why they did the chest x-ray. The resident has a history of pneumonia, that's how the history is, that's how (R34) gets. When queried regarding COVID-19 being known to cause pneumonia, the ICN stated, I understand COVID causes pneumonia. When asked if the facility was still performing weekly testing of residents for COVID-19, the ICN indicated they were not. The ICN was then asked if COVID monitoring was done based on assessing for new onset respiratory symptoms and stated that it was. The ICN was then asked what the rationale was for not testing a resident with new onset respiratory symptoms for COVID-19 was and stated, We go by what the doctor says. The doctor had concern for aspiration. There just wasn't concern for (R34) having COVID. They have history of pneumonia. The ICN was asked if there was any documentation explaining why COVID-19 was not ruled out for R34 or any documentation at all in the chart related to COVID-19 and R34 and indicated there was not. A review of R34's medical record revealed that the resident was last tested for COVID-19 on 8/19/20 with a negative result. A review of R34's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was admitted into the facility on [DATE] with medical [DIAGNOSES REDACTED]. Further review revealed the resident was moderately cognitively impaired and required extensive assistance from staff for activities of daily living. The MDS indicated the resident did not require oxygen therapy. Review of facility provided policy/procedure entitled, Surveillance for Healthcare-Associated Infections (dated 2/2018) revealed, The Infection Preventionalist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and epidemiologically significant infections . Review of facility provided policy/procedure enti(TRUNCATED)

Based on observation, interview and record review the facility failed to ensure the disposal of expired medications and failed to label and store medications appropriately on the B, E, and F units, resulting in the potential for resident's to receive ineffective medications. Findings include: On 09/16/2020 at 10:15 AM, the B-Wing medication cart was reviewed for medication storage with Registered Nurse (RN) A. Upon inspection of the medication cart, an opened bottle of Aspirin 81 milligrams was observed with the manufacture's expiration date of 7/20 in the top drawer of the medication cart. RN A explained that the nurse on the previous shift was supposed to look through the cart and throw away any expired medications and must have missed it. A tour of the F-Unit Medication Cart was completed on 9/16/20 at 8:08 AM with Licensed Practical Nurse (LPN) P. The following expired, undated, and/or un-labeled medications were noted in the cart: -One bottle of Cranberry 405 milligram (mg) capsules, quantity 60. Expired 04/20 -One bottle of Stool Softener Docucate Sodium 100 mg softgels, quantity 100. Expired 08/20 -One six fluid ounce (oz) bottle of Sore throat spray, cherry flavor ([MEDICATION NAME] generic). The bottle was opened, undated, and not labeled with Resident name/identification -[MEDICATION NAME] (insulin) 100 units/milliliter (mL) pen for Resident #5, dated as Opened 7/26. The sticker label on the insulin revealed, Good for 28 days after opened -Latanoprost 0.005% eye drops for Resident #52, opened and not dated -Latanoprost 0.005% eye drops for Resident #52, unopened and not refrigerated. The medication was delivered 9/1/20 and clearly labeled, refrigerate until opened. When queried regarding the Latanoprost 0.005% eye drops being unopened and in the medication cart, LPN P stated, Should have been refrigerated. When queried regarding the insulin being past 28 days in which it is able to be used and the expired/unlabeled medications in the cart, LPN P indicated they would dispose of the medications. No further explanation was provided. A tour of the E-Unit medication cart was completed with LPN C on 9/16/20 at 11:29 AM. A 100 count bottle of Aspirin 325 mg tablets was present in the cart. The Aspirin expired 08/20 and was dated as opened on 8/31/20. When asked, LPN C revealed the medication was floor stock and used for any Resident on the floor who has it ordered. When queried regarding the medication being opened on the date it expired, LPN C was unable to provide further explanation. An interview was completed with the Director of Nursing (DON) on 9/17/20 at 12:46 PM. When queried regarding facility policy/procedure pertaining to disposal of expired medications, labeling of medications, and temperature storage per manufacturer recommendations, the DON revealed they were aware of the concern. The DON further indicated they would address the issue. No further explanation was provided. A record review of the facility policy titled, Storage of Medications revised 6/23/16 revealed the following: 2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner . 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .

Based on observation, interview and record review, the facility failed to operationalize policies and procedures to promote and ensure dignity for one (#5) of one Residents reviewed for dignified care resulting in a severely cognitively impaired Resident being exposed and visible from the hallway of the facility. Findings include: On 9/15/20 at 9:56 AM, Resident #5 was observed in bed, positioned on their back from the hallway of the facility. The Resident was yelling out and uncovered with their brief and bare legs visible from the hallway. Licensed Practical Nurse (LPN) Q was observed standing at the medication cart in the hall, near the Resident's room at this time. Upon entering the room, Resident #5's call light was noted to be clipped to the side of their bed, hanging downward towards the floor, and not within their reach. A blanket was not in place near the Resident on the bed. An interview was attempted to be completed at this time. When asked a question, Resident #5 did not provide a meaningful response to the question asked but stated, There are needles in my legs. Resident #5 asked for assistance to adjust the pressure reduction boots in place indicating they were having pain. When asked additional questions, Resident #5 did not respond and continued to verbalize complaints of pain and needles in their legs. At this time, LPN Q was observed standing at the medication cart in the hallway and their assistance was requested for Resident #5. LPN Q entered the Resident's room and adjusted the pressure reduction boots in place on the Resident's legs. LPN Q left the Resident exposed when they exited the room. When asked why they left Resident #5 exposed and visible from the hallway, LPN Q did not a response. Record review revealed Resident #5's was most recently admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired, experienced delusions, and required limited to extensive assistance to perform Activities of Daily Living (ADLs). Review of Resident #5's care plans revealed a care plan entitled, The resident needs activities of daily living assistance . (Initiated and Revised: 3/18/20). The care plan included the interventions: -Ambulation: Non- ambulatory (Initiated: 3/19/20) -Bed Mobility: 2 Assist (Initiated: 3/19/20; Revised: 7/27/20) -Toilet Use: bedpan--hoyer needed (Initiated: 3/19/20; Revised: 7/27/20) -Encourage the resident to use call bell to request assistance (Initiated: 3/18/20) An interview was conducted with the facility Director of Nursing (DON) on 9/17/20 at 12:10 PM. When queried regarding facility policy/procedure related to a Resident being exposed with their brief and bare legs visible from the hall of the facility, the DON revealed Residents should not be exposed. The DON was then told about the observation that occurred on 9/15/20 of Resident #5 including LPN Q entering and exiting the room without covering the Resident. When queried if that was appropriate per facility policy/procedure, the DON revealed they would fix it immediately if they would have saw the Resident. When asked what actions should have been taken, the DON stated, I would have asked (Resident #5) if they wanted a blanket. The DON further revealed that if the Resident did not want a blanket, the privacy curtain in the room could have been pulled to provide privacy. A policy/procedure related to Resident privacy/dignity was requested from the facility administrator on 9/16/20 at 10:24 AM but not recieved by the conclusion of the survey.

Based on observation, interview, and record review, the facility failed to ensure placement and documentation of placement of a right-hand splint for one sampled resident (R48), resulting in the potential for worsening upper extremity impairment. Findings include: On 9/15/20 at 10:13 AM, R48 was observed to be receiving AM care from two Certified Nursing Assistants (CNAs), CNA H and CNA I. The resident was transferred to a reclining chair. R48's right hand and wrist appeared to be weak and without good muscle tone and was slightly flexed. No supportive device was noted on the right arm. On 9/15/20 at 1:28 PM, Confidential Witness J was interviewed via phone regarding R48's care at the facility. When queried regarding a supportive device for the resident's right hand, Witness J stated, (R48) is supposed to wear one on the right arm. On 9/15/20 at 1:45 PM, R48 was observed sleeping in bed. No supportive device was noted on the resident's right arm. A splint device was noted to be sitting on the resident's dresser toward the end of their bed. On 9/16/20 at 10:24 AM, R48 was observed sitting up in their chair. The splint device was noted to be sitting on the resident's dresser and not on the resident's right arm. On 9/16/20 at 12:11 PM and 12:29 PM, R48 was observed sitting up in bed eating lunch. The splint device was noted to be sitting on the resident's dresser and not on the resident's right arm. On 9/16/20 at 2:30 PM, 3:40 PM, and 4:23 PM, R48 was observed sleeping in bed. No supportive device was noted on the resident's right arm. The splint device was noted to be sitting on the resident's dresser. On 9/17/20 at 9:17 AM, R48 was observed sitting up in their chair. The splint device was noted to be sitting on the resident's dresser and not on the resident's right arm. A review of R48's care plan revealed the following: Splint to Right hand on 4-5 hours a day-check skin before applying and when removing-if any skin concerns develop, leave off and notify nurse immediately Date Initiated: 01/03/2020 Revision on: 04/20/2020. On 9/17/20 at 10:55 AM, the Nursing Home Administrator (NHA) was asked for a policy/procedure related to splint/brace application. The NHA stated, We do not have a specific (policy) for the splints/braces and application, we follow the physician's orders [REDACTED]. On 9/17/20 at 11:50 AM, R48 was observed sitting up in their recliner. The splint device was noted to still be sitting on the resident's dresser and not on the resident's right arm. CNA H entered the room and was queried regarding the application of the device and documentation of application, CNA H stated, Therapy was putting the splint on .When we put it on, (R48) doesn't like it. We haven't been putting it on (R48). When queried where refusal of splint application was documented, CNA H stated, We don't have a spot to document it on our charting. R48's medical record and progress notes were reviewed and found no documented refusals of splint application. On 9/17/20 at 12:03 PM, the Therapy Manager was queried regarding the splint for R48's right arm. The Therapy Manager stated she would look through her notes and it had been a while since the resident received therapy. The Therapy Manager was queried who was responsible for implementing brace application if therapy is no longer working with the resident and replied, It would be up to nursing to implement. On 9/17/20 at 12:14 PM, the Therapy Manager approached and stated, Back in December 2019 we educated staff on donning and doffing the brace (for R48), the wearing schedule, and then our process is that I put in a recommendation for a care plan update and give that to nursing staff. Up to nursing staff to implement. A review of R48's Occupational Therapy Treatment Encounter Note(s), dated 12/9/19 revealed: Discharge Recommendations: Restorative Splint and Brace Program .RUE (right upper extremity) splint 4 hours per day . Note on the same document dated 12/6/19 revealed, .Educated restorative CENA (CNA) on new splint . Note dated 12/4/19 revealed, .Resident tolerated 4 hours of right hand splint wear. Hourly checks completed and no signs of [MEDICAL CONDITION] or redness. CENA's educated on checking for any signs of irritation .Staff educated on splint wear .compliant with skilled interventions. On 9/17/20 at 2:44 PM, the Director of Nursing (DON) was interviewed regarding R48's right-hand splint. When queried if splint application was documented in the resident's record, the DON indicated she did not see any documentation. When asked if there should be documentation of splint application, the DON stated, It should be documented somewhere, yes. When asked if it was her expectation for staff to document any resident refusals of splint application, the DON stated, Yes. The DON reviewed R48's care plan and indicated the splint application was not on the Kardex (quick care reference for staff) and stated, That's odd. I just added it to the Kardex. A review of R48's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was admitted into the facility on [DATE] and re-admitted on [DATE] with medical [DIAGNOSES REDACTED]. Further review revealed the resident was cognitively impaired and required extensive assistance from one or more staff for bed mobility, transfers, dressing, toilet use, and hygiene. A review of the facility's policy/procedure titled, Restorative Nursing Program, dated 3/2019, revealed, The Restorative Nursing Program is led by the Director of Nursing (DON) or designee (i.e. Restorative Nurse, Unit Manager, Nurse Manager). The program is multidisciplinary and includes: Therapy (PT, OT, ST), Nursing (RN, LPN, RNA, CENA) .Resident .Employees that have been trained and shown competency may complete and participate in group restorative activities. Once determined that the resident would benefit from a restorative nursing program, implement the following: Determine if the resident is willing and able to participate, Document refusal in the medical record with education regarding risks and benefits. Re-visit at least quarterly to determine if the resident would still benefit. Determine willingness and ability and document refusals as previously completed, Determine resident and/or family goals for restorative care, Review during care plan review meeting .

