Every finding on record at Memorial Healthcare Center

Based on observation, interview, and record review, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 (Resident #12) of 8 reviewed for MDS assessments, resulting in the potential for inaccurate care plans and unmet care needs.Resident #12Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R12 was an [AGE] year old female originally admitted to the facility on [DATE], with diagnoses that included dementia. The above MDS reflected R12 had a Brief Interview for Mental Status (BIMS) score was 2/15 indicating severe cognitive impairment and was dependent on staff for all activities of daily living.During an observation and interview on 1/13/26 at 11:10 a.m. R12 was sitting in chair in room with family at bedside. R12 family reported had been on hospice services but had been discontinued around September of 2025 because R12 health had improved. During an interview and record review on 1/14/26 at 2:45 p.m., MDS staff D reported had been in position for about five months. MDS staff D reported R12 had an annual MDS completed 11/5/25 related to significant change because R12 graduated from Hospice services. After review of R12 MDS, dated [DATE], MDS staff D verified MDS reflected R12 was marked for receiving hospices services and stated should have been marked NO because she was discharged from hospice 11/5/25. MDS staff D reported R12 MDS was incorrect and planned to correct and was unsure why it had been marked in error. MDS staff D reported did not have to complete significant change MDS after 11/5/25 because data was collected under 11/5/25 annual assessment. Review of R12, Hospice Communication Log, dated 11/5/25, reflected, [named R12] no longer meets hospice criteria. Care team and family agreeable to hospice discharge. Discharge completed. Review of R12, MDS Note, dated 11/18/25, reflected, . [named R12] was due for her Q assessment but, ended up having a Significant change the week prior to assessment due to her graduating off of hospice . During an interview on 1/14/26 at approximately 3:10 p.m. Director of Nursing (DON) B reported would expect MDS assessments to be accurate and verified R12 had discharged from hospice services and should have had a MDS assessment that reflected that. During an interview on 1/14/2026 at 3:40 PM DON B verified MDS for Resident #12 was incorrect.

Based on observation, interview, and record review, the facility failed to properly install backflow protection devices, in two locations in the kitchen, resulting in the potential contamination of the domestic water supply. Findings include: On 2/13/23 at 9:30 AM, during an inspection of the kitchen, the atmospheric vacuum breaker (AVB) (a device commonly used in plumbing to prevent the backflow of contaminated liquids into the domestic water supply), at the waste disposal near the three-compartment sink, was observed to be plumbed in a position that makes the AVB functionally irrelevant. On 2/13/23 at 9:33 AM, the submerged inlet for the waste disposal, near the dish machine, was observed to not be provided with an AVB to prevent any contaminated liquid from entering the domestic water supply. At this time, Maintenance Supervisor E stated that they must have missed installing an AVB at the disposal. According to the 2017 FDA Food Code Section 5-203.14 Backflow Prevention Device, When Required. A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT, including on a hose [NAME] if a hose is attached or on a hose [NAME] if a hose is not attached and backflow prevention is required by LAW, by: (A) Providing an air gap as specified under S 5-202.13 P; or (B) Installing an APPROVED backflow prevention device as specified under S 5-202.14. P

Based on observation, interview, and record review, the facility failed to ensure physician orders for a therapeutic diet were routinely followed for one (Resident #19) of two residents reviewed for nutrition resulting in the potential for adverse consequences including coughing, choking, and aspiration (process of food, liquid, or other material entering a person's airway or lungs instead of being swallowed). Findings include: Resident # 19 (R19) initially admitted to facility 11/11/22 with 2/2/23 facility readmission with diagnoses including hematemesis, aspiration pneumonia due to gastric secretions, esophagitis, and severe protein-calorie malnutrition. Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/9/23 revealed that R19 was usually understood and understands with a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Section G of MDS revealed that R19 required two-person extensive assist with bed mobility and transfers, one-person extensive assist with dressing, and supervision with eating after set up. Section K of same MDS revealed that R19 had no swallowing disorders but was on a mechanically altered diet (required change in texture of food or liquids) while a resident. In an observation and interview on 2/13/23 at 9:25 AM, Resident # 19 (R19) was observed laying in bed with head of bed elevated at an approximate 45-degree angle. A breakfast tray with an egg omelet, cornflakes with milk, and a glass of milk was observed to be positioned in front of resident on an over the bed table. A Styrofoam cup half full of water and small ice cubes was observed on the over the bed table, as well, with R19 observed to use a spoon to eat the ice cubes and water throughout the interview as stated, my mouth gets so dry. R19 stated that he would not be drinking the milk as It has some sort of slime in it. During the same observation and interview, a staff member was observed to enter room and provide R19 with a prepackaged orange jello cup which resident was noted to consume half of throughout interview prior to placing on over the bed table. In an observation and interview on 2/14/23 at 1:33 PM, R19 was observed laying in bed with head of bed at an approximate 30-degree angle. A Styrofoam cup, labeled 2/14/23 6:00 AM, with thickened yellow liquid observed on over the bed table with R19 stating that he thought it was water with some kind of flavoring and slime thickener in it. An opened bag of Fritos noted at bedside, as well, with R19 stating, I like the flavor, but they stick to my mouth. They are too dry. When R19 was questioned regarding the ice chips and water that he was observed to consume 2/13/23, R19 stated, I ask for them and sometimes they bring them to me and sometimes they don't. I take them whenever I can get them. Review of R19's medical record complete with the following findings noted: ST (Speech Therapy) Swallow Study dated 1/20/23 indicated within Summary/History section, .assessed at bedside for swallow skill and safety and to determine the least restrictive oral food and liquid consistency diet he is able to tolerate without risk of aspiration. Assessment section of same study indicated, .According to the portions of this test that I could adequately complete, this gentleman has a mild oral dysphagia due to nothing tastes good and a mild pharyngeal phase dysphagia with cough of liquids post swallow. The Dysphagia Recommendations section of report indicated, Diet Consistency: Easy to chew, Liquid Consistency: Nectar Thick (Mildly thickened liquids to the consistency of nectar), Swallowing Precautions: Small bites and sips, Eat/drink slowly. Hospitalist History and Physical with 1/30/2023 hospital admitted indicated within Assessment and plan section, Aspiration pneumonia due to gastric secretions acute in nature with Qualifiers indicated to be bilateral lower lobe of lung Pneumonitis due to inhalation of food and vomit with Hospital Discharge note dated 2/2/23 under Diet instructions noted to state, advance to usual diet. Facility readmission physician order dated 2/2/2023 stated, Regular Diet with indication within order under Diet Modifications which stated, Easy to Chew, Nectar Thickened. A Nurse Note dated 2/4/23 at 4:05 AM stated, .Accepted HS (bedtime) snack, ate 100% of applesauce and jello cup . and a note dated 2/5/23 at 2:24 AM stated, .Accepted HS snack, ate 100% of small applesauce and jello cup . Nutrition/Dietician note dated 2/9/23 at 2:48 PM stated, .Diet: Regular, easy to chew, nectar thick liquids. Nutrition risk care plan with 2/9/23 updated/reviewed date included within the problem, Potential nutrition concerns: Poor PO (by mouth) intake - varied intake; Dysphagia: had a swallow evaluation on 1/20/23 and is recommended a dysphagia diet . and a corresponding intervention with a 2/9/23 start date, Diet order: regular, easy to chew, nectar thick liquids. In an interview on 2/14/23 at 1:47 PM, Patient Care Technician (PCT) D confirmed familiarity with R19 and that she was his assigned PCT. Per PCT D, R19 was on a regular diet but that his liquids needed to be thickened and that to her knowledge he could not have ice chips or water. PCT D stated that R19 was able to feed himself but that staff were supposed to provide supervision while he was eating. In an interview on 2/14/23 at 1:55 PM, Nursing Home Administrator/Director of Nursing (NHA/DON) A confirmed that R19 was in the hospital most recently with a diagnosis of aspiration pneumonia and stated, upon referencing R19's medical record, that current order was for regular diet, easy to chew, with nectar thickened liquids. NHA/DON A stated that the last bedside swallow evaluation was complete by Speech Therapy on 1/20/23 with recommendations for regular, easy to chew diet, with nectar thickened liquids as was currently ordered for R19. NHA/DON A further stated that from what she could see from review of the medical records, that R19 was not currently receiving speech therapy and that no follow up speech evaluation had been complete since 1/20/23 nor after 2/2/23 facility readmission from hospital with diagnosis of aspiration pneumonia. When NHA/DON A was questioned regarding food and fluids that would be acceptable on an easy to chew diet with nectar thickened liquids, stated that she would not recommend Fritos as acknowledged that they would not be part of his diet order at this time, that water with ice chips would not be considered part of a nectar thick liquid diet, but that would have to refer to dietician as to whether jello was included in a nectar thick liquid diet In an interview on 2/14/23 at 2:19 PM, Registered Dietician (RD) C confirmed familiarity with R19 and stated current diet order to be regular, easy to chew with nectar thickened liquids. When questioned, RD C stated that Fritos could be considered part of an easy to chew diet, as they softened when mixed with saliva, but that they should not be left at R19's bedside to be consumed unsupervised, that nectar thick ice cubes could be made but that R19 should not have regular ice chips with water to be consumed with a spoon on a nectar thick liquid diet, and that jello was considered a thin liquid and therefore would not be part of a nectar thick liquid diet. In a follow up interview on 2/14/23 at 3:25 PM, NHA/DON A stated that a Physician Order had been received for a Speech Evaluation with a review of orders within R19's medical record noted to reflect an order dated 2/14/2023 at 2:39 PM which stated Consult to Speech Therapy Stat (immediately) with the Reason for consultation within order indicated to be bedside swallow. On 2/15/23 at 9:51 AM, notified by NHA/DON A that a follow up speech evaluation had been complete for R19. Review of ST (Speech Therapy) Swallow Study dated 2/15/23 indicated within section titled Assessment that The oral and pharyngeal phases of the swallow are within functional limits with Dysphagia Recommendations noted to indicate Diet Consistency: Easy to chew; Liquid Consistency: Thin ., however, prior to the completion of the 2/15/23 Speech Therapy Swallow Study, R19 was placed at risk as was provided with food and fluids that were not consistent with the diet order that was in place from 2/2/23 to 2/15/23 for a regular, easy to chew diet, with nectar thickened liquids.

Based on observation, interview, and record review, the facility failed to maintain backflow protection resulting in the potential of contamination of the domestic water supply, affecting all residents and staff in the facility. Findings Include: On 3/2/22 at 1:17 PM, a submerged inlet (a water supply source that is below the flood level rim of a sink), located in the trough sink of the dish machine drain board, was observed to not be provided with a backflow protection device to prevent the backflow or backpressure of contaminated liquids into the potable water supply. Furthermore, the water supply line providing water to the trough submerged inlet continued on to another submerged inlet at the waste disposal. Both submerged inlets were not provided with a vacuum breaker. According to the 2015 Michigan Plumbing Code, incorporating the 2015 edition of the International Plumbing Code, Section 608 Protection of Potable Water Supply, 680.15.4 Protection by a vacuum breaker. Openings and outlets shall be protected by atmospheric-type or pressure-type vacuum breakers . On 3/2/22 at 1:21 PM, three separate preparation sinks throughout the kitchen were observed to not be provided with an air gap in the drain line to preclude the backflow of solid, liquid or gas contaminants. At this time, Dietary Manager M stated that they suspected that their was an air gap underneath the drain line cover and would follow up with the maintenance department. According to the 2013 FDA Food Code Section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed . On 3/2/22 at 1:53 PM, the atmospheric vacuum breaker (a device commonly used in plumbing to prevent backflow of contaminated liquid into the potable water supply) provided for the spigot near the utility sink, was observed to have a shut off valve downstream from the device, which allows the device to remain under pressure for extended periods of time, which can cause the device to fail. At this time, the water was observed to be on leaving the device under pressure. According to the Michigan Plumbing Code, Incorporating the 2015 edition of the International Plumbing Code, Section 608 Protection of Potable Water Supply, 608.13.6 Atmospheric-type vacuum breakers. Pipe applied atmospheric-type vacuum breakers shall conform to ASSE 1001 or CSA B64.1.1. Hose-connection vacuum breakers shall conform to ASME A112.21.3, ASSE 1011, ASSE 1019, ASSE 1035, ASSE 1052, CSA B64.2, CSA B64.2.1, CSA B64.2.1.1, CSA B64.2.2 or CSA B64.7. These devices shall operate under normal atmospheric pressure when the critical level is installed at the required height.

Based on observation, interview, and record review, the facility failed to properly monitor and maintain safe water temperatures, resulting in the potential for scalding, affecting all 18 residents in the facility. Findings include: On 3/3/22 at 1:00 PM, the bathroom hand sink water temperature, of Room 572, was measured using a Thermapen digital thermometer and found to be at 131.4 degrees Fahrenheit. No point of use mixing valve was observed at the hand sink. On 3/3/22 at 1:03 PM, the bathroom hand sink water temperature, of Room 574, was measured using a Thermapen digital thermometer and found to be at 130.2 degrees Fahrenheit. No point of use mixing valve was observed at the hand sink. On 3/3/22 at 1:05 PM, the bathroom hand sink water temperature, of Room 578, was measured using a Thermapen digital thermometer and found to be at 128.5 degrees Fahrenheit. No point of use mixing valve was observed at the hand sink. At this time, Facilities Manager N stated that one boiler provides hot water for the whole unit, which includes all the long-term care rooms. During an interview on 3/3/22 at 1:56 PM, Facilities Manager N was queried on what water temperature monitoring the facility does and stated that Maintenance Staff O on second shift checks the water temperatures and flushes the water. Additionally, Facilities Manager N stated that there is no central mixing valve at the heat exchanger, and that the set water temperature is what is provided to the Long-term care unit. During a phone interview on 3/3/22 at 2:17 PM, Maintenance Staff O was asked if they monitor water temperatures in the long-term care unit and stated, I do not. I know we did in the past. We were doing it on a daily basis, but it has been a few years since we did that. According to the facility's utility monitoring log, dated for the week of 2/20/22, it noted under, Hot Water Heaters, #1 House Hot Water, Sunday - 148 (degrees), Monday - 145 (degrees), Tuesday - 140 (degrees), Wednesday - 140 (degrees), Thursday - 145 (degrees), Friday - 150 (degrees), Saturday - 150 (degrees).