Based on interview and record review, the facility failed to operationalize policies and procedures to ensure consent is obtained for [MEDICAL CONDITION] medication administration for one (#5) of five Residents reviewed for [MEDICAL CONDITION] medications resulting in lack of consent for [MEDICATION NAME] (atypical antipsychotic medication used cautiously in elderly individuals) administration. Findings include: Review of Resident #5's medical record revealed the Resident was most recently admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired, experienced delusions, and required limited to extensive assistance to perform Activities of Daily Living (ADL). Review of Resident #5's Medication Administration Record [REDACTED] -[MEDICATION NAME] 25 milligrams (mg): One tablet every day and evening shift (Start: 8/19/20) -[MEDICATION NAME] 0.5 mg (anti-anxiety medication): One tablet three times a day (Start: 3/25/20) Additional review of Resident #5's medication order history revealed the Resident had taken [MEDICATION NAME] in March 2020, but it had been discontinued. [MEDICATION NAME] was ordered again due to behaviors and the Resident began taking the medication in June 2020. From June 2020 to September 2020, the medication dosage had been adjusted. Review of medication consents in Resident #5's medical record revealed a signed consent dated 3/20/20 for both [MEDICATION NAME] (no dose) and [MEDICATION NAME] (no dose) for generalized anxiety. An interview was conducted with the Social Services Director on 9/17/20 at 8:53 AM. When queried if [MEDICAL CONDITION] medication consent forms had to have the medication dosage, per facility policy/procedure, the Social Services Director stated, I've never been told to. It (dose) would be in the notes. When asked how Residents and/or Resident Representatives are informed of changes in medication dosages, the Social Services Director replied, (Provider) contacts the POA (Power of Attorney) if (Resident) not own responsible party. When asked if a different consent form is supposed to be utilized for each medication, the Social Services Director stated, No, we can use the same form for each med. A review of Resident #5's [MEDICATION NAME] medication therapy was completed with the Social Services Director at this time. When queried regarding a consent for the medication, the Social Services Director reviewed the Resident's medical record and revealed the only consent present in the medical record was from March, prior to the medication being discontinued. When asked if a new consent is required after a medication is discontinued and then restarted several months later, the Social Services Director indicated a consent should have been obtained and stated, I can't believe I missed that. The Social Services Director further indicated a consent would be obtained today. On 9/17/20 at 12:46 PM, an interview was conducted with the Director of Nursing (DON). When queried regarding lack of consent for [MEDICAL CONDITION] medication administration for Resident #5, the DON indicated a consent should be obtained whenever a [MEDICAL CONDITION] medication is ordered. No further explanation was provided. A policy/procedure pertaining to [MEDICAL CONDITION] medications including consents was requested from the facility Administrator on 9/16/20 at 10:30 AM but not received by the conclusion of the survey.

Based on interview and record review, the facility failed to ensure assessment and documentation of incompetency prior to enacting a Durable Power of Attorney (PDOA) for one (#42) of six Residents reviewed for Advance Directives, resulting in enactment of the DPOA with medical care decisions being made for the Resident with no legal documentation of determination of incompetency and the potential for the Resident's care wishes to not be followed. Findings include: Record review revealed Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive to total assistance to perform Activities of Daily Living (ADLs). Additional review of the Residents medical record revealed an individual other than the Resident had signed legal documentation including consent for [MEDICAL CONDITION] medications. Further review revealed the individual who had been signing legal documents for the Resident was listed as the Resident's DPOA on DPOA documentation within the medical record. The DPOA specified the DPOA became effective if the Resident was no longer able to make their own decisions. Resident #42's medical record also contained an incompetency document form signed by only one Physician. An interview was conducted with the Director of Nursing (DON) and the Social Services Director on 9/17/20 at 12:03 PM. When queried regarding Resident #42's competency and ability to make their own decisions, both the DON and Social Services Director indicated the Resident was not able to make their own decisions. When queried regarding documentation of incompetency for the Resident, both the DON and Social Services Director reviewed the medical record and provided the incompetency document only signed by one Physician. When queried how many Physicians are supposed to sign an incompetency documentation in order to determine that a Resident is unable to make their own decisions, the Social Services Director stated, Two. When asked why the DPOA was signing the Resident's legal documentation when only one Physician signed the incompetency document, both the Social Services Director and the DON revealed the incompetency document should have been signed by two Physicians and they were unsure how it had been missed. No further explanation was provided. A policy/procedure related to Advance Directives was requested from the facility Administrator on 9/16/20 at 10:24 AM but not received by the conclusion of the survey.

Based on observation, interview and record review, the facility failed ensure a gait belt was used during ambulation, affecting one resident (R#2) of three reviewed for hospitalization s, resulting in a fall and broken hip. Findings include: On 2/19/19 at 10:35 AM and 12:53 PM, R#2 was observed in bed turned toward their right side. R#2 was unable to appropriately answer interview questions. On 2/19/19 at 11:11 AM, a resident representative interview was conducted with Family Member H. When asked about any falls or hospitalization s involving R#2, they stated, There was a fall when (R#2) was in the bathroom. I don't remember it well but they called me when it happened. (R#2) used to be able to walk to the bathroom with a walker. (R#2) used to go to all the activities and every single church service. A review of R#2's medical record revealed the following: 12/7/2018 13:02 (1:02 PM) S[NAME]-Falls New Fall/Follow-Up: New fall on 12-3-18 Situation (where/when/what/who): Resident ambulating out of BR (bathroom) at 715 pm in room .was being assisted by staff with use of roller walker then (R#2) began leaning to the right and fell .A head to toe evaluation was completed with 2 skin tears on right arm and 1 on right earlobe .Factors involved (acute condition/environment, etc.): (left blank) . On 2/21/19 at 1:14 PM, Certified Nursing Assistant (CNA) I was interviewed regarding R#2's fall on 12/3/18 and was asked what happened. CNA I stated, Me and the other CNA (J) were walking with (R#2) out of the bathroom. We had to change their shirt because it was soiled. We had the gait belt on (R#2) when we transferred them to the toilet. (R#2) was still a two-person assist at that time. When we got (R#2) back up off the toilet, we forgot to put the gait belt on (them). We were two-assist walking with them but they leaned sideways and started falling. (R#2) got a skin tear on the arm and earlobe and fell on their right side. (They) didn't collapse, (they) tipped over .lost their balance. They changed (R#2) to a hoyer lift transfer after that. We should've had the gait belt on, that was our fault, totally. We were told after that we had to use a gait belt, always. On 2/21/19 at 1:22 PM, an attempt to contact CNA J for interview was made, but no call-back was received prior to survey exit. Further review of R#2's medical record revealed: 12/7/2018 13:58 (1:58 PM) Transcribed NP/PA Progress Note .Musculoskeletal: Range of motion diminished in the lower extremities .does have difficulty with elevation of lower extremities raising them off the bed Skin: Right upper extremity bruising/hematoma with skin tear to upper and lower arm with dressing in place and no drainage noted, there is abrasion to the right ear . 12/10/2018 13:13 (1:13 PM) Transcribed NP (Nurse Practitioner/PA (Physician's Assistant) Progress Note .Presenting Problem: Weakness in the lower extremities requiring Hoyer lift. History Of Present Illness: Patient is being evaluated at the request of nursing due to continued weakness in lower extremities requiring Hoyer lift for all transfers . 12/27/2018 13:38 (1:38 PM) Transcribed physician progress notes [REDACTED]. Patient had previous x-ray on (MONTH) 3 after suffering a fall. Initial x-ray was negative and showed intact arthroplasty. Patient was having more pain in the right hip and lower extremity per physical therapy patient unable to bear weight. (R#2) is a limited historian therefore review of systems limited .Musculoskeletal: No effusions, unable to bear weight on RLE (Right Lower Extremity), limited ROM (Range of Motion) due to pain .Plan: We will order repeat hip and pelvic x-ray due to worsening of hip pain . Radiology Report: 12/3/18 Hip/Pelvis x-ray, no fracture or acute dislocation seen. Radiology Report: 12/27/18 Hip/Pelvis x-ray, Comparison: 12/3/18 .Conclusion: Osteopenia is present, which limits the detection of nondisplaced fractures .Intact right hip arthroplasty. Non displaced proximal femur fracture. This is better seen on today's exam compared to prior. 12/28/2018 02:45 (2:45 AM) Nurses' Notes Note Text: Res (Resident) sent to hospital r/t (related to) x-ray showing a proximal rt (right) femur fx (fracture) (Right [MEDICAL CONDITION]) for eval (evaluation) and tx (treatment) hospital called and given report 12/28/18 Acute Care Hospital Discharge Summary: Final Diagnoses: [REDACTED]. 1/3/2019 17:47 (5:47 PM) Nursing Evaluation Summary Note Text: Res returned from (acute care hospital) at 5:45 this evening with primary Dx (diagnosis) of proximal rt femur Fx .mechanical lift for transfers until therapy eval . 1/4/2019 07:08 (7:08 AM) Transcribed NP/PA Progress Note .History Of Present Illness: Patient is being evaluated at the request of nursing due to a recent readmission. The patient .recently had a fall had x-rays which were negative for any acute fracture continue to have pain had repeat x-rays which did show a proximal femur fracture nondisplaced was sent to the acute care facility . 1/17/2019 10:09 (10:09 AM) Therapy Note Text: .Patient has been primarily bed bound since (they) recently broke (their) hip . The incident and accident report for R#2's fall on 12/3/18 was reviewed and revealed,Res began leaning to the side during transfer from bathroom to bed and staff (CNAs I and J) unable to stop just outside doorway in bedroom .fell on right side .states some pain (some grimacing) in R hip .Were planned interventions in place? No. If no, list reasons: No gait belt . On 2/21/19 at 1:46 PM, the Director of Nursing (DON) was interviewed regarding R#2's fall on 12/3/18. The DON indicated that the resident's fall happened before she began working at the facility. The DON then stated, I believe (R#2) ended up getting another x-ray. One showed the fracture and one didn't. I remember therapy recommending (R#2) get the second x-ray because (the resident) was complaining of increased pain. When queried regarding the use of a gait belt during ambulation, the DON stated, The expectation is to always be using a gait belt. A review of R#2's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE] and readmitted on [DATE] with medical [DIAGNOSES REDACTED]. Further review revealed the resident was severely cognitively impaired and required extensive assistance from two or more staff members for bed mobility, transfers, toileting, and hygiene. A review of the facility policy titled, Falls - Clinical Protocol, Reviewed/Revised 6/2018 revealed, 4. Interventions should be developed and implemented per the assessed needs.