Based on interview and record review the facility failed to ensure for five out of six confidential group resident interviews received their mail on Saturday's, resulting in residents not being able to exercise their rights to receive mail and access to communication. Findings Included: During a confidential group meeting on 3/03/2022, at 10:09 AM, five out of six resident stated they did receive mail on Saturdays, and stated they did not know why but would like to know why they did not. In an interview on 3/03/2022, at 10:45 AM, Administrator/Director of Nursing (DON) A stated that the mail for residents was delivered to the local post office, and and then a staff member would go to the post office Monday through Friday only to pick up all the mail, which was then sorted and delivered to residents. Administrator/DON A stated that no staff member was available to go to the post office on Saturdays to collect resident mail. Record review of the resident rights posted in the facility revealed that on page #10 under (i) Mail, The resident has the write to privacy in written communications, including the right to--(1) Send and promptly receive email that is un-opened . Review of an email received from Administrator/DON A on 3/03/2022, at 12:07 PM, revealed there was no facility policy and procedure regarding the resident mail process, and wrote in the email that she spoke with the local post office on the phone who stated to her that the post office had what they referred to as a firm hold out . A reply email was sent to Administrator/DON A asking her to define/explain what a firm hold out was, which Administrator/DON A replied, in a reply email, I cannot, those are the words of the post office. In another email received on 3/03/2022, at 2:48 PM, Administrator/DON A stated that she, .just had another conversation with the post master (in the town the facility was located in). She explained to me, It is not possible to pull out the mail because of our setup. It is sorted as a firm pickup hold due to the volumes and that this is not an active delivery point . In an interview on 03/03/2022, at 2:42 PM, Rural Supervisor (RS) (,who was the supervisor at the post office located in the town the facility was located in) stated that the post office was open on Saturdays from 9:00 AM to 2:00 PM where mail was available to be picked on Saturdays. According to https://faq.usps.com/s/article/What-is-Firm-Holdout-Service, a Firm Holdout is a service for customers who receive 50 or more pieces on the first stop on a Carrier Route. These customers may pickup their mail at the local Post Office facility once a day. According to https://tools.usps.com/find-location.htm?location= 80, the local post office Pickup Service Hours revealed that on Saturdays the hours to pickup mail were from 10:00 AM to 12:00 PM.

Based on interview and record review, the facility failed to demonstrate the provision of pertinent information such as benefits and potential side effects of the pneumococcal immunizations for five reviewed for immunizations (Residents #2, #9, #10, #16, and #218), resulting in increased risk of acquiring, transmitting, or experiencing complications from pneumococcal disease without pertinent information. Findings include: According to the Centers for Disease and Control (CDC) website at https://www.cdc.gov/vaccines/vpd/pneumo/public/index.html, recommended pneumococcal vaccination for adults 19 through [AGE] years old who had certain chronic medical conditions, including CHF and lung disease. The CDC recommended those who had not previously received any pneumococcal vaccine, to give 1 dose of Pneumococcal conjugate vaccine, PCV15 or PCV20. The CDC recommended if PCV15 was administered, follow with a dose of PPSV23 at least one year later. And if PCV20 was administered, a dose of PPSV23 was not indicated. CDC recommended pneumococcal vaccination for adults 19 through [AGE] years old who had certain chronic medical conditions, including CHF and lung disease, that had had previously received PPSV23, receive one dose of PCV15 or PCV20. Resident #2(R2) Review of R2's Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/9/21, indicated she was [AGE] years old, was admitted to the facility on [DATE] and had the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R2's electronic medical record, under immunizations, she had received Pneumococcal polysaccharide vaccine (PPSV23) in 2005 and Prevnar13 in 2016. There were no other consent forms or education found in R2's medical record regarding PCV15 or PCV20 vaccines. Resident #9(R9) Review of R9's Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/6/22, indicated she was [AGE] years old, was admitted to the facility on [DATE] and had the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The same MDS indicated R9 was up to date (in accordance with current Advisory Committee on Immunization Practices (ACIP) recommendations). There were no consent forms or education found in R9's medical record regarding PCV15 or PCV20 vaccines. Resident #10(R10) Review of R10's Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/20/22, indicated she was [AGE] years old, was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no consent forms or education found in R10's medical record regarding PCV15 or PCV20 vaccines. Resident #16(R16) Review of R16's Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/16/21, indicated he was [AGE] years old, was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The same MDS indicated R16 was up to date (in accordance with current Advisory Committee on Immunization Practices (ACIP) recommendations). There were no consent forms or education found in R16's medical record regarding PCV15 or PCV20 vaccines. Resident #218(R218) Review of R218's Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/24/22, indicated he was [AGE] years old, was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The same MDS indicated R218 was up to date (in accordance with current Advisory Committee on Immunization Practices (ACIP) recommendations). Review of R218's electronic medical record, under immunizations, he had received Pneumococcal polysaccharide vaccine (PPSV23) in 2017 and Prevnar13 in 2015. There were no consent forms or education found in R218's medical record regarding PCV15 or PCV20 vaccines. During an interview on 3/3/22 at 2:40 PM, Registered Nurses (RN) I and J reported nurses administer resident vaccines per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/3/22 at 4:20 PM, Administrator/Director of Nursing (NHA/DON) A reported unsure if PCV20 or PCV15 vaccines were currently being offered at residents but would have to check with pharmacy. NHA/DON A reported was assisting Infection Control Nurse because had only been in role for less than one week. During an interview on 3/3/22 at 4:30 p.m., Pharmacy Manager (PM) L reported hospital and facility were not offering PCV20 or PCV15 vaccines to residents yet and reported possible plans to start in the spring. PM L reported facility residents vaccines are pharmacy to dose.

Based on observation, interview, and record review the facility failed to record transmission-based precautions in the medical record to prevent the spread of infection in two (Resident #1, and #2) out of four residents resulting in placing staff and other residents at potential risk of infection. Findings Include: Review of the medical record revealed Resident #1 (R1) was admitted to the facility 10/07/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's most recent Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 08/19/2021 demonstrated a Brief Interview for Mental Status (BIMS) of 10 (moderate cognitive impairment) out of 15. Review of the medical record on 11/22/2021 revealed R1 was diagnosed with Novel Coronavirus Disease 2019 (COVID-19) on 11/8/2021 as the results of a Polymerase Chain Reaction (PCR) Test. It was noted that R1's medical record did not have a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It was also noted that R1 did not have a plan of care which demonstrated that she had been placed on airborne isolation because of a COVID-19 diagnosis. During observation on 11/23/2021 at 10:45 a.m. R1 was on airborne isolation precautions as evidenced by sign posted on the resident's door. Upon entering the room, it was observed that R1 was in bed. During attempted conversation with R1, she did not respond to verbal questions asked by this surveyor. It was observed that the Patient Care Technician (PCT) I was attempting to encourage R1 to get out of bed. R1 provided no verbal response to questions from PCT I. Review of the medical record revealed Resident #2 (R2) was admitted to the facility 12/20/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's most recent MDS with an ARD of 11/11/21 demonstrated a BIMS of 5 (severe cognitive impact) out of 15. Review of the medical record on 11/22/21 revealed R2 was diagnosed with COVID-19 on 11/01/2021. It was noted that R2's medical record did not have a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order for airborne isolation was still in effect as demonstrated by an active physician order. It was also noted that R2 did not have a plan of care which demonstrated that he had been placed on airborne isolation because of a COVID-19 diagnosis. During observation on 11/23/2021 at 09:55 a.m. R2 had no evidence of signage posted on his door. R2 was observed setting up in a wheelchair at the side of his bed. R2 did not recall if he had been diagnosed with COVD-19 disease but did explain that most of the time he is currently .feeling pretty good. During interview on 11/22/2021 at 01:50 p.m. the Director of Nursing (DON) B acknowledged that R1 did not have a plan of care in her record demonstrating that she was diagnosed with COVID-19 or that she was on airborne isolation. During interview on 11/23/2021 at 07:45 a.m. DON B was asked by this surveyor if it was expected that a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . DON B explained that the computer system would enter the order at the time of the positive test results but that this system feature had been turned off. She explained that a staff nurse identified this failure on 11/14/2021 and entered isolation orders for all residents that were on isolation at that time. She explained that she was not aware of this issue until during the time of this survey. When questioned on why R2 had an active order for airborne isolation, she explained that R2 was not currently on isolation and that the order should have been discontinued. DON B was asked if it was the expectation that the resident plan of care reflected that they were on airborne isolation related to COVID- 19. DON B explained that it was the expectation that residents plan of care should have been updated to reflect that they were placed on airborne isolation at the time of a COVID-19 diagnosis. DON B acknowledged that R1 and R2 did not have a plan of care demonstrating that they had been placed on airborne isolation at the time of a COVID-19 diagnosis.

Based on interview and record review, the facility failed to provide a copy of the baseline care plan to 2 residents (#9, 19) out of 11 residents reviewed for baseline care plans resulting in the likelihood that there would be a lack of communication among staff regarding the needs of the involved residents, decreased resident safety, no safeguard against adverse events that occur right after admission and no assurance the resident or their representative would be informed of the initial plan for care. Findings include: Resident #9 Resident # 9 (R9) was admitted on [DATE] with the following Diagnoses: [REDACTED]. On 6/5/19 at 10:21 AM, a record review of R9's medical information revealed a baseline care plan in the resident's paper medical record. However, after the review of the form, it was noted there was no resident or resident representative signature on the baseline care plan. In fact, it appeared the signature page of the baseline care plan was not in the chart. On 6/5/19 at 10:28 AM, during interview with Administrator/DON A was asked to locate baseline care plan. After reviewing the medical record, Administrator/DON A stated the baseline care plan was incomplete. On 6/5/19 at 10:39 AM, further review of R9's nurse's notes revealed there was no documentation that the baseline care plan or a summary of the baseline care plan was presented to the resident or the resident representative for review. On 6/5/19, a record review of the facility policy titled Comprehensive Patient-Centered Care Planning, dated (MONTH) 20, (YEAR), indicated that a baseline care plan would be developed within 48 hours of admission but had no reference to providing the resident or resident representative with a copy of the baseline care plan. Resident #19 (R19) Review of the medical record reflected that R19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment with a reference date of 4/25/19, reflected that R19 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). She required limited to extensive assistance of one person for activities of daily living. An Interim Admission (Interdisciplinary Care Plan) (baseline care plan) was signed by a nurse on 4/18/19. The section for I participated in the planning of care and I have received a copy of this care plan . was not signed or dated by R19 or a resident representative. Further review of R19's nurse's notes revealed there was no documentation that the baseline care plan or a summary of the baseline care plan was presented to the resident or the resident representative for review. During an interview on 6/5/19 at 10:12 AM, Nursing Home Administrator/Director of Nursing (NHA) A reported that the nurse that completed the baseline care was the nurse that signed the baseline care plan. According to NHA A, they were supposed to offer a copy of the baseline care plan (to the resident or their resident representative). She reported that the resident or the resident representative signed the baseline care plan.

Based on observation, interview and record review, the facility failed to document rationale for as needed (PRN) [MEDICAL CONDITION] medication orders that extended beyond 14 days for three (Resident #2, #12 and #17) of five reviewed for unnecessary medications, resulting in the potential for an unnecessary medication regimen and adverse side effects. Findings include: Resident #17 (R17) Review of the medical record reflected that R17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment with a reference date of 4/25/19, reflected that R17 had short-term and long-term memory problems. R17's cognitive skills for daily decision making were severely impaired. The MDS also reflected that R17 required limited to extensive assistance of one to two or more people for activities of daily living. On 6/5/19 at 12:16 PM, R17 was observed seated calmly at the dining table with three other residents. R17 was being assisted with lunch by a staff member. Review of R17's medical record reflected that [MEDICATION NAME] 0.5 milligrams (mg) by mouth every six hours was ordered PRN for anxiety on 10/26/18. On 10/28/18, an additional order for [MEDICATION NAME] 0.5 mg by mouth every six hours by mouth PRN for anxiety was written. R17's medical record reflected handwritten prescriptions for 60 tablets of [MEDICATION NAME] 0.5 mg by mouth every six hours PRN for anxiety/nausea on the following dates: 2/6/19, 2/20/19, 2/27/19, 3/13/19, 3/20/19, 4/10/19 and 5/8/19. R17's medical record reflected handwritten prescriptions for [MEDICATION NAME] 0.5mg by mouth every four hours PRN for anxiety/nausea on 11/28/18 (90 tablets) and 4/24/19 (60 tablets). R17's medical record reflected handwritten prescriptions for 90 tablets of [MEDICATION NAME] 0.5mg by mouth every four hours PRN for anxiety on 12/12/18, 12/26/18, 1/9/19, 1/23/19. R17's medical record reflected a handwritten prescription for 60 tablets of [MEDICATION NAME] 0.5mg by mouth every six hours PRN for anxiety on 5/22/19. Review of R17's Medication Administration Record (MAR) for (MONTH) 2019 reflected that R17 had orders for [MEDICATION NAME] 0.5 mg by mouth every six hours as needed for anxiety/nausea for 3/1/19 to 3/15/19 and for 3/16/19 to 3/31/19. The MAR reflected that R17 received PRN [MEDICATION NAME] 14 times for anxiety or agitation. R17's MAR for (MONTH) 2019 reflected orders for [MEDICATION NAME] 0.5 mg by mouth every six hours as needed for anxiety/nausea for 4/1/19 to 4/15/19 and 4/16/19 to 4/30/19. The MAR reflected that R17 received [MEDICATION NAME] 4 times for restlessness or agitation. R17's (MONTH) 2019 MAR reflected orders for [MEDICATION NAME] 0.5 mg by mouth every six hours as needed for anxiety/nausea for 5/8/19 with a stop date of 6/15/19. R17 did not receive any doses of PRN [MEDICATION NAME] for the month of (MONTH) 2019. The survey team requested documentation and physician evaluations for the continued use of PRN [MEDICATION NAME] for R17. A physician consultation for assessment of threatening behaviors towards staff on 8/8/18 failed to mention a recommendation for PRN [MEDICATION NAME]. A physician consultation for assessment for behavioral problems on 10/24/18 failed to mention a recommendation for PRN [MEDICATION NAME] use. Further review of physician progress notes [REDACTED]. During an interview on 6/5/19 at 12:28 PM, Social Worker (SW) B reported that R17 was on PRN [MEDICATION NAME] through hospice. SW B reported that R17's behaviors included striking out (hitting) during care and being aggressive with staff. She reported that R17's behaviors lately had not been as aggressive as in the past, and his condition was declining. According to SW B, effective interventions included redirection, reassurance and calling R17's family. She reported that calling R17's family worked very well for him. SW B reported that she had very little to do with ([MEDICAL CONDITION]) medications when someone was on hospice, as they were prescribed for comfort. Regarding PRN [MEDICATION NAME], SW B report that if it was not being used in a two week period, other than in a hospice case, the facility tried to discontinued the medication. SW B reported that she did not personally keep track of PRN [MEDICAL CONDITION] medications as much and that nursing followed those orders. According to SW B, R17 got very anxious. SW B reported that R17 displayed his anxiety by grabbing things off the table, grabbing the arms of his chair and by repeatedly moving objects that were on tables. Review of R17's behavior tracking logs for (MONTH) 2019, (MONTH) 2019 and (MONTH) 2019 included the following documented behaviors: decline in mood, angry with staff, aggression, tearful/sad expression, inappropriate comments and rejection of care. Resident #2 (R2) Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected R2 was a [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS reflected R2 had a BIM (assessment tool) score of 12 which indicated her ability to make daily decisions was moderately impaired, and she required one person physical assist dressing, hygiene, and bathing and and independent with locomotion on unit, toileting, transfers and eating. During an observation and interview on 6/03/19 at 11:27 a.m., R2 was observed sitting on the edge of the bed in her room. R2 appeared in a good mood, calm and well groomed. R2 appeared to have some sort term memory loss but remained calm throughout interview. R2 reported a recent upper respiratory infection with cough and currently getting better. Review of the facility, Physician Orders, dated and signed 5/3/19, reflected R2 had an order for [REDACTED]. Review of the facility, Medication Administration Record (MAR), dated 4/1/19 through current(June 2019), reflected R2 had an order for [REDACTED]. During an interview on 6/05/19 at 11:35 a.m., Social Worker (SW) B reported R2 sister was R2's secondary Durable Power of Attorney (DPOA) who signed the antipsychotic consents. SW B reported R2 has had several psychiatric evaluations, followed by neurology physician and recently transferred to palliative care. SW B reported R2 had a long history of mental illness including [MEDICAL CONDITION]/personality disorder. SW B verified R2 takes Latvian as needed per the physician order. During an interview and record review on 6/05/19 at 11:59 a.m., Registered Nurse (RN) C reported she routinely worked with R2 and was familiar with care. RN C reported recent changes in R2's scheduled [MEDICATION NAME](used to treat anxiety) timing related to R2 increased negative behaviors. RN C reported R2 had a current physician order [REDACTED]. RN C verified, after reviewing R2's Medication Administration Records, occasional use of PRN [MEDICATION NAME] longer that 14 days. Resident #12 (R12) Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected R12 was a [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS reflected R12 had a BIM (assessment tool) score of 11 which indicated her ability to make daily decisions was moderately impaired, and she was independent with transfers, locomotion on unit, toileting, eating, dressing, showering and hygiene. During an observation and interview on 6/03/19 at 12:24 p.m., R12 was in her room and appeared to be alert and oriented to person, place and time and appeared calm and well groomed. Review of the facility, Physician Orders, dated and signed 5/3/19, reflected R12 had an order for [REDACTED]. Review of the facility, MAR, dated, 4/1/19 through 6/4/19, reflected R12 had received almost daily doses of PRN [MEDICATION NAME] 0.5 mg for two months. During an interview on 6/5/19 at 11:05 a.m. Social Worker (SW) B reported had worked at the facility for five years. SW B stated R12 was, pretty together, and able to make needs known. SW B reported R12 had been deemed incapable to make medical decisions in the hospital prior to admission to the facility, however, after facility admission SW B requested a repeat evaluation because R12 appeared able to make own choices with no changes. SW B reported nursing staff address [MEDICATION NAME] orders for residents. During an interview and record review on 6/05/19 at 11:59 a.m., Registered Nurse (RN) C reported R12 had an order for [REDACTED]. RN C verified frequency of R12 PRN [MEDICATION NAME] on the MAR and reported R12 had received PRN [MEDICATION NAME] routinely almost every day for the last two months. During an interview on 6/05/19 at 1:28 p.m., Director of Nursing/Administrator (DON/ADM) A reported she would expect to see rational from the physician in the chart for PRN use of [MEDICATION NAME] or [MEDICATION NAME] greater than 14 days. DON/ADM A reported she was unable to locate documented rational for R2 use of [MEDICATION NAME] or R12 PRN use of [MEDICATION NAME] greater than 14 days. DON/ADM A reported additionaly if a resident needed frequent use of PRN [MEDICATION NAME] or [MEDICATION NAME] it should be considered to change to scheduled dose.

Based on observation, interview and record review, the facility failed to ensure updated and accurate advanced directive information was in place for 1 resident (R12) of 1 residents reviewed for advanced directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), from a total sample of 11 residents, resulting in the potential for a resident's preferences for medical care to not be followed by the facility, or other healthcare providers potentially affecting up to the facility census of 29 residents. Resident #12 (R12) Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected R12 was a [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS reflected R12 had a BIM (assessment tool) score of 11 which indicated her ability to make daily decisions was moderately impaired, and she was independent with transfers, locomotion on unit, toileting, eating, dressing, showering and hygiene. Review of the facility, Durable Power of Attorney for Healthcare (Patient Advocate) policy and procedure, dated (MONTH) (YEAR), reflected, Patients and families have the right to be involved in decisions regarding forgoing/withdrawing life sustaining measures within the legal requirements to which the Long-term Care and Skilled nursing units must confirm . During an observation and interview on [DATE] at 12:24 p.m., R12 was in her room and appeared to be alert and oriented to person, place and time and appeared calm and well groomed. R12 reported she had a recent change in guardian. R12 reported she did not want to receive cardiac [MEDICAL CONDITION] resuscitation (CPR) or feeding tubes but was told that she had to related to guardian. R12 reported prior to admission at the facility it was her wishes to be Do Not Resuscitate (DNR) and her son was aware. Review of the facility, Physician Orders, dated and signed [DATE], reflected R12 was a FULL CODE. Review of the facility guardianship documents on [DATE] at 3:28 p.m., dated [DATE], reflected R12's guardian F had both medical and financial guardianship. Review of the facility determination documents on [DATE] at 3:31 p.m., dated [DATE], reflected R12 had been determined unable to make medical choices by two physicians. Review of the facility Advanced Directive Care Plans on [DATE] at 3:40 p.m., dated [DATE], reflected R12 had an area checked, Allow resident, if able to discuss feelings regarding their Advanced Directives. An Advance Directive can be revoked or changed if the resident and/or appointed health care representative changes their mind about the medical care they want delivered. The resident's decision making will be assessed quarterly and as needed and will invoke a health care agent or legal representative if applicable . During an interview on [DATE] at 3:20 a.m., Certified Nurse Aide (CNA) G and H reported they were familiar with R12. CNA G and H reported R12 had dementia that had slowly worsened since admission but was able to make needs known. During an interview on [DATE] at 11:05 a.m. Social Worker (SW) B reported had worked at the facility for five years. SW B stated R12 was, pretty together, and able to make needs known. SW B reported R12 had been deemed incapable to make medical decisions in the hospital prior to admission to the facility, however, after facility admission SW B requested a repeat evaluation because R12 appeared able to make own choices with no changes. SW B reported initially R12 son was planning to be guardian, however, did not follow through. SW B reported she applied for guardianship for R12 with help of the hospital legal office with R12 son involved. SW B reported R12's son routinely took R12 to church on Sundays. SW B reported R12 would do well at an assisted living or less restrictive setting and reported plan to discuss discharge at the next care conference and the guardian and R12 son aware of plan. SW B reported R12 was a full code. SW B reported R12 code status on admission was FULL CODE and after R12 was deemed incapable to make medical choices R12 son requested DO NOT RESUSCITATE (DNR), prior to long term care admission. SW B reported R12 had no prior Durable Power of Attorney (DPOA) documents. SW B reported when she became involved, at the time of long term care admission, R12 son had planned to become R12 guardian and did not follow through with process and that was when SW B started the process of appointing a guardian that took place with permanent guardianship ,[DATE]. SW B verified documents. SW B reported she was aware R12 did not want life sustaining measures including CPR but agreed related to having been deemed. SW B reported had not involved ombudsman and did not recall having conversation with guard about R12 wishes to be a no code. SW B reported she felt R12 was capable of making the choice to be a no code, however, had not involved the guardian related to making that choice legally. SW B reported plan to involve Ombudsman and legal guardian as well as R12 and R12 son to address code status at next care conference. During an interview on [DATE] at 1:25 p.m. Director of Nursing/Administrator (DON/ADM) A reported she would expect a guardian to have a conversation with the resident about the code status if the resident expressed a desire to be a no code and move forward with that process. DON/ADM A reported she was not aware R12 wanted to be a no code. DON/ADM A reported she has never seen R12 guardian visit R12 or ombudsman for several months.

Based on interview and record review, the facility failed to provide a written reason of transfer/discharge for two (Resident #2 and #29) of two reviewed for hospitalization , resulting in the potential for residents and/or family being un-informed of the reason for transfer/discharge. Findings include: Resident #29 (R29) Review of the medical record reflected that R29 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment history reflected a discharge return anticipated assessment with a reference date of 3/12/19. Further review of the medical record reflected that R29 was discharged to the emergency room (ER) on 3/12/19 after becoming unresponsive. R29 regained consciousness prior to being transferred to the ER. The medical record did not reflect that a transfer/discharge notice had been provided to R29. A TRANSFER TO ANOTHER FLOOR OR FACILITY CHECKLIST dated for 3/12/19, reflected that a transfer sheet had not been completed due to (R29) left unit already. During interview on 6/5/19 at 4:15 PM, Nursing Home Administrator/Director of Nursing A reported that a transfer form had not been completed or provided to R29 upon her transfer to theER on [DATE]. Resident #2 (R2) Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected R2 was a [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS reflected R2 had a BIM (assessment tool) score of 12 which indicated her ability to make daily decisions was moderately impaired, and she required one person physical assist dressing, hygiene, and bathing and and independent with locomotion on unit, toileting, transfers and eating. During an observation and interview on 6/03/19 at 11:27 a.m., R2 was observed sitting on the edge of the bed in her room. R2 appeared in a good mood, calm and well groomed. R2 appeared to have some sort term memory loss but remained calm throughout interview. R2 reported a recent upper respiratory infection with cough and had gone to the hospital. Review of Electronic Medical Record and paper chart, reflected R12 had a recent transfer to the hospital. During an interview on 6/05/19 at 1:50 p.m., Director of Nursing/Administrator (DON/ADM) A reported written appeal rights and ombudsman contact information was not provided to residents or responsible party at the time of hospital transfer. During an interview on 6/05/19 at 3:15 p.m., Unit Manager (UM) I reported nurses do not provide residents or responsible party with a copy of written transfer notice that included appeal rights or ombudsman contact information at the time of a hospital transfer.

Based upon observation, interview and record review the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting all 28 residents who receive meal services (oral foods) out of the facility's total census of 28 residents. Findings include: On 7/11/18 during a dietary tour of the facility between the hours of 8:03 AM and 12:52 PM the following observations and interviews took place: 1. The Assistant Manager, staff E, Cook, staff F, and Dietary aides, staff C, D, G, H and I, were observed not washing their hands prior to donning gloves while switching between kitchen tasks such as taking and recording food temperatures, touching refrigeration equipment, utilizing cutting boards, and handling food preparation equipment and utensils while preparing lunch for the day. Upon observation, the surveyor asked the CDM, staff B, if the facility had a written policy regarding proper glove use and they responded, Yes, we do. I am revising it, but I can get you a copy. On 7/11/18 at 4:51 PM upon record review of the policies received entitled, HEALTH/HYGIENE OF DIETETIC PERSONNEL, POLICY NUMBER and DIETARY FOOD HANDLING, a requirement to wash hands prior to donning gloves was not found. Review of U.S. Public Health Service Food Code, as adopted by the Michigan Food Law, effective (MONTH) 1, 2012 Chapter 2-301.14 When to Wash directs that: FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLEUSE ARTICLES and: and contamination and to prevent cross contamination when changing tasks; (H) Before donning gloves for working with FOOD; and (I) After engaging in other activities that contaminate the hands. 2. Dietary aides staff, C, G, and I, were observed on multiple occasions not using a hand barrier to shut off the faucet when done washing their hands. On 7/11/18 at 11:55 AM the surveyor requested the facilities handwashing policy from the CDM, staff B. At this time placards were observed by the surveyor posted in the kitchen above and/ or next to the multiple designated handwashing sinks containing information on proper handwashing techniques. On 7/11/18 at 4:54 PM upon record review of the policies received entitled, HEALTH/HYGIENE OF DIETETIC PERSONNEL, POLICY NUMBER and DIETARY FOOD HANDLING a requirement to wash hands in a particular manner to prevent recontamination was not found. Review of U.S. Public Health Service Food Code, as adopted by the Michigan Food Law, effective (MONTH) 1, 2012 Chapter 2-301.12 Cleaning Procedure directs that: (C) TO avoid recontaminating their hands or surrogate prosthetic Devices, FOOD EMPLOYEES may use disposable paper towels or similar clean barriers when touching surfaces such as manually operated faucet handles on a HANDWASHING SINK or the handle of a restroom door.