This citation refers to MI 253, MI 533, MI 535 Based on observation, interview and record review the facility failed to ensure and maintain an environment free from physical abuse for three sampled residents (R902, R903, R904) of four reviewed for resident to resident abuse in a total sample of four, resulting in unprovoked physical contact, physical injury and psychosocial injury. Findings include: On 01/18/18 at 9:25 a.m., R904 was observed in bed. R904 did not respond to query by name nor to any question. On 01/18/18 at 9:29 a.m., R903 was observed in bed. R903 did not respond to query by name nor to any question. On 01/18/18 at 9:37 a.m., R901 was observed to be dressed and seated on their bed. R901 upon query responded only with a yes or no nod of the head. R901 was queried if R901 had any problems with other residents and nodded yes. R901 was queried if any concerns with other residents and nodded yes. R901 was queried if any incidents with other residents and nodded yes then nodded no. When asked if felt safe, R901 nodded yes. On 01/18/18 at 9:46 p.m., Nurse E was queried about R901. Nurse E reported having cared for R901 since admission to the facility. Nurse E was queried about the incidents with R901 and R902, R903 and R904. Nurse E stated, Generally it comes out of nowhere, the swatting at people. Nurse E confirmed the prior interactions between R901 and other residents was verbal rather than physical. The care plan for R901 was reviewed and noted R901's agitation and inappropriate interactions and Nurse E stated, (R901) is easily redirected. On 01/18/18 at 11:41 a.m., the facility Education Director Staff G was queried about staff education post the incidents with R901 and R902, R903 and R904. An in-service dated 12/12/17 and 12/13/17 was viewed with Staff G. Staff G reported the in-service included training on reacting more quickly to situations of abuse and potential situations of abuse. A further review of the in-services and education dates indicated a date of 11/17/17 for abuse identification but no dates immediately after the 11/28/17 and 11/29/17 incidents. On 01/18/18 at 12:15 p.m., the MIACTS (facility incident report to State Agency) reports for R902, R903 and R904 were reviewed and revealed: Report dated 11/28/17 at 7:00 p.m., revealed: (R901) approached (R903) in the hallway and extended (their) hand to (R903) as if to shake hands. (R903) did not respond to the gesture and (R901) then struck (R903) on the right shoulder. Incident was witnessed by (Witness C). Investigation: At approximately 7:00 p.m., on November 28, 2017 (R901) was walking to (their ) room from an activity, when (R901) stopped to shake (R903's) hand. (R903) made no attempt to reciprocate the hand shake , which upset (R901), resulting in (R901) swatting (R903) on the back of the right shoulder, and continuing on to his room. (possibly to hide post the incident). (Witness C) stated he felt (R901) was just trying to say hi to (R903). (R903) did not contribute to any precipitating factors that would have instigated being struck by (R901). Neither resident is able to be interviewed due to cognitive limitations. Neither experienced harm. Intervention: Conducted UA (urinalysis) and 15 minute checks. Report dated 11/29/17 at 10:30 a.m., revealed: (R901) extended (their) right hand to (R904) to shake (their) hand. (R904) didn't shake his hand and (R901) struck (R904) on the bicep of the left arm. At approximately 10:20 a.m., on November 29, 2017, (R901) was walking from (their) room and went across the hall when (R901) stopped to shake (R904's) hand. (R904) mad no attempt to reciprocate the hand shake , which upset (R901) resulting in (R901) swatting (R904) three times on the back of the left arm and continuing back to (R901's) room. Laundry aide (Witness D) stated, I was passing resident clothing and I saw (R901) striking (R904) three times on the upper left arm. I separated (R901) and (R904) and asked (R901) what (R901) was doing and (R901) replied, He won't shake my hand. In conclusion of the investigation, it has been determined, from a witness to the incident that (R901) struck (R904) in the back of the left arm. (R904) did not contribute to any precipitating factors that would have instigated being struck by (R901). Neither resident is able to be interviewed due to cognitive limitations. Due to second incident in two days involving (R901), (R901) was placed on a one to one observation. Report dated 12/13/17 at 8:00 a.m., revealed: At approximately 8:00 a.m. on 12/13/2017, (R901) was eating breakfast at the same table as (R902). (R901) was sitting next to (R902), and as (R902) finished, (R902) began to head to the dining room exit. (R901) finished breakfast and then headed to the same exit. It was at this exit that (R901) stopped, and struck (R902) in the Right eye, with (the) Right hand. (R901) then immediately continued back to (their) room. As a result of this incident, (R902) now has a bruise on (their) right eye. At approximately 7:50 a.m. on December 13, 2017, (Nurse A) observed (R902) get hit in the face, by (R901). Nurse A immediately separated the residents. Nurse A observed bruising to the right eye of (R902). (R902) stated; that prior to being hit, I was eating breakfast at the same table as (R901) and as (R901) talked to me, I nodded. (R902) also stated that she was finished and was leaving the dining room when (R901) stopped me. (R901) kept asking me to take off my glasses. Finally (R901) said please, and I did. Then (R901) punched me and I screamed, and everyone came running. Witness (CNA-certified nursing assistant B) states; she observed (R902) leave the table, and then (R901) left the table. Both were headed to the exit, when she heard (R901) ask (R902) to take off (R902's) glasses. By the time CNA B could get to (R902), (R901) had hit (R902) in the right eye with a closed fist. Per video review, (R901) and (R902) are seen sitting at the same table, calmly eating their breakfast. As (R902) finished, (R902) began to wheel toward the exit. Moments later, (R901) stood up from the table and walked toward the exit. (R901) is seen stopping to talk to (R902), and then hits (R902). An X-ray was conducted for (R902) and the results are; no displaced acute fracture seen. (R902) stated that (R902) had a dull ache, and denied the need for pain (medication). Ice was applied to right orbital area. In conclusion of the investigation, it was confirmed through witness statements and video evidence, that (R902) and (R901) ate breakfast at the same table. As both residents were leaving the dining room, (R901) stopped (R902) at the entrance of the dining room, and then hit (R902) in the right eye. This incident resulted in (R902) receiving a bruise to (their) right orbital area. On 01/18/18 at 12:49 p.m., CNA B was queried about the incident with R901 and R902. CNA stated, I was in the dining room helping a resident to eat and I looked up and saw (R901) talking to (R902). I got up but was too late. (R901) had hit (R902). I took (R902) back to (R902's) room. (R902) was crying and scared. On 01/18/18 at 1:28 p.m., and 2:36 p.m., the MIACTS reports and incidents between R901 and R902, R903 and R904 were reviewed with the DON (Director of Nursing). The DON confirmed the information in the reports. Witness statements were reviewed with the DON and the DON confirmed they reflected what was in the MIACTS reports. Nurse A statement was reviewed and included, (Nurse A) stated was 15 feet away at med cart, heard (R901) speak in a normal tone can you take off your glasses. I was popping pills out when I looked up (R901) was in the act of hitting (R902) in the face. (R901) punched (R902) and immediately walked away . (A phone interview with Nurse A was attempted. A message was left but the call was not returned.) R903's statement included, (R901) stopped me and asked me to take off my glasses four times. I told (R901) no. Then (R901) said please so I did. That is when (R901) punched me in the eye. I screamed and people came running. The CNA B statement included, By the time I got to their spot (R901) was swinging (their) arm in a closed fist at (R902's) right eye. (R902) was sitting in (a) wheelchair at the dining room doorway. The DON was queried if the one to one was still in place at the time of the 12/13/17 incident with (R902) and reported it was not. 15 minutes checks were reported to be in place rather than the one to one. The DON was queried about the findings related to the incidents as abuse or not and indicated they were not substantiated as abuse based on the mental status of (R901) and that R902 remained in the facility until discharge and felt (R901) was not of their right mind. On 01/18/18 at 11:00 a.m. a review of the medical record for R901 revealed: R901 was admitted into the facility on [DATE], [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment dated [DATE] indicated moderately impaired cognition and the need for limited assistance of one person with most ADL's (activities of daily living). The Kardex/CNA care guide revealed, I like to be friendly, but this can be misinterpreted by others as I can be too excited around others. Please observe for such behaviors and redirect me as needed esp(ecially) in DR(dining room) or activities I attend. I often attempt to shake hands with others and can become upset when they don't want to shake my hand. An every 15 minute visual check form dated 12/13/17 indicated R901 was in the dining room from 7:15 a.m. to 7:45 a.m. A note at the line for 7:45 a.m. noted R901 hit another resident. The CNA I on the form was not documented as interviewed by the facility. The I have DD (developmental delay) and [MEDICAL CONDITION] nursing care plan initiated 11/10/17 and revised 12/13/17 and 12/26/17 revealed R901 may become agitated and yell out. I may attempt to shake others hands and become upset when others misinterpret my actions and don't want to return a handshake. Interventions revealed 15 min checks ongoing 12-9-17 initiated 12/09/17 revised 12/13/17. A note by the DON revealed: 12/09/17 Resident struck two peers when attempting to shake their hands. Resident has had one on one observation, 15 minute checks and with return from ER eval was supervision when out of room. Care plans were updated continue with supervision. DON notes for 12/15/17 indicated involved in incident with resident four times prior to 12/13/17. On 01/18/18 at 10:40 a.m. a review of the medical record for R902 revealed: R902 was admitted into the facility on [DATE] and discharged on [DATE]. The MDS dated [DATE] indicated intact cognition with a 15 out of 15 BIMS (brief interview of mental status) score and the need for extensive assist of one person for ADL's. On 01/18/18 at 4:00 p.m., a review of the medical record for R903 revealed: R903 was admitted into the facility on [DATE]. The MDS dated [DATE] indicated severely impaired cognition and the need for total assist of one person for ADL's. On 01/18/18 at 4:15 p.m., a review of the medical record for R904 revealed: R904 was admitted into the facility on [DATE]. The MDS dated [DATE] indicated severely impaired cognition and the need for extensive assist of one person for ADL's. On 01/18/18 at 4:24 p.m., the facility Abuse Prevention Program and Abuse Investigations policies (not dated) were reviewed and revealed, Policy Statement: Our residents have the right to be free from abuse . The facility Abuse Investigations policy (not dated) was reviewed and revealed, Policy Statement: All reports of resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by the facility management.