Based on interview and record review, the facility failed to ensure updated and accurate advance directive information was in place for 6 residents (Resident #10, 16, 231, 12, 17, 29) of 12 residents reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility, or other healthcare providers potentially affecting up all residents in the facility. Findings include: Review of the MICHIGAN DO-NOT-RESUSCITATE PR[NAME]EDURE ACT, Act 193 of 1996 (revised 2014), revealed that, An order executed under this section shall be on a form described in section 4. The order shall be dated and executed voluntarily and signed by each of the following persons: (a) The declarant, the declarant's patient advocate, or another person who, at the time of the signing, is in the presence of the declarant and acting pursuant to the directions of the declarant. (b) The declarant's attending physician. (c) Two witnesses [AGE] years of age or older, at least 1 of whom is not the declarant's spouse, parent, child, grandchild, sibling, or presumptive heir. (3) The names of all signatories shall be printed or typed below the corresponding signatures. A witness shall not sign an order unless the declarant or the declarant's patient advocate appears to the witness to be of sound mind and under no duress, fraud, or undue influence. Further review of this Act revealed, Sec. 4. A do-not-resuscitate order executed under section 3 or 3a shall include, but is not limited to, the following language, and shall be in substantially the following form: DO-NOT-RESUSCITATE ORDER This do-not-resuscitate order is issued by _______________________________________, attending physician for _________________________________________. (Type or print declarant's or ward's name) Use the appropriate consent section below: A. DECLARANT CONSENT I have discussed my health status with my physician named above. I request that in the event my heart and breathing should stop, no person shall attempt to resuscitate me. This order will remain in effect until it is revoked as provided by law. Being of sound mind, I voluntarily execute this order, and I understand its full import. _______________________________________ _______________ (Declarant's signature) (Date) _______________________________________ _______________ (Signature of person who signed for (Date) declarant, if applicable) _______________________________________ (Type or print full name) B. PATIENT ADV[NAME]ATE CONSENT I authorize that in the event the declarant's heart and breathing should stop, no person shall attempt to resuscitate the declarant. I understand the full import of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law. _______________________________________ _______________ (Patient advocate's signature) (Date) _______________________________________ (Type or print patient advocate's name) C. GUARDIAN CONSENT I authorize that in the event the ward's heart and breathing should stop, no person shall attempt to resuscitate the ward. I understand the full import of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law. _______________________________________ _______________ (Guardian's signature) (Date) _______________________________________ (Type or print guardian's name) _______________________________________ _______________ (Physician's signature) (Date) _______________________________________ (Type or print physician's full name) ATTESTATION OF WITNESSES The individual who has executed this order appears to be of sound mind, and under no duress, fraud, or undue influence. Upon executing this order, the declarant has (has not)received an identification bracelet. ______________________________ ______________________________ (Witness signature) (Date) (Witness signature) (Date) ______________________________ ______________________________ (Type or print witness's name) (Type or print witness's name) THIS FORM WAS PREPARED PURSUANT TO, AND IS IN COMPLIANCE WITH, THE MICHIGAN DO-NOT-RESUSCITATE PR[NAME]EDURE ACT. (http://www.legislature.mi.gov/(S([MEDICAL CONDITION]))/documents/mcl/pdf/mcl-Act-193-of-1996.pdf) Resident #17 Resident #17 (R17) was a [AGE] year old female who was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R17 was unable to carry on a conversation. On 07/11/18 at 11:15 AM, a record review of R17's advance directive revealed the advance directive did not follow the format required by the State of MI. The language in the facility form did not reflect the language requirements required by the Michigan Do Not Resuscitate Procedure Act. Resident #29 Resident #29 (R29) was an [AGE] year old male who was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 07/11/18 at11:22 AM, a record review of the advance directive in the electronic medical record revealed Resident # 29 had an advance directive in place which did not conform to the State of Michigan format. The language in the facility form did not reflect the language requirements required by the Michigan Do Not Resuscitate Procedure Act. Resident #231 Resident #231 (R231) was an [AGE] year old male who was admitted to the facility with a [DIAGNOSES REDACTED].# 231 has an advance directive but it doesn't comply to the State of MI format. The language in the facility form did not reflect the language requirements required by the Michigan Do Not Resuscitate Procedure Act. Resident #10 Review of the clinical record including the Minimum Data Set ((MDS) dated [DATE], revealed Resident #10 was an [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #10 had long and short term memory impairment, with severely impaired cognition for daily decision making. Review of Resident # 10's Advanced Directives included a Do Not Resuscitate order and was signed by her Durable Power of Attorney (DPOA) on 3/15/18. The language in the facility form did not reflect the language requirements required by the Michigan Do Not Resuscitate Procedure Act. Resident #12 Review of the clinical record including the Minimum Data Set ((MDS) dated [DATE], revealed Resident #12 was an [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED].#10 scored 3 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Review of the facility's Do Not Resuscitate Order (DNR) form that was signed on 3/29/2018. The facility's DNR form did not reflect the language requirements required by the Michigan Do Not Resuscitate Procedure Act. Resident #16 Review of the clinical record including the Minimum Data Set ((MDS) dated [DATE], revealed Resident #16 was an [AGE] year old male admitted to the facility on [DATE] with a readmission date of [DATE], with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #16 scored 12 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Review of the facility's Do Not Resuscitate Order (DNR) dated 4/24/2018 did not reflect the language requirements required by the Michigan Do Not Resuscitate Procedure Act. On 07/12/18 11:55 AM, during an interview with facility Social Worker L she reported she was not aware of the language requirements by the Michigan Do Not Resuscitate Procedure Act.

Based on observation, interview and record review the facility failed to develop a care plan for wander guard / elopement alarms for 1 Resident (#8) out of 5 reviewed for wander guard / elopement alarms resulting in the potential for resident #8 leaving the facility unobserved due to the failure to function or the removal from resident of the wander guard / elopement alarms unnoticed by staff. Findings include: Resident #8 Record review of Resident #8's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #8 was coded with a wander/elopement alarm at a (2) that indicated the alarm was used daily. According to Resident #8's physician incapacity statement resident was deemed unable to make informed consent regarding health decisions on 4/12/18. Record review of Resident #8's Elopement risk dated 7/12/18 was evaluated as a 16. A score of above 12 indicated a risk for elopement. Record review of Resident #8's care plans revealed no documentation of any intervention for a wander guard/ elopement alarm. On 7/12/18 at 4:20 PM, with Registered Nurse RN J and Administrator/Director of Nursing (NHA/DON) A during a Record review of Resident #8's physician orders [REDACTED]. On 07/12/18 at 10:47 AM, during an interview, Social Worker (SW) L reported Resident #8 was reported as a concern for elopement, was deemed incompetent, had a guardian, and unsure if had ever tried to leave the facility. SW L reported Resident #8 often sat by the elevator, made comments about wanting to leave the facility and talked to visitors about wanting to leave the facility. SW L reported Resident #8 appeared alert and oriented and to a visitor looked normal and could easily have gotten on the elevator and left the facility if not for the alarm. SW L reported Resident #8 has the right to wander around the facility and without the wander guard she could be gone from the facility. Resident #8 will be evaluated with her next quarterly evaluation and the wander/elopement alarm may be removed at that time. SW L reported Resident #8 received visitors often, grand children also visited and Guardian had provided a list of people that resident could leave the facility with for outings. SW L reported Resident #8 had voiced wanting to attend church outside of the facility but, there was concern that Resident #8 would be dropped off at the door and not be brought back to the unit and ensure resident's safety. SW L reported that it had been discussed that Resident #8 could attend Church if the arrangement of safety could be made. On 07/12/18 at 11:21 AM, Resident #8's wander guard was observed on her right ankle. During an interview Resident # 8 stated, I would like it (wander guard) off so I can go walk around. I don't feel I need it on there. On 07/12/18 at 02:03 PM, during an interview, SW L stated an assessment for elopement was completed was to have a score of 12 or more had an original score of 16 on meditec (computer program) on 6/12/18. SW L stated, There should have been on an elopement care plan and there is not one. On 07/12/18 at 02:35 PM, during an interview, MDS Registered Nurse (RN) J, reported being responsible for the long term care plan. RN J reported Resident #8's wander guard may have been from a physician order [REDACTED]. RN J stated, the elopement evaluation should have been a (nine) '9 not an 11 as initially evaluated. RN J agreed the assessment was incorrect and stated resident was resistant to placement at the time which could have added 5 points to the assessment making the evaluation score 14. RNJ stated, Staff have a tool that is used to test the wander guard, it was tested yesterday I believe. It was unclear how often the wander guard was checked for placement or function. RN J reviewed Resident #8's care plans and was unable to locate a wander/elopement alarm on the care plans and stated, It should be on an elopement care plan or ADL care plan, and I do not see it on either. Record review of the facility Daily Wander Guard Tracking Sheet for (MONTH) (YEAR) revealed there were 5 residents monitored including Resident #8. Residents were monitored 13 out of 31 days for placement and function. Record review of the facility Daily Wander Guard Tracking Sheet for (MONTH) (YEAR) revealed there were 4 residents monitored including Resident #8. Residents were monitored 16 out of 30 days for placement and function. Record review of the facility Daily Wander Guard Tracking Sheet for (MONTH) (YEAR) revealed there were 4 residents monitored including Resident #8. Residents were monitored 7 out of 12 days for placement and function. On 7/10/18 one Resident alarm was initiated, on 7/11/18 was documented as not functioning and was replaced. On 7/12/18 at 4:15 PM, during an interview, NHA/DON A stated, I have checked and there is no policy to check the wander guards for placement or function.

Based on interview and record review, the facility failed to utilize and maintain complete grievance documentation resulting in grievances not being documented, tracked, and the results of conclusions and/or resolutions not being recorded. This deficient practice has the potential to affect all 28 residents that reside in the facility. Findings include: On 07/11/18 at 11:00 AM and again on 07/11/18 at 03:19 PM, a request was made to review the facility's grievance documentation. Administrator/Director of Nursing A provided a log of missing items. During an interview with Administrator/Director of Nursing A on 7/11/2018 at 3:30 PM, she reported the facility did not maintain grievance documentation. When queried about when or if a resident had a concern such as, cold food, call light not answered timely or a concern with their room not being cleaned etc . how or where the information is documented, and tracked for patterns and trends, stated she would check with Activity Director M who handles grievances. Administrator / Director of Nursing A stated the facility planned to make adjustments. There was no complete grievance documentation ensuring that all written grievance decisions included the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident concern or any correction action taken etc. 07/12/18 at 09:58 AM during an interview with Activity Coordinator M, it was queried how resident grievances were communicated, tracked and how resolutions were formed. Activity Coordinator M reported she would send concerns via e-mail to specific department that was involved. According to the facility policy titled Filing Complaints by Nursing Home residents and other Interested Parties dated (MONTH) (YEAR), page 1. E. All complaints received will be reduced to writing on the Nursing Home Complaint Form.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting all residents who receive meal services (oral foods) out of the facility's total census of 26 residents. Findings include: On 10/24/17 during the dietary tour of the facility between the hours of 7:14 a.m. and 11:07 a.m. the following observations, interviews and record review took place: 1. Improper and inconsistent date-marking of ready to eat potentially hazardous foods were observed on the following products as indicated by their labeled start and use by dates on their foods containers: Bacon dated 10-19 through 11-19 Pepperoni dated 10-18 through 11-19 Sloppy Joe dated 10-18 through 11-19 Black bean burgers dated 10-18 through 11-19 Meatloaf dated 10-18 through 11-19 Meatballs dated 10-18 through 11-19 Sausage dated 10-21 through 11-21 Upon observation the surveyor asked the dietary manager, staff F, if they could explain the facility's date-marking system to them and they replied, that's not right and proceeded to ask dietary aide, staff E, why these were labeled in this manner and they replied, I thought they all got a month. At this time the surveyor asked staff F for a labeling and date-marking policy to review. On 10/24/17 at 1:21 p.m. upon record review it was confirmed in item number 7 in the facility's standard operating procedure entitled storage that the facility has a policy to, Store potentially hazardous foods no more than 7 days at 41 degrees F from the date of preparation, which counts as day 1. Review of U.S. Public Health Service Food Code, as adopted by the Michigan Food Law, effective October 1, 2012 Chapter 3-501.17 Ready-to-Eat, Potentially Hazardous Food (Time/Temperature Control for Safety Food), Date Marking directs that: (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (D) and (E) of this section, refrigerated, READY-TO-EAT, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days.

Based on observation, interview, and record review, the facility failed to have detailed written plans and procedures to meet all potential emergencies and disasters potentially effecting all 26 residents and its staff. Findings include: On 10/24/2017 during the facility's emergency preparedness plan review between the hours of 1:03 p.m. and 2:42 p.m. the following observations, record review and interviews took place: 1. Upon record review of the facility's Memorial Healthcare 2017 Emergency Operations Plan manual the surveyor observed that no risk assessment for the facility was conducted. Pages 29 through 31 were observed left blank with no information regarding event type, probability, risk, or preparedness level of poor, fair, or good was identified. Further record review reviled on page 27 that no signatures or date of approval for use of this plan were given by the following identified individuals: Director ancillary services/Emergency manager Senior vice President of patient care services/COO President/CEO Chair person performance improvement committee board of trustee Upon interview with the DON, staff B on the current status of the plan they stated, we've been working on it prior to June 2017 and have been using it since. We had a full evacuation drill on June 7th.

Based on interview and record review, the facility failed to follow their resident payment policy regarding a Medicaid payment made for 1 resident (Resident #5) of 9 residents reviewed for Medicaid/Medicare payment of a total of 9 sampled residents, resulting in resident anger and potential for Medicaid overpayment and fraud. Findings Include: On 10/25/17 at 10:15 AM during a family interview, FM #1 reported she had paid over $3700.00 ($3758.70) to the facility for Resident #5's care per facility request for payment for Resident #5's care. Following the interview it was noted Resident #5 was noted to have Medicaid. On 10/26/17 at 8:30 AM, Financial Manager P was asked about Resident #5's payment and reported the family had paid $3758.70, was not aware he had a Medicaid pending application and reported she had reviewed the file and discovered that the value code 22 was missing from the claim. Financial Manager P was then asked, so you had not been aware of this prior to my requesting a review of the information, and responded, no. I was first aware of his having medicaid when I reviewed the system in CHAMPS on 6/24/17 and noted the medicaid update. Financial Manager P stated, the biller failed to make a claim to the state at that time we should have put on the information to the state that a payment was made. The facility received a full payment from the state (Medicaid) 4/18/17 through 4/30/17 for the services that the family had paid. Financial Manager P reported had notified her boss today on 10/25/17 Corporate Financial Officer (CFO)Q who was out of the office and unavailable for interview. Review of the facility billing forms for Resident #5 revealed there was no code 22 listed in the appropriate area and the amount indicated of $3758.70 was not listed in the appropriate area during the period of 4/18/17 - 4/30/17. Financial Manager P reported the facility had received $294.10 and had not reported the $3758.70. On 10/26/17 at 9:20 AM, Corporate Executive Officer (CEO) R was notified of the concern, had attempted to contact CFO Q who was unavailable and reported they would follow up on the concern. CEO R reported that an audit should have caught the mistake. There was no answer as to why an audit had not caught the mistake between 4/18/17 and 6/24/17 to 4 months later on 10/25/17. On 10/26/17 at 10:10 AM, CEO R reported Financial Manager P had reported documentation of conversations with Medicaid regarding the payment and information of how Medicaid wanted Financial Manager R to handle the situation. On 10/26/17 at 10:30 AM, Financial Manager P was asked if she had any documentation that she had contacted Medicaid related to Resident #5's payment of $3758.70 and stated, not with this resident. Financial Manager P was then requested to obtain records for all residents on the sample that had medicaid for any potential payments by the family. Information, provided by the facility financial manager P on 10/26/17 at 1:15 PM, from the Michigan Department of Health and Human Services, dated 1/4/17, revealed, Nursing facility must also report resident payments in their Community Health Automated Medicaid Processing System (CHAMPS) claims using Value Code 22. The Note portion of the claim must include a description of the money received, including the date that the nursing facility contacted the resident's eligibility case worker. This requirement was also addressed in Medicaid letter L16-12, issued March 2016 . Failure to report these monies on the Medicaid claim and to the local office may constitute Medicaid fraud as published in the General Information for Providers chapter of the Medicaid Provider Manual, Section 16- Billing Without Reporting Other Resources. The Medicaid Provider Manual is available on the MDHHS website at www.michigan.gov/medicaidproviders>>Policy and Forms.

This citation pertains to intake MI 462. Based on interview and record review, the facility failed to investigate timely, according to the facility policy for injuries of unknown origin for potential abuse, neglect, or mistreatment, and failed to report to the state agency timely for one sampled resident (#7) out of total sample of 10 residents reviewed, resulting in delay notification of the incident. Findings include: According to admission face sheet, Resident #7 was a [AGE] year old female admitted to the facility 4/9/14, readmitted [DATE], with [DIAGNOSES REDACTED]. Resident #7 was not residing in the facility during the abbreviated survey. According to facility Policy and Procedure on Abuse/Neglect/Mistreatment/Misappropriation/Injury of Unknown Source/Suspicion of Crime Investigation Guide dated November 23, 2016, documented the facility utilizes a process that requires all reports of abuse, neglect, mistreatment, misappropriation, injury of unknown source, or suspicion of a crime, are promptly and thoroughly investigated. Under Procedure documented that the Compliant Officer/Director of Nursing will notify the Administrator and immediately begin the investigation. Following a through investigation, the Administrator will follow the reporting guidelines, reporting immediately, but no later than two hours in accordance with State Law. Review of facility's 5 day investigative report dated 7/27/17, documented an injury of unknown origin on Resident #7, bruising to Resident #7's left breast area which was reported by staff to Administrator A on 7/27/17, and an investigation was opened and delegated to a Registered Nurse and Social Worker by Administrator A. According to the investigation report, Staff A said an investigation was completed and felt there was reason for concern. Director of Nursing B was not informed of the bruise until 8/1/17, and met with Administrator A and discussed that the criteria met injury of unknown origin and should be reported to State Agency with in 24 hours with Administrator A agreeing. According to the investigative report, Resident #7 had been assessed on 7/27/17, by Physician and staff and denied anyone hurting her, with no changes in behaviors or routines, and denied pain. An interview was conducted with Director of Nursing B on 10/25/17, at 3:00 PM., related to injury of unknown origin for Resident #7. DON B said that the the injury of unknown origin met the criteria as suspicious due to the location, and should have been reported immediately to the State Agency, but was not. DON B verbalized that Administrator A had been involved with that investigation while DON B was out of the facility for a period of days and upon her return had the conversation with Administrator A that this should have been reported immediately. DON B indicated that the report was not submitted to the State until 8/9/17, which was 13 days after the discovery of the bruise. DON B said she submitted the reports to the State late, but felt it was better to report late then not to report at all, and agreed they did not follow the reporting guidelines and their policy for injury of unknown source. DON B verbalized they were not able to substantiate Abuse, but failed to report timely to the State Agency.

Based on observation, interview and record review the facility failed to prevent the development of and promote the healing of pressure ulcers in 3 of 3 residents (Residents #2, #4, and #5) reviewed for pressure ulcers in a total sample of 10 residents, resulting in Resident #2 developing a Stage 1 pressure ulcer to the coccyx; Resident #4 developing 2 unstageable pressure ulcers (with no dressings in place as ordered by the physician) and Resident #5 developing 4 Stage 2 pressure ulcers and 2 unstageable pressure ulcers. Findings include: The facility was placed in Immediate Jeopardy as a result of the facility's failure to prevent the formation of avoidable pressure ulcers, and the facility's further failure to accurately assess, monitor, and implement appropriate and physician-ordered treatment interventions to promote the healing of the facility-acquired pressure ulcers for residents. This deficient practice placed all residents at the facility at risk for the development of avoidable pressure ulcers and the subsequent lack of assessment, monitoring and treatment to heal. On 10/28/16 at 11:10 AM the Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy that began on 10/27/16 at approximately 9:50 AM, due to the facility's failure to prevent pressure ulcer development, accurately assess residents' skin and monitor and treat pressure ulcers. On 10/31/16, the surveyors verified the following corrective action plan had been implemented: · Skin assessments have been completed on all 39 residents - began POC 10/27/16. · Physician orders [REDACTED]. · The PA wound care specialist has assessed all current residents with skin care areas of concern - began POC 10/27/16. · The PA wound care specialist will ensure treatment plans and all reasonable interventions are in place based on the resident's condition - began 10/27/16. · A wound care contract is being developed for the physician who oversees the PA wound care specialist to provide weekly and prn visits - began 10/28/16. · The wound care specialist (PA) will perform ongoing assessments on all residents identified with skin care areas of concern, any resident who develops changes in a skin care area, and any new admissions with skin concerns or breakdown. The PA will document the progress - began 10/27/16. · When orders are received from the PA, the LTC/Skilled nursing care staff will notify the Medical Director and provide an update on the resident(s), and any interventions or treatments ordered - began 10/28/16. · The Medical Director will document in the physician progress notes [REDACTED]. · The facility is developing a policy on the appropriate process for obtaining physician orders [REDACTED]. · The facility is currently re-writing our policy on Skin and Wound Care Prevention - began 10/27/16. · The nursing care plans and process of updating the plans is being revised. All nursing care plans for residents who currently have skin care areas of concern are being reviewed and updated - began 10/27/16. · The DON or Designee will provide face-to-face education with each staff member prior to them working their next scheduled shift. The education will cover the revised skin and wound care policy, documentation forms (both paper and electronic), the process involving the PA wound care specialist, nursing ' s role in timely updates to the Medical Director, communicating skin issues and information to the next shift's nurse via bedside reporting and updating the CENA ' s who will be working the shift with them. CENA ' s will also be performing bedside report with the oncoming and outgoing shift - began 10/28/16. · The facility is scheduling the PA wound care specialist to provide education and training to all staff on assessment, prevention, what to do if skin issues are found, monitoring of wounds, appropriate documentation of wounds with measurements, and wound staging - began 10/28/16. · Daily skin assessments will be completed by a licensed nurse, preferably with the resident's CENA present - began 10/28/16. · Weekly skin assessment rounds will be completed weekly by a licensed nurse, the CENA caring for the resident(s), and the PA wound care specialist - began 10/27/16. · The CENA's will perform skin sweeps on residents when they are providing personal care (i.e., bathing, showering, or bed bath), or if the resident is incontinent. If any skin changes are observed, the CENA will call the nurse to the resident's room and together they will visually review the skin care area of concern. If the nurse is not available to come to the resident's room at that time the CENA contacts them, he/she will update the nurse on the skin care area of concern. When available the nurse will accompany the CENA to the resident's room to view the area of concern. If the resident refuses to be disturbed at that time or is sleeping the nurse and CENA will return to the resident later in the shift and request to assess his/her skin - began 10/28/16. · The resident and family/DPOA will be updated on any new skin care areas of concern and on the progress of any existing areas of skin breakdown or discoloration - began 10/27/16. · An ad hoc QAPI meeting will be scheduled to review the IJ POC and provide an update on the progress of the skin and wound care changes implemented - began 10/28/16. · Resident #4 and #5 have had the following interventions completed - began 10/27/16: Ø Head to toe skin assessments with wound measurements Ø Consult with PA wound care specialist Ø Wound care specialist assessed both residents on Friday, 10/28/16, interventions and treatments ordered Ø Progress note placed by PA wound care specialist and Medical Director Ø Nursing care plans reviewed and updated Ø Consult for Therapy evaluation obtained on resident #4 to assess for weight re-distribution, possible positioning devices/equipment, and pressure reduction appliance for heels Ø Labs, ABI test, and Therapy evaluation completed on resident #5. The Therapy evaluation was for assessment of weight re-distribution, appropriate heel protectors and Roho cushion for recliner The Immediate Jeopardy was removed on 10/28/16, when the corrective action plan was verified to be implemented, however the facility remained out of compliance with a scope of isolated and severity of Actual harm that is not immediate jeopardy as sustained compliance could not be verified. Findings include: The policy/procedure for Pressure Ulcer Treatment, Med-Pass (last revised 2/2014) reflected, General Guidelines, 1. The pressure ulcer treatment program should focus on the following strategies: a. assessing the resident and the current status of the pressure ulcers. B. Current support surfaces. C. Pressure ulcer care. D. Managing bacterial colonization and infection. E. Education and quality improvement. 2. When eschar is present, a pressure ulcer cannot be accurately staged until the eschar is removed .Definitions .Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough .eschar (tan, brown, or black) in the wound bed. Further description: Until the slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined . Documentation: 1. the date and time the dressing was changed .All assessment data (i.e., wound bed, color, size, drainage, etc.) . Resident #4: Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed that Resident #4 was a [AGE] year-old female, who was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4 ' s MDS, dated [DATE], for the Brief Interview for Mental Status (BIMS), reflected a score of 5 out of 15 representing severe cognitive impairment. Resident #4 required extensive assistance and a mechanical lift for all activities of daily living. Section M (MDS) reflected no pressure ulcers. According to the physician's order [REDACTED].#4 had an open area to the left toe; dated 6/11/16- had blood cultures and started an antibiotic. On 6/21/16 another antibiotic was ordered and on 6/24/16 there was an order for [REDACTED]. According to the skin assessment, dated 8/23/16, Resident #4 had open areas to the right and left feet. The MDS, dated [DATE], did not reflect the presence of these two pressure ulcers. During Surveyor # interview on 10/27/16 at approximately 9:50 AM, LPN J was asked about the wounds to Resident #4 ' s feet. LPN J stated, She does not have a treatment for [REDACTED]. Hospice discontinued the treatment because they aren ' t doing anything anyway. During an observation of care on 10/27/16 at approximately 10:00 AM, Resident #4 was in bed as CNA H and CNA I provided incontinence care. Resident #4 ' s feet were bare and noted to have a wound on each foot. The right foot had a wound to the ball of the foot that had a dark thick cover to the wound bed (eschar) that was approximately 2 cm X 1 cm. The outer aspect of the left great toe had a large thick eschar that was approximately 2.5 cm by 1.5 cm. Both CNA ' s denied that Resident #4 had dressing of the feet. Review of the physician orders, dated 10/26/17 at 4:40 PM, reflected an order for [REDACTED]. During an interview on 10/27/16 at approximately 10:015 AM, LPN J was asked about the treatment for [REDACTED]. Resident #4) was just admitted to hospice and they discontinued the wound treatments. When asked if there were any treatments or dressing for Resident #4, LPN J stated, No. The facility was asked to provide weekly measurements for the left toe ulcer and the right foot ulcer. The DON B stated that there were no measurements to review. A skin assessment, dated 10/26/16 unsigned and untimed, reflected, a scab on the outer aspect of the great left toe 2.5 cm x 1.5 cm and the ball of the right foot that had a scab that measured 1.5 cm x .7 cm. The skin care plan (undated) reflected that on 9/26/16 Resident #4 had a wound to the left great toe and did not identify the second pressure ulcer to the right ball of the foot that was noted during the observation. The Treatment Administration Record was reviewed for September 2016 and October 2016 and there were no documented treatments provided for the left toe ulcer or the right foot ulcer. Resident #5: Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], reflected that Resident #5 was a [AGE] year-old male, who was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5 ' s MDS, dated [DATE], for the Brief Interview for Mental Status (BIMS), reflected a score of 9 out of 15 which represents moderate cognitive impairment. Resident #5 required extensive assistance and a mechanical lift for all activities of daily living. Section M (MDS) reflected no pressure ulcers. During the initial tour on 10/24/16 at approximately 7:30 AM, LPN K advised Surveyor # that Resident #5 did not have any pressure ulcers. During an interview on 10/24/16 at approximately 3:35 PM, LPN K was asked about Resident #5 ' s most recent skin assessment. LPN K stated that Resident #5 ' s skin was assessed earlier in the shift and had no skin issues except a slight redness to the coccyx area from a recent BM. LPN K was asked about the cushioned boots in Resident #5 ' s room. LPN K stated that he needs to wear them while he is in bed and anytime he has pressure on his feet. This surveyor accompanied by with LPN K entered Resident #5 ' s room and observed Resident #5 seated in recliner chair with his feet resting directly on the foot rest (without the cushion boots on). Resident #5 was transferred to the bed (per his request) and his skin was assessed with [REDACTED]. dark purple deep tissue injury. The Treatment Administration Records (TAR) for September 2016 and October 2016 were reviewed and revealed that on only 2 days (9/19/16 and 10/19/16) were treatments provided for the coccyx pressure ulcer and no treatments for the other pressure ulcers. The weekly skin assessments noted the following:6/6/16 tiny scab to the right heel, 6/13/16 purple area to right heel, and scabs to the top of the toes to the left foot, 8/1/16 redness/bruise to the coccyx, 8/21/16-a pin point open area to the coccyx, 9/5/16- scab area to the right heel, 8/29/16-abrasions and open areas to the top of the toes. Measurements were requested for the wounds and the DON stated that there weren ' t any. The skin care plan, dated 10/24/13, did not reflect the presence of the 6 pressure ulcers, which were observed and noted with LPN K on 10/24/16 nor interventions or treatments to promote healing. Resident #2: During an observation on 10/27/16 at approximately 10:20 AM, when Resident #2 stood from the toilet a dressing dated 10/27/16 at 0330 was observed on her coccyx area. See record review and interview done by Surveyor regarding this pressure ulcer. (# ) On 10/24/16 at about 7:40 AM, during initial tour, Licensed Practical Nurse K stated Resident 5 had an air mattress and moon boots, when asked did Resident 5 have any pressure ulcers, LPN K replied no ulcers. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected Resident 2 was an [AGE] year old female who had resided at the facility since 11/3/15 and had [DIAGNOSES REDACTED]. Resident 2's Weekly Skin Observation Sheet dated from 4/6/16 to 10/26/16 reflected Resident 2's skin was intact until 8/3/16 and 9/14/16. The entry for 8/3/16 appeared as if a yes was put there, then it was changed to no. The chart documentation for 8/3/16 reflected a Red area in the crease of the buttock and the Director of Nursing (DON) was not notified. On 9/14/16 there was a Red/Split area in the crease of Resident 2's buttock, representing an open area. According to the reference Medical Surgical Nursing Volume 1, 7 th edition chapter 13 page 207 described a stage 1 pressure ulcer as an observable pressure-related change of intact skin whose indicators, as compare to an adjacent or opposite area on the body, may include changes in one or more of the following: Skin temperature (warmth or coolness) Tissue consistency (firm or boggy) sensation (pain, itching) The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue or purple hues. Both the 7/12/16 and the 8/18/16 Braden scale (skin assessments) reflects scores of 16 which indicates mild risk. During an interview with MDS Registered Nurse G on 10/31/16 at 10:50 AM, assessed residents based on what the nurses tell her and the documentation on the skin sheet, that she only observes the skin if she was aware it was a problem area. When asked about the description on the Weekly Skin Observation Sheet dated 8/3/16 where it indicated redness in the crease of Resident 2's buttock, MDS RN G replied the nurse told her skin was red because her brief was soiled and that was the reason her skin was red, thus she did not observe Resident 2's skin. Due to the facility's lack of knowledge of the an accurate assessment of this area of skin, no notification to the DON and no change in care or treatment, Resident 2 developed an open area on 9/14/16. The Braden scale (skin assessment) score completed after an open area was found, had a score of 9 dated 9/15/16, which reflected Resident 2 was at a severe high risk of pressure ulcers. ( )