Based on observation, interview and record review the facility failed to prevent the spread of Influenza A, by not immediately providing appropriate isolation precautions, including the use of Personal Protective Equipment (PPE) and unoccupied, available private rooms for Residents that had contracted the highly infectious Influenza A virus and isolating affected residents in available private rooms for 3 ( #'S 711, 715 and 716) of 3 sampled residents reviewed for infections from a total sample of 19. An Immediate Jeopardy ( IJ) arose when the facility identified Residents were positive for Influenza A, but failed to implement Infection Control policy interventions to prevent the spread of Influenza throughout the facility, resulting in the spread of the Influenza virus causing serious illness and death. The Immediate Jeopardy was identified on [DATE] at 11:35 AM. The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:43 PM and the Administrator was instructed to provide a plan of correction to remove the immediacy. The IJ was removed on [DATE], based on the providers implementation of corrective actions on [DATE], as verified onsite on [DATE] during the completion of the standard survey. Although the IJ was removed, the facility deficient practice was not corrected and remains at isolated. Actual harm that is not immediate jeopardy. Findings include: Resident #711 During initial tour that began at 8:40 AM on [DATE], it was revealed by facility staff that Resident #711 was positive for Influenza A. Resident #711 was not in isolation and was residing in her room with two other roommates. There was no signage located on or near the Resident's room to alert staff and visitors of precautions required before entering the room and there was no isolation cart observed outside of the resident's room. On [DATE] at 1:07 PM, a review of resident #711's face sheet revealed that the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the resident's most recent Minimum Data Set (MDS) assessment, dated [DATE], the resident was cognitively intact. Review of laboratory (lab) results revealed a laboratory test obtained and dated [DATE] at 12:44 PM, for Influenza. The results were received by the facility on [DATE] at 5:26 PM and indicated that Resident #711 was positive for Influenza A. Resident #711's Care Plans were reviewed. There was not a care plan located for the treatment of [REDACTED]. On [DATE] at 4:05 PM, Certified Nursing Assistants (CNAs) were observed providing care to Resident #711 and the resident was not responding to the CNAs when they were speaking to her. Resident #711 only stared and made minimal facial expressions. Resident #711's two roommates were still occupying the room as well. On [DATE] at 5:30 AM, the Director of Nursing (DON) reported the facility had three deaths in the facility the night prior. On [DATE] at 9:20 AM, the curtains were observed drawn on all sides of Resident #711's bed. The Resident was observed lying in bed and appeared to be deceased . At 9:37 AM on [DATE], progress notes for Resident #711 were reviewed. There were no notes found as it related to the Resident's death in the facility. On [DATE] at 11:45 AM, the Infection Control Nurse A was queried about when Resident #711 and #715 tested positive for Influenza A and when, if any precautions were initiated, once the facility was aware. The Nurse A reported the laboratory results were received by the facility on Friday ([DATE]). She became aware of the results on Monday when she returned to work that Resident #711 and #715 were positive for the flu (Influenza A). Nurse A explained that normally facility staff would isolate the patient that was positive, but there were no empty rooms available. Nurse A stated, They did the best they could. They pulled the curtains in the rooms. Nurse A was asked about the numerous unoccupied rooms that were available on the E Wing. The nurse reported those beds were not available. Nurse A was queried as to if Resident #711's roommates were tested for Influenza. Nurse A reported that one of the Residents was tested for Influenza. The Nurse explained the other Resident was not tested because she had a different Physician, who did not order the test for the Influenza virus. The Infection Control Nurse stated that when the facility received the laboratory results back on the weekend they should have put isolation carts outside of the Resident's room. On [DATE] at 9:37 AM, a review of Resident #711's progress notes were completed. It showed on [DATE] at 7:25 PM, a progress note entered regarding the Residents death in the facility. The note stated, Res (resident) vital signs ceased at 7:28 AM, double checked by second floor nurse . An order was observed for Resident #711 to be admitted to Hospice for [DIAGNOSES REDACTED]. On [DATE] at 11:50 AM, an interview was conducted with the Infection Control Nurse A. It was explained the letter C denoted next to the laboratory results for Resident #711 means critical and when lab results are critical the lab will call the facility with the results, in addition to faxing them. Nurse A was queried as to if the lab contacted the facility about the positive results. Nurse A reported she would contact the laboratory for an answer to the question. Nurse A was then queried as to whose initials were denoted at the bottom of the lab results for Resident #711 and #715. Nurse A explained the initials at the bottom of the lab results are from their Medical Director (MD). The Infection Control Nurse reported that the MD signs off on all of the lab results and the date next to the MD initials is the date he became aware of results. Resident #715 During initial tour that began at 9:00 AM on [DATE], Resident #715 was observed laying in bed watching television. Resident #715 was neat, clean and answered simple questions appropriately. There was not a sign located on or near the Resident's room to alert staff and visitors of precautions required to enter the room and there was no isolation cart observed outside of the resident's room. On [DATE] at 2:55 PM, an isolation cart was observed outside of Resident #715's room and a sign on the Residents door instructing staff to visit the nurse's station before entering the room. CNA C was queried about the isolation cart and sign on the Resident's door. CNA C stated Resident #715 tested positive for Influenza A which is why they are on isolation precautions. Nurse D was interviewed and reported they think the lab results for this Resident came back on Saturday. On [DATE] at 1:15 PM, a review was completed of Resident #715's laboratory results and it revealed the Resident was tested for Influenza on [DATE] at 1:08 PM. The results of the test were received by the facility on [DATE] at 5:26 PM. The results indicated the Resident was positive for Influenza A. On [DATE] at 9:20 AM, a review was completed of Resident #715's face sheet and it revealed the Resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the most recent MDS assessment dated [DATE] the Resident was cognitively intact. Resident #715's care plan for Influenza was added on [DATE]. The care plan stated, Droplet precautions until further notice . On [DATE] at 1:45 PM, the Director of Nursing was queried if the laboratory contacted the facility by phone with the results of the Influenza test results for Resident #711 and #715. The DON reported the lab did not contact the facility via phone with the critical lab results. The DON further explained that the facility nurse receive all lab results off of the fax machine, review them and then place in the Medical Director's book for review. On [DATE] at 3:30 PM, an interview was conducted with the DON and Administrator in regards to the residents in their facility that are positive for influenza. The DON reported the staff is now aware they need to immediately isolate Residents when they are showing signs and symptoms of the flu. When lab results are received after hours or on the weekend, facility staff should notify the DON and then isolate the resident(s). The DON and Administrator reported they were not notified by phone of the positive flu results for Residents #711 and #715 until Monday ([DATE]). The DON and Administrator stated the facility staff should have initiated isolation precautions on Friday when the results were received from the lab. On [DATE] at 3:45 PM, the facility policy entitled, Isolation- Categories Transmission- Based Precautions, revised [DATE], was reviewed. It revealed the following under Droplet Precautions, .Place resident in a private room .wear a mask when working within three feet of the resident . Further review of the policy revealed, Signs - Use color coded signs and/or other measures to alert staff of the implementation of Isolation or Droplet Precautions, while protecting the privacy of the resident. On [DATE] at 4:15 PM, The Michigan Department of Health and Human Services (MDHHS) Guidelines for Influenza and Respiratory Virus Outbreaks in Long-Term Care Facilities, dated [DATE], was reviewed and it revealed, .Cohort and/or isolate ill residents .Maintain influenza precautions and conduct daily active surveillance for respiratory illness among residents .'. According to Center for Disease Control and Prevention, strategies for seasonal influenza in healthcare settings include, .Place patients with suspected or confirmed influenza in a private room or area . These strategies were reviewed on [DATE] at 4:30 PM. Resident #716 On [DATE] at 8:45 a.m., during an initial tour, Resident #716 was in his room with two other roommates. There was no isolation cart or notice outside the room indicating that Resident #716 had a contagious infection. On [DATE] at 2:00 p.m., a record review of the Minimum Data Set (MDS) assessment and face sheet on Resident #716 was completed. According to the face sheet, Resident #716 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED].#716 had a moderate impaired cognition and had no infections present. On [DATE] at 2:50 p.m., Resident #716 was observed in his room. There was an isolation cart outside of his room and a sign on the door indicating to see a nurse before entering the room. Inside the cart was personal protection equipment (PPE) which included gloves, goggles, masks and gowns utilized to prevent the spread of infection. Resident #716 was lying in bed with his eyes closed. Resident #716 appeared to be flushed and was wearing a hospital gown. On [DATE] at 10:50 a.m., Resident #716 was in a private room (different from the room he was in on the initial tour) and was lying in bed awake. Resident #716 appeared flushed and confused. Resident #716 had clear nasal drainage and sounded congested. On [DATE] at 1:30 p.m., a record review of the progress notes and lab results for Resident #716 revealed the following: [DATE]-Resident #716 had a low grade fever of 99.8 Fahrenheit (F) and had a congested, occasional cough. [DATE]-Nurse practitioner/physicians assistant (NP/PA) notes-Temperature 99.1 (F) .Has had cough and congestion. Lungs-Few expiratory wheezes. Assessments-Cough, nasal congestion, wheezing, increased temperature. [DATE]-Nurses notes-Sporadic nonproductive cough .Face flushed. [DATE]-NP/PA note-Coughing, few expiratory wheezes heard. Evaluated for cough and fever at request of nursing, along with body aches .He (Resident #716) does look fatigued . [DATE]-Lab results-Resident #716 had tested positive for Influenza A (the respiratory flu virus). On [DATE] at 1:45 p.m., a record review of the temperature readings for Resident #716 revealed the following: [DATE] 101.8 F [DATE] 99.8 F [DATE] 99.1 F On [DATE] at 2:00 p.m., a record review of the care plan that was initiated on [DATE] revealed that Resident #716 had the flu and was placed on droplet precautions. Removal plan for F441 Residents # 711, 715, 716 and 720 have been placed in isolation droplet precautions, with PPE available, which includes the use of 4 private rooms, on [DATE], by the Director of Nursing. Resident temperatures are being taken Q-shift. The physicians and medical director were notified and orders for their care was obtained. We are currently following physician orders [REDACTED]. The Health Department was notified for further guidance. The medical director initiated [MEDICATION NAME] treatment for [REDACTED]. Current residents residing in the facility have been assessed for any signs and symptoms of influenza. 92 out of 92 residents have been assessed. 11 additional residents were noted to have increased temp. and/or signs and symptoms. After their physicians were notified, swabs were obtained and sent to the lab to test for influenza, results pending. Isolation droplet precautions are in place with PPE available to staff and visitors. Care plans will be updated. All private rooms are currently in use and further confirmed influenza residents will be cohorted. The resident's physicians as well as the Medical Director were notified and orders obtained for care. (Resident's temperatures have been and will continue to be obtained every shift) for 72 hours status [REDACTED]. Infection Control Nurse/Designee will monitor residents for increased temperatures and signs/symptoms of influenza daily. Any new suspected cases of influenza will be reported to the resident's physician, Medical Director, Director of Nursing and Administrator. The infection control policies have been reviewed by the Administrator and DON and remain appropriate. All Staff will be re-educated on isolation procedures and the use of PPE for any resident that may produce signs/symptoms of influenza. Any staff not educated will not work until the education has been provided. 108 out of 133 staff have received the education as of [DATE] and is ongoing. All new Infections will be discussed at the daily clinical meeting, Monday through Friday. An audit will be conducted by the Infection Control Nurse/Designee on a weekly basis, to ensure that all residents identified with infections, will have appropriate precautions initiated. Results of the audit, will be brought to the Monthly QAPI Committee Meeting for 3 months or until substantial compliance is achieved. The Medical Director has approved this plan. The Administrator is responsible for sustained compliance. Compliance Date [DATE]

This deficient practice pertains to Intake Number MI 848 Based on interview and record review, the facility failed to implement with consistency the use of non-skid floor safety strips to aide in the prevention of possible falls for one resident (#701) of three residents reviewed for falls with injury from a total of three sampled residents, resulting in the resident being placed at increased risk for falls with potential injury. Findings Include: On 10/28/15 at 11:05 a.m., a review of the clinical record revealed Resident #701 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the clinical record revealed a past medical history of [REDACTED]. A review of the 14 Day Minimum Data Set ((MDS) dated [DATE], documented Resident #701 was moderately cognitively impaired for activity of daily living (ADL) and decision making, and required extensive assistance with transfer and toilet use with two person physical assistance. The MDS assessment also revealed Resident #701 had one fall after she was admitted into the facility. Further review of the clinical record revealed Resident #701 had 9 falls 2-6 months prior to admission. A Fall Risk assessment dated [DATE] indicated a Total Score of (9). If total score is 10 or greater, the resident should be considered at High Risk for potential falls. The care plan for falls dated 4/17/15 indicated Resident #701 was at risk for falls R/T related to self-transferring and unaware of safety. A review of the facility's Incident/Accident (I/A) reports for Resident #701 revealed the following: I/A - 5/8/15 at 2:20 a.m. - Unobserved fall in resident's room. Staff reported resident had been found on floor. When staff entered resident's room, she was laying quietly in bed, and as staff approached her, she began snoring. Resident stated she rolled out of bed. Injury: Skin Tear (L) elbow 3 centimeters (cm). Area cleansed, steri-strips applied. Care Plan Updated. 15 minute nuero-checks. Physician notified: 5/8/15 at 2:30 a.m. Called RP on 5/8/15 at 10:45 a.m., left a message. Results of Investigation: Resident self-transfers and having behavior changes from her normal 15 minute visual checks. Was planned intervention in place: Yes - non- skid strips to open side of bed. If site of incident was examine: Yes on 5/11/15 at 1:38 p.m. I/A - 5/19/15 at 11:40 p.m. - Unobserved fall in resident's room at bedside. Licensed Practical Nurse (LPN) E observed resident on the floor at the end of her bed lying with her head towards window. Resident stated, 'I had to go to the bathroom.' Resident put in bathroom after fall and stated, 'I don't have to go to the bathroom.' Refused to use the bathroom, and brief was dry. Skin Tear (R) right elbow 2 cm. First aid administered. Physician notified: 5/19/15 at 11:45 p.m. Called RP on 5/20/15 at 2:30 p.m. Care Planned Interventions: Assist x (times) 1 with RW (rolling walker) for transfers, toileting, bed mobility, non-skid strips to open side of bed, appropriate foot wear, bag at side of bed for personal items, call light in reach. Further review of the facility's I/A report dated 5/19/15 documented the following: Were Planned Interventions in place: 'No.' If no list reasons: Non-skid strips not on open side of bed. Hi-Lo bed by wall - not enough room; would have to rearrange. When queried if the white non-skid strips had been added to the opened side of Resident #701's bed, Nurse Manager G stated, At that time, the resident was in Room F8-1. On 4/20/15 at 2:00 p.m., when I checked that room, there was a Hi-Lo bed, two positioning bars, bed was by the wall, and non-skid strips on the floor at bedside. Nurse Manager G further stated, Resident #701 Had a room change on 5/13/15. The falls on 4/17/15 and 5/8/15 were in Room F8-1, and the fall on 5/19/15 was in Room B2-2. When queried why the same interventions were not in place in Room B2-2, Nurse Manager G stated, That, I am not sure of. Nurse Manager G further stated, There wasn't enough room for the strips. After the fall, maintenance rearranged the bed to apply the non-skid strips. On 10/28/15 at 1:30 p.m., a review of the radiology report dated 5/23/15 revealed the following: Examination: Femur Anteroposterior (AP) and LAT (Lateral) 2V (Views), Right Results: Intertrochanteric right femoral fracture with mild angulation. Joint spaces narrowed and soft tissue swelling. Conclusion: Acute, mildly angulated right intertrochanteric femoral fracture Broken Thighbone). Further review of the clinical record revealed On 5/24/15 - Per the on call Nurse Practitioner I, (IPC-Physicians Network), Send to Hospital. On 10/28/15 at 5:15 p.m., during an interview, the Administrator and Director of Nursing (DON) stated, A Facility Reported Incident (FRI) had been investigated and completed pertaining to Resident #701's fall on 5/19/15, and the facility was found to be in compliance. The Administrator was queried as to who was responsible for applying the non-skid strips to Resident #701's floor in Room B2-2. The Administrator stated, It should have been on the maintenance 'TELLS Programs' (application for system events). A review of the facility's policy titled Falls - Clinical Protocol updated February 2013, documented the following: IPOC/Comprehensive Care Plan 4. Interventions should be developed and implemented per the assessed needs. Monitoring and Follow-Up 1. The staff will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. ( )

THIS CITATION PERTAINS TO INTAKE # MI 133 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT EACH RESIDENT RECEIVES ADEQUATE SUPERVISION AND ASSISTANCE DEVICES TO PREVENT ACCIDENTS IN 1 OF 4 SAMPLED RESIDENTS (#103), RESULTING IN A FRACTURED PELVIS FOR RESIDENT #103. FINDINGS INCLUDE: ACCORDING TO THE FACE SHEET DATED 02/04/2011, RESIDENT #103 WAS A [AGE] year-old-FEMALE LIVING AT THE FACILITY SINCE 02/03/2011. HER [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM (MDS) data set [DATE], RESIDENT #103 REQUIRED MINIMALLY ONE STAFF MEMBER TO ASSIST WITH TRANSFERS, AMBULATION, DRESSING, EATING, HYGIENE, BATHING AND CONTINENCE. RESIDENT #103 COULD NOT BALANCE WITHOUT HUMAN ASSISTANCE DURING TRANSFERS, WALKING, TURNING, TOILETING, OR WHILE CHANGING POSITIONS. ACCORDING TO THE ADMISSION NURSING NOTE ON 02/03/2011, RESIDENT #103 WAS CONFUSED TO PLACE, TIME AND EVENT. SHE COULD RECOGNIZE PERSON BUT COULD NOT CONSISTENTLY VERBALIZE HER NEEDS OR "USE CALL LIGHT FOR ASSISTANCE". NURSING FURTHER DOCUMENTED THAT RESIDENT #103 HAD CONFUSION AND WAS "SELF-TRANSFERRING". ACCORDING TO THE ACTIVITIES OF DAILY LIVING CARE PLAN DATED 02/03/2011, RESIDENT #103 REQUIRED ONE PERSON TO ASSIST HER WITH ALL TRANSFERS AND AMBULATION. ACCORDING TO THE NURSING CARE PLAN DATED 02/04/2011, STAFF WERE TO ASSIST RESIDENT #103 WITH ALL TRANSFERS AND AMBULATION. ACCORDING TO OCCUPATIONAL THERAPY'S CARE PLAN DATED 02/04/2011, PROBLEM AREAS FOR RESIDENT #103 INCLUDED DECREASED MOBILITY, A DECLINE IN HER ACTIVITIES OF DAILY LIVING, A DECLINE IN FUNCTIONAL TRANSFERS AND POOR BALANCE. ACCORDING TO THE OCCUPATIONAL THERAPY assessment dated [DATE], NURSING STAFF WERE MADE AWARE OF THERAPY'S "SAFETY CONCERNS AND (THE) FALL RISK" FOR RESIDENT #103. THERAPY DOCUMENTED A DECREASED SAFETY AWARENESS AND COGNITION FOR RESIDENT #103 MAKING IT DIFFICULT FOR HER TO RECOGNIZE COMPROMISES IN ENDURANCE, BALANCE AND STRENGTH. ACCORDING TO THE PHYSICAL THERAPY assessment dated [DATE], RESIDENT #103 REQUIRED STAFF ASSISTANCE WITH SAFETY AWARENESS, BED MOBILITY, BALANCE, WALKING AND ALL TRANSFERS. ACCORDING TO NURSING NOTES DATED 02/05/2010, 02/06/2010, 02/07/2010, 02/08/2010, 02/09/2010, 02/10/2010 RESIDENT #103 EXPERIENCED CONFUSION AND REQUIRED MINIMALLY ONE STAFF MEMBER TO ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING. ON 02/11/2010 AT 7:00 P.M., NURSING DOCUMENTS THAT RESIDENT #103 REQUIRES MINIMALLY ONE STAFF MEMBER FOR ALL TRANSFERS/AMBULATION AND THAT SHE IS "UNABLE TO MAKE (HER) NEEDS OR WANTS KNOW". ON 02/15/2010 AT 6:00 P.M., STAFF DOCUMENT AGAIN THAT RESIDENT #103 REMAINS CONFUSED, NEEDING THE ASSISTANCE OF ONE STAFF MEMBER FOR ALL TRANSFERS/AMBULATION AND THAT SHE IS "UNABLE TO MAKE (HER) NEEDS KNOW". ON 02/01/2011 AT 11:50 A.M., EMPLOYEE "F" SAID THAT SHE WAS THE CERTIFIED NURSING ASSISTANT WHO PLACED RESIDENT #103 IN BED THE EVENING OF 02/15/2011. SHE SAID SHE BARELY KNEW RESIDENT#103, WORKING WITH HER ONLY ONCE BEFORE. SHE SAID SHE DID NOT KNOW ON 02/15/2011 THAT RESIDENT #103 had a history of [REDACTED].#103 SEEMED ORIENTED AT THE TIME, SO SHE PLACED HER IN BED WITH UNSAFE FOOTWEAR IN PLACE. ACCORDING TO THE INCIDENT AND ACCIDENT REPORT DATED 02/15/2011 AT 8:10 P.M., RESIDENT #103 HAD NO STAFF ASSISTANCE WHEN SHE TRANSFERRED INDEPENDENTLY FROM HER BED WEARING "REG. (REGULAR) SOCKS". STAFF FOUND RESIDENT #103 ON THE FLOOR IN FRONT OF HER BED. THE INITIAL NURSING ASSESSMENT SHOWED BRUISING WITH TWO SKIN TEARS TO THE LEFT SIDE OF HER HEAD, A SKIN TEAR TO HER RIGHT FOREARM, AND A SKIN TEAR TO HER LEFT LOWER EXTREMITY. ACCORDING TO NURSING NOTES DATED 02/16/2011 AT 8:45 A.M., RESIDENT #101 COMPLAINED OF SEVERE LEFT HIP PAIN. HER PHYSICIAN IMMEDIATELY ORDERED A PELVIS X-RAY WHICH SHOWED A "DISPLACED FRACTURE OF THE LEFT SUPERIOR PUBIC RAMUS IN THE REGION OF THE BODY OF THE PUBES" AND "A FRACTURE OF THE LEFT INFERIOR PUBIC RAMUS WITH SLIGHT IMPACTION". ON 02/18/2011 AT 11:05 A.M. THE DIRECTOR OF NURSING WAS UNAVAILABLE FOR REVIEW. THE ADMINISTRATOR SAID EMPLOYEE "G" WOULD STEP IN FOR THE DIRECTOR OF NURSING TO ANSWER QUESTIONS. ACCORDING TO EMPLOYEE "G", A REGISTERED NURSE, SUPERVISOR AND MINIMUM DATA SET NURSE, RESIDENT #103 WAS SO CONFUSED THAT SHE COULD NOT MAKE HER OWN DECISIONS. SHE SAID NURSING WAS AWARE RESIDENT #103 had a history of [REDACTED].