Based on observation, interview and record review, the facility failed to supervise 3 of 4 sampled residents (Residents 20, 21 and 23) to prevent falls and accidents from a total of sample of 10 resulting in increased pain, immobilization and injuries. Findings include: According to the facility policy Assessing Falls-and Their Causes Clinical Protocol, dated October 2010 with no LTC (Long Term Care) staff or Medical Director revision, stated, 1. After a Fall: a. If a resident has just fallen, or is found on the floor without a witness to the event, nursing will record vitals signs, and evaluate for possible injuries to the head, neck, spine, and extremities. b. If there is evidence of a significant injury such as a fracture or bleeding, nursing staff will provide appropriate first aid. c. Once an assessment rules out significant injury, nursing will help the resident to a comfortable sitting, lying , or standing position, and then document relevant details e. Nursing staff will observe for delayed complications of a fall for approximately forty-eight hours after an observed or suspected fall, and will document findings in the medical record. f. Documentation will include any observed signs or symptoms of pain swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. It will note the presence or absence of significant findings. g. An incident report must be completed for resident falls. The incident report form should be completed by the nursing supervisor on duty at the time and submitted to the Director of Nursing Services no later than 24 hours after the fall occurs. 2. Defining Details of Falls: a. After an observed or probable fall, the staff will clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred. (1) Rolling . (2) Falling . (3) Falling . E. Identify Causes of a Fall or Fall Risk: a. Within 24 hours of a fall, the nursing staff will begin to try to identify possible or likely causes of the incident. They will refer to resident-specific evidence including medical history, known functional impairments, etc. b. Staff will evaluate chain of events or circumstances preceding a recent fall, including (1) Time of day of the fall; (2) Time of the last meal; (3) What the resident was doing; (4) Whether the resident was standing, walking, reaching, or transferring from one position to another; (5) Whether the resident was another other persons or alone; (6) Whether the resident was trying to get to the toilet; (7) Whether any environmental risk factors were involved .; (8) whether there is a pattern of falls for this resident. c. The staff will continue to collect and evaluate information until they either identify the cause of falling or determine that the cause cannot be found. d. The Unit Manager or Director of Nursing Services should consult with the Attending Physician or Medical Director to confirm specific causes from among multiple possibilities. e. As indicated the Attending Physician will examine the resident or may initiate testing to try to identify causes .; f. When possible, the Attending Physician or nursing staff will document the basis for identifying specific factors as the cause. g. If the cause of a fall is unclear, if the fall may have a significant medical cause such as a transient ischemic attack or an adverse drug reaction .; h. If causes of fall cannot readily identified .; 4. Performing a Post-Fall Evaluation: a. After a first fall, a nurse and/or physical therapist will watch the resident attempt to rise from a chair without using his or her arms walk several paces, and return to sitting, and will document the results of this effort. b . c. If the individual has difficulty or is unsteady in performing this test, additional evaluation may be initiated as warranted. Documentation When a resident falls, the following information should be recorded in the resident;s medical record: 1. The condition in which the resident was found (e.g., resident found lying on the floor between bed and chair.) 2. Assessment data, including vial signs and any obvious injuries. 3. Interventions, first aid, or treatment administered. 4. Notification of the physician and family as indicated. 5. Completion of a falls risk assessment. 6. Appropriate interventions taken to prevent future falls. 7. The signature and title of the person recording the data. 1. Notify the following individuals when a resident falls: a. The resident's family; b. The Attending Physician. c. The Director of Nursing Services and; d. The Nursing Supervisor on duty . Resident #20 According to the Quarterly Minimum Data Set (MDS) Assessment, dated 12/19/16, Resident 20 was an [AGE] year old female admitted to the facility 6/14/16 with [DIAGNOSES REDACTED]. This same Quarterly MDS, reflected a Brief Interview for Mental Status score of 7 out of a possible 15, indicating she had severe cognitive impairment. This same Quarterly MDS dated [DATE] also reflected Resident 20 had 2 falls this past quarter since her admission with no injuries. On 2/7/16 at about 9:30 AM, during initial tour, Resident 20's family member stated she had 3 recent falls and two of them were on 2/6/17. Resident 20 was observed with a wound on her forehead covered by a Band-Aid. Resident 20's family member was heard telling a facility employee that Resident 20 had not been assessed yet, but Hospice had been called and the Hospice nurse told facility to put a Band-Aid on it. Incident and Accident reports since the plan of correction to the present were requested and received. Resident 20 had 4 falls and one hot liquid spill since the plan of correction date of 12/6/16. A typewritten investigation with staff education, reflected Resident 20 had hot coffee spilled on her lap on 12/8/16, with the intervention she should not have hot liquids without supervision. Fall event report dated 12/11/16 reflected Resident 20 tried to stand up from her wheelchair, lost her balance and fell on floor, onto her right side. On 1/21/17 Resident's daughter observed Resident 20 on floor with sensor alarming. Resident 20's daughter attempted to find other staff, who were all assisting other resident's, and stated she was unable to find anyone, so she put Resident 20 the chair by herself. On 2/9/17 at about 8:20 AM, during an interview with LPN AA, on 2/6/17 (according to Licensed Practical Nurse AA and Patient Care Technician O on 2/14/17 at 12:00 PM) the time was between 1:45 AM and 2:15 AM. Resident 20 was left alone on the toilet and had a fall. The Fall Event report dated 2/6/17 described Resident 20's rib area as a new area of disfigurement. The Fall Event report dated 2/6/16 at 4:00 PM, reflected Resident was propelling herself to the dining room leaned forward, lost her balance and fell on to the floor. Resident 20 has a jagged laceration on right side of her forehead, approx .3 X .3, cleaned wound with NS wipe, patted dry and applied steri strips, this is per Hospice RN. The report for 12/8/16 reflected Resident 20 was given hot coffee in the dining room between 5:30 AM and 6:30 PM. The nurse on duty documented 15 to 20 minutes after Resident 20 received the coffee a patient care technician reported the coffee spill. The facility recommended a lid to be placed on hot liquids and to supervise Resident 20 to ensure she did not attempt to manipulate the lid, also to use a clothing protector. These interventions were not placed on the care plan. The Fall Event report dated 12/11/16 reflected Resident 20 tried to standup from a wheelchair lost her balance and fell on the floor, onto her right side, no injury. Details of the investigation show that Resident 20 has poor safety awareness, attempts to stand frequently without assistance. The facility concluded the action taken to prevent recurrence was to ensure foot pedals are removed from w/c (wheelchair) when w/c (wheelchair) not being pushed by others to eliminate the possibility of resident tripping over pedals. This intervention was not added to her care plan. The Fall Event report dated 1/21/17 reflected Resident 20's daughter observed resident on floor of room, care sensor was alarming. Daughter attempted to find other staff, who were all assisting other resident's, and stated she was unable to find anyone so she put resident in her chair herself. Resident 20's told daughter at the time she was trying to go to the bathroom . The details of investigation were Resident has poor safety awareness, she does not recall to use call light to ask for assistance. Care plan was being followed at time of incident. Resident (20) was assisted with toileting needs 15 minutes prior to incident. Resident had asked to lay down so staff assisted resident to bed. Bed was in low position, call light within reach, floor pads in place, care sensors on and functioning. Under resolution comment the facility wrote No injuries. Will discuss incident with IDT for additional methods to reduce falls. No new interventions were added to Resident 20's care plan. On 2/8/17 between 11:30 AM and 12:30 PM, during an interview with Assistant Director of Nursing (ADON) B when questioned about no staff being available to pick Resident 20 off of the floor, ADON B replied that they staff were all busy and we can't hire an aide for each resident. The Fall Event report dated 2/6/17 reflected patient care technician (PCT O) assisted Resident 20 to the toilet stepped out of room, heard her cry and went in and was found on the bathroom floor. One of the contributing factors were Staff - Inadequate System for Covering Patient Care. On 2/9/17 at 8:20 AM, during an interview with LPN AA she stated she made a mistake when she documented the incident took place and 1:15 AM, instead the time was 2:15 AM. On 2/14/17 at about 12:00 PM, during an interview with PCT O he stated this incident occurred after lunch. That after lunch (1:30 AM) he got on the phone and spoke to Registered Nurse Manager BB about splitting the schedule at a latter date. Then heard the alarm sounding and he and Licensed Practical Nurse (LPN) AA went into Resident 20's bathroom and found her on the floor. On 2/14/17 at about 12:00 PM PCT O stated he was aware he should not have left Resident 20 on the toilet alone. No new intervention was added to Resident 20's care plan after the above incident. The Fall Event report dated 2/6/17 at 4:00 PM, reflected Resident 20 was sitting in her wheelchair and propelling herself into the dining room, resident appeared to have leaned forward and lost her balance and fell on to the floor. Staff was on unit at the time and assisted her with care. Resident has a jagged laceration on right side of her forehead, approx.3 X .3, cleaned wound with NS wipe, patted dry and applied steristrips, this is per hospice RN. Care plan was reviewed and in place at the time incident. Although no new intervention were mentioned in the Fall Event report, a new approach was added on 2/7/17 when Resident 20 leans forward, which was visual or physical monitoring of resident when in wheelchair. Four of the 5 incidents that occurred, occurred because there was no supervision and thus were avoidable. In the days following the fall on 2/6/16 Resident 20 was found to have injuries and a steady decline. Resident 20's medication administration record from 2/4/17 to 2/14/17 showed that most of her medications were refused, withheld per doctors orders or she was physically unable to take. Hospice notes from 2/6/17 to 2/12/17 explain Resident 20's decline as follows: (1) 2/6/17 Patient was injured during her fall when found on the floor - she has a large protrusion on right side lower rib cage. X-ray ordered and found . fracture of the 11th rib. During my report, via phone, (LPN K) saw patient fall out of her wheelchair laceration of right side of her head. Resident 20 had 2 falls on 2/6/17. (2) 2/7/16 .Steristrips noted to right forehead . Right rib cage protrusion to which pt (patient) states no pain upon palpation . hematoma at site noted . (3) 2/7/16 Order written for ortho (orthopedic) consult and for Roxanol for patient due to fall and rib pain. Discussed with (Medical Director L,) daughter and patient spouse injury, head contusion and treatment and [DIAGNOSES REDACTED]. Daughter states her decision to treat will not change based on head CT or MRI, so declines to seek order for test . Patient had previously been exhibiting pain symptoms such as facial grimacing and leg restlessness and moaning. Daughter states she does not believe Tylenol to be effective . (4) 2/8/17 Team Meeting