THIS CITATION PERTAINS TO INTAKE # MI 133 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE THE NECESSARY CARE AND SERVICES TO ATTAIN OR MAINTAIN THE HIGHEST PRACTICABLE PHYSICAL, MENTAL AND PSYCHOSOCIAL WELL-BEING IN ACCORDANCE WITH THE COMPREHENSIVE ASSESSMENT AND PLAN OF CARE FOR 2 OF 4 SAMPLED RESIDENTS (#101 AND #102), RESULTING IN: 1) RESIDENT #101 SUFFERING WITH UNCONTROLLED BACK PAIN FOR SEVENTEEN HOURS, AND 2) RESIDENT #102 EXPERIENCING THREE DAYS OF UNCONTROLLED BACK PAIN AND SUBSEQUENT DISTRESS. FINDINGS INCLUDE: RESIDENT #101 ACCORDING TO THE FACE SHEET DATED 11/09/2010, RESIDENT #101 WAS A [AGE] year-old-FEMALE LIVING AT THE FACILITY SINCE 11/08/2010. ACCORDING TO THE MINIMUM DATA SHEET DATED 11/23/2010, RESIDENT #101 WAS ALERT AND ORIENTED WITH NO COGNITIVE DEFICITS. SHE REQUIRED MINIMALLY ONE STAFF MEMBER TO PROVIDE ASSISTANCE WITH TRANSFERS. RESIDENT #101 COULD NOT BALANCE WITHOUT HUMAN SUPPORT. STAFF DOCUMENTED THAT THE RESIDENT DID NOT WALK AND HAD NO HISTORY OF FALLS BUT THIS DID NOT PROVE TO BE ACCURATE. ACCORDING TO A COMPETENCY FORM DATED 11/08/2010, RESIDENT #101 WAS DEEMED COMPETENT TO MAKE MEDICAL AND FINANCIAL/LEGAL DECISIONS. ACCORDING TO HOSPITAL RECORDS DATED 11/22/2010, RESIDENT #101 WAS admitted TO THE FACILITY AFTER "LUMBAR (BACK) SURGERY". HER DISCHARGE INSTRUCTIONS PROVIDED TO THE FACILITY SAID "SOME DISCOMFORT AND MUSCLE CRAMPING IS NORMAL, HOWEVER, PERSISTENT, SEVERE PAIN ...IS NOT. IF SHE EXPERIENCED SUCH PAIN STAFF NEED TO CALL A DOCTOR." FURTHER INSTRUCTION STATED, "SEVERE PAIN NOT RELIEVED BY MEDICATIONS" REQUIRED HER PHYSICIAN TO BE CONTACTED. ACCORDING TO FACILITY admission orders [REDACTED]. ACCORDING TO THE UNDATED CARE PLAN IN HER MEDICAL RECORD, STAFF DETERMINED THAT RESIDENT #101 HAD INCREASED "PAIN R/T (RELATED TO HER) RECENT BACK SURGERY" AND REQUIRED HER PAIN RX (PRESCRIPTION MEDICATIONS) AS ORDERED, FOR STAFF TO ASSESS FOR DISCOMFORT AND "NOTIFY (THE) DR (DOCTOR) AS NEEDED". ACCORDING TO THE ADMISSION NURSING NOTE DATED 11/22/2010 WITHOUT A TIME, RESIDENT #101 COMPLAINED OF BACK PAIN ON ADMISSION RATING IT 4 ON A SCALE OF 0 TO 10, WHERE 0 IS NO PAIN AND 10 IS CONSIDERED THE WORST PAIN EVER. ACCORDING TO THE FACILITY'S "MEDICATION ADMINISTRATION" POLICY DATED 03/2009, "WHEN PRN (ADMINISTERED AS NEEDED) MEDICATIONS ARE ADMINISTERED, THE FOLLOWING DOCUMENTATION IS PROVIDED". STAFF IS TO DOCUMENT "COMPLAINTS OR SYMPTOMS FOR WHICH THE MEDICATION WAS GIVEN" AND "RESULTS ACHIEVED FROM GIVING THE DOSE AND THE TIME RESULTS WERE NOTED". ACCORDING TO NURSING NOTES DATED 11/22/2010 AT 4:30 P.M., THE FACILITY HAD NOT RECEIVED THE ORDERED [MEDICATION NAME] WHEN RESIDENT #101 COMPLAINED OF PAIN AND STAFF ADMINISTERED THE ORDERED [MEDICATION NAME] AND [MEDICATION NAME]. ON 02/15/2011 AT 12:30 P.M., THE DIRECTOR OF NURSING SAID THAT STAFF IS REQUIRED TO DOCUMENT PAIN ASSESSMENTS AND REASSESSMENTS FOR THE ADMINISTRATION OF [MEDICATION NAME] OR PAIN MANAGEMENT. SHE SAID THIS IS A STANDARD OF NURSING PRACTICE AND THE ONLY WAY TO DETERMINE IF THE RESIDENT HAS OBTAINED PAIN CONTROL, ESSENTIAL TO THEIR WELL-BEING AND THE HEALING PROCESS. SHE THEN REVIEWED THE MEDICAL RECORD FOR RESIDENT #101 AND SAID SHE COULD NOT ESTABLISH THAT RESIDENT #101 OBTAINED PAIN CONTROL ON 11/22/2010 AT 4:30 P.M. BECAUSE NURSING DID NOT DOCUMENT THE NECESSARY PAIN ASSESSMENT. ACCORDING TO NURSING NOTES DATED 11/22/2010 AT 9:15 P.M., RESIDENT #101 COMPLAINED OF PAIN AND STAFF PROVIDED HER ANOTHER [MEDICATION NAME]. ON 2/15/2011 AT 12:30 P.M., THE DIRECTOR OF NURSING REVIEWED THE MEDICAL RECORD FOR RESIDENT #101 AND SAID SHE COULD NOT ESTABLISH THAT LEVEL OF PAIN EXPERIENCED BY RESIDENT #101 OR IF SHE EVER OBTAINED PAIN CONTROL ON 11/22/2010 AT 9:15 P.M. BECAUSE NURSING DID NOT DOCUMENT THE NECESSARY PAIN ASSESSMENT FOR ADMINISTERING PRN MEDICATIONS. ACCORDING TO NURSING NOTES DATED 11/22/2010 AT 11:30 P.M., RESIDENT #101 COMPLAINED OF INCREASED AND "UNCONTROLLED PAIN" FROM WHICH SHE WAS "VERY ANXIOUS ABOUT PAIN RX (TREATMENT) AND EFFECTIVENESS". NURSING DOCUMENTED THAT THE RESIDENT WAS CONSIDERING GOING TO THE HOSPITAL AT THIS TIME. ON 02/15/2011 AT 12:19 P.M., EMPLOYEE "D", THE NIGHT LICENSED PRACTICAL NURSE ASSIGNED TO CARE FOR RESIDENT #101 ON 11/22/2010 INTO 11/23/2010, SAID, "WE HAD A TERRIBLE TIME GETTING (RESIDENT #101) HER CONTROLLED SUBSTANCES FROM A PHARMACY". SHE SAID SHE ASSESSED RESIDENT #101 ON 11/22/2010 AROUND 10:30 P.M. AND FOUND SHE WAS IN "UNCONTROLLED PAIN ...GRIMACING, UNABLE TO SIT STILL, (AND) ANXIOUS". EMPLOYEE "D" SAID SHE CALLED THE DOCTOR FOR AN ANXIETY MEDICATION. SHE SAID SHE DID NOT ASK FOR PAIN MEDICATION BECAUSE THEY ALREADY HAD AN ORDER AND WERE JUST WAITING FOR IT TO COME IN. SHE SAID DESPITE ADMINISTERING [MEDICATION NAME] AND [MEDICATION NAME] AT 11:30 P.M., [MEDICATION NAME] AT 1:30 A.M. AND [MEDICATION NAME] AGAIN AT 5:30 A.M., RESIDENT #101 CONTINUED TO HAVE SO MUCH PAIN THAT SHE ONLY RESTED FOR "A MINUTE" REMAINING AWAKE, ATTEMPTING TO OBTAIN POSITIONAL COMFORT AND WHEN SHE COULDN'T SHE ASKED STAFF TO CALL HER AN AMBULANCE FOR THE "UNCONTROLLED" PAIN. EMPLOYEE "D" DENIED CALLING FOR AN AMBULANCE AND SAID SHE DID NOT MAKE ANY FURTHER ATTEMPTS TO CONTACT HER PHYSICIAN FOR PAIN CONTROL ORDERS. ON 2/15/2011 AT 12:30 P.M., THE DIRECTOR OF NURSING REVIEWED THE MEDICAL RECORD FOR RESIDENT #101 AND SAID SHE COULD NOT ESTABLISH THAT RESIDENT #101 OBTAINED PAIN CONTROL ON 11/22/2010 AT 11:30 P.M., 11/23/2010 AT 1:30 A.M. OR 11/23/2010 AT 5:30 A.M., BECAUSE NURSING DID NOT DOCUMENT THE NECESSARY PAIN ASSESSMENT BEFORE OR AFTER ADMINISTERING PRN MEDICATIONS. NURSING NOTES DATED 11/23/2010 AT 8:00 A.M., CONFIRM THAT THE ORDERED [MEDICATION NAME] REMAINED UNAVAILABLE AND AT 9:45 A.M. THE PHYSICIAN WAS CONTACTED FOR "INCREASED PAIN". NURSING NOTES DATED 11/23/2010 AT 10:00 A.M., DOCUMENT "DAUGHTER AND RESIDENT CONCERNED ABOUT INADEQUATE PAIN CONTROL SINCE ADMISSION YESTERDAY UP UNTIL NOW". SUBSEQUENTLY, THEY BOTH REQUESTED HER IMMEDIATE "DISCHARGE" FROM THE FACILITY. IN AN INTERVIEW ON 02/28/2011 AT 9:00 A.M., RESIDENT #101 SAID THAT SHE EXPERIENCED ONGOING, INCREASING AND UNCONTROLLED PAIN BETWEEN 11/22/2010 AT 4:30 P.M. AND 11/23/2010 AT 10:00 A.M. SO BAD THAT SHE WAS "OUT OF HER MIND" AND STAFF DID NOT HELP, INSTEAD JUST CLOSED HER BEDROOM DOOR TO REDUCE THE NOISE SHE MADE. RESIDENT #102: ACCORDING TO THE FACE SHEET DATED 02/07/2011, RESIDENT #102 WAS A [AGE] year-old-FEMALE LIVING AT THE FACILITY SINCE 02/04/2011. HER [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM (MDS) data set [DATE], RESIDENT #101 WAS ALERT AND ORIENTED WITH NO COGNITIVE DEFICITS. SHE REQUIRED MINIMALLY ONE STAFF MEMBER TO PROVIDE ASSISTANCE WITH TRANSFERS AND TWO STAFF MEMBERS TO ASSIST WITH AMBULATION. SHE DID EXPERIENCE PAIN. ACCORDING TO HOSPITAL RECORDS DATED 02/04/2011, RESIDENT #101 WAS hosptalized on [DATE] THROUGH 02/04/2011 WITH A LISTED ALLERGY TO [MEDICATION NAME] (PAIN MEDICATION). DURING THIS hospitalization SHE RECEIVED [MEDICATION NAME] IN HER [MEDICATION NAME] 7.5/325 MG TABLETS EVERY 4-6 HOURS AS NEEDED FOR PAIN. SHE HAD NO ALLERGIC REACTION TO THIS MEDICATION. UPON DISCHARGE HER PHYSICIAN REQUESTED SHE REMAIN ON [MEDICATION NAME] TO CONTROL HER PAIN. ACCORDING TO THE CARE PLAN DATED 02/08/2011, RESIDENT #101 NEEDED ASSISTANCE WITH MOBILITY DUE TO WEAKNESS, RECENT hospitalization , SURGICAL PROCEDURE AND LOW BACK PAIN. STAFF WERE TO OBSERVE FOR SIGNS AND SYMPTOMS OF PAIN AND NOTIFY THE PHYSICIAN AS INDICATED WHILE PROVIDING TREATMENTS FOR PAIN AS ORDERED. ACCORDING TO FACILITY PHYSICIAN ORDERS [REDACTED]. ACCORDING TO NURSING NOTES DATED 02/05/2011, STAFF admitted RESIDENT #102 WITH A PAIN LEVEL OF 6 OUT OF 10. ON 2/15/2011 AT 12:30 P.M., THE DIRECTOR OF NURSING REVIEWED THE MEDICAL RECORD FOR RESIDENT #102 AND SAID SHE COULD NOT ESTABLISH THAT RESIDENT #102 OBTAINED PAIN CONTROL ON ARRIVAL BECAUSE NURSING DID NOT DOCUMENT THE NECESSARY PAIN ASSESSMENT. ACCORDING TO NURSING NOTES DATED 02/05/2011 AT 2:15 A.M., STAFF FOUND RESIDENT #102 "MILDLY ANXIOUS" AND NURSING ADMINISTERED TYLENOL 1000 MG BY MOUTH. ON 2/15/2011 AT 12:30 P.M., THE DIRECTOR OF NURSING REVIEWED THE MEDICAL RECORD FOR RESIDENT #102 AND SAID SHE COULD NOT ESTABLISH THAT RESIDENT #102 OBTAINED PAIN CONTROL ON 02/05/2011 AT 2:15 A.M., BECAUSE NURSING DID NOT DOCUMENT THE NECESSARY PAIN ASSESSMENT BEFORE AND AFTER THE ADMINISTRATION OF THE PRN TYLENOL. ACCORDING TO NURSING NOTES DATED 02/05/2011 AT 8:00 A.M., STAFF TOLD THE PHYSICIAN THAT RESIDENT #102 SUFFERED FROM AN ALLERGY TO [MEDICATION NAME] AND IMMEDIATELY THE ORDER WAS DISCONTINUED LEAVING HER TO RECEIVE TYLENOL 1000 MG IF NEEDED FOR PAIN. ACCORDING TO NURSING NOTES DATED 02/05/2011 AT 1:00 P.M., RESIDENT #101 COMPLAINED OF LOWER "BACK PAIN" AND SHE WAS RESTLESS GETTING IN AND OUT OF BED BUT VOICING "ACHING, THROBBING PAIN". ACCORDING TO THESE SAME NOTES SHE RECEIVED THE TYLENOL AS ORDERED AT 8:15 A.M.. ON 2/15/2011 AT 12:30 P.M., THE DIRECTOR OF NURSING REVIEWED THE MEDICAL RECORD FOR RESIDENT #102 AND SAID SHE COULD NOT ESTABLISH THAT RESIDENT #102 OBTAINED PAIN CONTROL ON 02/05/2011 AT 8:15 A.M. OR 1:00 P.M., BECAUSE NURSING DID NOT DOCUMENT THE NECESSARY PAIN ASSESSMENT BEFORE AND AFTER THE ADMINISTRATION OF THE PRN TYLENOL. ACCORDING TO NURSING NOTES DATED 02/05/2011 AT 6:30 P.M., RESIDENT #102 COMPLAINED OF PAIN IN HER BACK AND THE INABILITY TO SLEEP FOR THREE DAYS. ACCORDING TO MEDICATION ADMINISTRATION RECORDS THE ORDERED TYLENOL HAD BEEN GIVEN AT 3:00 P.M. ON 2/15/2011 AT 12:30 P.M., THE DIRECTOR OF NURSING REVIEWED THE MEDICAL RECORD FOR RESIDENT #102 AND SAID SHE COULD NOT ESTABLISH THAT RESIDENT #102 OBTAINED PAIN CONTROL ON 02/05/2011 AT 3:00 P.M. OR 6:00 P.M. BECAUSE NURSING DID NOT DOCUMENT THE NECESSARY PAIN ASSESSMENT BEFORE AND AFTER THE ADMINISTRATION OF THE PRN TYLENOL. ACCORDING TO NURSING NOTES DATED 02/06/2011 AT 1:15 A.M., RESIDENT #102 COMPLAINED OF LOW BACK PAIN ACHING AND THROBBING. THE NURSE DOCUMENTS THE ADMINISTRATION OF TYLENOL AS ORDERED. ON 2/15/2011 AT 12:30 P.M., THE DIRECTOR OF NURSING REVIEWED THE MEDICAL RECORD FOR RESIDENT #102 AND SAID SHE COULD NOT ESTABLISH THAT RESIDENT #102 OBTAINED PAIN CONTROL ON 02/06/2011 AT 1:15 A.M. BECAUSE NURSING DID NOT DOCUMENT THE NECESSARY PAIN ASSESSMENT BEFORE AND AFTER THE ADMINISTRATION OF THE PRN TYLENOL. ACCORDING TO NURSING NOTES DATED 02/06/2011 AT 4:00 A.M., STAFF KNEW RESIDENT #102 WAS "TEARFUL" AT START OF SHIFT WITH "PAIN INTENSE AT TIMES TO BACK AND HIP". ACCORDING TO NURSING NOTES DATED 02/06/2011 AT 7:00 A.M., NURSING ASSESSED AND DOCUMENTED THAT THE "SON AND RESIDENT STATE 0 (NO) ALLERGIC REACTION TO [MEDICATION NAME]". ACCORDING TO PHYSICIAN ORDERS [REDACTED].M., THE PHYSICIAN RE-ORDERED THE [MEDICATION NAME] 7.5/325 MG TABLET EVERY FOUR HOURS IF NEEDED FOR PAIN. ACCORDING TO NURSING NOTES DATED 02/06/2011 AT 1:15 P.M., RESIDENT #102 COMPLAINED OF ACHING AND THROBBING LOW BACK PAIN. ACCORDING TO THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. WHEN STAFF RECEIVED THE ORDERED [MEDICATION NAME] AND BEGAN ITS ADMINISTRATION. ON 02/11/2011 AT 2:15 P.M., RESIDENT #102 REPORTED THAT SHE WAS IN CONSTANT PAIN AND HAD NOT SLEPT WELL FOR THE INITIAL TWO TO THREE DAYS BECAUSE THEY HAD TAKEN HER OFF HER PRESCRIBED [MEDICATION NAME] SHE HAD BEEN ON FOR YEARS. SHE SAID THAT SHE DID NOT HAVE AN ALLERGY TO THE MEDICATION, SHE ONLY EXPERIENCES NAUSEA FROM TIME TO TIME. HER SON WAS PRESENT AND CONFIRMED THAT ONCE HIS MOTHER RECEIVED THE [MEDICATION NAME] ON 02/07/2011, SHE BEGAN TO SLEEP BETTER AND OBTAIN SOME PAIN CONTROL. ON 02/18/2011 AT 11:49 A.M., THE PHYSICIAN SAID SHE DISCONTINUED THE [MEDICATION NAME] ON 02/05/2010 BECAUSE NURSING TOLD HER RESIDENT #102 WAS ALLERGIC TO [MEDICATION NAME]. THE PHYSICIAN SAID THIS INFORMATION WAS NOT ACCURATE, THE RESIDENT WAS NOT ALLERGIC TO THE MEDICATION AND HAD IN FACT BEEN PRESCRIBED IT FOR YEARS. SHE SAID RESIDENT #102 SHOULD NOT HAVE BEEN REMOVED FROM THE [MEDICATION NAME] BECAUSE WHILE TAKING TYLENOL SHE OBTAINED NO PAIN RELIEF. SHE SAID WHEN SHE WAS IDENTIFIED THE ERROR SHE IMMEDIATELY RESTARTED THE [MEDICATION NAME].

THIS CITATION PERTAINS TO INTAKE MI 691 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW THE FACILITY FAILED TO PROVIDE THE NECESSARY CARE AND SERVICES TO ATTAIN OR MAINTAIN THE HIGHEST PRACTICABLE PHYSICAL WELL-BEING IN 1 OF 14 SAMPLED RESIDENTS (#104) RESULTING IN AN IMMEDIATE JEOPARDY WHEN FACILITY STAFF FAILED TO IMPLEMENT CARDIOPULMONARY RESUSCITATION (CPR) TO RESIDENT #104, WHO WAS A FULL CODE, AFTER FINDING HIM IN HIS BEDROOM, UNRESPONSIVE, WARM TO THE TOUCH, AND WITHOUT A PULSE OR RESPIRATIONS RESULTING IN DEATH. FINDINGS INCLUDE: ACCORDING TO THE FACE SHEET, RESIDENT #104 RESIDED AT THE FACILITY SINCE [DATE], UNTIL HIS DEATH ON [DATE] AT 8:05 A.M. THE FACE SHEET IDENTIFIED THE RESIDENTS WIFE AS HIS RESPONSIBLE PARTY. ACCORDING TO THE MINIMUM DATA SET ((MDS) dated [DATE], RESIDENT #104 HAD SOME DIFFICULTY COGNITIVELY IN NEW SITUATIONS WITH NO LONG OR SHORT-TERM MEMORY LOSS. RESIDENT #104 REQUIRED MINIMALLY ONE STAFF MEMBER TO ASSIST WITH ALL ACTIVITIES OF DAILY LIVING. ACCORDING TO PHYSICIAN admission orders [REDACTED]. THIS FORM DID NOT DOCUMENT HIS CODE STATUS. ACCORDING TO TRANSFER PAPERWORK RECEIVED WITH THE RESIDENT ON [DATE] FROM A LOCAL AREA HOSPITAL, RESIDENT #104 HAD DOCUMENTED HIS END OF LIFE DECISION TO BE A FULL CODE, WISHING EMERGENCY MEDICAL TREATMENT INCLUDING CPR. THE FACILITY admitted RESIDENT #104 THE [DIAGNOSES REDACTED]. ACCORDING TO ADMISSION NURSING NOTES DATED [DATE], RESIDENT #104 WAS ALERT AND ORIENTED TO PERSON AND PLACE, HAD BLOOD PRESSURE OF ,[DATE] (NORMAL), RESPIRATIONS AT 22 BREATHS PER MINUTE (NORMAL) THAT WERE NON-LABORED, AND HEART RATE OF 85 BEATS PER MINUTE (NORMAL). ON [DATE] AT 10:10 A.M., THE DIRECTOR OF NURSING SAID RESIDENT #104 CAME to the facility on [DATE] WITH A PIECE OF METAL LODGED NEXT TO HIS CAROTID ARTERY (THE MAJOR BLOOD VESSEL SUPPLYING BLOOD TO HIS BRAIN), INCREASING HIS RISK OF SUDDEN DEATH. SHE REVIEWED RESIDENT #104'S MEDICAL RECORD AND SAID FACILITY PHYSICIANS/STAFF DID NOT DOCUMENT ANY END-OF-LIFE DISCUSSIONS OR CHANGES IN HIS DESIRED CODE STATUS SINCE HIS ADMISSION TO THE FACILITY. THE DIRECTOR OF NURSING SAID RESIDENT #104 REMAINED A FULL CODE ON [DATE] AND [DATE], REQUIRING STAFF TO PERFORM CPR IN THE EVENT OF AN EMERGENCY. ON [DATE] AT 11:05 A.M., RESIDENT #104'S RESPONSIBLE PARTY SAID SHE AND RESIDENT #104 DID WANT FACILITY STAFF TO PROVIDE CPR IN THE EVENT THAT HIS HEART STOPPED BEATING OR HE STOPPED BREATHING. SHE SAID THAT RESIDENT #104'S ADMISSION, STAFF DID NOT OBTAIN CONSENT OR DISCUSS ANY CHANGES IN RESIDENT #104'S CODE STATUS OR END OF LIFE CHOICES. ACCORDING TO NURSING NOTES DATED [DATE] AT 4:00 A.M., RESIDENT #104 HAD "VSS (VITAL SIGNS STABLE)" AND A PALPABLE PULSE. ACCORDING TO A LATE ENTRY DATED [DATE] AT 7:00 A.M., EMPLOYEE "A" (THE REGISTERED NURSE ASSIGNED TO CARE FOR RESIDENT #104) DOCUMENTED RESIDENT #104 COMPLAINED OF "PAIN" AND "LABORED" BREATHING. ON [DATE] AT 10:10 A.M., THE DIRECTOR