to discuss plan of care. Patient is now a hoyer lift for safety. Recent fall and has a questionable fracture of rib. Patient is now starting Roxanol for pain . warning to staff to make sure she is handled carefully. (5) 2/9/17 TC (telephone call) from (MDS Nurse H) States patient is moving right leg up and down frequently and daughter requesting X-ray of hips. Call received approx 1 hour later. X-ray positive for fracture of left greater trocanter. Daughter (name) called to update on patient condition and results from x-ray. Daughter verbalizes understanding of result of X-ray. Also requests CT of head due to decreased LOC and increased agitation since last Monday. Daughter states 'I know it won't change anything but I want the most information possible.' This RN contacted (Medical Director L) informed of request and (Medical Director L) gave order for head CT without contrast and also ordered ortho (orthopedic) consult for safety recommendations and transfers with trocanter fracture. Discontinued mechanical lift for transfers until orders from ortho doc obtained. Daughter aware of ortho consult and bedrest recommendation until further order can be obtained form orthopedic physician. complete bedrest until further orders obtained. (6) 2/10/17 Patient in bed. Did a full bed bath, did not shampoo hair. Patient was very agitated and facial expressions suggest that patient is in pain due to hip fx (fracture) and rib (fracture). Notified facility nurse that patient seemed to be in pain . (7) 2/12/17 Telephone call received agency, Hospice RN D, that Resident 20 was now actively dying. During an interview on 2/10/17 at approximately 12:00 PM, Resident #20's family member Y stated that the facility notified her that Resident #20 sustained a fall during the early morning hours of 2/6/17 when she was assisted to the bathroom and left unattended by staff. The facility had reported that assessments were done and no injury was noted to Resident #20. Resident #20's family member stated that she came to visit that same morning (2/6/17) and Resident #20 was droggy and didn't eat her breakfast. Resident #20's family member stated, I went to roll her over in bed (onto her good side) when I noticed a protrusion to her chest area that had not been there before so I notified the nurse .I received a call Tuesday morning (2/7/17) from the facility to inform me of the X-ray results. They said she (Resident #20) had fractured #11 rib. Resident #20's family member showed this surveyor a picture of Resident #20 right chest area and stated, I just don't understand that if they checked her out like they say they did why was I the first to notice this protrusion from her chest area? The picture revealed a raised area approximately the size of a baseball from chest wall. Record review of the nursing notes of the following dates and times reflected, 2/6/17 at 2:50 AM, Heard Resident cry out and upon entering room found her sitting in front of the toilet. PCT (patient care tech) left her alone on toilet for a few minutes. Assessment done and no injuries noted at this time .assisted off the floor and back on toilet and then assisted to bed .2/6/17 at 4:56 PM, Resident daughter assisted resident to bed after lunch, called me to room to look at resident right side, rib area, raised area and appears slight bruising Gave Resident her PRN (as needed) Ativan 0.5 mg (antianxiety medication) at 0945 due to crying, trying to get get out of WC (wheelchair), yelling out, attempted to redirect and was unsuccessful. Resident is now resting quietly in bed . Record review of Corrective Action Form dated 2/6/17 unsigned by supervisor and employee reflected, (Name of CNA O) admits to placing resident on toilet and exiting room, leaving resident unassisted. Resident is care planned as a 1 person assist .Corrective Action Taken: Administrative leave pending investigation effective 2/9/17 while investigation in process. During a telephone interview on 2/14/17 at approximately 11:50 AM, CNA O stated that he assisted Resident #20 to the bathroom on 2/6/17 at approximately 2:15 AM, attached a fall alarm to Resident #20 and then exited the room to make a phone call at the nurses desk. CNA O stated that he heard the alarm a few minutes later and entered the bathroom and found Resident #20 on the floor. When asked if Resident #20 was to be left unattended in the bathroom, CNA O stated, No, I made a mistake leaving her there with or without alarms. It was a bad call in judgement. Resident #4 According to Resident #4's Minimum Data Set ((MDS) dated [DATE] Resident was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident's Brief Interview for Mental Status (BIMS) indicated a 9 and indicated resident was moderately cognitively impaired. Resident was also evaluated to have no pressure ulcers and weighed 206 pounds. Review of Resident #4's Incident Reports revealed Resident had 3 falls dated 12/22/16, 12/29/16 and 1/29/17. On 12/22/16 Resident #4 was found on the floor during rounds next to the bed intervention was to place an alarm. On 12/29/16 found on floor, frequently stating I have to go. 1:1 supervision to ensure resident safety while awake was implemented. On 1/29/17 Resident #4 was found on right side of geri-chair in patient room. Resident was last seen within 10 minutes of incident. Resident frequently wakes without indication and thinks she is able to walk. Care plan reviewed by ID. Will request Hospice to supply new Geri-chair, encourage visitors staff to offer toileting while awake or as soon as possible after resident wakes. Staff to continue to sit near residents room in order to respond quickly. Resident to continue with sitting up by nurses station while awake. There was no documentation of a post fall assessment completed following any of Resident #4's falls on 12/22/16, 12/29/16 or on 1/29/17 according to the facility policy. Review of Resident #4's Fall Care Plan R/T weakness R/T tracheomalcia, pulmonary edema, A-fib, HTN, DM dated 11/25/17 and revised on 12/22/16 revealed intervention that included the following, answer call light (resident was not able to activate the call light), bed in low position, toilet every 2 hours, care sensor on bed, wheel chair and chair, floor mat opposite bed of care sensor, up with 2 assist to transfer, mechanical lift and coordinate care with hospice services. There were no interventions to round more frequently, staff to sit with chair by room during night time hours during charting, geri-chair at nurses station while awake, 1:1 supervision when increased agitation, anti-anxiety medication for severe agitation to prevent further falls. Resident #4's urine output records were requested since admission and received information from 12/6/16 through 12/21/16. Review of that information revealed Resident #4's was toileted 1-2 times per day usually in the morning and late in the afternoon for approximately 150-650 cc. On 2/8/17 at 10:10 AM, PCT N reported Resident #4 was a 2 person assist and sits down really hard. Patient Care Tech (PCT) N reported she had reported the bruise (on the left hip), she was climbing out of the chair and bed at the same time it was noted when we were putting her on the commode, and it might be from the commode. PCT N reported when Resident #4 when resident was agitated it was a signal she needed to go to the bathroom and she would not use the bed pan, we got her up with a 2-3 person assist with a gait bet and she used the commode. This information was not identified on the care plan. On 2/9/17 at noon, Registered Nurse (RN) I reported resident had a fall on 1/28/17, was not on 1:1 supervision. There was a time she was (on 1:1) but not on my shift. RN I reported Resident #4 was given Valium (anti-anxiety) due to being quite anxious and trying to get out of her bed and chair prior to the fall. RN I reported Resident #4 had fall interventions in place such as a low bed, mats on the floor next to the bed, alarms, and they would sit her in a recliner chair next to the nurses station, and make rounds every 30-60 minutes. RN I reported Resident #4 had a fall between these rounds on 1/28/17. On 2/14/17 at 11:00 AM, Director or Nursing (DON) B was asked about Resident #4's falls and resident's increased agitation and if she had ever considered increased supervision? DON B stated I kept trying to bump it up even when she was sleeping and have her sit at the nurses station, at night they are to have a chair by her room to do their charting. DON B was asked, Is that in her care plan? and responded, I would like to say it is. DON B was asked about 1:1 supervision for when Resident is extremely anxious and stated I have never officially had her on 1:1, they have just done it. DON B was asked, Were you aware that the staff have had to get assistance from your safety officer? and responded, No. On 2/14/17 at 11:20 AM, Hospice RN D was asked about Resident #4's falls and stated, Resident #4 was on 1:1 supervision for a long time, was extremely agitated almost aggressive and staff had to call public security officer to assist (prevent resident injury). She has had a sitter (Hospice) for 24 hours a day at times since admission due to the falls and agitation. On 1/14/17 at 1:45 PM, Resident #4 was observed in her room lying on her back attempting to remove her shirt and get out of bed, yelling help. PCT N and a new orientee were observed sitting at the nurses station. Review of Resident #4's Hospice Admission records revealed she was on long term use of insulin prior to admission, cardiac death successfully resuscitated, and had safety precautions that included aspiration precautions, fall precautions, oxygen safety precautions, bleeding precautions, sedation precautions, universal precautions and diabetic precautions. There was an intervention that included Daughter requests not to check glucose due to decreased patient oral intake and extreme agitation. There was no documentation on education related to how the effects of not providing resident with insulin would affect agitation, confusion and potentially increased fall risk with the resident. Resident #23 According to Resident #23's Minimum Data Set (MDS) assessment dated [DATE] Resident was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #23's Brief Interview for Mental Status (BIMS) indicated a 15 and indicated resident was cognitively intact. Review of Resident #23's Fall Incident Report dated 1/8/17 revealed resident was ambulating to the bathroom with one assist with her walker, gait belt in place. Resident fell back into nurse while ambulating. Knee gave out. Resident was evaluated by PT to see if has potential for strengthening. Review of Resident #23's Fall Incident Report dated 2/2/17 revealed Patient was using her walker to ambulate back to her recliner with my assistance. I was walking behind her and right before we got to the chair her right knee gave out. Care Plan was reviewed. IDT discussed and PT recommended for staff to have resident use w/c to restroom door, then ambulate to toilet with walker and staff to shorten distance resident walking at one tie. To continue ambulation, Staff to ambulate with resident in hallway with walker, staff push w/c behind for support. Review of Resident #23's Fall Care Plan revealed the intervention was not on the care plan. On 2/9/17 at 11:20 AM, Registered Nurse (RN) FF reviewed Resident's Incident Reports and Care Plans and stated, I don't see the interventions on the care plan. Review of Resident #23's Physician orders [REDACTED]. On 1/6/17 Clarification of order stated, OT to evaluate and treat lt side weakness. Review of PT progress note dated 1/6/17 revealed one entry Discuss declines with DON and Dr. (name) to explore possibility of therapy services. Had discussion with resident this date and she feels she could benefit from therapy services. Review of PT progress note dated 1/11/17 revealed, Physical therapy was notified by occupational Therapist that Resident had a fall and required a re-assessment by Physical therapy. At this time no orders have been received for Physical Therapy assessment. Following a fall however a char review confirmed that Resident fell while walking with staff on 1/9/17 Per note Resident had a posterior loss of balance when walking with staff and was lowered to the floor. Re-assessment completed on this date by physical Therapy due to recent fall .An email will be sent to her doctor and the DON requesting out patient therapy orders and a FWW.

Based on observation, interview, and record review, the facility failed to ensure the safety of residents to prevent falls in 2 of 3 sampled residents (Resident #2 and #3) reviewed for falls, from a total of 10 sampled residents, resulting in a fall with fracture on 5/9/15 for Resident #2 and the increased potential for serious injury from a fall for Resident #3. Findings include: Resident #2 According to Resident #2's MDS/Minimum Data Set, dated dated [DATE], she was an [AGE] year old who had moderately impaired cognition, ambulated with assistance, and [DIAGNOSES REDACTED]. According to Resident #2's MDS, dated [DATE], she had severe cognitive impairment and never ambulated. Review of Resident #2's Safety Net Reports (Incident/Accident reports) and the complete medical record for the past 12 months revealed Resident #2 had the following 6 falls in that time period: - 2/19/15 at 12:20 AM - Owner (staff member completing report): (LPN/Licensed Practical Nurse P) .found sitting on floor next to roommate's bed .scrape on right inner arm, wrist area that is 6 cm long by 1/2cm side .bruising along the side of scrape. Right knee has a 1/4 cm x 1/4cm round mark, bruising . The report did not indicate if any interventions had been put immediately into place to prevent further falls. - 5/19/15 at 2:40 PM - Owner: (LPN O) - found on the floor lying on her Rt (right) side. Pt (Resident #2) was then helped off the floor. She was then c/o (complaining of) Rt hip pain and also Rt ankle pain .daughter was in the room when it happened and said that she was visiting with roommate and tripped over the cord that was at the end of her roommate's bed. According to an physician progress notes [REDACTED].pain management . - 6/27/15 at 7:00 AM - Owner: (LPN S) found on floor .Resident's strength has declined and she had had 2 other recent falls without injury .resident is being asked to call for assistance . - 6/30/15 (time not recorded) - Owner: (Nurse Tech/Aide R) found Resident on the floor . The report did not indicate if any interventions had been immediately put into place to prevent further falls. - 7/01/15 (time not recorded) - Owner: (LPN Q) - found resident on her back on floor .Sensor was still attached to chair unattached from resident .Resident has an increased incidence of falls lately. Resident disregarded calling for assistance and did not use any assistive device to ambulate . The report did not indicate when if any interventions had been put immediately into place to prevent further falls. - 8/19/15 (not timed) - Owner: (LPN E), Resident #2 fell on [DATE] at 3:55 PM; location not documented. According to the Brief Description: Found her on the floor. Head injury - bleeding got 2 staples. CT of head done, nothing noted. x-rays done - nothing noted per (MPOA/Medical Power of Attorney K). Contributing Factors (Reported): Action by Patient/Resident, Limited Ambulation, Lost/Impaired Balance, Fall Prevention Strategies Implemented, Patient Assessed (Vitals), Referred to ED (emergency), Treatment Provided .Injury Details .Bleeding/Hemorrhage, Head Injury, Injury to her head and possible to her back and pelvis. All tests came back negative. Did receive 2 staples to laceration to her head. The report did not include the vital signs or neuro checks, whether the call light or bed alarm were sounding at the time of the fall, when Resident #2 was last seen and/or toileted, the names of staff assigned to Resident #2 at the time of the fall, or witness statements. According to an untitled typed noted regarding Resident #2, dated 8/19/15, .unwitnessed fall when ambulating to the bathroom in her room .fell backwards, landing on her back/pelvic area and hit the back of her head on the floor .did not call for staff assistance as instructed . An imaging report, dated 8/19/15 (not timed) revealed Resident #2 had Chronic right superior and inferior pubic rami fractures. Review of Resident #2 Fall Care Plans revealed all Approaches/Interventions did not contain the name of the staff member or the date of entry, making it impossible to determine if/when interventions were added to prevent continued falls after fall incidents. In an interview, on 12/01/15 at 3:13 PM, LPN E reported she was assigned to Resident #2 when Resident #2 fell and sustained a head injury on 8/19/15 at 3:55 PM. LPN E said she was called into the room by a Nurse Aide, but could not remember who the Nurse Aide was or where she found Resident #2. LPN E said she remembered seeing Resident #2 laying flat, noticed blood, so she held something on Resident #2's head and sat her up. LPN E said Resident #2 winced when they sat her up and took her vital signs. When asked if she had performed Range of Motion prior to sitting her up, LPN E stated she asked Resident #2 to move her toes and fingers, but not specifically her arms, legs, shoulders, or hips. LPN E reported she did vital signs and neuro checks on Resident #2 and passed them along to MDS/Minimum Data Set Coordinator D, and said, I don't think they (vital signs and neuro checks) are in the medical record. When asked if Resident #2's personal alarm was sounding, LPN E said, I honestly don't remember if it was sounding. When asked about Side Rails X 2 designated on the Incident Report that she initiated, LPN E said, The bed rails are on her bed for safety, in case she rolls back and forth. LPN E stated, (Resident #2) has declined a lot in the past several months. She has had more falls, but she now needs to be fed and is no longer continent of bowel and bladder; before, she kept getting up to help her roommate. LPN E said staff were long aware Resident #2 kept getting up out of bed to help her roommate, but wasn't moved until after the fall; then, Resident #2 was moved closer to the Nurses' station. When asked what intervention was used to immediately prevent additional falls, LPN E said, I made sure she had her call light. When asked if Resident #2 used her call light, LPN E said, (Resident #2) was impulsive. When asked if the facility had ever educated her (LPN E) on post fall assessment/interventions, LPN E reported she had worked at the facility for 2 1/2 years and never had education regarding post-fall assessing/safely transferring/ putting interventions in place to prevent continued falls, and said, We use a fall risk bracelet/ it alerts us who is at risk for falls. When asked if she had revised Resident #2's Fall Care Plan after the fall, LPN E said, I've never been told to do that. Resident #2 is no longer impulsive. In an interview, on 12/02/15 at 2:00 PM, Resident #2's MPOA K reported the facility told her Resident #2 was found on the bathroom floor on 8/19/15 at 3:55 PM, and Resident #2 was ambulatory prior to the fall, then wasn't. MPOA K reported Resident #3 was given a tab alarm after that fall. ( ) Resident #3 According to Resident #3's MDS/Minimum Data Set, dated dated [DATE], she had severe cognitive impairment, restraints (bedrails) were in use, and [DIAGNOSES REDACTED]. According to Resident #3's Fall Risk Assessment prior, dated 8/12/15, she scored 10 (Total score above 10 represented a high risk for falls). Review of Resident #3's Safety Net Reports (Incident/Accident reports) and the complete medical record since 6/25/15 revealed Resident #3 had the following 5 falls in that time period; vital signs (except on 6/25/15)/neuro checks/orthostatic blood pressures, or range of motion were either not done/documented on the majority of the Safety Net Reports listed below or in the medical record: - 6/25/15 at 4:30 PM - Owner: (Nurse Tech/Aide U) - found sitting up on the floor beside the bed .She had taken her care sensor off and wound the cord around it, so her sensor was not alarming. I immediately got the nurse .When we lifted her back into the bed and visually checked her skin over, I did not notice any redness, bruising, or abrasion. I took her vitals at 16:45 (4:45 PM) (recorded) .3 day 30 minute check and charts for fall risk monitoring was initiated. Also her care sensor was moved from her visual field to reduce the likelihood of her taking it off . Review of Resident #3's Potential for Falls Care Plan revealed there was no intervention documented to move her sensor out of her visual field. - 7/02/15 at midnight - Owner (LPN S) - noted resident sitting on the floor beside the bed sitting up right. rom wnl (range of motion within normal limits) . LPN S did not document whether the care sensor was alarming, where it was, what assessments were completed, or immediate interventions to prevent further falls. - 7/10/15 at 8:30 PM - Owner: (Nurse Tech/Aide T) - Found resident on floor next to her bed .Nurse Tech/Aide T did not document whether the care sensor was alarming, where it was, what assessments were completed, when Resident #3 was last toileted, whether injuries were sustained, or immediate interventions to prevent further falls. - 10/02/15 at 3:05 PM - Owner: (Nurse Tech/Aide F) - Resident found sitting on floor beside bed. Care sensor intact .Resident stated that she was trying to go for a walk . In an interview, on 12/01/15 at 4:21 PM, Nurse Tech/Aide F reported she found Resident #3 sitting on the floor on 10/02/15 at 3:05 PM. Nurse Tech/Aide F said, I just happened to walk by. (Resident #3) said she was trying to go for a walk - the alarm was still attached. The tab alarm box was on the other side of the bed. Nurse Tech/Aide F stated the string on the alarm was so long, the tab never separated from the box, and therefore did not alarm. Nurse Tech/Aide F said, We shortened it (the string) after that fall. Nurse Tech/Aide F reported she called the nurse (but could not remember the nurse's name); the nurse checked Resident #3's arms, hips, necks, and asked Resident #3 if she was in pain. We put (Resident #3) into bed and checked her all over for cuts and bruises. We did vital signs when (Resident #3) was still on the floor, and did more vital signs and checked her eyes. - 10/09/15 at 2:05 PM - Owner: (Nurse Tech/Aide I) - found resident on floor next to her bed. Care sensor was attached to resident . Nurse Tech/Aide I did not document whether the alarm was sounding. In an interview, on 12/02/15 at 10:17 AM, Nurse Tech/Aide I reported he was working on 10/09/15 at 2:05 AM when he found Resident #3 laying the other way on the floor. Nurse Tech/Aide I said, I was doing rounds and found (Resident #3) next to her bed between the wall and the register. The string was still connected to the box (that was attached to the side rail) - it didn't trigger the alarm. The tab alarm string was too long. Nurse Tech/Aide I said he was unsure how long Resident #3 had been on the floor. Nurse Tech/Aide I said, It couldn't have been more than an hour, when I last made rounds. Nurse Tech/Aide I said he called a nurse (but couldn't remember which nurse) and the nurse asked Resident #3 to squeeze her hand and had Resident #3 move her feet, but I don't think she checked her eyes. When asked if the either he or the nurse asked Resident #3 if she hit her head when she fell , Nurse Tech/Aide I stated, No. When asked, Nurse Tech/Aide I said, (Resident #3) told me she was going to her chair in the corner to get her stuffed animal. She had one of them in bed with her, but she likes to have both of her stuffed animals with her when she goes to bed - I give them both to her now, they make her happy. When asked if having her stuffed animals with her when she is in bed was on the Care Guide, Nurse Tech/Aide I said, I don't think so. Review of Resident #3's Fall Care Plans revealed all Approaches/Interventions did not contain the name of the staff member or the date of entry, making it impossible to determine if/when interventions were added to prevent continued falls after fall incidents. There was no intervention to make sure the alarm (placement or cord length), and no mention that she should have her stuffed animals when in bed. In an interview, on 12/01/15 at 4:40 PM, DON/Director of Nursing B stated the facility used an electronic Incident Report called Safety Net Report, and vital signs (that are taken at the time of the fall) get separated and go to the MDS office. This Surveyor requested the complete investigations, including witness statements regarding falls sustained by Resident #2 and Resident #3. In an interview, on 12/02/15 at 8:00 AM, this Surveyor again requested from DON B all information regarding the investigations requested on 12/01/15. In an interview, on 12/01/15 at 2:40 PM, DON/Director of Nursing B reported she was the Falls Coordinator, in charge of investigating and analyzing falls, and she did not collect witness statements when falls occur. In an interview, on 12/02/15 at 10:55 AM, DON B said she filled out the Fall Event Details on the Safety Net Report, including the types of fall safety precautions in place at the time of the fall. When presented with the Safety Net Report for Resident #3, dated 10/09/15 at 2:05 AM, and asked specifically about Safety Alarm (recorded as being in place) and whether it was sounding at the time of the fall (not documented on the Safety Net Report), DON B said she did not ask if the alarm was sounding during her investigation. DON B reported she was unaware the string was still attached and that Resident #3 was out of bed in search of her stuffed animal. In an interview, on 12/02/15 at 9:30 AM, CCC/Clinical Care Coordinator L reported it was an ongoing issue with staff not filling out the electronic Safety Net report with substitive information. CCC L stated she had not been apprised of Resident #3's alarm cord being too long for either of the falls she sustained on 10/02/15 at 3:05 AM or 10/09/15 at 2:05 AM. CCC L said, It's an ongoing problem - staff not filling out the form completely. (DON B) tells them to fill it out completely. It it's not documented where its normally documented, it's getting missed. The (computer) program is not user friendly. CCC L reported she didn't have anything to do with interventions put in place after a fall. In an interview, on 12/01/15 at 3:40 PM, DON/Director of Nursing B the facility knew they were deficient in that area, and that the facility had developed a post-fall investigation tool. Review of the facility's Fall Protocol Policy and Procedure, dated 9/30/15, revealed the last sentence of the policy was, .If a patient has a fall, the post-fall assessment will be completed and the Fall Protocol will be implemented or continued. The care plan will be revised. In an interview, on 12/01/15 at 3:40 PM, DON B reported the Post Fall Investigation Worksheet - To be completed by charge nurse at time of fall . (page 4 of the Fall Protocol Policy and Procedure) had not been implemented yet. When asked what she taught nurses to do post-fall, DON B said, They evaluate, do vital signs, get the patient up, then the fall committee does stuff. It's a work in progress .still growing. In an interview, on 12/02/15 at 1:37 PM, DON B reported the facility had no policy and procedure that contained post-fall assessment, intervention, or documentation guidelines. When asked who the Unit Manger for the residents was, DON B stated the Unit Manger was CCC/Clinical Care Coordinator L. DON B reported that many Safety Net Reports were filled out by Nurse Techs/Aides because it was facility practice to have the first person on the scene fill out the electronic Safety Net report. When asked who filled out the information regarding which fall preventions were in place at the time of the fall, DON B stated she completed that section of the electronic Safety Net form after she had gathered the information. While examining the Safety Net Reports, DON B was unable to say or recall whether the sensor alarm was sounding and was unaware of the cord being too long on the sensor box when Resident #3 fell on both 10/02/15 and 10/09/15. In an interview, on 12/01/15 at 4:05 PM, MDS Coordinator D stated she did not put the vital signs/neuro checks done after falls in the medical record because, It's not a legal document. MDS Coordinator D stated she formulated all of nursing care plans for the facility residents, and when asked about Approaches/Interventions not having the author and date documented (when they were added or deleted), MDS Coordinator D did not comment. ( )