OF NURSING REVIEWED THE MEDICAL RECORD AND WAS UNABLE TO FIND ANY DOCUMENTATION REGARDING PHYSICIAN NOTIFICATION OF RESIDENT #104'S ACUTE CHANGE OF CONDITION. SHE SAID SHE COULD NOT IDENTIFY ANY INTERVENTIONS TAKEN TO ASSIST RESIDENT #104 BY FACILITY STAFF. ON [DATE] AT 9:50 A.M., EMPLOYEE "A" SAID THAT HER DOCUMENTATION DATED [DATE] AT 7:00 A.M. WAS AN ACCURATE REFLECTION OF HER ASSESSMENT OF RESIDENT #104. EMPLOYEE "A" SAID SHE DID NOT NOTIFY A PHYSICIAN OF THE RESIDENTS SHORTNESS OF BREATH AND LEFT RESIDENT #104 UNSUPERVISED IN HIS BEDROOM. EMPLOYEE "A" SAID, "I WASN'T THAT CONCERNED." ACCORDING TO THE NURSING NOTES DATED [DATE] AT 8:05 A.M., EMPLOYEE "A" FOUND RESIDENT #104 DEAD, NOT BREATHING, AND WITHOUT A PULSE. IN AN INTERVIEW ON [DATE] AT 9:38 A.M., EMPLOYEE "R", A CERTIFIED NURSING ASSISTANT, STATED SHE HAD SPOKE TO RESIDENT #104 WHILE HE LAY IN HIS BED, FIFTEEN MINUTES PRIOR TO FINDING HIM UNRESPONSIVE, WARM TO TOUCH, NOT BREATHING, AND WITHOUT A PULSE ON [DATE] AT 8:04 A.M. EMPLOYEE "R" SAID SHE IMMEDIATELY NOTIFIED THE ASSIGNED REGISTERED NURSE (EMPLOYEE "A") WHO ASSESSED RESIDENT #104. EMPLOYEE "R" STATED EMPLOYEE "A" FOUND RESIDENT #104 TO HAVE NO PULSE, NO RESPIRATIONS, AND PRONOUNCED HIM DEAD. EMPLOYEE "R" REMAINED IN THE ROOM TO COMPLETE POST MORTEM CARE FOR RESIDENT #104. EMPLOYEE "R" REPORT THAT NO STAFF MEMBER INITIATED CPR OR OBTAINED ANY EMERGENCY MEDICAL CARE FOR RESIDENT #104 AFTER PRONOUNCING HIM AS DEAD. IN AN INTERVIEW ON [DATE] AT 2:10 P.M., EMPLOYEE "A" SAID SHE IS CPR TRAINED AND THAT EVEN THOUGH SHE WAS AWARE THAT RESIDENT #104 WANTED EVERY POSSIBLE MEASURE INCLUDING CHEST COMPRESSIONS AND ARTIFICIAL BREATHING TO PROLONG HIS LIFE IN THE EVENT OF AN EMERGENCY, SHE DID NOT INITIATE OR DIRECT STAFF TO PROVIDE CPR OR SEEK OTHER EMERGENCY MEDICAL CARE/treatment for [REDACTED].#104 WITH NO PULSE OR RESPIRATIONS ON [DATE] AT 8:05 A.M., BUT DID NOT PERFORM CPR BECAUSE THE FACILITY POLICY STATES THE DEATH MUST BE WITNESSED TO START CPR. EMPLOYEE "A" SAID SHE DID NOT WITNESS HIM LOOSE HIS PULSE OR RESPIRATIONS. EMPLOYEE "A" SAID SHE PRONOUNCED RESIDENT #104 DEAD BECAUSE HE HAD NO PULSE OR RESPIRATIONS. HOWEVER, EMPLOYEE "A" WAS UNABLE TO STATE THE ESTABLISH FACILITY POLICY OR STANDARDS OF PRACTICE REQUIRED FOR PRONOUNCING A RESIDENTS' DEATH. EMPLOYEE "A" STATED "YOU MAKE SURE THERE IS NO PULSE AND NO RESPIRATIONS AND OTHER THEN THAT, I WOULD HAVE TO BE THERE". EMPLOYEE "A" STATED AT TIMES SHE WOULD CHECK RESIDENTS PUPILS TO SEE IF THEY WERE "FIXED AND DILATED". REVIEW OF THE PHYSICIAN ORDERS [REDACTED].M., REVEALED EMPLOYEE "A" WAITED 25 MINUTES AFTER FINDING RESIDENT #104 WITH NO PULSE AND NO RESPIRATIONS BEFORE NOTIFYING THE PHYSICIAN AT WHICH TIME THE PHYSICIAN ORDERED THE RELEASE OF RESIDENT #104'S BODY TO THE FUNERAL HOME. IN AN INTERVIEW ON [DATE] AT 10:10 A.M., THE DIRECTOR OF NURSING SAID SHE DID REVIEW RESIDENT #104'S DEATH. SHE SAID SHE SPOKE TO EMPLOYEE "A" WHO CONFIRMED THE DEATH STATING, "I KNOW DEAD AND HE WAS DEAD". THE DIRECTOR OF NURSING COULD NOT PROVIDE A FACILITY POLICY OR PRACTICE FOR DETERMINING DEATH. THE DIRECTOR OF NURSING STATED, "YOU MUST BE THERE TO DECIDE WHAT TO EVALUATE" WHEN DETERMINING DEATH. THE DIRECTOR OF NURSING SAID NURSES CURRENTLY PRONOUNCE RESIDENTS DEATHS AT THE FACILITY AND CONTACT THE PHYSICIAN LATER. THE DIRECTOR OF NURSING REVIEWED THE MEDICAL RECORD FOR RESIDENT #104 AND STATED THAT WAITING 25 MINUTES TO CALL THE DOCTOR LEFT THE PHYSICIAN NO OPPORTUNITY TO INITIATE APPROPRIATE CARE AND TREATMENT. THE DIRECTOR OF NURSING REVIEWED THE CURRENT CPR POLICY AND SAID DEATHS MUST BE WITNESS TO START CPR. SHE SAID THIS POLICY DID NOT MEET STANDARDS OF PRACTICE AND NEEDED TO BE CHANGED. IN AN INTERVIEW ON [DATE] AT 12:30 P.M., THE FACILITY EDUCATOR SAID SHE TAUGHT CPR TO FACILITY STAFF. THE FACILITY EDUCATOR SAID TO MEET STANDARDS OF PRACTICE, THE FACILITY AND STAFF MUST HONOR EACH RESIDENTS END OF LIFE DECISIONS, INCLUDING THE DELIVERY OF CPR IF THE RESIDENT WAS A FULL CODE. THE FACILITY EDUCATOR SAID DESPITE POLICY, STAFF WERE REQUIRED TO PROVIDE FOLLOW THE STANDARDS OF PRACTICE AND INITIATE CPR TO RESIDENT #104 ON [DATE] WHEN THEY FOUND HIM WITH NO PULSE AND NOT BREATHING WHILE SIMULTANEOUSLY NOTIFYING HIS PHYSICIAN OF THE CHANGE IN CONDITION. THE FACILITY EDUCATOR, SHE COULD NOT LOCATE ANY EVIDENCE OF TRAINING STAFF IN THE TECHNIQUE FOR THE DETERMINATION OF DEATH BUT KNEW THAT STAFF PERFORMED THIS FUNCTION. IN AN INTERVIEW ON [DATE] AT 12:30 P.M., THE DIRECTOR OF QUALITY ASSURANCE SAID THE DEATH OF RESIDENT #104 REVEALED THAT THE FACILITY'S CURRENT CPR POLICY DOES NOT MEET STANDARDS OF PRACTICE FOR THE DELIVERY OF CPR AND MUST BE CHANGED. THE DIRECTOR OF QUALITY ASSURANCE REPORTED IT CAN TAKES UP TO 14 DAYS TO DETERMINE A RESIDENTS END OF LIFE CHOICES, WHICH COULD BE TOO LATE. ON [DATE] AT 3:04 P.M. THE ADMINISTRATOR WAS NOTIFIED OF AN IMMEDIATE JEOPARDY THAT BEGAN ON [DATE] WHEN FACILITY STAFF FAILED TO PROVIDE CPR TO RESIDENT #104 AFTER HE WAS FOUND NOT BREATHING AND WITHOUT A PULSE, WHICH RESULTED IN RESIDENT #104'S DEATH. ON [DATE], THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. RESIDENT #104 WAS NO LONGER AT THE FACILITY. 2. ON [DATE], THE FACILITY MANAGERS COMPLETED A CHART REVIEW OF ALL RESIDENTS TO ESTABLISH END OF LIFE DECISIONS. 3. ON [DATE], THE FACILITY REVIEWED AND REVISED THE FOLLOWING POLICY'S: A) CPR POLICY - REVISIONS INCLUDE THE PROVISION OF CPR TO ALL RESIDENTS WHO DOCUMENT THIS TO BE THEIR END OF LIFE CHOICE AND FOR ALL RESIDENTS WHO HAVE NO TREATMENT PROTOCOL/ADVANCE DIRECTIVE IN PLACE WITH THE ABSENCE OF VITAL SIGNS, B) THE TREATMENT PROTOCOL POLICY - REVISIONS SPECIFY THAT "UNTIL COMPLETED (A TREATMENT PROTOCOL/ADVANCE DIRECTIVE) RESIDENT ARE CONSIDERED A YES TO CPR" AND "UNTIL (RESIDENT) COMPETENCY IS COMPLETE, THE RESIDENT WILL RECEIVE CPR", AND C) THE PHYSICIAN NOTIFICATION POLICY - REVISIONS INCLUDE "THE CHARGE NURSE IS RESPONSIBLE TO NOTIFY THE RESIDENT'S PRIMARY PHYSICIAN OF DETERMINATION OF DEATH, IMPLEMENTATION OF CPR ...". ADDITIONALLY, "RESIDENTS' CHARGE NURSE MAY NOTIFY THE PRIMARY CARE PHYSICIAN FOR ANY OTHER REASON THE NURSE FEELS THE PHYSICIAN NEEDS TO BE AWARE". 4. ON [DATE], THE FACILITY DEVELOPED A NEW POLICY TITLED "DETERMINATION OF DEATH" TO MEET RESIDENT NEEDS AND THE STANDARDS OF PRACTICE IF A RESIDENT IS FOUND WITH THE ABSENCE OF SPONTANEOUS VITAL SIGNS. 5. ON [DATE], THE FACILITY BEGAN MANDATORY EDUCATION FOR ALL STAFF MEMBERS REGARDING THE NEWLY REVISED AND DEVELOPED POLICIES REGARDING CPR, DETERMINATION OF DEATH, TREATMENT PROTOCOL, AND PHYSICIAN NOTIFICATION. 162 OF THE FACILITY'S 168 EMPLOYEES (INCLUDING CONTRACTED THERAPY STAFF) WERE EDUCATED AS OF [DATE]. THE REMAINING STAFF WILL NOT BE PERMITTED TO RETURN TO WORK UNTIL THEY HAVE RECEIVED THE IN-SERVICE EDUCATION. 6. ON [DATE], THE FACILITY IMPLEMENTED DAILY AUDITS TO ENSURE RESIDENTS END OF LIFE CHOICES ARE IN PLACE ON ADMISSION. AS OF [DATE], THE FACILITY admitted SIX RESIDENTS ALL OF WHICH HAVE HAD END OF LIFE DECISIONS IMPLEMENTED. 7. ON [DATE], THE FACILITY INITIATED AUDITS FOR ALL DEATHS AND HOSPITAL TRANSFERS TO EVALUATE THE QUALITY OF CARE DELIVERED BASED ON END OF LIFE CHOICES. WHILE THE IMMEDIATE JEOPARDY WAS REMOVED ON [DATE], THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF ISOLATED AND A SEVERITY OF NO ACTUAL HARM WITH POTENTIAL FOR MORE THEN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY DUE TO ALL STAFF HAD NOT BEEN EDUCATED AND SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY.