Every finding on record at Mission Point Nursing & Physical Rehab Center of D

Based on observation, interview, and record review the facility failed to: 1. Properly store food items in the kitchen; 2. Remove undated, unlabeled food from the kitchen walk-in cooler and resident refrigerators; and 3. Adequately clean kitchen surfaces. These deficient practices had the potential to affect all residents who consumed food from the kitchen and resident refrigerators, resulting in an increased potential for foodborne illness.Findings include:On 1/21/2026 beginning at 9:41 AM, the initial tour of the kitchen was conducted with Kitchen Manager (KM) A. During the tour, the following items were observed:-in the walk-in cooler two containers of chicken soup undated KM A said the soup was for staff and should not be in the cooler.-one box of opened turkey lunch meat undated. KM A said the box should be labelled and dated.-one box of opened raw hamburgers dated 12/1/26. KM A said the date is wrong and was not sure when they were opened or if they are still good.-one tray of uncovered, unlabeled, undated fish. KM A said the fish should be covered, labelled and dated. -in the pantry one opened 158 oz barbeque sauce bottle. KM A said the opened bottle should be stored in the fridge. -the flooring under and between the deep fryer and stove was heavily soiled. KM A said the floor should be deep cleaned.On 1/22/2026 at 12:32 PM, the third-floor resident refrigerator was observed with Licensed Practical Nurse (LPN) E. The following items were found:-unlabeled and undated food leftovers.-unlabeled and undated opened drinksLPN E said all food and drinks should be labelled and dated.On 1/22/2026 at 12:40 PM, the fourth-floor resident refrigerator was observed with LPN B. The following items were found:-unlabeled, undated food leftovers.LPN B said that nursing was responsible to maintain resident refrigerators and all food should be labelled and dated.On 1/23/2026 at 12:48 PM, the Nursing Home Administrator (NHA) was interviewed and said the expectation is for the kitchen staff to follow kitchen policies and the food code. The kitchen should be clean and sanitary, and food should be stored properly. Review of the facility policy titled Food Storage date issued 1/2024 revealed in part. Food storage areas shall be maintained in a clean, safe and sanitary manner. Refrigerated food outside of original package shall be labeled, dated, and monitored so that it is used by the use by date, frozen, or discarded, whichever is applicable. Food items that are opened shall be put into sealable containers or bag, labeled and dated with open and use by-date.Review of the facility policy titled Use and storage of Food Brought in by Family or Visitors date revised 11/25 revealed in part.It is the right of the residents of this facility to have food brought in by family or other visitors; however, the food must be handled in a way to ensure the safety of the resident. All food items must be labelled with resident name and date. If not consumed within three days food will be thrown away by facility staff.

Based on observation, interview and record review, the facility failed to ensure nursing staff verified tube placement prior to administering medication through a PEG tube for one resident (R6) of two residents reviewed for tube placement. This deficient practice had the potential to result in improper medication administration and resident harm.Findings include:On 1/22/2026 at 1:49 PM, observed Licensed Practical Nurse (LPN) B administer medication through a R6 PEG tube without checking tube placement prior to administration.On 1/23/2026 at 11:01 AM LPN B was interviewed and confirmed they did not check placement before administering the medication. LPN B said they checked placement when they administered morning medication and that is why they did not check when they administered afternoon medications. LPN B said they should check PEG tube placement prior to every use.On 1/23/2026 at 12:06 PM, the Director of Nursing (DON) was interviewed. The DON said staff are expected to verify PEG tube placement every time prior to using it.Review of electronic medical record (EMR) indicated R6 was admitted on [DATE]. R6 had a diagnosis of Acute and chronic respiratory failure with hypoxia, Metabolic encephalopathy, Tracheostomy, Gastrostomy and Tremors.Review of Minimum Data Set (MDS) dated [DATE] noted R6 Brief Interview for Mental Status (BIMS) was unable to be completed.Review of facility policy titled, Care Plan and Treatment of Feeding Tube, with revision date of 6/23 documented, tube placement will be verified before beginning a feeding or before administering medication.

Based on interview and record review, the facility failed to ensure a preadmission screening and resident review (PASARR) was obtained for one resident (R9) of one resident reviewed for PASARR, resulting in R9 not being screened for mental health services and the potential for care needs being unmet.Findings include:On 1/23/26 at 10:50 A.M. review of the Electronic Health Record (EHR) for R9 indicated the resident was admitted to the facility on [DATE], with diagnoses that included: restlessness and agitation, irritability and anger, profound intellectual disabilities, other developmental disorders of scholastic skills. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], R9 had severe cognitive impairment (BIMs=1) and required supervision for most activities of daily living.On 1/23/26 at 11:00 A.M., Social Worker (SW) C was interviewed about R9's Level 11, a comprehensive evaluation by the appropriate state-designated authority which cannot be completed by the facility. This evaluation determines whether the individual has a Mental Disorder, Intellectual Disability, or Related Condition and determines the appropriate setting for the individual and recommends any specialized services and/or rehabilitative services the individual needs due to the resident's diagnoses of profound intellectual disabilities. SW C stated, (R9) never had a level II. The resident has been at this facility for about two years, and our department never received Level I. (R9) does have a diagnosis of intellectual disability but there is no Level II. Exiting the room SW C stated, Let me check further.In a follow up interview at 1:00 P.M. SW C explained R9 should have a Level I and SW C was directed what to do to trigger that evaluation. SW C acknowledged R9 had a diagnosis of intellectual /developmental disability in addition to dementia. On 1/23/26 at 3:00 P.M., SW C presented a revised Level I Screening Form dated 1/23/26 timed stamped 12:37 P.M. Documented under section 11- Screening criteria, all six items were marked yes. Item #5 stated noted R9 had a diagnosis of an intellectual disability or a related condition including, but not limited to, epilepsy, autism, or cerebral palsy and this diagnosis manifested before the age of 22. Documented in the explanation section of the form stated Explain any YesDX: Schizoaffective Disorder, bipolar type; unspecified intellectual disabilities; dementia in other diseases classified elsewhere, unspecified severity, w/psychotic disturbance.Rx: Seroquel; and Namenda for behaviors (new).On 1/23/26 at 3:30 P.M. review of the facility's policy titled: Resident Assessment-Coordination with PASARR program, Revised 1/24 stated: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs . #9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review.

Based on observation, interview, and record review, the facility failed to apply a wheelchair cushion for one resident (R4) with a stage three Sacro Coccyx (base of spine) pressure injury (Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) out of three residents reviewed for pressure ulcers.Findings include:On 1/21/2026 at 12:54 PM, R4 was interviewed about care in the facility and stated, I don't have a wheelchair cushion and my bottom hurts. I would like one. R4 was observed sitting in a wheelchair without a wheelchair cushion.On 1/22/2026 at 11:41 AM, R4 was observed sitting in a wheelchair without cushion in the first-floor dining room.On 1/22/2026 at 2:43 PM, R4 was observed with Certified Nursing Assistant (CNA) D and Licensed Practical Nurse (LPN) E sitting in a wheelchair without a wheelchair cushion. When LPN E was asked about R4's wheelchair LPN E stated, R4 does not have a wheelchair cushion and should since R4 has a stage three pressure ulcer on her bottom. CNA D agreed R4 should have a wheelchair cushion and R4 did not have one.On 1/23/2026 at 9:09 AM, the Director of Nursing (DON) and Unit Manager F were interviewed and said R4 did not have a wheelchair cushion and should since R4 had a stage three pressure ulcer on coccyx. The DON said the expectation for any resident at risk for skin breakdown should be given a wheelchair cushion upon admission and for the nursing staff to check that the wheelchair cushion was on the wheelchair prior to transferring the resident in the wheelchair.On 1/23/2026 at 1:37 PM, Rehab Manager (RM) G was interviewed and said the rehab department provides residents with wheelchairs and cushions upon admission. RM G said a wheelchair cushion is always given with a wheelchair. Record review of R4's Electronic Medical Record (EMR) revealed R4 was admitted to the facility on [DATE] with diagnoses which included congestive heart failure, and need for assistance with personal care.Review of the Minimum Data Set (MDS) dated [DATE] for R4 revealed a Brief interview for Mental Status of 12/15 moderate impaired cognition, dependent assistance for wheelchair mobility and stage three pressure injury upon admission and indicated a wheelchair pressure relief device.Review of R4's Kardex did not reveal a wheelchair pressure relief device.Review of R4's care plan revealed I have a Pressure Injury, Stage: 3; Location: Sacro coccyx. This wound was present on admission. Date Initiated: 10/09/2025 Created on: 10/09/2025. R4's care plan did not reveal a wheelchair pressure relief device.Review of the facility policy titled Skin and Pressure Injury Risk Assessment and Prevention date revised 3/23 revealed in part. Residents determined as at risk for developing pressure injuries will have interventions documented in plan of care based on specific factors identified in the risk assessment. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. Evidence-based interventions for prevention will be implemented for residents who are assessed at risk and/or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to:i. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.);ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination.iii. Provide appropriate, pressure-redistributing, support surfaces.iv. Maintain or improve nutrition and hydration status, where feasible. Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present.Review of the facility policy titled Therapy screening Policy date revised 12/25 revealed in part.Therapy services will perform a screen for needed services for all new admissions and readmission to the facility. Therapists will complete screens within three days of facility new admissions, readmissions, and referrals of current residents. Screening to include necessity for durable medical equipment, such as: wheel chairs, wheelchair cushions, walkers, etc. The screen will be documented in the resident's medical record and discussed with nursing as clinically indicated

Based on observation, interview and record review the facility failed to ensure nursing staff provided respiratory care in accordance with acceptable standards of clinical practice during deep suctioning for one resident (R6) of one resident reviewed for respiratory care. This deficient practice placed the resident at risk for decreased oxygenation and respiratory compromise.Findings include:On 1/22/2026 at 1:39 PM, observed License Practical Nurse (LPN) B provide deep suctioning to R6. LPN B did not provide hyperoxygenation prior to initiating deep suctioning.On 1/23/2026 at 11:41 AM, LPN B was interviewed and said they did not know they should have hyper oxygenated the resident before deep suctioning. The nurse said they can see the need for hyper oxygenating because oxygen saturation could drop during the deep suctioning process.On 1/23/2026 at 12:24 PM, interviewed the Director of Nursing (DON) and they said nursing staff go through a competency check-off and they expect nursing staff to hyper oxygenate residents prior to performing deep suctioning.Review of electronic medical record (EMR) indicated R6 was admitted on [DATE]. R6 had a diagnosis of Acute and chronic respiratory failure with hypoxia, Metabolic encephalopathy, Tracheostomy, Gastrostomy and Tremors.Review of Minimum Data Set (MDS) dated [DATE] noted R6 Brief Interview for Mental Status (BIMS) was unable to be completed.Review of policy titled, Tracheostomy Care, with a revision date of 1/24 did not address hyperoxygenation.

This citation pertains to intake # 2588852Based on interview and record review, the facility failed to ensure a resident was free of misappropriation of funds for one (R402) of three residents reviewed for misappropriation of funds.A review of the facility's incident report was received by the State Agency via online submission on 8/1/25 revealed the following: Incident Summary Unauthorized charges have been made on (R402) debit card. Card was cancelled and Detroit Police Department was notified.Investigation Summary Analysis: (R402) admitted to (this facility) on 5/10/2024.On 8-01-2025 (Nursing Home Administrator), was notified by the (Business Office Manager) that she received an alert by phone regarding (R402's) (bank) account. The alert showed that someone was attempting to withdrawal $800.00 from the account. (Business Office Manager) immediately responded to the alert, notifying the fraud department at the bank. The card was cancelled immediately. The resident (R402) was interviewed regarding (their) account .The Administrator reviewed transactions from (R402's) checking account that occurred from 6-3-25 to present. The following transactions were identified as concerns. The purchase at (an online clothing retailer) that occurred on 6-16-25 and the transactions that occurred at a (discount store) on multiple dates. The resident reports that he did allow (Certified Nursing Assistant) CNA B to use (R402's) debit card to purchase cigarettes.The resident denies giving the PIN number to anyone. On 8/20/2025 at 10:45AM, R402 was observed in bed wearing a gown. R402 had their face covered with a washcloth. R402 was interviewed and asked about their bank debit, and who (R402) allowed to their bank card. R402 said, I gave my debit card to (CNA B) and (CNA B) would buy items for him, mostly cigarettes. R402 was asked if (they) ever allowed other staff to use the debit card. R402 said, No. I never gave my card to anyone but (CNA B) .I'm happy the State is investigating this because it was wrong for (CNA B) to take my money. R402 stated (they) did not want to talk about it anymore. A review of R402's electronic medical record revealed an admission to the facility on [DATE] with the diagnoses of Parkinson's Disease, Hypertension, Peripheral Vascular Disease, Major Depression, and Insomnia. R404 Brief Interview for Mental Status (BIMS) score is 14/15 which indicates no cognitive impairment. R402 is non-ambulatory and requires minimal one person assistance with care. A review of R402's care plan revealed the following: Focus: I have a psychosocial well-being problem (actual or Potential) related to Anxiety/depression from misappropriation of funds. Dated 8/13/25.Interventions: Residents debit card will be kept by the Business Office Manager. On 8/20/25 at 11:36AM, CNA B was interviewed and queried about the usage of R402's debit card. CNA B said, I would use (R402's) debit card to go shopping for (R402) out of the kindness of my heart. I did not know that I was not supposed to use their card.From what I understand, there were other staff that would go shopping for R402. CNA B was asked the names of other staff that used R402's debit card. CNA B said she did not know any names. CNA B was asked if (they) used debit cards or cash to go shopping for other residents. CNA B said, Yes. I go shopping for (R404) and (R405) .I was only helping residents out of the kindness of my heart.not everybody steals.I was told that I couldn't do that anymore. CNA B was asked if they were suspended during the investigation. CNA B said she's been helping and shopping for residents for years. CNA B stated that they were suspended for three days. On 8/20/25 at 11:57 AM, R404 was observed sitting in their wheelchair in the hallway. R404 was interviewed and asked if they ever gave money or their bank card to CNA B shopping. R404 said she would give CNA B cash to buy snacks at the store. R404 said, I hope (CNA B) does not get in trouble. A review of R404's electronic medical record revealed an admission to the facility on [DATE] with the diagnoses of Glaucoma, Lymphedema, Muscle Weakness, Kidney Disease, and Osteoarthritis. R404 Brief Interview for Mental Status (BIMS) score is 15/15 which indicates no cognitive impairment. On 8/20/25 at 12:08PM, R405 was observed in the resident's dining room drinking coffee. R405 was interviewed and asked if they ever gave money or their bank card to CNA B for shopping. R405 said, I gave (CNA B) my EBT card (An Electronic Benefits Transfer (EBT) card is used in the U.S. to access public assistance benefits, primarily the Supplemental Nutrition Assistance Program (SNAP) (formerly food stamps), but also for cash aid and other programs) to go shopping. (CNA B) is good people. R405 was asked if they checked their EBT card balance. R405 answered, No, I have not. According to the U.S. Department of Agriculture (USDA), using someone else's EBT card is a form of food stamp fraud and is illegal under federal and state law, even if you have the cardholder's permission. A review of 405's electronic medical record revealed a facility admission date of 05/05/25 with the diagnoses of Fracture Humerus, Heart Failure, Peripheral Vascular Disease, and Difficulty Walking. R405 Brief Interview for Mental Status (BIMS) score is 15/15 which indicates no cognitive impairment. On 8/20/25 at 1:30 PM, the Business Office Manager was interviewed and questioned about R402's bank card. The Business Office Manager said, On August 1st (R402's) bank notified facility that there was an attempt to withdraw $800 from (R402's) account. The Business Office Manager asked R402 if (they) tried to withdraw $800 from (their) account. R402 said CNA B was supposed to buy cigarettes. The Business Office Manager asked R402 for the location of their debit card. R402 told the Business Office Manager CNA B had the debit card. CNA B was not working on August 1st. In addition, the Business Office Manager stated that CNA B had questioned her about funds of two other residents because they were asking for cigarettes. A review of the bank transactions received from the Business Office Manager and Nursing Home Administrator (showing purchases not made by R402) revealed the following: 6/10/2025: Card Purchase $1.99 6/16/2025: Debit Card Purchase from an online retail store for scrubs: $28.30 6/20/2025: Debit Card Purchase Food Delivery $5.00 6/20/2025: Debit Card Purchase Food Delivery Company $24.896/20/2025: Debit Card Purchase Food Delivery Company $39.99 6/27/2025: Debit Card Purchase Discount Store $20.27 6/27/2025: Debit Card Purchase Discount Store $11.52 6/30/2025: Debit Card Purchase unknown Store $26.00 6/30/2025: Debit Card Purchase Discount Store $49.65 7/01/2025: Debit Card Purchase Discount Store $4.00 7/01/2025: Debit Card Purchase Discount Store $24.86 7/01/2025: Debit Card Purchase Discount Store $79.20 7/07/2025: Debit Card Purchase Discount Store $33.27 7/07/2025: Debit Card Purchase Discount Store $68.51 7/07/2025: Debit Card Purchase Discount Store $29.50 7/11/2025: Debit Card Purchase Discount Store $90.71 7/15/2025: Debit Card Purchase Discount Store $33.01 7/18/2025: ATM Transaction Fee Balance Inquiry $3.00 7/21/2025: ATM Transaction Fee Balance Inquiry $3.00 7/21/2025: Debit Card Purchase at Gas Station: $ 0.64 The Discount Store is the same store the Debit Card Purchase were made. On 8/20/25 at 3:15 PM, Nursing Home Administrator (NHA) was interviewed and queried about CNA B use of R402's debit card. The NHA stated that they were able to verify from the purchase at (an online clothing retailer) that occurred on 6-16-25 was for scrubs. The NHA said, Staff should not take cash or residents' bank cards.If residents need anything from the store they should speak to Business Office Manager or the Social Worker. The facility's policy for Abuse was not received as requested on 8/20/2025.

Based on observation, interview, and record review the facility failed to ensure a sanitary physical environment in the Dietary Department, resulting in a potential for contamination of food from soiled ceiling tiles and corroded, rusted vents. This deficient practice had the potential to affect 50 residents that received meals and/or food from the kitchen. Findings include: On 12/11/2024 at 12:00 P.M. during a follow up observation in the kitchen four of five ceiling vents were observed soiled with grease, rust and corroded discolored areas. The tiles around the perimeter of the vent exiting the doorway to the tray line had visible black, greasy, lint spots. During the observation Dietary Manager C was queried concerning who was responsible for cleaning of the vents in the kitchen. The manager indicated the department had a porter who had recently cleaned the vents, but the areas observed on the vents were rust and the vents needed to be replaced. The manager indicated the outer portions of the vents had been recently cleaned but the inner lining and adjacent ceiling tiles required deep cleaning or replacement by the Maintenance Department. On 12/11/24 at 1:40 P.M. Maintenance Director D was interviewed concerning the cleaning of the vents and ceiling tiles in the kitchen. Maintenance Director D reported the maintenance department was only responsible for cleaning the facility's vent throughout the building, but that cleaning did not include cleaning the vents in the Dietary Department. On 12/12/24 at approximately 1:00 P.M. the Director of Nursing (DON), in the absence of the Dietitian & Administrator, was made aware of the conditions of the vents and ceiling tiles in the kitchen. The DON was asked to observe the vents and ceiling tiles around the vents in the kitchen. On 12/12/24 at 2:00 P.M. during the Quality Assurance Interview the DON indicated observation of the ceiling vents and tiles were noted and stated the soiled tiles and rusted vents needed to be replaced Review of the facility's policy titled, Cleaning Interior vents, dated 1/11/2021, stated in part The Plant/OPS Maintenance Department vent cleaning should be performed throughout the entire facility quarterly to ensure compliance. Avoid servicing the Dining room or kitchen vents during mealtimes or when food is exposed. The policy did not identify who was responsible for cleaning of the vents in the kitchen area. On 12/12/24 at 4:00 P.M., according to the 2019 Food Code under 6-501.12 and 6-501.14 stated(A) Physical facilities shall be cleaned as often as necessary to keep them clean, (B) Except for cleaning that is necessary due to spill or other accident, cleaning shall be done during periods when the least amount of food is exposed such as after closing. 6-501.14(A). Cleaning ventilation systems, Nuisance and Discharge Prohibition. (A). Intake and exhaust air ducts shall be cleaned, and filters changed so they are not a source of contamination by dust, dirt, and other materials.

Based on interview, and record review the facility failed to revise care plans in a timely manner for three residents (R10, R260, and R7) out of 14 residents reviewed for care planning. Findings include: R10 On 12/10/24 at 9:59 AM R10's guardian was interviewed and stated that R10 has had recent falls and was concerned. Record review of R10's electronic health records (EHR) revealed admission into the facility on [DATE] with pertinent diagnoses of epilepsy, and traumatic brain injury. According to the Minimum Data Set, dated dated dated [DATE], R18 had severely impaired cognition and was dependent for Activities of Daily Living (ADLS). Record review of R10's fall report dated 10/6/24 revealed that Resident observed on floor next to bed laying on his back no c/o (complaints) pain nor distress noted, resident verbally responsive. Record review of R10's active care plans revealed the following: Focus: I had an actual fall on 10/6/24 revision on 12/11/24. Goal I will exhibit less behaviors resulting in me placing myself on the floor. Date initiated 10/6/24 created on 12/11/24. Interventions: keep resident occupied with activities while awake. Date initiated 10/6/24 created on 12/11/24. On 12/11/24 at 11:44 AM the Director of Nursing (DON) was interviewed and said R10's fall care plan was updated on 12/11/24 after the 10/6/24 fall was identified during the survey. The DON agreed the 10/6/24 care plan update was not timely and ideally should be updated within 24 hours of the fall. R260 Record review of R260's electronic health records (EHR) revealed admission into the facility on [DATE] with pertinent diagnoses of cellulitis of right orbit and other psychoactive substance abuse. According to the Minimum Data Set, dated dated dated [DATE] R260 had intact cognition. Record review of the physician's orders revealed hydroxyzine HCL oral tablet 50 mg give 1 tablet by mouth every 4 hours as needed for anxiety start date 11/19/2024. Review of the December 2024 Medication Administration Record (MAR) revealed R260 received hydroxyzine on 12/3/24, 12/8/24, 12/9/24, and 12/10/24. Review of R260's care plan did not reveal an anxiety diagnosis and/or anxiety medication care plan. On 12/11/24 at 4:06 the Director of Nursing (DON) was interviewed and said R260 received an anti-anxiety medication and agreed there should be a care plan for anxiety and hydroxyzine. 15194 R7 On 12/12/24 at 8:30 A.M. review of the admission record for R7 documented the resident was admitted to the facility on [DATE] with pertinent diagnoses which included: history of falls, chronic obstructive pulmonary disease, chronic kidney disease stg 3, schizophrenia, morbid obesity and pulmonary embolism. According to the minimum data set (MDS) dated [DATE], R7 was cognitively intact with periods of confusion, had long and short-term memory deficits and required 2 person assist for transfer. Record review of R7 Electronic Health Record and Falls care plan documented on 10/29/24, revealed R7 had a witnessed fall. According to the report a Nursing Student reported R7 fell on the floor attempting to transfer to bed and hit his head on the floor R7 stated he was trying to get into bed and lost his balance. On 10/29/24 R7 was transferred out of the facility for further evaluation to rule out head trauma secondary to anti-coagulant therapy. Record review of R7 Care Plan revealed the following Focus: I am at increased risks for falls r/t BLE weakness initiated, created and revised 8/15/24. Goal My risk for falls Will be reduced through the next review date initiated 12/1/24, created 8/15/24, revised 12/9/24. Further review of the falls care plan revealed no evidence the facility revised or reviewed the original Fall care plan dated 8/15/24. Per the facility's interventions revisions of care plan will occur quarterly and after each fall.

Based on interview and record review the facility failed to ensure an Advance Directive was completed for one resident (R210) of fourteen residents reviewed resulting in the potential for inaccurate life sustaining measures or withholding medical treatment. Findings include: On 12/10/24, at approximately 2:00 PM, record review of the Electronic Medical Record (EMR), revealed R210 was initially admitted into the facility on [DATE] with diagnoses that included Acute Respiratory Failure, and Muscle Weakness. In addition, R210 was being treated for Carbapenem-resistant Enterobacteriaceae, (CRE). CRE is a bacterium which is resistant to certain antibiotics. There was no signed Advance Directive. According to admission Minimum Data Set (MDS) assessment dated [DATE], R210 had moderately impaired cognition. R210 required extensive one-person assistance with activities of daily living (ADLs). On 12/12/24 at 9:10 AM, Social Worker G was interviewed regarding R210's Advance Directive and said while looking and calling other parties the signed hard copy of R210 Advance Directive could not be located. SW G said they know the importance of having an Advance Directive is to honor patient's wishes. On 12/12/24 at 2:50 PM, the Director of Nursing was interviewed, and confirmed there was no Advance Directive for R210. The DON said the importance of having an Advance Directive for residents is to abide by the resident's wishes.

Based on interview, and record review the facility failed to consistently provide one resident (R5) out of three residents reviewed for limited range of motion (ROM) a restorative therapy. Findings include: On 12/10/24 at 11:44 AM, R5 was interviewed and stated, I'm not getting any rehab or exercises. I'd like to because my shoulder is starting to hurt more. Record review of Electronic Health Record (EHR) revealed R5 admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke) and paraplegia (paralysis that affects the lower half of the body). Review of the Minimum Data Set (MDS) dated [DATE] for R93 revealed a Brief interview for Mental Status (BIMS) 15/15 intact cognition and functional limitation in range of motion impairment to both upper extremities. Record review of the physical therapy discharge summary note dated 10/14/24 with Physical Therapist (PT) A revealed discharge recommendations: patient referred to FMP (functional maintenance program). Functional maintenance program established/trained = range of motion program. Range of motion program established/trained: 15 rept x 2 sets (15 repetitions for 2 sets). Prognosis to maintain CLOF (currently level of function) = good with consistent staff follow-through. PT A said he did not complete a therapy to restorative form on 10/14/24 but should have and agreed R5 should be having a ROM program. Record review of the EHR did not reveal a therapy to restorative form completed for the physical therapy discharge on 10/14/24. Further review of the EHR for R5 revealed no orders, care plan and/or Kardex for a restorative ROM program. On 12/11/24 at 1:20 PM R5's restorative log was requested for October 2024 but was not provided. Review of R5's November restorative log revealed 15 minutes of ROM was provided on 11/13/24. Dates 11/15/24 through 12/11/24 revealed not applicable. There were no refusals of a ROM program noted in the EHR. On 12/11/24 at 4:06 the Director of Nursing (DON) was interviewed and said R5 was not receiving restorative services and should have been and that the restorative log should not have been marked not applicable. Review of the facility policy titled Restorative Nursing Programs revised 6/23/24 revealed in part . It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. The discharging therapist, restorative coordinator, or designated licensed nurse will communicate to the appropriate restorative aide, the provisions of the resident's restorative nursing plan, providing any necessary training to carry out the plan. Restorative aides will implement the plan for a designated period, performing the activities and documenting in the clinical record.

Based on observation, interview and record review the facility failed to provide hair care for one resident (R1) of 14 sampled residents reviewed for activities of daily living (ADL), resulting in poor grooming. Findings include: On 12/10/24 at 1:25 P.M. R1 was observed sitting in the hallway outside of her room. R1's hair was observed loose around the front portion of the resident's face and the back braids had scattered patches of unbraided rows. The resident's scalp was dry in appearance and unkempt. R1 was observed on 12/11/24 at 12:00 P. M during lunch in the main dining room and on 12/12/24 at 8:14 A.M. exiting the elevator going to activities. R1's hair was not groomed, and the resident's hair remained in the same condition as it was observed on 12/10/24. Review of the Admission Record for R1 indicated the resident was admitted to the facility on [DATE], with diagnoses that included: Down Syndrome, Diabetes Mellitus, dry eye syndrome, seizure disorder and other symptoms and signs involving cognitive function. According to the Minimum Data Set (MDS) dated [DATE], R1 was severely impaired in cognitive skills for thinking, was rarely or never understood and was incontinent of bowel and bladder. On 12/12/24 at 9:10 A.M., review of the Care Plan titled: Activities of Daily Living (ADL) self-care performance deficit related to Down Syndrome, initiated 9/20/22, indicated R1 was dependent on staff for personal hygiene (meaning the resident does none of the effort to complete the activity which) included combing hair, shaving and applying make-up. On 12/12/24 at11:10 A.M. License Practical Nurse (LPN) B was interviewed concerning the appearance of R1's hair. LPN B indicated the Nurse Aides were responsible for combing resident's hair every day and R1's hair was usually braided and oiled on her shower days. LPN B indicated R1 shower days were Mondays and Thursdays. LPN B was queried if R1 hair was groomed on Monday, 12/9/24. The nurse indicated she was not sure because the one nurse aide who normally combed R1's hair had not been scheduled on the unit that week. LPN B was asked to observe the resident's hair. During the observation the nurse's stated Not all the nurse aides on the unit, know how to braid hair and when the one aide that could braid hair was off or on vacation, there was no one else except maybe a nurse to braid the resident's hair. Review of the Task assignment for R1 revealed no documented evidence R1 received hair care on Monday or any day for the month of November and/or December. On 12/12/24 at 11:30 A.M. the Director of Nursing (DON) was interviewed concerning R1's hair. The DON indicated the nurse Aides were responsible for ensuring resident's hair was washed and groomed on shower days. The DON was not able to provide a reason why R1's hair wasn't combed or brushed the days of observation. The facility's policy was requested related to Activities of Daily Living but was not provided upon exiting the facility at 4:30 P.M.

Based on observation, interview, and record review the facility failed to implement preventative measures for one resident (R210) of one resident reviewed for transmission-based precautions. was free from the potential spread of infectious pathogens. Findings include: Record review of the Electronic Medical Record, (EMR) clinical record documented R210 was initially admitted into the facility on [DATE] with diagnoses that included Acute Respiratory Failure, and Muscle Weakness. In addition, R210 was being treated for Carbapenem-resistant Enterobacteriaceae, (CRE). CRE is a bacterium which is resistant to certain antibiotics. According to the admission Minimum Data Set (MDS) assessment dated [DATE], R210 had moderately impaired cognition 11/15 (BIMS), Brief Interview for Mental Status. R210 required extensive one-person assistance with activities of daily living (ADLs). On 12/11/24 at 12:50 PM, Certified Nursing Assistant, (CNA) H was observed to take R210's lunch tray into the room. CNA H did not use any personal protection equipment, (PPE). There was PPE located outside of the room. The door was marked for Transmission based precautions. The room door was left open and it was observed that R210 did not receive an isolation tray. On 12/11/24 at 2:40 PM, CNA H was queried about R210 and said R210 gets a regular tray it comes on regular dishes. CNA H was asked if there were any special precautions for R210. CNA H said only when providing patient care. On 12/11/24 at 2:45 PM, CNA I was queried and indicated that a regular tray (a tray with regular dishes) was given to R210 and was returned to the kitchen. On 12/11/24 at 3:00 PM, Licensed Practical Nurse, (LPN) F was interviewed and she said R210 was on precautions for a respiratory infection. LPN F added they wear PPE when they provide personal care for R210. LPN F was queried if there was a difference in the meal tray for residents on transmission-based precautions, LPN F explained on day shift R210 received a regular tray and on night shift R210 receives Styrofoam trays. LPN F said she is not sure why R210 receives the Styrofoam at night. On 12/12/24 at 2:50 PM, the Director of Nursing, (DON) was interviewed and said R210 even though they had completed antibiotics they would remain on transmission-based precautions until test results came back clearing them. The DON said R210 would be receiving all their meals on Styrofoam Record review of the facilities infection prevention and control program dated 4/17. The program is designed to provide a safe sanitary and comfortable environment. This program is to help prevent the development of communicable diseases and infections. When a resident has an identified they shall be placed on transmission-based precautions. The policy also stated, All staff will receive training relevant to their role and responsibility regarding the infection prevention and control program. Staff will also demonstrate competence related to infection control practices. Furthermore, there will be an annual review of the policy and based on that review any needed updates will occur.

This citation pertains to MI00145588. Based on interview and record review, the facility failed to thoroughly conduct and document an investigation of a resident to resident altercation for two residents (R103 and R104) out of four residents reviewed for abuse, resulting in missed opportunities to implement corrective measures and interventions. Findings include: The facility self-reported incident documented that on 5/25/24 at 2:00 AM, Resident #103 (R103) pulled up Resident #104's (R104) pants and pushed him in the back. This incident was observed by Certified Nurse Aide (CNA) A. A review of the facility's complete investigation indicated that Social Worker (SW) B completed a wellness visit for both residents and there were no psychosocial changes noted to either resident related to the incident. Residents reported feeling safe in the building. A review of the Admission Record for R103 documented an admitted [DATE] with diagnoses that included Crohn's Disease, acquired partial absence of both the stomach and pancreas, and protein-calorie malnutrition. A Minimum Data Set assessment dated [DATE] documented intact cognition. A review of the Admission Record for R104 documented an admitted [DATE] with diagnoses that included encephalopathy, adult failure to thrive, and dementia. A MDS assessment dated [DATE] documented severe cognitive impairment. On 7/16/24 at 3:30 PM, a review of the clinical records for R103 and R104 was conducted with the Nursing Home Administrator (NHA). The NHA stated wellness visits were necessary to make sure there was no mental anguish from the incident and should be documented in the resident's clinical record. The completion of a wellness visit was not documented in the clinical records of R103 or R104. On 7/16/24 at 3:40 PM, SW B said she did not complete a wellness visit for R103 or R104. SW B said if a wellness visit was conducted, it would be part of the resident's clinical record. A review of the facility document title, Abuse, Neglect and Exploitation, dated 1/28/2002, revealed in part the following: - Investigations may include but not limited to providing complete and thorough documentation of the investigation. - The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to providing emotional support and counseling to the resident during and after the investigation, as needed. On 7/16/24 at 5:25 PM during the exit conference, the NHA did not offer additional documentation or information when asked.

This citation pertains to intake MI00145046. Based on observation, interview, and record review the facility failed to provide routine floor stock pain gel medication for one (R402) of three residents reviewed for medication administration resulting in R402 not receiving a prescribed pain. Findings include: It was reported to the State Agency that a resident's medication was not given according to physician's orders. On 6/18/24 at 9:35 am R402 was observed sitting in her room with bare foot. Both feet appeared swollen. R402 was asked about her feet and stated, My feet hurt and are swollen. The doctor here ordered lidocaine to help with the pain, but I am not getting it. On 6/18/24 at 1:15 pm Licensed Practical Nurse (LPN) A was interviewed and said R402's pain gel 'Lidocaine 2.5%' was not available for administration. LPN A said that R402 had not received the pain gel to date, but her pain was controlled by another medication. LPN A said the 'Lidocaine 2.5%' pain gel was a floor stock item and had not been available since it was ordered for R402 on 6/13/24. According to R402's Electronic Health Record (EHR) the resident was admitted to the facility on [DATE] with a pertinent diagnosis of difficulty in walking. Review of the Minimum Data Set (MDS) dated [DATE] for R402 revealed a Brief interview for Mental Status BIMS of 15/15 intact cognition. Review of physician orders revealed 'Lidocaine 2.5%' pain gel was prescribed on 6/13/24. A record review of R402's Medication Administration Record (MAR) for June 2024 revealed R402's 'Lidocaine 2.5%' pain gel had not been available for administration five of five prescribed times: 6/13/24, 6/14/24, 6/15/24, 6/16/24, and 6/17/24. Review of a communication note dated 6/15/24 revealed, Can central supply please provide the 2nd floor with some Lidocaine 5% cream or gel. Called pharmacy, they said it is house stock. There was no documentation to support the physician, or the Director of Nursing (DON) was notified of the missing pain gel. On 6/18/24 at 2:20 pm the Director of Nursing (DON) was interviewed and said, the unit manager did not read the communication note from the weekend staff, so the Lidocaine gel was not ordered. The DON confirmed she was responsible to order the facility's pharmacy floor stock items which included the 'Lidocaine 2.5%' pain gel. She stated, I just became aware of the missing lidocaine gel and will be getting it today. The DON agreed the physician should have been notified that the medication was not available. Review of the facility policy titled Medication Orders not dated revealed in part; . The prescriber is contacted by nursing for direction when delivery of a medication will be delayed, or the medication is not available.

This citation pertains to intake number MI00144395. Based on observation, interview and record review, the facility failed to provide timely incontinence care for one resident (R101) of three residents reviewed for Activities of Daily Living (ADL), resulting in the potential for skin breakdown and infection. Findings include: In an observation and interview on 5/17/24 at 8:24 a.m., R101 sat in a wheelchair and wore a gown. A urine smell was noted in R101's room. R101 reported just getting up and stated, I need someone to wash me up and put on a dry diaper. Review of an Admission Record revealed, R101 originally admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnosis which included Chronic Obstructive Pulmonary Disease (COPD). Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R101 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15 out of 15. Review of a care plan revealed R101 had focus I experience bladder incontinence . Interventions included, check me every 2 hours and as needed for episodes of incontinence initiated on 4/3/24. In an observation on 5/17/24 at 9:27 a.m. Certified Nursing Assistant (CNA) A removed a soiled bed pad off R101's bed. In an observation on 5/17/24 at 9:44 a.m., R101 transferred self into bed. R101's brief was visibly heavily soiled indicated by two dark blue lines down the center of the brief from front to back. R101 reported being last dried around 10:30 p.m. the previous night. At this time, CNA A was observed to provide incontinence care. On 5/17/24 at 9:50 a.m., CNA A was queried and reported this was the first time changing R101. In an interview on 5/17/24 at 12:50 p.m., Licensed Practical Nurse (LPN) B reported rounds are completed at the beginning of the shift to make sure everyone is dry. LPN B then reported residents are checked and changed every 2 hours. In an interview on 5/17/24 at 1:54 p.m., the Director of Nursing (DON) reported residents should be checked and changed every 2 hours. The DON then reported staff should do rounds at shift change to check on the residents. Review of a AL: Basic Care Services policy implemented 6/1/22 documented, . Procedure: 1. Each shift will have a designated supervisor of resident care (HFA). 2. At the beginning of each shift, there will be communication between off going and oncoming staff to discuss any changes for the care of residents. 3. Each resident is monitored on a routine basis. Check on residents frequently throughout the shift, unless indicated otherwise on the resident's service plan .

Based on observation, interview, and record review the facility failed to follow the standards of infection control (gloves use and hand hygiene), for one residents (R101) out of three residents reviewed for Activities of Daily Living (ADL), resulting in the potential for increased cross-contamination of diseases which place a vulnerable population at high risk for infections. Findings include: In an observation on 5/17/24 at 8:24 a.m., a pile of soiled linen sat on R101's floor in a corner that was visible from the hallway. Review of an Admission Record revealed, R101 originally admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnosis which included Chronic Obstructive Pulmonary Disease (COPD) and Type 2 Diabetes. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R101 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15 out of 15. In an interview on 5/17/24 at 8:28 a.m., Certified Nursing Assistant (CNA) A was asked about the soiled linen on R101's floor and reported the linen was left by midnight shift. In an observation on 5/17/24 at 9:27 a.m. CNA A entered R101's room and put on gloves with no hand hygiene before application. CNA A removed a soiled bed pad off R101's bed, opened the blinds, then leaned against the wall and placed gloves hand behind her back which touched the wall. CNA A then removed the gloves, exited the room, and did not perform hand hygiene. In an observation on 5/17/24 at 9:39 a.m., CNA A filled a basin up with soapy water. CNA A then touched resident wheelchair and bedside table with gloved hands. CNA A spilled water on the floor, cleaned it up, removed gloves and exited the room and did not perform hand hygiene. In an observation on 5/17/24 at 9:42 a.m., CNA A entered R101's room and put on gloves with no hand hygiene before application. In an observation on 5/17/24 at 9:44 a.m., CNA A washed R101's peri area and buttocks with a soapy washcloth, rinsed and dried resident, then applied a new brief. With the same gloves used to clean R101, CNA A then removed R101's oxygen tubing. In an observation and interview on 5/17/24 at 9:59 a.m. CNA A removed gloves and began to exit the room without performing hand hygiene. CNA A was asked about the expectations of hand hygiene with glove use. CNA A reported hands should be washed before and after glove use. In an interview on 5/17/24 at 1:54 p.m., the Director of Nursing (DON) reported hand hygiene should be performed before and after glove use. The DON then reported staff should not touch personal items while wearing gloves. Review of a Hand Hygiene policy revised 12/20 documented the following: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors . Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .

This citation pertains to intake MI00143185. Based on interview and record review the facility failed to provide a safe environment or supervise one (R801) of three residents reviewed for supervision/accidents when R801 eloped through the front door of the facility unbeknownst to staff to take a bus to his physician's office. Findings include: The State Agency (SA) received a Facility Reported Incident (FRI) on 2/19/24 at 4:59 AM that reported R801 had walked out the front door of the facility on 2/19/24 at 1:25 AM with his personal belongings as viewed via camera. An investigation report on 2/27/24 indicated that on 2/19/24 at 9:00 AM, R801's personal physician's office called the facility to notify them R801 was at their office seeking medication. R801 had no injuries, was not in any distress, and denied having any pain. R801 stated he left the facility, walked to the nearby shelter, ate, changed clothes, went to the bus transit center, and took two different buses to get to the physician's office. R801 refused to return to the facility and signed an 'Against Medical Advice' form. R801 was transported to the local Hospital by facility staff per the resident's request. R801's Legal Guardian (LG) was aware. Further inspection of the facility's front door revealed the keypad code (a locking mechanism on the door that required a code to be entered for the door to open) had been disabled at a switchbox located near the top of the door. This disabled the keycode and allowed the front door to open from the motion sensor only. On 5/1/24 at 1:05 PM the Nursing Home Administrator (NHA) said the investigation revealed that R801 was able to walk out the facility's front door because the keypad code had been disabled at the switchbox. Review of video surveillance at the front door could not conclude how this occurred because the camera's view did not include a visual of the switchbox area. The NHA said Certified Nursing Assistant (CNA) C was assigned to R801 on 2/19/24 and had been terminated due to not properly supervising the resident. CNA C had been observed with their 'eyes closed and appeared to be sleeping' at the nurse's station during that shift by another facility staff member. Registered Nurse (RN) B had been assigned to R801 on 2/19/24 was from an agency that is no longer utilized by the facility. A voice message was left for CNA C 5/1/24 at 12:53 PM and 3:47 PM and no response had been received prior to the survey exit. A voice message was left for RN B on 5/1/24 at 12:50 PM and 3:35 PM and no response had been received prior to the survey exit. . A closed record review of R801's Electronic Health Record (EHR) revealed the resident admitted to the facility on [DATE] with multiple diagnoses that included malnutrition, major depressive disorder, and early onset dementia. R801 was not at risk for elopement according to the elopement risk assessments conducted on 6/9/23, 9/9/23, and 12/28/23. The Minimum Data Set (MDS) dated [DATE] indicated R801 had moderately impaired cognition and was independent with Activities of Daily Living. R801 had a Legal Guardian (LG). During a care conference on 12/18/23, R801's LG reported the resident was not a candidate for discharge to a group home setting. The LG did not disclose the reason the resident was not a candidate for a group home setting. On 5/1/24 at 11:42 AM R801's LG was left a voice message and no response had been returned prior to the survey exit.

This citation pertains to MI00142402 and MI00142509. Based on interview and record review, the facility failed to administer wound care treatments per physician order for one (R504) of four residents reviewed for pressure ulcers. Findings include: A review of R504's EMR (Electronic Medical Record) revealed R504 was admitted to the facility 12/20/23 and discharged [DATE]. R504 had the following medical diagnoses: Cerebral Infarction due to Embolism of a Cerebral Artery, Paraplegia, and difficulty walking. A review of R504's MDS (Minimum Data Set) dated 12/29/23, revealed R504 had a BIMS (Brief Interview of Mental Status) score of 15 out of 15 (cognitively intact). According to the MDS, R504 had one stage III (3) pressure ulcer and three stage IV (4) pressure ulcers all present on admission. The MDS was documented that R504 required maximal assistance with bed mobility and was dependent with transfers. A review of R504's pressure ulcer care plan dated 12/20/23 revealed, Administer wound and skin treatments as ordered and monitor for effectiveness. A review of R504's TAR (Treatment Administration Record) for December 2023 revealed the following orders: Clean left heel stage 3 wound with wound cleaner/normal saline, pat dry apply betadine soaked 4x4, apply ABD (abdominal) pad, wrap with Kerlix (gauze bandage), secure with tape every dayshift. Start date 12/21/23. Discontinue date 1/24/24. Missing dates: 12/25/23 and 12/30/23. Clean left ischium wound with wound cleaner/normal saline, pack with Kerlix soaked Dakins 1/4 solution, apply ABD and cover with a border gauze. every dayshift. Start date 12/21/23. Discontinue date 1/24/24. Missing dates: 12/25/23 and 12/30/23. Clean right groin wound with wound cleaner/normal saline, apply xeroform gauze, cover with a border gauze every dayshift. Start date 12/21/23. Discontinue date 1/17/24. Missing dates: 12/25/23 and 12/30/23. Clean right heel unstageable wound with wound cleaner/normal saline, pat dry apply betadine soaked 4x4, apply ABD pad, wrap with Kerlix, secure with tape every dayshift. Start date 12/21/23. Discontinue date 1/24/24. Missing dates: 12/25/23 and 12/30/23. Clean right hip wound with wound cleaner/normal saline, pack with Kerlix soaked Dakins 1/4 solution, apply ABD and cover with a border gauze every dayshift. Start date 12/21/23. Discontinued date 1/24/24. Missing dates: 12/25/23 and 12/30/23. Clean right lateral lower leg stage IV wound with wound cleaner/normal saline, apply medihoney gel, apply ABD pad, wrap with Kerlix, secure with tape every dayshift. Start date 12/21/23. Discontinue date 1/24/24. Missing dates: 12/25/23 and 12/30/23. Clean sacrococcyx wound with wound cleaner/normal saline, pack with Kerlix soaked Dakins 1/4, apply ABD and cover with a border gauze every dayshift. Start date 12/21/23. Discontinue date 1/24/24. Missing dates: 12/25/23 and 12/30/23. A review of R504's TAR (Treatment Administration Record) for January 2024 revealed the following orders and missing dates: Clean left heel stage 3 wound with wound cleaner/normal saline, pat dry apply betadine soaked 4x4, apply ABD (abdominal) pad, wrap with Kerlix (gauze bandage), secure with tape every dayshift. Start date 12/21/23. Discontinue date 1/24/24. Missing dates: 1/11/24, 1/14/24, and 1/16/24. Clean left ischium wound with wound cleaner/normal saline, pack with Kerlix soaked Dakins 1/4 solution, apply ABD and cover with a border gauze. every dayshift. Start date 12/21/23. Discontinue date 1/24/24. Missing dates: 1/11/24, 1/14/24, and 1/16/24. Clean right groin wound with wound cleaner/normal saline, apply xeroform gauze, cover with a border gauze every dayshift. Start date 12/21/23. Discontinue date 1/17/24. Missing dates: 1/11/24, 1/14/24, and 1/16/24. Clean right heel unstageable wound with wound cleaner/normal saline, pat dry apply betadine soaked 4x4, apply ABD pad, wrap with Kerlix, secure with tape every dayshift. Start date 12/21/23. Discontinue date 1/24/24. Missing dates: 1/11/24, 1/14/24, and 1/16/24. Clean right hip wound with wound cleaner/normal saline, pack with Kerlix soaked Dakins 1/4 solution, apply ABD and cover with a border gauze every dayshift. Start date 12/21/23. Discontinued date 1/24/24. Missing dates: 1/11/24, 1/14/24, and 1/16/24. Clean right lateral lower leg stage IV wound with wound cleaner/normal saline, apply medihoney gel, apply ABD pad, wrap with Kerlix, secure with tape every dayshift. Start date 12/21/23. Discontinue date 1/24/24. Missing dates: 1/11/24, 1/14/24, and 1/16/24. Clean sacrococcyx wound with wound cleaner/normal saline, pack with Kerlix soaked Dakins 1/4, apply ABD and cover with a border gauze every dayshift. Start date 12/21/23. Discontinue date 1/24/24. Missing dates: 1/11/24, 1/14/24, and 1/16/24. A review of R504's TAR (Treatment Administration Record) for February 2024 revealed the following orders and missing dates: Clean Left ischium wound with wound cleaner/normal saline, pack with Kerlix soak Dakins 1/4 solution, apply ABD and cover with a border gauze every dayshift. Start date 2/1/24. Discontinue date 2/12/24. Missing dates: 2/2/24, 2/7/24, 2/8/24, 2/9/24, 2/10/24, 2/11/24. Clean right glute with wound cleaner/normal saline, pat dry, apply medihoney gel, apply calcium alginate and cover with border gauze every dayshift. Start date 2/1/24. Discontinue date 2/12/24. Missing dates: 2/2/24, 2/7/24, 2/8/24, 2/9/24, 2/10/24, 2/11/24. Clean right hip wound with wound cleaner/normal saline, pack Dakins 1/4 soaked kerlix, apply ABD and cover with a border gauze every dayshift. Start date 2/1/24. Discontinue date 2/12/24. Missing dates: 2/2/24, 2/7/24, 2/8/24, 2/9/24, 2/10/24, 2/11/24. On 3/6/24 at 10:48 AM the DON (Director of Nursing) was interviewed regarding the missing wound treatments for R504. The DON said it was the expectation that all wound treatments should be documented per. skin treatment policy. The DON said if the treatments are not documented, it is assumed, they were not done. A review of the facility's policy titled, Wound Treatment Management and Documentation, with a reviewed date of 2/2024, revealed, Wound treatments will be provided in accordance with physician orders .Treatments will be documented on the Treatment Administration Record.

Based on observation, interview, and record review, the facility failed to perform a wound treatment prior to documenting completion for one (R506) of four residents reviewed for pressure ulcers. Findings include: On 3/5/24 at 9:53 AM, R506 was queried about having pressure ulcers and wound treatments. R506 said he had a wound on his left hip. R506 said he received wound treatments but that the facility staff did not change the dressing for the wound every day. At that time, R506 revealed the dressing on his left hip that was dated for 3/3/24. On 3/5/24 at 2:15 PM, R506 was interviewed regarding the dressing change that was to be completed. R506 said that no one had changed his dressing since we had spoken last. On 3/5/24 at 2:21 PM, LPN A was queried about 506's scheduled dressing changes. LPN A said she did not get a chance to change 506's dressing. During this time, LPN A was looking at R506's TAR (Treatment Administration Record) in the EMR (Electronic Medical Record). LPN was queried if she had checked it off in the EMR. LPN A said she checked it off that it was done but that it must have been a mistake. On 3/5/24 at 2:27 PM, the DON (Director of Nursing) was interviewed regarding the order of performing and documenting wound care. The DON said the nursing staff can not document the treatment was done before performing the treatment. The DON said it is her expectation that nurses are being truthful about documenting and providing treatments. A review of 506's EMR revealed R506 was admitted to the facility on [DATE]. R506 had the following medical diagnoses: Diabetes Mellitus Type 2, difficulty walking, and the need for assistance with personal care. A review of R506's MDS (Minimum Data Set) dated 2/25/24 revealed R506 had a BIMS score of 12 out of 15 (moderate cognitive impairment). According to the MDS, R506 needed moderate assistance with bed mobility and transfers. The MDS was documented that R506 had one stage IV (4) pressure ulcer. A review of R506's care plan revealed, Administer wound and skin treatments as ordered and monitor for effectiveness. A review of R506's March 2024 TAR revealed the following treatment order and date of documented completion: Clean left hip wound with wound cleanser/ normal saline, paint with betadine and cover with border gauze every day shift. Start date 3/1/24. Documented completion dates: 3/1/24, 3/2/24, 3/3/24, 3/4/24, and 3/5/24.

Based on observation, interview, and record review the facility failed to ensure the 2nd floor 'wireless' call light system was effectively utilized by staff or had consistently functioning pagers and centralized monitor screen on the 2nd floor resulting in delayed call light response times and the potential for resident care need to be unmet. Findings include: On [DATE] at 12:41 PM, a 2nd floor resident (R54) said the staff doesn't answer the call light in a timely manner. R54 said, They don't wear the pagers that tells them I pushed the call light. When I asked them why it takes so long to answer my light, they said the call light system wasn't working properly. At this time R54's call light was activated. At 12:47 PM CNA C walked down the hall, passed R54's room and did not enter. CNA C was then asked how staff became aware a call light was on. CNA C said, We have pagers, but I don't have one right now. I go up to the nurse's station to look at the monitor screen to see who has a call light on, but sometimes it's not accurate. At this time CNA C went to the 2nd floor nurse's station and pointed to a monitor screen that displayed which call lights were on. The monitor's screen display was dark and not displaying anything. Licensed Practical Nurse (LPN) G was seated at the nurse's station and asked how staff became aware of call lights. LPN G said the 2nd floor's call light pager was in (not on) the medication cart. LPN G confirmed she was the only staff person to have a key to the medication cart. LPN G unlocked the medication cart and produced the pager. Upon inspection the pager was vibrating to indicate R54's call light was on. LPN G said the pager should be on the medication cart so all staff would be able to access it (the pager). LPN G was unable to clear R54's call light alert and removed the batteries then re-inserted them. R54's call light alert was not displayed on the pager's screen. At 12:50 CNA F was asked about the facility's call light system and replied, We are supposed to wear pagers, but we only have one that works on this floor. There are three of us on the 2nd floor. We usually keep it (the pager) at the nurse's station or on the medication cart. The monitor usually works, but sometimes it goes off-line. On [DATE] at approximately 10:30 AM, second floor resident (R19) said that staff take a long time to answer the call lights because they don't wear the pager. On [DATE] at 12:26 PM on the 2nd floor, LPN B was asked about the call light system. LPN B said she had the pager on her medication cart, but it was not functioning. The pager's batteries were dead. CNA C and CNA H were present at this time and neither of them had a pager for the call light system. Upon inquiry, LPN B said they were utilizing the nurse's station monitor screen to determine who had their call light on. Inspection of the display screen indicated 7 residents had their call lights on. LPN B said, All those call lights have been answered we just don't know how to clear them from the display screen. During this time the 7 residents were interviewed, and it was determined all 7 resident did have their call lights answered by staff and did not have their call light currently on. On [DATE] at 1:22 PM during an interview, the Environmental Director (ED) D said that the call light system was working, and that staff were educated on how to 'clear the display' screen after call lights had been answered. ED D said he audits the facility's call light pagers every Friday and all floors always have two functioning pagers per floor. ED D said that staff has access to batteries to replace them as needed. At this time inspection of the 2nd floor's call light monitor display screen at the nurse's station had written instructions visibly affixed to the monitor on 'how to clear a call light' after it had been answered. On [DATE] at approximately 2:35 PM the Nursing Home Administrator (NHA) said the staff are educated at orientation on the use of the wireless call light system and expected care and usage of the pagers. The NHA said all direct care nursing staff is expected to have access to the pagers and know how to use them and the monitor display screen at the nurse's station. According to the facility's policy for 'Call Lights System' last revised on ,d+[DATE]; The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Policy Explanation and Compliance Guidelines: 1. Staff will have knowledge of the resident call system, including how the system works and ensuring resident access to the call light 6. Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied . (Examples include: replace call light, provide a belll or whistle, increase frequency of rounding, etc.) 7. Ensure the call system alerts staff members directly of goes to a centralized staff work area 32000 On [DATE] at 9:45 AM, upon interview with ED D, on the current state of the nurse call system they stated, it's old, but it works most of the time. Sometimes we have to reset the monitors at the nurse's stations to show the rooms have been canceled. I made signs and taped them to the monitors at the nurse's station so they should all know how to do it. At this time the surveyor inquired with ED D, on what the facility would normally do if the nurse call system is not functioning as designed and in its originally approved condition to which they replied, we have bells we can provide and each floor also has a wireless doorbell that can be given to a resident if they can't shake the bell well. On [DATE] between 10:05 AM and 10:49 AM, upon environmental tour of the facility with ED D, the following observations were made: Upon review of the fourth floors monitor at the nurse's station after triggering the bed side call light in room [ROOM NUMBER], no notification was observed. At this time ED D stated, it must need to be reset. This is not normal. The surveyor then observed ED D shutting the power off to the monitor, turning it back on and stating to the surveyor, there it is, it's back up again. Upon testing of the bed side call light in room [ROOM NUMBER], the room number was observed by both ED D, and the surveyor not registering with the correct room number on one of the nurses pagers as it displayed room [ROOM NUMBER] being in need of assistance. Upon observation ED D, stated, that is so weird, we don't even have a fifth floor. Let's cancel it and try it again. Moments later the surveyor observed ED D, canceling the call light and re-triggering it at the same location in room [ROOM NUMBER]. Upon additional review of the same nurses pager by both ED D, and the surveyor it displayed the correct room number associated with the bed side call light. Bells and a wireless doorbell on each resident floor were observed available for use during this tour.

This citation has two deficient practice statements. Deficient Practice Statement #1. Based on observation, interview, and record review, the facility failed to adequately monitor and implement interventions to prevent constipation for one resident (R109) of four reviewed resulting in fecal impaction. Findings include: On 6/20/2023 at 12:30 PM, Resident #109 (R109) was observed awake and sitting up in the bed. R109 stated, I went to the hospital because of constipation. My stool was like clay. R109 said stool was in her rectum but would not fully evacuate. The bowel movement was scrapping her rectum and it really hurt. R109 stated, I was having sharp pain in my chest, back, and arm and was sent to the hospital. They had to manually remove the stool at first. I was told that Norco stopped up my bowels. A review of the clinical record for R109 documented an initial admitted [DATE], discharged to the hospital on 5/28/2023, and readmitted to the facility on [DATE]. R109's diagnoses included cerebral infarction and diabetes mellitus-type 2. A Minimum Data Set assessment dated [DATE] documented intact cognition. A review of a document titled, Patient Discharge Instructions (from local hospital), with a discharge date of [DATE] documented R109's Discharge Diagnosis as Fecal impaction in rectum. Further review of R109's clinical record documented in part the following: - Nursing note of 5/28/2023 at 9:04 AM: Resident complained of chest pain 10/10 (ten out of ten) that radiates down right arm, BP (blood pressure) 170/120, HR (heart rate) 100 . Resident asking to be transferred to hospital. Dr made aware of situation. - Nursing note of 6/2/2023: Resident arrived on unit at 7:45 PM, via stretcher, BP 142/84, heart rate 86. Resident is being readmitted after hospitalization for chest pain, hypertension and fecal impaction. The following care plan was created after R109 returned from the hospital with a diagnosis of fecal impaction. - Care plan focus: I am at risk for constipation related to decreased mobility and use of medication that cause constipation. Created on 6/16/2023. Interventions included in part: Follow bowel protocol for bowel management and monitor medications for side effects of constipation. Keep physician informed of any problems. Created on 6/16/2023. During an interview and record review on 6/22/2023 at 2:40 PM with the Director of Nursing (DON), R109's May 2023 Medication Administration Record (MAR) revealed PRN (as needed) hydrocodone-acetaminophen oral tablet 5-325 mg (Norco) was administered on 5/8/23, 5/10/23, 5/11/23, 5/12/23, 5/13/23, 5/17/23, 5/19/23, 5/20/23, and 5/24/23. The DON said if someone is on Norco the potential for constipation should be addressed on a care plan. Per review of the Food and Drug Administration website, https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/040099s023lbl.pdf, advise patients of the potential for severe constipation. CNA (Certified Nurse Assistant) documentation of R109's bowel movements prior to hospital admission included: 5/24/23: none documented 5/25/23: 1 medium soft-formed, 1 small soft-formed 5/26/23: 1 medium soft-formed 5/27/23: 1 large formed During an interview on 6/26/2023 at 9:42 AM, R109 stated, I was constipated. R109 denied that she had a bowel movement on 5/26/2023 and 5/27/2023. R109 stated, How could I be clogged up like I was on 5/28? It was hard like clay. I wish I did have a bowel movement on 5/26 and 5/27. R109 said a nurse at the facility gave her a liquid on 5/28/2023 to help her have a bowel movement, but it made it worse. A review of R109's May 2023 MAR and nursing notes did not reveal administration of a medication for constipation relief. On 6/26/2023 at 10:05 AM, a request was made for a copy of the facility's bowel elimination protocol. During an interview on 6/26/2023 at 4:08 PM, the DON said the facility does not have a specific bowel elimination protocol. Nurses are to call the physician for orders as clinically indicated. However, R109's care plan created on 6/16/23 noted the following, Follow bowel protocol for bowel management and monitor medications for side effects of constipation. In effect, there was no bowel management or bowel elimination protocol for staff to reference in order to identify when nursing staff would notify the physician. On 6/26/2023 at 5:50 PM, during the exit conference, the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and no substantially new information was provided. Deficient Practice Statement #2. Based on interview and record review, the facility failed to ensure prescribed medications gabapentin (used for nerve pain) and Cardizem (used to manage high blood pressure) were provided in a timely manner for one resident (R115) out of four residents reviewed for medication administration, resulting in the potential for unmet health care needs. Findings include: A review of the clinical record for Resident #115 (R115) documented an admitted [DATE] and death in the facility on 5/24/2023. R115's diagnoses included diabetes mellitus-type 2 and hypertension. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. A review of physician's orders included the following: 1. Cardizem LA tablet 180 mg. Give 1 tablet by mouth one time a day for high blood pressure. Start date: 5/20/2023. End date: 5/22/2023 2. Gabapentin capsule 100 mg. Give 1 capsule by mouth one time a day for neuropathy. Start date: 5/20/2023. End date: 5/22/2023 3. Gabapentin capsule 100 mg. Give 1 capsule by mouth three times a day for neuropathy. Start date: 5/22/2023. End date: 5/26/2023 A review of nursing medication administration notes documented the following: 1. 5/20/23 Cardizen LA, give 1 tablet by mouth one time a day for HTN (hypertension) on order. 2. 5/20/23 Gabapentin, give 1 capsule by mouth one time a day for neuropathy on order. 3. 5/21/23 Cardizem LA, give 1 tablet by mouth one time a day for HTN on order. 4. 5/21/23 Gabapentin, give 1 capsule by mouth one time a day for neuropathy on order. 5. 5/22/23 Gabapentin, awaiting delivery. During an interview and record review on 6/22/2023 at 2:19 PM, the Director of Nursing (DON) said that the discharging hospital did not send a three day supply and a hard copy of the prescription for the narcotic gabapentin. The DON indicated that the pharmacy required a hard copy of a prescription for a narcotic and that the receiving nurse could have called the hospital to try to get a hard copy. The DON added that the facility nurse should have notified the doctor to see if he wanted to do something different since the medications were not sent from the hospital. A review of R115's clinical record documented no evidence that the physician was contacted regarding this concern. A review of the facility policy titled, Non-Controlled Medication Orders, dated September 2018, documented, The prescriber is contacted by nursing for direction when the medication is not or will not be available for administration or in accordance with facility policy. On 6/26/2023 at 5:50 PM, during the exit conference, the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and no substantially new information was provided.

Based on observation, interview, and record review the facility failed to maintain an environment free of accident hazards as evidenced by a portable space heater located in Resident #901's room. This deficient practice resulted in an immediate jeopardy on 1/19/23 when the facility Administrator observed the portable space heater inR901's room. This deficient practice places all 48 residents at risk for the likelihood of serious injury, harm, and/or death from burns or fire. Findings include: During an observation on 1/24/23 at 9:15 AM of R901's room, a portable space heater was observed in the corner of the room. The portable space heater was next to the wardrobe closet. During an observation and interview on 1/24/23 at 11:35 AM, R901 was asked how long they had the space heater in their room. R901 stated, I think I have had it in my room since September of last year (2023), but I had it put up with my things. When asked if the space heater had ever been used, R 901 said, Yes, sometimes when I am in my wheelchair, I will plug it up to keep warm. When asked if staff assisted with plugging it in, R901 said, No, I can do it myself. Resident then proceeded to demonstrate how they could bend over and plug the space heater into the wall. Record review of R901's face sheet revealed admission into the facility on [DATE] which included a pertinent diagnosis of paraplegia (paralysis of lower body). According to the Minimum Data Set (MDS) dated [DATE], R901 had intact cognition and was an extensive assist with most Activities of Daily Living (ADLS). During an interview on 1/24/23 at 11:50 AM, the Nursing Home Administrator (NHA) was asked if she was aware that R 901 had a space heater. The NHA stated, Yes. The NHA was asked how long they were aware that R901 had the space heater, NHA said, About five days. The NHA was asked if she had known about the space heater since 1/19/23, NHA stated, Yes. When asked if it was appropriate for residents have a space heater in their room, the NHA said, No, they should not. The NHA was asked why space heaters were prohibited at the nursing facility, NHA said, The potential of fire hazards. The NHA was asked if R901 was informed that space heaters should not be used in their room. The NHA, said, No I did not do anything formally. I told the resident it shouldn't be used. When asked if the space heater should have been removed immediately when discovered, NHA, stated, Yes. During a follow-up interview on 1/24/23 at 1:15 PM with R 901, it was observed that the portable space heater was removed from the room. R 901 was asked about the space heater, R 901 said, After you left earlier, they came in and got it. I told them to go ahead and take it, if I knew it was not allowed, I wouldn't have had it brought into the building. During an interview on 1/24/23 at 1:20 PM with Licensed Practical Nurse (LPN) C, they confirmed that the space heater was given to the Maintenance Supervisor to hand over to the Administrator. During record review of facility policy Resident Personal Property dated 8/2020 documented, . Prohibitions .Portable electric heaters. Further review of policy Electrical Appliances updated April 2020 documented 1. Residents may not maintain any electrical appliances . On 1/24/23 at 3:05 pm, the Nursing Home Administrator was notified of the Immediate Jeopardy (IJ) that began on 1/19/23 due to the facilities failure to maintain an environment free of accident hazards, as evidence of a portable space heater located in one resident's room [ROOM NUMBER]. A written plan of removal for the immediate jeopardy was received and verified on 1/24/23. The facility removal plan documented the following: Identification of Residents Affected or Likely to be Affected: Include actions that were performed to address the citation for recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the facility's noncompliance and the date the corrective actions were completed. (Completion Date: 1/24/23) Identified space heater was removed from the building 1/24/23 Facility was audited by facility leadership to ensure no further space heaters present 1/24/23 Residents with space heaters in room were assessed by a licensed nurse for injury - none noted. Actions to Prevent Occurrence/Recurrence: Include actions the facility will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, by whom and when those actions were completed. (Completion Date: 1/24/23) Space Heater Policy reviewed and revised by the Regional Director of Environmental Services on 1/24/23. An electronic message was sent to residents & family members informing of Space Heater policy on 1/24/23. All staff to receive re-education by the facility NHA/designee regarding the Space Heater policy, beginning 1/24/23. No staff will work prior to receiving the education. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 1/24/23 Although the Immediate Jeopardy was removed on 1/24/23, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with the potential for [NAME] than minimal harm that is not immediate jeopardy due to sustained compliance had not yet been verified by the State Agency.

This citation pertains to Intake# MI 008. Based on interview and record review, the facility failed to ensure one Resident (R#503) was not in possession of hair curlers and cigarette lighter out of three residents reviewed for accidents, resulting in a preventable burn while using hair curlers and a cigarette lighter to aid in hair styling, which required hospitalization for further evaluation and treatment. Findings include: On 10/13/20 at 10:05 a.m., review of the clinical record revealed R#503 was initially admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], R#503 was cognitively intact and required limited one-person assistance with Activity Daily Living (ADLS). On 10/13/20 at 10:15 a.m., review of the resident's ADLs care plan with no date documented, Resident requires minimum-to-moderate amount of assistance with her ADLs. No Documentation of the resident independence with the use of curler to style her hair. Review of the resident's clinical medical record revealed no documentation of R#503 being independent with hair curler. Review of the resident's Admit/Readmit Screener assessment effective date 7/10/19 and admission date of [DATE] documented, Admission Details: (Altered Mental Status) .Transfer self-performance: (Limited assistance) .Dressing self-performance:(Limited assistance) .Personal Hygiene: (Supervision) .Skin: (Normal) .Pain level: 10. On 10/14/20 at 9:35 a.m., review of the facility's investigation report dated 4/16/20 documented, On the afternoon of 4/16/20, a unit manager (C) smelled an unusual odor. Upon entering the resident's (R#503) room, the nurse observed the resident's hair smoking. Resident immediately taken to the shower to apply cool compresses to the resident' skin and to inspect. No actual burning noted as assessed near the sink. Resident states, I was trying to clip my ends. Skin assessment revealed darkened areas along hairline and cold compresses applied .Resident insisted on not going to the hospital .Physician aware of situation and advised to monitor resident and treatment orders started. Resident placed on 15-30-minute checks, wound care nurse involved .Skin checks continued and later, minute blisters were noted to areas of skin. Injuries observed at time of incident documented, Injury Type: Burn .Location: Top of scalp, left ear, back of head, face, and right ear. On 10/14/20 at 9:55 a.m., review of the physician's orders [REDACTED]. the wound area, help prevent moisture seepage, and help reduce risk of infection , protect heavily draining .), wrap with kerlix (Rolls provide fast-wicking action, superior aeration, and excellent absorbency .cushion and protect wound areas) and secure with tape every day shift every two days for wound care and every twenty four hours as needed for wound care. On 10/14/20 at 10:15 a.m., further review of the facility's investigation report documented, R#503 was attempting to style own hair and burned self. Resident 's (R#503) description documented, I was trying to clip my ends. The Resident (R#503) admitted to using curlers, but during the second day the resident 's injuries were not consistent with the resident's story. She (R#503) then admitted to having used a lighter to remove an uneven piece of hair causing her artificial hair to burn. Skin assessment revealed swelling at the site. Physician notified. Staff convinced resident to go to the hospital for further evaluation. Resident transferred to a local hospital and admitted . The facility's Investigation Report revealed the Employee Interview of Unit Manager C documented, Question number 3) Did you see anyone else from the staff assisting the resident or in the resident's room .Answer No .Question number 5) Did you see a family member or a visitor in the room during your shift .Answer No .Question 9) Do you have any idea how the resident could have received the injury .Answer, Family supplied resident with appliance and curlers and etc., in her personal belonging. On 10/14/20 at 11:00 a.m., the Administrator was interviewed and asked, did she recall the incident on 4/16/20 with R#503? The Administrator stated, I just had got here, and I believe it happened the next day, so I can't tell you much about it. The Administrator was asked, how she thought the resident got the curlers and the cigarette lighter? The Administrator stated, It could have been dropped off by someone for her. The Administrator was then asked, if the curlers and the lighter were dropped off, would it mean a staff member brought the curlers and cigarette lighter into the facility for the resident. The Administrator did not respond. The Administrator was asked, if the facility a none smoking facility, why should the resident have a cigarette lighter? The Administrator stated, Yes, the facility is nonsmoking. The Administrator was asked, what is the facility's policy for bringing in items such as curlers, cigarettes lighters etc.? The Administrator stated, 'They can't have them, the front desk should check everything that's brought in. The Administrator was then asked, was there anything showing the resident personal belonging was screened or checked for such items. The administrator stated, The front desk is to do an inventory for the admission residents. The Administrator was asked, where are the inventory sheets kept? The Administrator stated, It should be in the computer. It was brought to the administrator attention that the inventory sheet for (R#503) was not observed in the computer. The Administrator was offered to review the computer for the document with the surveyor and did not. The Administrator stated, I will try to get it for you. On 10/14/20 at 11:33 a.m., the facility's policy titled Admission Policies with no date documented,2) Our admission policies apply to all residents admitted to the facility without regard to race, color, creed, national origin, age, sex .4) It shall be the responsibility of the administrator, through the admissions department, to assure that the established admission policies, as they may apply, are followed by the facility and resident .Policy statement 1) Residents may not maintain any electrical appliances (i.e., heating irons, cooking utensils, etc.) within their living areas, unless approved , in writing by the Administrative, or his/her designee .3) Any violation of this policy may result in the removal of such items from the resident's room.

This citation pertains to intake #MI 471. Based on observation, interview and record review, the facility failed to implement pressure relief interventions and to provide timely and appropriate care and treatment for two (#s 802, 804) of four sampled residents reviewed for skin integrity, resulting in development of pressure sores, delayed healing of existing sores, development of wound infection, mental status changes,[MEDICAL CONDITION] (infection in the bloodstream) and emergency hospitalization . Findings include: The complainants reported to the State agency that wound dressings were not changed timely, infections developed to wounds, residents developed pressure sores, the sores were not properly treated and residents were not being turned and repositioned. Resident #802- On 2/28/20 at 11 AM, the resident's clinical record was reviewed with the Director of Nursing (DON)/Administrator, who was in and out of the room, and Assistant DON (ADON). The resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set (MDS) completed 10/2/19 noted the resident had severe cognitive impairment, required total assistance for all care and had one stage 3 (full thickness skin loss) pressure sore on admission. The resident's Braden (pressure ulcer risk) scales dated 9/27 and 10/4/19 noted the resident was at very high risk for development. The facility's contracted wound specialist evaluated the resident's pressure sore on 9/23/19 and noted: a sore to the sacral/bilateral buttocks measuring 9.4 centimeters (cm) x 7 cm x 0.2 cm deep; unstageable (unable to see the base due to coverage by necrotic (black, dead) tissue; no odor; moderate sero-sanguineous (red-tinged) drainage; cicatrix (scars from healed pressure sores) to left hip and bilateral heels; Recommendations- [MEDICATION NAME] (wound debridement) gel prescribed daily and PRN (as needed), frequently reposition. The resident's wound treatment record noted that the treatment was not done on 9/26/19. The ADON looked and was unable to find a documented reason why. The resident's pressure ulcer care plan did not list the wound care or to monitor the wound as interventions. The ADON said, It should be there. The specialist noted the following wound evaluations: On 9/30/19- 9 x 8.2 x 0.2, no sign of infection, moderate drainage, apply [MEDICATION NAME] + [MEDICATION NAME] (anti-irritation and anti-bacterial) cream around wound perimeter daily and PRN , continue [MEDICATION NAME]. On 10/7/19- 8.3 x 8 x 0.2, no odor or signs of infection, moderate drainage. The treatment record noted that wound treatments were not done on 10/2, 10/6, 10/9 and 10/13/19. The ADON said the treatments should have been done and documented. On 10/14/19- 7.5 x 8 x 0.2, no odor or signs of infection, moderate drainage. The treatment record noted that wound treatment was not done on 10/17/19. On 10/21/19- (increase in size): 10.5 x 10 x 0.2; large amount of sero-sanguineous drainage; mild odor wound is deteriorating; [MEDICATION NAME] changed to crushed [MEDICATION NAME] (antibiotic) tablet + Hydrogel (debridement agent) applied directly to the wound daily and PRN x 14 days and [MEDICATION NAME] (antibiotic) to ingest twice a day x 10 days for infected wound. Per the resident's vital signs record, he had a low grade fever (between 99-100 degrees) on 10/19 and 10/20/19. On 10/22/19, the resident was sent out on a scheduled appointment to the Cardiologist. Per notes, the Cardiologist's office called the facility and said that they sent the resident to the hospital emergency room due to mental status changes. When asked why the resident was sent to the appointment in that condition, the ADON did not respond. During the record review with the ADON, the hospital records were requested. She called the facility physician to facilitate the request. The physician said he did not have access to records at that particular hospital. He then said, I've been knowing him (resident) for a long time and his wound was not that bad. When told that the resident had an infected wound, had a low grade fever and the Cardiologist made the decision to send the resident to the hospital, rather than the facility sending the resident directly themselves, he did not respond. The hospital records were obtained directly from the hospital and noted: Patient presents to ED (emergency department on 10/22/19) with a chief complaint of altered mental status accompanied by his significant other. She states that the patient was seen today for routine cardiology checkup difficult to arouse He also has a decubitus ulcer (pressure sore). She is concerned this may be infected Patient has a decubitus ulcer across the sacrum with eschar (leathery, dead tissue). On 10/23/19-Large necrotic ischemic sacral ulcer requiring debridement wound area of sacrum prepped for excisional debridement of eschar [MEDICATION NAME] the necrotic abscessed ischemic (restricted blood flow) skin subcutaneous and muscle tissue multiple pockets of purulent (pus) material disrupted Per Infectious Disease Consultant: Continue IV [MEDICATION NAME] and [MEDICATION NAME] (antibiotics) off-loading techniques and frequent turning Per Critical Care Consultant: Altered mental status likely combination of toxic metabolic [MEDICAL CONDITION] ([MEDICAL CONDITION] with symptoms of [MEDICAL CONDITION] and/or confusion not related to any structural brain damage that may be associated with other illnesses, like infection and commonly seen in the very ill and elderly) and low-[MEDICAL CONDITION] from seeding of sacral decubitus Overall his mentation has been worsening since admission yesterday Blood cultures thus far 1 out of 2 positive for gram-negative bacilli Resident #804- On 2/27/20 at 9 AM, Unit Manager Confidential Witness (CW) C was asked to conduct a skin observation on resident #804. The resident was lying on his back and had undated bilateral foot dressings. The resident's heels were resting directly on the bed. Pressure relief boots were observed on a chair in the room. When asked about the boots CW-C said they should have been on the resident's feet. The resident, who was confused and immobile, was turned to the side by CW-C and revealed a large stage 4 (full thickness skin loss down to bone) pressure sore to the sacrum/bilateral buttock. The area was covered with an undated dressing totally saturated with beige purulent (pus) malodorous fluid that had drained into the resident's incontinence brief. The resident's treatment record noted that the dressings were to be changed daily and PRN and were last changed on 2/25/20. At 10 AM, the DON/Administrator and ADON were called to the resident's room. The resident was lying on his back and the pressure relief boots still remained on the chair. They saw the purulent drainage inside the resident's brief. The ADON said, It's (dressing) supposed to be dated. I can't tell when it was done. When asked if she smelled an odor, that was detected from the doorway, the ADON said, Yes, it's coming from the wound. The undated dressing was removed from the left foot and revealed a large amount of brown drainage from pressure sores on the heel. Upon further observation, the resident had red, open stage 3 (full thickness skin loss) pressure sores to bilateral gluteal areas that were not covered by dressings and red, dime-sized open sores on the back of the scrotum over each testicle. The scrotum had been tightly wedged down between the inner thighs. The scrotum, except for the sores, and gluteal fold were heavily coated with a thick white cream. There was stool protruding at the opening of the rectum. When asked if the gluteal and scrotal sores should have been covered with dressings, the ADON said, yes. When told that CW-C had seen the boots on the chair earlier and that they were still not on the resident, the DON did not comment. When asked why the dressings were not changed for two days, the DON said, We had to let the wound care nurse go yesterday (2/26/20) due to poor performance. We're waiting for a nurse (CW-B) to come in today to do wound care. When asked, the ADON said the nurse was dismissed in the afternoon. They did not respond why the treatment for this resident was not done earlier in the day before she left. At 10:20 AM, CW-B arrived and identified herself as the wound care nurse. The resident was observed continuing to lay on his back at 11:20 AM, 12:10 PM and 1:30 PM. On 2/28/20 at 12 Noon, the resident's clinical record was reviewed with the DON who was in and out of the room, and the ADON. Treatment records noted that the treatments were not done on 1/12 and 1/13/20. The ADON looked and did not find a documented reason why. The resident's pressure sore care plan noted that heel lift boots were to be in place and did not mention turning and repositioning the resident. The ADON said, I don't see it on the care plan. When asked if the resident had a schedule to be turned, she said, I know some places have turning schedules but we don't. Turning/repositioning was not mentioned on the resident's Kardex (care guide used specifically by nurse aides). Further review of the resident's clinical record noted, an original admission into the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] noted the resident had severe cognitive impairment, a urinary catheter, was incontinent of bowel, required extensive assistance for care, including turning and repositioning, although he appeared to require total assistance, and had one-stage 3 and one-stage 4 pressure sore. Pressure sores, which were present on admission, were evaluated by the wound specialist on 1/13/20 and noted: Sacral/bilateral buttocks-stage 3, measuring 4 cm x 3 cm (no mention of odor/infection). Right glute-stage 3, 1.5 cm x 1.5 cm. Right heel-dead tissue area, 1 cm x 1.5 cm. Left heel-dead tissue area, 5 cm x 3 cm. Soft heel lift (pressure relief) boots and frequent repositioning was recommended. The resident was hospitalized from [DATE] to 2/3/20 for signs/symptoms of stroke and re-admitted on [DATE]. Upon return, the Nursing Admission assessment dated [DATE] noted the sacral/bilateral buttock pressure sore measured 14 centimeters (cm) by 11 cm by 3 cm deep with no signs/symptoms of infection or odor. A Braden (pressure ulcer risk) scale dated 2/4/20 noted the resident was at risk for development. The wound specialist noted the following wound evaluations: On 2/11/20- Sacral/bilateral buttocks-stage 4, 12.5 x 8 cm x 3 cm deep (no mention of odor/infection). Right glute-stage 3, was resolved (healed). Right heel pressure sore, now labeled as a diabetic ulcer- (which can be caused by unrelieved pressure), 0.7 cm x 1.8 cm x 0.2 cm deep. Left heel pressure sore, now labeled as a diabetic ulcer- 4 cm x 3.5 cm, dry non-draining. Scrotum-[MEDICAL CONDITION] (bacterial skin infection) in scattered areas. The resident was prescribed: [MEDICATION NAME] + [MEDICATION NAME] cream to scrotum daily and PRN Dakins (anti-bacterial) solution to sacral/buttocks daily and PRN Dry dressing left heel every 2 days [MEDICATION NAME] gel to right heel daily and PRN, off-load pressure Heel lift boots, frequent repositioning *The treatments remained the same unless otherwise specified.* On 2/18/20- Sacral/bil buttocks-11 x 9 x 2 (no mention of odor/infection). Right heel-0.5 x 1.5 x 0.3. Left medial heel-(New pressure sore), 1.5 x 1.0, *treat with [MEDICATION NAME] and dressing daily and PRN* Left lateral heel-4 x 4. Scrotum-(Increase in size) 2.5 x 2, moderate sero-sanguineous drainage and slough (shedding dead skin). The Braden scale conducted 2/18/20 noted high risk for development. On 2/25/20- Sacral/bil buttock-12 x 9 x 2 with strong odor Wound is deteriorating. *Add crushed [MEDICATION NAME] (antibiotic placed directly on the sore) + Hydrogel (for wound debridement) with the Dakins solution daily and PRN* Right heel-0.5 x 1.0 Left medial heel-0.5 x 0.5 Left lateral heel-4 x 4. Scrotum-(Increase in size), 3 x 2.5. Right glute pressure sore-(New), stage 3, 3 x 2.5 x 0.2, necrotic base (black, dead tissue), *[MEDICATION NAME] daily* and a dressing. Left glute pressure sore-(New), stage 3, 1 x 1, necrotic base, *[MEDICATION NAME] daily* and a dressing. The sacral/bil buttocks wound drainage was noted as moderate and sero-sanguineous on 2/25/20. However, two days later on 2/27/20, it was observed as very heavy, beige in color and purulent, as previously noted. The Braden scale conducted on 2/25/20 noted high risk for development. During each wound evaluation, including the one on 1/13/20, the specialist recommended: Venous and Arterial Doppler (testing to determine blockage in blood circulation) to rule out [MEDICAL CONDITION] and [MEDICAL CONDITION]-bilateral lower extremities. There was no documented indication the testing was ever done, in order to rule that the heel wounds developed due to a circulatory problem rather than caused by unrelieved pressure. On 2/28/20 at 6 PM, per review of the facility's policies on Skin Management dated 10/2028 and Facility-Acquired Pressure Ulcers dated 10/27/19: -It is the policy of the facility that a resident does not develop pressure injury unless clinically unavoidable. Residents with wounds and/or pressure injury and those at risk for skin compromise are identified, assessed and provided appropriate treatment to promote healing The licensed nurse will document preventative measures on the care plan/kardex A care plan is developed or updated to reflect the new problem and interventions The resident kardex will also be updated to reflect changes. -Pressure ulcers are unavoidable if the facility evaluated the resident's clinical condition, identified risk factors, assessed; care planned, implemented the care plan, evaluated the resident and the care plan was revised accordingly to outcome, and revised the care plan as needed. If not, the pressure ulcer was avoidable. For existing pressure ulcers, the facility is compliant if appropriate assessment, care planning, and treatment were provided, the resident's outcome was evaluated. The facility is compliant if they develop a care plan and qualified personnel implement the resident's care plan.

This citation pertains to intake #s MI 517, MI 354, MI 471. Based on observation, interview and record review, the facility failed to implement timely neurological checks, emergency services and wound care, and to test and record blood glucose levels for three (#s 803, 805, 806) of six sampled residents reviewed for quality of care, resulting in delay in proper and thorough evaluation of mental status changes, and the potential for compromise/decline in health status related to diabetes and a surgical wound. Findings include: The complainants reported to the State agency that there was a delay in proper emergency care, wound dressings were not changed according to schedule and blood glucose (sugar) levels were not monitored as prescribed. Resident #803- On [DATE] at 10:50 AM, the resident's clinical record was reviewed with the Director of Nursing (DON)/Administrator who was in and out of the room, and the Assistant DON (ADON). The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. [MEDICATION NAME] for diabetes was prescribed at bedtime and on [DATE], blood sugar checks were prescribed before each meal (three times a day). The resident's medication records noted that [MEDICATION NAME] was not given by staff on ,[DATE] and [DATE] and to see progress notes for the reason. The ADON read the notes and said the reason was not documented but should have been. On ,[DATE], ,[DATE] and ,[DATE], [MEDICATION NAME] was not given because Vitals outside the parameters for administration. When asked what that meant, the ADON said, I assume the blood sugar was too low to give it. The ADON looked in the record and said the blood sugar levels were not documented on the dates it was withheld but should have been. When asked what should have been done, the ADON said, If withheld, contact the physician. When asked if there were written parameters as to how high or low the blood sugar levels should be before withholding insulin and/or to notify the physician, the ADON said there were none but parameters should have been written. The resident's blood sugar levels on her vital signs record were reviewed and noted that only five levels were recorded during admission, as follows: [DATE]=196 (normal range=,[DATE]) [DATE]=172 [DATE]=141 [DATE]=190 [DATE]=204 The ADON searched progress notes and medication records and found only one other blood sugar level of 333, the morning of [DATE]. Progress notes leading up to [DATE] were as follows: On [DATE] at 8 AM: Writer was informed by CNA (certified nurse assistant) that resident was on the floor in her room. Resident was observed sitting on the floor in her room without clothes. Family was present. Resident was assessed and assisted back into bed. No noted distress has a behavior of undressing and putting herself onto the floor. Will continue to monitor. Doctor notified. There were no further documented notes about the resident until [DATE] at 12:09 PM. On [DATE] at 12:09 PM: (Blood pressure) ,[DATE]. (pulse) 64. (temperature) 97.4. (respirations) 18. (oxygen level) 98%. Resident alert and oriented x 1 with noted confusion. Resident observed by writer leaned down in chair. Resident 'slow to respond' to writer when assessing for alertness. Resident then proceeded to remove her clothing with right arm. Staff members informed nurse that is this had been resident behavior since admission. On [DATE] at 12:59 PM: Resident is not eating or drinking. CNA reported that she did not eat breakfast and is refusing to eat lunch. Call placed to Dr Labs: CBC (complete blood count), CMP (comprehensive metabolic panel), [MEDICATION NAME], Protein ordered. Continue to monitor and encourage resident to eat/drink. At 1:30 PM: Writer notified by therapy less than 10 minutes from leaving floor that resident doesn't want to participate in therapy, and resident was just leaning on the table. Due to prior assessment before therapy DON and MD notified of potential change in condition. Vitals were normal and orders received from MD for labs to be drawn. Family present at time of reassessment, resident responding appropriately to family, however she would not respond to staff. Resident was observed looking at staff with a fixed gaze while assessing for pain and distress. The resident voiced pain only to family in a whispering tone, not responding to writer but writer was able to hear response. Pain medication given orally because she reported pain to leg, pain medication effective. Family remained visiting for about another hour and no more concerns were reported to writer. Resident rested calmly when family left room. At 4:19 PM: Resident has old bruising noted to the right leg, right knee, bilateral arms. During palpation of right hip resident have noted grimacing. Vitals Blood Pressure ,[DATE] Pulse 90 Respirations 18 Temperature 97.8. (MD) notified of findings new orders given x-ray right hip, right knee, and skull, and neuro checks (neurological assessments to test for [MEDICAL CONDITION]/trauma) x 72 hours. Oncoming nurse have been notified that neuro checks are in place. At 4:26 PM: Writer administered Tylenol 500mg by mouth related to grimacing. Pain (level) 7 out of 10. Writer will reassess resident in one hour. There were no further documented notes regarding the resident's status until [DATE] at 7:01 AM. On [DATE] at 7:01 AM: Lab personnel states unable to obtain (blood for ordered lab tests). At 9:28 AM: [MEDICATION NAME] Tablet for hypertension held due to (low) blood pressure. At 9:33 AM: [MEDICATION NAME] for hypertension (withheld) low blood pressure. At 10:39 AM: Patient is alert but not responding to verbal stimuli .not performing simple task Staff asked writer to help her transfer patient to wheelchair. Patient is in chair unable to maintain balance eyes are glassy and patient is incoherent placed back in bed. Vitals are taken ,[DATE] Blood Pressure, 93 Heart Rate, 26 Respirations, 88% oxygen (level on) room air placed on Oxygen at 2 Liters via Nasal Cannula Blood Sugar is 333. Writer went out the room to call doctor and staff approached patient and stated that she doesn't look right. Writer assessed and patient has some drooping on the left side of her face still not responding verbally. Physician contacted writer back and stated that he was pulling in to the building and would be right in to assess patient. Will continue to monitor patient for health and safety during shift. At 11:00 AM: Late Entry: Note: After speaking to physician writer re-evaluated resident SPO2 (oxygen level) had increased to 94% on Oxygen 2 Liters still presented a low Blood Pressure ,[DATE] Heart Rate 95 Respirations 20. Writer and attending nurse placed patient in a Trendelenburg position (feet elevated above head) to try to elevate Blood Pressure. Bed was placed in a low position. Around 12 PM patient had a male visitor in room. X-ray tech came to take x-rays of skull, Right hip and Right knee. Physician arrived to facility and he along with two NP's (Nurse Practitioners) assessed patient. Laboratory (staff) arrived at 1 PM and was unable to draw any labs. Patient was rounded on every hour and was stable. At approximately 3 PM resident was being rounded on by staff and was noted to be in distress and a code blue was called (CPR initiated). (The time of this late entry was noted as 11 AM, although there was documentation in this note regarding events occurring up to 3 PM.) At 4:39 PM: Resident had orders for labs to be drawn. Laboratory came out on two separate occasions today to draw the ordered labs but was unsuccessful. MD was in the facility at the time the second attempt was made (at 1 PM per the previous note) and orders were received to transfer resident out to (hospital) emergency room related to Acute change of condition. While in process of trying to transfer resident out to hospital writer received report that resident was displaying respiratory distress. Writer immediately went to assess resident, resident was in distress gasping for air, faint pulse, 911 called from room phone, CODE (blue)called, crash cart retrieved, CPR started, MD and 2 NP's responded to CODE also and started helping with CPR, starting IV Fluids, MD ordered [MEDICATION NAME] (to increase blood pressure and open airway), writer went to retrieve, NP gave injection, CPR continued Fire Department EMS arrived and took over. Resident transport out to hospital. The Incident/Accident (I/A) report of the fall was reviewed. The ADON was asked about the resident's fall, whether she hit her head and the results of the x-rays. The ADON said, She didn't hit her head. Her family was with her when she fell . However, the notes indicated the family was present. When asked how she knew the family was in the room when the fall occurred versus the resident being on the floor when they arrived, since the resident was noted to be on the floor undressed, and whether the family was asked if the resident had hit her head, the ADON did not respond. She presented results of the portable x-rays, which were negative for fractures. The hospital ER records were then requested. The ADON called the facility physician to facilitate the request. The physician said he had accessed the records, said he was actively looking at them while on the phone and that he would fax them to the facility. The physician and ADON offered no explanation as to what may have caused the resident's change in condition and why the resident was not sent to the hospital sooner. By survey end, the ADON said that the fax the physician said he was sending, was never received. The records were then obtained directly from the hospital and revealed: Per the EMS emergency run sheet, EMS personnel were dispatched to the facility at 3:18 PM and arrived at the resident's bedside at 3:25 PM. Upon their arrival, CPR was in progress by facility staff, EMS continued CPR and the resident was transported with continuing CPR and assisting ventilations without any changes The hospital ER records noted: [AGE] year old presents as a medical code and CPR in progress EMS states that she has a history of kidney disease but otherwise they do not know any other pertinent medical history Unresponsive with fixed and dilated pupils CPR was continued from arrival to 3:53 PM at which time the resident was pronounced dead. Resident #805- On [DATE] at 12:30 PM, the resident's clinical record was reviewed with the DON/Administrator who was in and out of the room, and the ADON. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. On [DATE], the resident was prescribed [MEDICATION NAME] and [MEDICATION NAME] tablets twice a day for diabetes and blood sugar checks before each meal and at bedtime (four times a day). The parameters for the blood sugar checks: Notify physician if blood sugar level less than 80 or greater than 200. A review of the resident's vital signs record revealed only two recorded blood sugar levels, including one on [DATE] at 8:30 AM recorded at 121. According to nursing notes that day, by 9:20 AM the resident was found unresponsive and was transported to the hospital. Hospital emergency room records were requested but not provided by the end of the survey. The ADON looked for other levels and said, I don't see it. (The complainant reported to the State agency that the resident's blood sugar level was 21 on arrival to the hospital.) Resident #806- On [DATE] at 9:25 AM, the resident was observed alert, fully oriented and sitting in a wheelchair in her room with a dressing on the left foot dated [DATE]. The resident said, It was changed two days ago. I got it wet yesterday in the shower and asked to get it changed but they didn't come so I didn't worry about it. She then said, I got up at 2 this morning to use the bathroom and wet on myself and accidentally got urine on it. I told the (midnight shift) aide this morning to tell the nurse but they haven't changed it yet. The resident held her foot up to show the dressing soiled with yellow stains. When asked what happened to her foot, the resident said, They took the big toe off. She said, I have an appointment this morning at 10 for my foot. I hope they change it before I leave. The resident's clinical record was reviewed and noted, an admission into the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. Per the hospital notes, the resident had an abscess to the left great toe associated with osteo[DIAGNOSES REDACTED] (bone infection). A wound culture showed Staph bacteria. The toe was swollen with purulence (pus) at the bone. The resident's toe was amputated on [DATE] and the resident was placed on two antibiotics. The hospital discharge summary recommendations noted: Keep left foot dressing clean, dry, intact at all times. On [DATE], there was an order for [REDACTED]. At 10:20 AM, the resident was dressed and ready to go to her appointment with the transporter there waiting to leave. The dressing had not been changed. Nurse Confidential Witness (CW) B, who identified herself as the facility's new wound care nurse, was called to the room to observe the stained dressing. She then gathered wound care supplies so that Unit Manager CW-D could change the dressing. CW-D had to pry the dressing away from the wound with repeated sprays of a wet solution. Brown drainage was on the inside of the dressing. When asked earlier at 10 AM, why another resident's dressing was observed unchanged for two days as with this resident (#806), the DON said, We had to let the wound care nurse go yesterday ([DATE]) due to poor performance. We're waiting for a nurse (CW-B) to come in today to do wound care. On [DATE] at 6 PM, per review of the facility's policies on Blood Glucose tests dated ,[DATE] and Skin Management dated ,[DATE]: -Purpose-To detect or monitor residents' blood glucose levels Record results and notify MD if necessary. -Residents with wounds are provided appropriate treatment to promote healing.

This citation pertains to intake MI 488 Based on interview and record review, the facility failed to ensure one resident (R507) of three reviewed for abuse, from a total sample of seven was free from physical abuse when resident #41 (R41) punched R507 on the left side of her face and left eye resulting in swelling and a blackened eye and the potential for further incidents of abuse. Findings include: On 5/21/17 at 2:00 p.m., the medical record was reviewed for R507 and revealed the following: R507 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) with an annual reference date of 2/10/17, indicated that she needs one person assistance with transfers, dressing, and personal hygiene and requires two person assistance with bathing. The BIMS score (Brief Interview of Mental Status) was 15/15 indicating she had intact cognition. On 5/21/17 at 2:30 p.m., review of the medical record for R41 revealed a [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) with an annual reference date of 4/20/17, indicated that he needs one person assistance with transfers, dressing, and personal hygiene and requires two person assistance with bathing. The BIMS score (Brief Interview of Mental Status) was 02/15 indicating he had severe cognitive impairment. Care plans for R41 were reviewed and revealed the following: Behavior Symptom Care Plan with last reviewed date of 5/11/17. Targeted Behaviors-Agitation, poor safety awareness. Approach- Be alert for triggers of potential evidence of pending behavioral episodes. Depression/Anxiety/Sad Mood Care Plan with last reviewed date of 2/21/17. Problem-Repetitive physical movements. Approach- Encourage resident and staff to be alert to events or situations that precipitate episodes of restlessness or anxiety. On 5/22/17 at 9:30 a.m., A document titled Behavior Tracking Log for R41 was reviewed and revealed the following: 5/3/17 at 1:05 p.m., Walked past #507 and punched her in the face. 5/5/17 at 8:30 a.m., Got up while eating and punched R507. Review of the Nurses Note dated 4/30/17 at 4:25 p.m., indicated the following: Resident (R507) was siting in dinning area watching TV when a male resident (identifier) walked up to her and stood over her then punched her in the face with his right fist on the left side of her face for no reason. Staff immediately intervened and broke up the two and separated them. No blood or broken skin noted. X-ray ordered for skull and orbit views. Dr. Notified and family notified. CNA and writer monitoring very closely to assure safety of both residents. On 5/21/17 at resident R507 was queried about abuse incident on 4/30/17 and stated the following: He (resident identifier) thought I was his girlfriend and I told him I wasn't and he punched me. He made my face and eyes swell up. They tried to moved me down to the 1st floor but the elevator was stuck. I don't even know why he did it. He busted my face up real bad though. On 5/22/17 at 1:13 p.m., Staff member A was queried if they had witnessed R507 had sustained any injuries from the abuse incident on 4/30/17, and replied, I saw R507 on April 30 9th and her eye was black. She also had a black eye on May 3rd. She was asked if she thought R507 had the black eye as a result of getting punched and she stated that's why her eye was black. On 5/22/17 at 2:02 p.m., Staff member B was queried if she had noticed if R507 had any injuries from the incident on 4/30/17, and she stated that R507 had a black eye due to R41 hitting her for multiple days after the incident occurred. On 5/21/17 at 3:58 p.m., Administrator was queried about R507 being punched in the face by R41. She stated nobody tole me about that. She was shown the nurses note on 4/30/17 and said this should have been called in. On 5/22/17 at 12:15 p.m., Document titled St. Francis Nursing Center Abuse Protocol was reviewed and revealed the following: Purpose: 1. To ensure that residents are not subject to abuse by anyone including but not limited to, facility staff, other resident's, consultants or volunteers, staff or other agencies serving the resident family members or legal guardians, friends or other individuals.

This citation pertains to complaint #MI 005 Based on observation, interview and record review, the facility failed to assess resident's risk consistently, and implement interventions consistently with resident's individualized plan of care and ensure measures were in place to prevent the development of one unstageable pressure ulcer, one stage three pressure ulcer and one stage two pressure ulcer for one sampled resident (#402) and one stage three pressure ulcer for one resident (#401) from three residents who have developed pressure ulcers from a total sample of three. This resulted in two residents developing unnecessary pressure ulcers. Findings include: On 5/11/17 at 8:50 a.m., during a dining room meal time observation, it was observed that one Certified Nursing Assistant (CENA) A was feeding a resident while standing up. Observed resident #402 sitting up in a geri-chair in the dining room. The geri-chair did not have a gel cushion. On 5/11/17 at 9:02 a.m., the facility's wound care book was observed to have resident #402 wound care written that included care for wounds acquired to his right and left hip. At 10:15 a.m., resident #402 continued to be sitting in the dining room on a geri-chair without a gel cushion. On 5/11/17 at 10:30 a.m., wound care nurse D was requested to allow a wound care observation for resident #402. When nurse D was queried when was the wound first observed, responded, They notified me when he had the wound and it had eschar and it was dark already. When nurse D was further queried, why did it take that long to have been notified of having a unstageable eschar ulcer? Nurse D responded, I don't know. When queried why was he sent to the hospital on the day you discovered the wound, nurse D responded, We sent him out to the hospital because he wasn't feeling well. A physicians order was reviewed at this time documented: date 4/10/17, Transferred to hospital r/t (related to) mental status change and failure to thrive. On 5/11/17 at 11:15 a.m., wound care observation with nurse D was as follows: - Resident #402 was lying supine and had a brief on and a Foley bag (without a privacy bag) that contained very dark amber urine hung on the bed rail. Resident #402 appeared to be very thin. - Nurse D washed her hands for five seconds (timed observation) and donned gloves, - Nurse D removed the brief to reveal an old dressing applied to the right hip that was dated 5/10, - Nurse D re-washed her hands for five seconds (timed observation), - Resident #402's brief was soiled and contained a round ball of a bowel movement (BM)and appeared to have dried BM adhered to skin to buttocks and scrotum, - Nurse D had removed the brief to reveal a necrotic centered area and stated, she was off of work the day before and when she came back to work the next day noticed necrotic tissue on the 9th of April. Nurse D continued to report that resident #402 was Not eating, poor appetite, did not want to get up, - The coccyx wound had an older dressing dated 5/9, nurse D reported it was a Stage two, - Nurse D removed soiled gloves and re-washed hands for four seconds (timed observation) and donned new gloves, - Nurse D removed old dressing and Re-washed hands for two seconds and donned gloves, - Nurse D washed buttocks from feces and the scrotum. The scrotum was excoriated. Resident scooting moaned shook his head, - Nurse D re-washed her hands for two seconds and donned gloves, - Nurse D applied Santyl (an enzymatic ointment used for [MEDICATION NAME] skin by breaking down dead skin) to wound to the right hip, resident #402 tried to scoot away. Nurse D was reminded she had to measure the wound. Nurse D dropped tape to be used on the wound onto the floor then picked tape up off the floor and placed on table allowing it to touch the dressings on the table, - Nurse D re-washed her hands for three seconds (timed observation), then left room to obtain tape measure, - Nurse D left door and curtain open with resident exposed when she left the room, a house keeping staff was just outside of door, - Nurse D proceeded with an eight second re-washing of her hands, donned gloves, - Nurse D measured the wound to the right hip, it measured 5.0 centimeters length (cm) by 3.0 cm width x 0.4 cm depth, - Nurse D taped tape directly to the unclean bedside table, - Nurse D measured the left buttocks near coccyx which measured 1.1 cm length by 1 cm width pink base, - Nurse D Re-gloved no washing hands, - Nurse D washed wound after measuring, then regloved for Allevyn dressing, - Nurse D proceeded with a two second handwashing (timed observation) then touched resident and his bed, - The left hip old dressing was dated 5/10/17, nurse D removed the old dressing revealing a large necrotic wound, - Nurse D did a six seconds hand-washing, and donned new gloves, - Nurse D measured the wound; 4.5 cm length by 4.5 width cm and stated this is a deep tissue injury, nurse D did not measure the area surrounding wound which was red and non-blanchable, this wound had a red bridge that connected it to another wound which measured 5 cm length by 3.8 cm width, - Nurse D after measuring, cleansed wound without washing her hands then removed gloves, re-gloved then proceeded to apply treatment, - Nurse D applied Santyl to tissue surrounding necrotic center, applied the 4x4 gauze then borderless dressing, ABD and cloth tape, - Nurse D touched brief and resident, re-washed her hands for five seconds (timed observation), then touched curtain surrounding resident #402's bed, did not re-wash her hands then re-gloved, - Nurse D proceeded to resident's left foot which revealed an old dressing dated 5/9, - Nurse D stated, this is a Left MP (Metaphalenges area which actually is the bones at the end of toes) joint deep tissue, - Nurse D measured the wound to the left ankle and measured 3 cm length by 2.2 cm width and stated, Theses were there when he came back from the hospital. Nurse D proceeded to measure the wounds to the middle lateral foot which measured 3 cm length by 1.5 cm width, and another wound to the ankle measured 0.5 cm length by 0.7 cm width. Observed were scattered wounds on the little toe, nurse D neglected to measure. Upon pointing out that there was a wound on the little toe, nurse D stated, there is? Nurse D then measured the wound to be 1.5 cm length by 0.5 cm width, - Nurse D re-washed her hands for four seconds (timed observation), 4 second rewash, - Nurse D left the old dressing around the ankle after cutting it open and then proceeded to wash wound, removed gloves, re-gloved, applied dry dressing [MEDICATION NAME]. While wrapping the new dressing [MEDICATION NAME] would touch the old dressing lying under resident #402's foot, nurse D used tape that fell on to the floor previously to adhere the [MEDICATION NAME] together, - Nurse D ended with a four second hand-washing. On 5/11/17 at 12:22 p.m., during a lunch observation in the dining room, resident #402 was brought into the dining room. CENA E push the Geri-chair that resident #402 was in, they could be observed in the hallway prior to the dining room. CENA E dragged resident #402's feet on the floor from his room, down the hallway and into the dining room where resident #402 was going to sit for lunch. Resident #402's feet were not elevated to prevent his feet from touching the floor. Resident #402 did not have a gel cushion in his chair and was observed feeding self during his lunch. Resident #402 was eating well. Resident #402 could answer questions by shaking his head yes or no. Resident was also observed at 1:20 and 3:28 in the dining room sitting in his geri-chair without a gel cushion. On 5/11/17 at 1:55 p.m., resident #402's clinical record revealed an original admission date of [DATE] and a re-admission date of [DATE] with [DIAGNOSES REDACTED]. An Minimum Data Set (MDS) scored resident as completely dependent on staff to meet his activities of daily living and transfer needs. An annual MDS, dated [DATE], revealed a 00 score on the BIM's (mental status was done but rated a low score, resident #402 is non-verbal) and that resident #402 did not have a pressure ulcer. Continued review of resident #402's clinical record revealed the following: - Initial nursing assessment for 4/17/17 at 2:30 (no p.m or a.m. indicated), Is a two person assist, non verbal is not continent and has a Foley, no pressure ulcer was documented or was indicated. - Skin assessment dated [DATE] titled, Pressure Ulcer Risk Evaluation, scored a 12. A total score of 8 or above represents high risk. No further assessments were completed on this form for any future dates. The form revealed that an intervention protocol should be initiated immediately. No other skin assessments were completed or documented skin observations done to show if wounds were assessed prior to their initial discovery. No pressure ulcer assessments were done Prior to skin changes. There were no other documentation's that would support that wounds were observed prior to the discovery of a necrotic pressure ulcer (S) or prior to wound development found in resident #402's chart, - Two different dates for a Care Plan (4/10/17 and on 4/18/17) titled, Pressure Ulcers, Potential related to: Sensory perception, Moisture/Incontinence, Decreased Activity, Impaired mobility, Nutritional/Hydration risks, Friction and shear problem, Co-morbid conditions, Hx of healed pressure ulcer. Added to care plan on 4/24/17 left hip UTS (unstageable) via wound care, eschar, UTS, Left Hip stage 3, Left hip UTS via wound care NP (nurse practitioner). Goal: Pressure ulcer will show signs of healing, pressure ulcer risk will be minimized with interventions date 7/18/17. Approach: Apply pressure reduction mattress to bed, Apply pressure reduction cushion to chair or wheel chair, Reposition in chair every two hours and PRN, Turn and reposition every two hours PRN(as needed) while in bed, provide incontinence care QS (every shift) PRN and after each incontinent episode, Measure and stage wound weekly using the pressure ulcer healing assessment form, Complete a full body check weekly, Monitor lab values as ordered. Pressure ulcer treatment as ordered, other Santyl Q2D (every two days) and PRN right and left hip. (No mention of coccyx or heels) - The care plan dated, 4/18/17, revealed, Actual skin impairment: Co-morbid conditions, Thin, fragile skin, Left lat hip DTI, L MP joint DTI, Left Ankle [DIAGNOSES REDACTED] on 4/24/17 left lat foot DTI (deep tissue injury), - A Bradens scale (tool to determine risk of developing a pressure ulcer) was not found in the thinned record or the current hard chart. - Nursing Notes dated, 4/9/17 at 1:00 p.m., documents per wound care nurse, note to have right hip eschar 4.5 length x 4.0 width cm black in color with pink perimeters, zero drainage noted, left hip, stage 3 pink base with sanguineness no odor, left heel small pink area noted but no open areas. MD (physician) notified and new phone order noted. Right hip Santyl QD (everyday) and PRN, Left hip Hydrogel QD and PRN and dry dressing to left heel foot QD and PRN. Resident alert and oriented x 2-3. Needs anticipated by the staff. Turn and reposition Q2 and PRN by staff. Incontinent of bowel and bladder and kept clean by staff. Placed in wound care log to be evaluated by MD. Heels elevated on pillows. Used two pillows to turn and reposition hips. Will continue to monitor. - Reviewed Charge Nurse to Treatment Nurse Communication Form, dated April 2017, under form's dated area 4/9/17 Resident #402's skin alteration: Escar to right trochanter. Left hip was not indicated. (this was the first indication documented that there was a wound on resident #402), - Physicians orders reviewed dated, 4/1/17-4/30/17, Safety orders - [MEDICAL CONDITION] precautions: low bed, floor mat, bed alarm, - Review of all physician's orders [REDACTED]. - Physician's re-evaluation dated, 1/12/17, revealed General appearance: in no acute distress, well developed, well nourished has weakness, On 5/11/17 at 9:15 a.m., during the initial tour of the facility, resident #401 was observed in his room, lying on a low lying regular bed, and appeared very thin. When queried how was his appetite, responded, It is good, but I weigh 137 and am 6'2 tall. In the middle of his room was a dirty floor mat. On 5/11/17 at 12:54: p.m., a wound care observation was done for resident #401 with nurse D. The following was observed: - The physician's orders [REDACTED]. - Nurse D did not wash her hands prior to going into the wound care cart, squeezed Santyl out into cup placed everything on top of dressing cart (was not observed washed) opened dressing on top of cart and dated dressing (borderless gauze), Touched dressings with bare unwashed hands. Washed hands, touched table, donned gloves, - Nurse D walked into resident's room then left room to obtain measuring tape, proceeded to do an 11 second hand-washing (timed observation), - The wound observed was a small opening, - Nurse D removed brief and did not wash hands and proceeded to measure the opening on the coccyx which measured; 1.5 cm length by 0.4 cm width by 0.01cm depth then cleansed wound without washing hands. Further continued by applying the Santyl on a tounge depressor then applied dressing, - Nurse D was queried, when did the wound start? and replied, The wound started here, not sure why it started. On 5/11/17 at 5:22 p.m., resident #401's clinical record revealed an admission date of [DATE] and a re-admission date of [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] did not reveal that resident had a pressure ulcer. Resident #401 was completely dependent on the facility's staff for all activities of daily living including transferring needs. Continued review of resident #401's clinical record revealed a care plan dated 4/10/17 titled, Pressure Ulcers - Actual related to Moisture/incontinence, Decreased activity, Impaired mobility, Friction and shear problem, Co-morbid conditions, History of healed pressure ulcer, and Sacrococcyx stage two. The goal revealed Pressure ulcer will show signs of healing and Pressure ulcer risk will be minimized with reduction interventions by 7/10/17. Approach revealed Apply pressure reduction mattress to be, Turn and reposition every two hours and as needed while in bed, Provide incontinence care every shift and after each incontinent episode, Measure and stage wound weekly using the pressure ulcer healing assessment form, Complete a full body check weekly, Pressure ulcer treatment as ordered. Review of the wound care physician's notes dated, 5/8/17, revealed resident had a wound as follows: #1. coccyx is a stage three pressure injury pressure ulcer and has received a status of not healed. Subsequent wound encounter measurement are 1.2 com length by 0.6 cm width by 0.01 cm depth, with an area of 0.72 sq cm and a volume of 0.007 cubic cm. irregular edges. Additional orders: Pressure relief/offloading low air loss mattress, frequently reposition. Another wound care physician's note dated, 4/24/17, revealed the following: coccyx wound 1.0 cm length by 0.5 cm width by 0.01 cm depth, [DIAGNOSES REDACTED]. Resident #401 was not on a low loss air mattress. His care plan did not indicate he had a stage three pressure ulcer. On 5/11/17 at 2:30 p.m., the DON was queried if she could show me what was in place prior to developing the pressure ulcer wounds on resident #402 and 401 or even immediately afterwards. One could not be shown. The DON stated, Once we see that there was a problem we order a bed for him and the wound care nurse should have ordered it right there and then. The DON reviewed requisition for the Reactive Air Pro Mattress System for resident #402 and it revealed it was not ordered until 4/20/17 and was not delivered until 5/11/17. Further queries for the DON regarding how does the facility utilize their tools for the discovery of wounds?; how often are you looking at the skin and/or evaluations; such as the Braden Scale and Pressure Ulcer Risk Assessments, or assessing whether resident is at risk? The DON explained It is done quarterly everything is done quarterly. The DON further added, Pressure Ulcer Risk evaluations are also done quarterly, or every three months. The DON was told that only one was done on 4/17 and is the only one for resident #402. The DON could not offer an explanation as to why that happened. When queried on how often did resident #402 get showered, replied, Showers are done twice a week. When queried if I could review the shower chart, revealed that only one day on the April did resident #402 receive a shower from the days between 1-10. The last head to toe skin check was done on 4/4/17 which revealed that resident #402's skin did not have bruises, skin tears, abrasions but had rashes. March shows a gap of two weeks between 3/14 to 3/28 and there was no head to toe skin checks. The DON stated, that staff were responsible for notifying the treatment nurse in writing. On 5/11/17 at 2:49 p.m., While reviewing the facility's policy and procedure titled, Protocol Prevention of Pressure Ulcers, dated January 2012, revealed that An individualized care plan will be implemented based on the resident needs as assessed in the Braden Scale. Residents at risk for skin break down will be provided a pressure relief mattress and or other pressure relief supplies as needed. On bath days, each resident will have a skin assessment performed by the charge nurse. In the event that there is a concern, the nurse is responsible for notifying the treatment nurse in writing. Additionally, In the event the CENA observe a skin concern he/she is to report it to the charge nurse, and The treatment nurse is responsible for documenting the measurements and description of the wounds. Additional policy and procedures reviewed titled, Skin Management Facility Guidelines, dated October 27, 2016 revealed, 1. Conduct a baseline had-to-toe skin check on each resident upon admission, readmission, quarterly and with a significant change (complete the appropriate skin form for all identified areas), and 2. The Pressure Risk Assessment will be completed upon admission and quarterly.

Based on interview and record review, the facility failed to provide a safe environment and proper supervision for one resident (#509) out of one sampled for falls from a total sample of nine resulting in accidents with injuries that included subdural hematomas and a craniotomy surgery. Findings include: On 12/20/16 at 11:09 a.m., review of resident #509's clinical record revealed an admission date of [DATE] and a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #509's Minimum Data Set (MDS), dated [DATE], scored resident as dependent on staff to assist with her transfers, to the toilet and activities of daily living (a one person assist). The MDS scored resident #509's cognition as intact. Further review of resident #509's clinical record revealed the following documentation: A Physician's note dated, 9/27/16, revealed a fall, This [AGE] year old frail female who has a history of end stage renal disease on hemodialysis on Monday, Wednesday and Friday. The patient had a fall while on dialysis and was diagnosed with [REDACTED]. The 'General Examination,' revealed, .the patient has a right frontotemporal (sic)occipital area shaved and a big incision of U shape with clean and dry staples and well approximated edges. No exudate, [DIAGNOSES REDACTED] or fluctuation. Physician added, further assessments 1. Fall Subdural hemorrhage status [REDACTED]. 11. Osteoarthritis, 12. Unsteady Gait, 13. Cerebrovascular Accident and 14. Hemiparesis. Treatment: We will monitor patient for falls and patient is going to have follow-up appointment with the neurosurgeon. We will monitor incision daily. Staff advised to call if there is redness, exudate, swelling or unusual tenderness in the area, also for mental status changes or weakness. Physician orders [REDACTED]. A specific physician's orders [REDACTED]. A 'Fall Risk' assessment was reviewed and revealed the following: 9/26/16 scored 25 and 11/16 scored 26, a '10' or higher meant resident was a high risk for falls. On 12/20/16 at 10:00 a.m., after the facility's initial tour, a request for Incident and Accident Reports (I&A'S) on resident #509 was requested from the Director of Nursing (DON). On 12/21/16 at 10:07 a.m., Review of the I&A'S, hospital history and physical (H&P), nursing notes, and resident #509's care plans along with an interview with the DON, revealed the following: Dated: (I&A) 8/9/16 at 11:00 a.m., witnessed fall in Dining Room resulting in injury. Resident hit the back of her head. Brief statement regarding incident Resident lost her balance while trying to maneuver around another resident, assessment performed, vitals taken, physician new orders no first aid, no hospital family notified state not notified. Nursing Notes dated 8/9/16 at 11:00 a.m., Resident observed falling in the dining room attempting to maneuver around other resident with her rolling walker, fell on back of head, resident said wasn't in any pain, writer obtained vitals, neuro-checks performed resident observed and assessed by physician on site, new order written, neuro-checks wnl (with in normal limits). Resident stable, will continue to monitor. 8/9/16 care plan added lost balance, maneuvering around resident. DON queried, 'what changed?', DON responded, we added the chair alarm. A 'Fall Care Plan' dated, 7/21/16, did not identify a chair alarm was ever added. Care plan reviewed date as 8/9/16 to place frequently used items within reach. Interventions whether updated or not, based on incident dated 8/9/16, were not included on care plan or identified on the I&A or in nursing notes. , Reviewed Care Plan titled, At Risk for Falls dated 7/21/16 Goal will be free of fall related injury through next review 10/21/16. Approaches: Observe for potential patterns of falls to identify possible causes. Offer/assist to toilet frequently and as accepted on a Falling Star Program date reviewed 8/25/16. Per the DON, we don't have a Falling Star program. Dated: (I&A) 8/10/16 at 3:40 p.m., location, resident's room not identified under type, area of injury right hip, comment c/o (complains of) pain to right hip without injuries noted. A+Ox3 (awake and orientated on three spheres; name, place and time) mobility with assistance vitals taken and perrla blank, statement, Resident observed on room floor stated, I fell trying to make it to the bathroom. Pt. educated to use walker at all times. No treatment or hospital. X-rays to right hip. Care plan noted date of 8/10/16 problem resident observed on room floor. Goal to remain fall and pain free plan educate resident ask for assistance when needed. Use roller walker when ambulatory stat right leg Xray. Continue with POC (Plan of Care) update. X-ray results dated 8/10/16 no fracture. No mention of an alarm sounding or whether any other interventions were in use, such as non skid socks. Nursing Notes dated 8/10/16 at 3:45 p.m., Resident observed on room floor. Resident assisted up into bed. Resident stated, I was trying to make it to the bathroom and tripped over my feet. Resident c/o pain to right hip. Head to toe assessment completed. No injuries noted. Resident lying in bed resting. Physician notified stat X-ray to right hip ordered resident ambulated without assistance. Resident assisted to bed with call light in reach. Resident will continue to monitor. Dated: (I&A) 8/15/16 at 2:00 a.m., location in shower room, observed on the floor no injury, A+Ox3, wheelchair mobility, Brief statement regarding incident: Resident in bathroom yelling out observed resident on bathroom floor attempting to remove self off of toilet. (Per DON right on the first floor) Interventions: If need to be toileted, use signal light to call for help or assistance. Care Plan added: dated 8/15/16 2:00 a.m., Problem: Observe on bathroom yelling observed on floor. Goal: Remain free of falls, Plan: continue reinforcing to call for assistance with transfers. No mention of chair alarms sounding. Nursing notes, dated 8/15/16, at 2:00 a.m., revealed Resident observed on bathroom floor. Resident stated she attempted to get off toilet slipped and fell . Assessment done no laceration/abrasion noted. Found small lump to right side of head, resident stated that lump was already there. She pointed to back of head, no lumps noted. Denied pain or discomfort. Will continue to monitor. Dated: (I&A) 8/28/16 at 10:30 p.m., Location: Hallway, observed on the floor Not witnessed, no injury A+Ox3 mobility wheelchair and walker. Statement: Observed resident lying on the floor on right side. Preventative measures: Assist with toileting. Instruct to use call light. Treatment: X-ray of bilateral knees. No mention of chair alarms sounding or if wearing non skid shoes or slippers. Care Plan 8/28/16 at 10:30 p.m., Problem; resident observed on the floor, goal: to decrease falls, Plan: Re-educate resident on importance of asking for assistance with toileting and transfers provide safe clutter free environment. When the DON was queried as to the multiple times the I&A reports revealed to Instruct the resident to use the call light, and how this clearly was not being done, why then was this the only intervention identified and since it was not working, why weren't other interventions identified? Per DON, she just won't call I see what you mean, we should have addressed the alarm and the shoes, I don't know why we didn't catch that. Dated: (I&A) 9/13/16 at 5:20 p.m fell in her room had skin tear and laceration/cut to above right eye and forehead. Comment: Resident states she was reaching for her w/c (wheelchair) and lost balance and fell to the floor. Was alert first aid provided. Sent to the hospital. (Care plan was unchanged). No mention of an alarm on her bed or if it was sounding when she got up. Nursing Notes: 9/13/16 at 5:40 p.m., Resident sent out to the hospital. Resident was attempting to get in wheelchair without assistance per instructions. Resident rolled on floor and hit right side of her face on floor. Doctor called, emergency contact called . Resident has laceration on right side of her forehead. ( neuro checks could not be identified as done). Further, there is no evidence of any communication with the Dialysis Center regarding resident #509's high risk for falls. It was imperative that the Dialysis Center be aware of the patient's high risk for falls because during dialysis, the patient is routinely anticoagulated, which increases the risk of bleeding from trauma. As a result of her fall at the Dialysis Center on 9/13/16, the patient required a craniotomy to drain a subdural hematoma. Hospital H&P (History and Physical) reviewed, dated 9/14/16 at 0037 a.m., (12:37 a.m.) History of Present Illness: Resident is a 73 yo AA (African American) lady with past medical history of [REDACTED]. She hit her head on the dresser and lacerated her right eyebrow. She was subsequently brought to the (hospital )ED (emergency department) and CT-head (cat scan) on admission showed subacute SDH (subdural hematoma). Patient reported that she had a similar fall approximate. 2 weeks ago, however was not taken to hospital at that time. She reported having pain in her right hip, however the pelvic X-ray is negative for any acute fractures. She otherwise feels back to her baseline and denied any weakness in her extremities. She denied any changes in her vision, facial weakness, sensory changes, changes in her urinary bowel habits. Dated: (I&A) 11/16/16 at 6:50 p.m., Observed on the floor, laceration to above left eye, Resident observed on the floor laying on left side with a laceration to the left eye, is alert times two and is confused at times, mobility with assistance and wheelchair. Resident stated, 'she stood up on her own without assistance when she became unsteady and fell .' Nursing Notes, dated,11/16/16 at 6:50 p.m., Resident's room observed on the floor laceration to left eye, comment: Resident observed on the floor laying on left side with a laceration to left eyebrow .Resident stated she stood up on her own without assist when she became unsteady and fell . No mention of alarms sounding from bed, or wheelchair either on the I&A or in nursing notes. A 72 hour assessment on resident #509 was not done consistently after all the falls. When the DON was queried as to why there were no changes to the interventions on the Fall care plan and why there wasn't a post analysis regarding root cause of the falls after all the aforementioned falls,and why no mention of an alarm sounding or apply applied, the DON could not offer an explanation and said, there will be now. A Pain Care Plan was also reviewed at this time, initiated on 9/27/16, was reviewed and revealed the following: actual pain related to a recent fall and recent surgery. At risk for falls related to history of previous falls, balance problem/standing, balance problem walking utilizes assistive devices, decreased muscle coordination, Hypotension diagnosis, CVA diagnosis, Narcotics in use, Goal: will be free from fall related injury through next review date 12/27/16 Interventions: date reviewed 12/6/16 for falling star program, Encourage resident to ask for assist, Ensure that resident has proper footwear as indicated and accepted, Provide assistive devices rolling w/c as indicated and accepted (bed and chair alarm was not checked off although ordered) Place call light within reach, Observe for potential patterns of falls to identify possible causes, offer assist to toilet frequently and as accepted .other, low bed with floor mat. Although the physician's note dated 9/27/16, revealed hospitalization on [DATE] to 9/17/16 as a result of a fall during dialysis at the dialysis clinic, the facility did not investigate the fall, did not develop any interventions to prevent further falls and did not identify the fall either on an I&A. Additionally, a fall risk assessment was not initiated until 9/26/16 and last done on 11/16/16; both with scores that placed resident at high risk for falls. A review of a Psychiatric Progress Note, dated 11/22/16, revealed the following: Dictation: This [AGE] year old single unemployed African American female is seen for medication review follow-up because of the concerns of her combativeness towards the staff. Her chart reviewed and case discussed and much of her agitation was related to recent surgeries and the pain that she was having as she had surgeries because of injuries she sustained by falls at the nursing home and at the dialysis center. She reportedly had a port put on in the right arm, which she complains about pain, but she has a follow-up appointment for the same. When approached talked to her, she is wheeling herself in the wheelchair and accompanied me to her room. She is pleasant on approach. She state that things are fine other than the pain that she is having and that she wanted it to be addressed by the medical consultants. No reported suicidal or homicidal thoughts or feelings. She continues with somatic preoccupations. On Mental status examination, she is appropriately dressed and ambulates in the wheelchair. Psycho-motor activity is neither increased or decreased. She is able to follow redirection. No evidence for any active suicidal behaviors, but tended to be rather irritable with short attention span and concentration and preoccupation, believing that the people may have bad intentions and not help her, but would not say who these people are. Diagnostic Impressions: Major affective disorder, depression with psychosis anxiety and possible mood changes secondary to head injury .Continue with close monitoring and supervision and re-evaluation assessment of her recover from brain injury. On 12/20/16 at 12:20 p.m., resident #509 was sitting up in her wheelchair in the dining room. Resident #509 did not have an alarm attached to her wheelchair. Resident #509, when queried regarding previous falls, revealed she had two of them that required hospitalization and proceeded to reveal how long she had been in the hospital. On 12/21/16 at 1:17 p.m., an interview with resident #509 revealed that she remembered the falls and stated when queried if she used the call light for assistance, I used the call light prior to going to the bathroom and getting up, they just didn't come. Resident's roommate, commented, she would get me to call on the call light, they just wouldn't come when called. She ended up falling in here (bed room). Per resident #509, I had to go to the hospital twice, once when I had a laceration over my right eye and again when I fell at the dialysis center. I didn't have any alarms. Resident was observed to not be wearing an alarm to her wheelchair at the time of this interview. There were no revisions to the care plans after the falls, including since the last fall at dialysis on 9/14/16. On 12/21/16 at 12:14 p.m., review of the facility's policy and procedure titled, Fall Management Guidelines dated, March 2016, revealed the following: OVERVIEW: Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices, and or functional programs as appropriate to minimize the risk for falls. Residents will be evaluated by the interdisciplinary team for their risk for falls. A plan of care is developed and implemented based on this evaluation with ongoing review. PRACTICE GUIDELINES: 2. Residents identified at risk for falls will have a care plan developed and implement fall prevention interventions as needed based on their assessment. 3. When a fall occurs, the nurse should assess the resident for injury and provide appropriate first aid based on standard of practice. If there is a suspected head injury, neuro checks should be completed per physician order [REDACTED]. The licensed nurse will document the incident on: Interdisciplinary Post-Fall Assessment (if the incident is a fall). 9. The nursing staff will assess the resident over the next 72 hours and document in the nurses notes to identify any possible injuries, including pain, that may not have been evident immediately after the fall. 11. The Interdisciplinary Team (IDT) will review all resident falls at the next morning meeting to evaluate/investigate the circumstances and root cause for the fall. 12. The IDT will review/modify the plan of care to minimize the risk of repeat falls. 13. The IDT will complete the Interdisciplinary Post-Fall Assessment. 14. The Director of Nursing will document falls on the Unusual Occurrence Report Log and the Individual Resident Unusual Occurrence Log as they occur. Residents that had a fall since the previous meeting to assure measures have been put into place and any new risk factors addressed. ( )

The following citation contains two deficient practice statements and pertains to intake numbers MI 259, MI 252, and MI 254. Deficient Practice Statement #1 Based on observation, interview and record review, the facility failed to secure a door known to have a broken door lock which disabled the alarm, resulting in immediate jeopardy (IJ) when Resident #710 left the building in his wheelchair in sub-zero temperatures, without staff's knowledge because the alarm could not sound. On the following day, at 7:30 am, a construction worker found Resident #710's wheelchair next to a dumpster approximately one block away from the facility. Resident #710 was found inside the dumpster. Resident #710 subsequently died . This deficient practice had the potential to affect 26 residents who were smokers and used the patio/fire door from a total of 65 residents, placing them at risk for serious harm, injury, or death. The IJ was identified at 4:30 p.m. on [DATE] and the Administrator was notified of the IJ at 2:35 p.m. on [DATE]. A plan of correction was requested to remove the IJ. The IJ was removed on [DATE] at 4:30 p.m., when the facility submitted the acceptable plan of correction that was implemented and verified on site by the survey team. Although the IJ was removed, the facility's deficient practice was not corrected and remained at a pattern with no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: Review of the emergency medical services report (Run Sheet), dated [DATE], revealed that Resident #710 was Found in an outside dumpster, temperature outside is 11 degrees Fahrenheit. Patient found by morning construction crew, unknown down time. Patient vitals absent, hands frozen, but his chest and neck once exposed, are warm to the touch. Patient extricated from dumpster to rig, passive warming with truck heat. Cardiopulmonary Resuscitation (CPR) initiated. Automated External Defibrillator (AED), no shock advised. CPR continued. Patient transferred to (Acute Care Facility 'Z'). The report also noted that when Resident #710 was found he was unresponsive and had no respirations. According to Acute Care Facility 'Z's discharge information, Resident #710 was discharged on [DATE] at 11:29 am and noted Preliminary Cause of Death: Accidental Hypothermia. Accidental Hypothermia is an involuntary drop in core body temperature of less than 95 degrees Fahrenheit. The average body temperature is 98.6 degrees Fahrenheit. On [DATE] at 9:00 am, after the entrance conference with the Administrator and the Director of Nursing (DON), the Administrator and the DON were queried regarding the facility reported incident dated [DATE], regarding an elopement involving Resident #710. The DON explained that she had received a phone call at approximately 6:30 am from Nurse 'E' regarding Resident #710. The DON further explained that Nurse 'E' reported that facility staff were not able to find Resident #710 and that the last time they saw him it was around 3:00 am on [DATE]. The DON stated, I instructed her (Nurse 'E' ) to call a 'Code Green' to search for the missing resident because it's cold outside. The DON added that she did not know why the Code Green was not activated sooner when staff first identified that Resident #710 was missing. The Administrator reported that she contacted Security Staff 'G' and he reported that he had not seen Resident #710. The DON stated, I spoke to the second floor nurse (Nurse 'I') and he was unaware that Resident #710 was missing. I asked him to find (Resident #710) because it was cold outside. The DON and the Administrator stated that they arrived to the facility at about 8:00 am. Upon their arrival they continued with the search for Resident #710. The Administrator called 911 (Emergency Services) around 9:15 am and then called (Acute Care Facility 'Z'). She stated that after that time the police arrived and explained that they heard a call on the radio around 7:30 am that a construction worker found a body in a dumpster not too far from the facility. Emergency medical services (EMS) worked on the body for 45 minutes and that he was pronounced dead at (Acute Care Facility 'Z'). The Administrator then explained that the police informed her that there was a wheelchair next to the dumpster with a foot print in the seat. The administrator stated, They suspected that he climbed into the dumpster to stay warm and that they did not suspect any foul play. A copy of the police report was requested at this time. The Administrator added that it was at this time that, We identified that the back door may need another alarm. I knew the key was broken off into the alarm, but I was not aware that the door was not alarming. On [DATE] at 11:00 am an observation of the first floor dining room, patio/fire door, and smoking/patio area was made along with Security Staff 'O.' Security Staff 'O' entered the dining room area and walked toward the patio/fire door. The distance from the dining room entrance to the patio/fire door was approximately 60 feet. Security Staff 'O' explained that this was the door that residents and staff used to go out onto the patio mostly to smoke. Security Staff 'O' then demonstrated how the patio/fire door worked. Security Staff 'O' identified the key used to turn the lock and inserted it into the lock. He then turned the key and pressed a button adjacent to the lock and stated, The key turns the lock and then you press the button so the alarm does not go off. When asked what happens if the door closes and you are on the outside, Security Staff 'O' explained that you can't get back in. He stated, There is no key hole for the outside and there is no handle. You would have to bang on the door and windows pretty hard to get someone's attention. On [DATE] at 2:50 pm, Maintenance Assistant 'J' was interviewed and explained that the key to the patio/fire door was broken off into the lock rendering the alarm nonfunctional. When asked if he knew about the alarm not working he stated, I was made aware on Saturday ([DATE]) by an in-house page that the key was broken off into the lock. Maintenance Assistant 'J' was asked who made him aware of the nonfunctioning alarm and said he could not recall. When asked if the door was monitored to prevent residents from exiting the door without staff being aware, Maintenance Assistant 'J' stated, No. Security was supposed to monitor the door. On [DATE] at 3:10 pm, the Administrator, who identified herself as the Head of Security, was interviewed regarding the specifics of the patio/fire door alarm not functioning. The Administrator explained that the key was broken on Friday ([DATE]) but, I didn't find out that they were not able to set the alarm until [DATE]. If security was aware that the alarm was not able to be set, then they should have contacted me. When asked if the broken key should have been logged for repair the Administrator stated, They don't have to log that. That's a 911! which indicated that nonfunctional exit door alarms needed to be addressed as soon as possible. On [DATE] at 3:50 pm, the Activities Director was interviewed and explained that the facility offers smoke times for residents at 8:30 am, 10:30 am, 1:30 pm, and at 3:00 pm or 4:00 pm each day. The Activities Director acknowledged that Resident #710 was a smoker. When asked how residents are monitored to ensure that they return into the facility after smoking, the Activities Director explained that staff are very familiar with the residents and know who go out to smoke. They all sit at two tables and we keep an eye on the residents in wheelchairs so they don't roll away. The Activities Director then explained that activity staff retrieve the key to the patio/fire door from security staff when they take residents out to smoke and return the key to security after the smoke break. When asked if she was aware of the key broken off into the lock of the patio/fire door the Activities Director stated, Yes. (Activity Assistant 'K') and I reported it to the Administrator and she told the Maintenance Director. I was not here on the weekend but to my understanding the key was broken off into the lock. On [DATE] at 10:00 am, the Maintenance Director was interviewed and reported that the broken key remained in the lock over three days. The Maintenance Director explained that initially, I was not aware that the key was broken off into the lock. I was not aware that the activity staff were not exchanging the key with security staff, which indicated that since the key was broken off into the lock, anyone could disarm the alarm and exit the building. The Maintenance Director then acknowledged that the residents had access to the patio/fire door and had the opportunity to turn the key (disable the alarm) and exit the facility without any of the facility staff knowing. The Maintenance Director added, Now that I think about it, someone should have supervised (monitored) the patio/fire door. On [DATE] at 10:20 am, Maintenance Staff 'J' was interviewed regarding the broken key in the patio/fire door. Maintenance Staff 'J' reported that he was aware that the key had broken off into the lock on Friday [DATE] th and stated, The alarm was armed when I left it on Friday. There was enough (key) stuck out of the door to use it (turn the key and exit the door). When asked if he made anyone aware of the key being broken off and stuck in the lock, Maintenance Staff 'J' stated, I told the Maintenance Director and I told (Security Staff F). On [DATE] at 11:30 am, Nurse 'E' was interviewed and explained that she started her shift at 7:00 pm on Sunday, [DATE]. Nurse 'E' reported that she attempted to administer Resident #710's medications at 9:00 pm and he refused them. She then reported that she observed him in bed between 2:00 am and 3:00 am on [DATE]. Nurse 'E' stated, He sleeps with his coat on. I saw his green winter coat on the bed arranged the way he sleeps. I left (Resident #710) alone because he's a bear if you wake him up. I went into his room at 4:30 or 4:45 am and turned the light on. His coat was there but he wasn't there. Nurse 'E' was asked if she was aware of the key broken off into the lock of the patio/fire door. Nurse 'E' stated, I work the pm (7 pm - 7 am) shift and residents do not go out to smoke on my shift. I did not know that the door was broken and not alarming. They told me after (Resident #710) was missing that the key was broken off into the door and that the alarm would not go off. If I had known the alarm was broken I would have locked the Dining Room (where the patio/fire door is located) down and not have let anyone into that room. On [DATE] at 1:30 pm, Activities Assistant 'K' was interviewed. Activities Assistant 'K' explained that on Friday [DATE], the key was broken off into the lock, but it could be turned to turn off the alarm. Activities Assistant 'K' stated, The patio/fire door was working on Friday when I left, but the door (alarm) was broken on Saturday and Sunday. On Saturday and Sunday I did not have to use the key to take the residents out to smoke. I just pushed the patio/fire door open. When queried further, Activities Assistant 'K' explained that no alarm sounded when she pushed the door open to take the residents out to smoke. Activities Assistant 'K' was asked how staff were able to get back into the facility after taking residents out to smoke and she stated, I don't close the door. I just push it up. I don't close the door because if you close it (the door) you can't get back in. You cannot open the door from the outside. On [DATE] at 4:00 pm, Security Staff 'F' was interviewed regarding the patio/fire door where residents exit to smoke. Security Staff 'F' explained that the key was broken off into the lock but he was able to set the alarm on the door by inserting a bobby pin. When asked if he reported that the key was broken off into the lock, Security Staff 'F' stated, I reported it to the Maintenance Director and the Administrator. When asked if there was any documentation pertaining to the broken key, Security Staff 'F' explained that the security staff only gives a verbal report to the oncoming staff. When asked if the patio/fire door was physically checked to ensure that the alarm was working Security Staff 'F' stated No. When asked to explain why he documented on the Door Alarm Log that the door was secure from 3 pm until 11 pm on [DATE] when he identified that the key was broken off into the lock, Security Staff 'F' explained that the door was closed each hour that I checked it. On [DATE] at 1:15 pm, Security Staff 'G' was interviewed regarding the patio/fire door. Security Staff 'G' explained that he was new to working security at the facility and that he worked the 7 pm to 7 am shift on [DATE] and [DATE] and stated, I knew something was wrong with the door because the key wasn't on the chain. Security Staff 'G' explained that the key was broken off into the door and that the key had to be turned to disable the alarm before residents could go out to smoke. When asked if there was a bobby pin in the lock to turn the key to disarm the alarm, Security Staff 'G' stated, No. When asked if he made Nurse 'E' aware that the key was broken off into the lock, Security Staff 'G' stated, No. When asked if he had seen Resident #710 on [DATE] or on [DATE] Security Staff 'G' stated, I did not see (Resident #710) on Saturday or Sunday night. When asked if he heard the alarm sound at any time during his shift on Saturday or Sunday, Security Staff 'G' stated, No. If I had heard an alarm I would have checked it. When queried why he documented All Doors Secured each hour of both 7 pm to 7 am shifts he worked, Security Staff 'G' said that the light was on the alarm, which indicated to him that the alarm was working. On [DATE] at 1:35 pm, Nurse Practitioner (NP) 'H' was interviewed. NP 'H' explained that on [DATE] at 6:00 am, she entered the facility and observed the facility staff walking and moving in and out of resident rooms. It looked like they were looking for someone or something. NP 'H' added, I saw staff looking inside the building and outside of the building. I was there for about 45 minutes. When I got ready to leave I asked (Nurse 'E') who were they looking for and she said that they were not able to locate (Resident #710). I had been in the facility for almost an hour and no one asked me if I had seen the resident. I asked (Nurse 'E') when was the last time she saw him. She told me she went in to administer his inhaler at 4:30 am. I said, 'That was almost two hours ago!' I then asked if they called the Director of Nursing, the Administrator and notified the Police because it was freezing cold outside. It was about 6:45 am or so when I heard her talking (on the phone) to the DON. On [DATE] at 2:05 pm the Director of Nursing was queried regarding the incident. When asked if she knew that the patio/fire door (alarm) was not functioning properly the DON stated, I didn't know that there was a problem with the door. If I would have known, I would have locked the Dining Room down and had someone posted at that door to make sure no resident got outside through the patio/fire door. On [DATE] at 9:30 am the facility investigation file regarding Resident #710 revealed that the following interviews were conducted: 1. On [DATE] (no time) Acute Care Facility 'Z' Nurse 'L' reported that facility staff identified Resident #710, that he was worked on for 45 minutes and pronounced dead at 8:45 am, Resident hands was frozen solid. Hospital notified City Medical Examiner. Body prepared to go to morgue. 2. On [DATE] (no time) Certified Nurse Assistant (CNA) 'M', the CNA assigned to Resident #710 on that shift at that time documented, Didn't see Resident (#710) last night on [DATE]. Didn't physically check inside room walked by and glanced through. He was covered under coat. 3. On [DATE] (no time), CNA 'N' indicated that he covered for CNA 'M' at 2:30 am (for a scheduled break) on the morning of [DATE] and, I looked into (Resident #710's room) seen coat on bed (edge). No wheelchair or resident. No one said anything about (Resident #710) until around 5 am. 4. On [DATE] (no time), Security Staff 'O' indicated that he reported to work around 6:20 am and, Came in started making rounds noticed back door in 1st floor dining room leads to patio was ajar. There was no indication that the alarm was sounding or had sounded at that time. On [DATE] at 11:50 am, clinical record review revealed the following: Per the face sheet Resident #710 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed that according to Resident #710's most recent comprehensive Minimum Data Set ((MDS) dated [DATE], that Resident #710 was able to express his needs, that Resident #710 had impaired cognition, had not exhibited any signs of wandering, was physically able of transferring on his own, and was physically able to move throughout the facility on his own with the use of a wheelchair, and that Resident #710 required supervision when moving distances throughout the facility such as the dining area. The Elopement Risk Assessment dated [DATE], indicated that Resident # 710 was at zero risk for elopement. However, interventions indicated on the assessment for Resident #710 included exit and stairwell alarms, secured unit, frequent monitoring, and identification bracelets. On [DATE] at 5:00 pm, review of facility policies revealed the following: 1. The facility policy titled, Accidents and Supervision (no date) noted, The facility must ensure that the resident environment remains as free from accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. The policy notes that an avoidable accident occurs when the facility fails to identify environmental hazards in the resident's environment. The policy cited physical surroundings such as common use areas and broken exit alarms. 2. The facility policy titled, Elopement Policy and Procedure dated [DATE], documented, In the event a resident is suspected to have eloped or is otherwise absent without leave from the facility, staff will follow the procedure listed below: -Notify the administrator, Director of Nursing Services, they will give you additional instructions that may include local police notification. -Check the entire building and area to definitely determine that the resident in question is missing. -If the resident cannot be located the Emergency and Elopement policy must be implemented immediately. 3. Facility policy titled, Elopement and Emergency Policy and Procedure dated [DATE] that indicated the any resident missing for more than two hours or any event that resulted in an unnatural or unusual death should be reported to the Administrator, Director of Nursing, and that the local police may be notified. 4. Review of the facility Smoking Policy dated ,[DATE], revealed that there was no system in place to ensure that residents were accounted for when returning from smoking on the patio. 5. Review of the facility, Door Alarm Log revealed an area to note the disposition of door alarms. However, there were no policies that addressed locking/securing exit doors or systems in place to ensure that exit doors were armed or that exit door alarms were functioning properly. On [DATE] at 2:30 pm, during the Quality Assurance interview, the Administrator explained that resident safety is discussed monthly during the monthly facility Quality Assurance meetings and that securing the doors to ensure that residents do not exit the building was priority. The Administrator further explained that security staff were responsible for ensuring that the facility doors that led to the outside were secure. When the doors were known to not be functioning correctly they should have clearly explained what was wrong with the doors so that we could have fixed the patio/fire door that led to the area where residents smoke. The Administrator stated, The security staff should have reported the nonfunctioning alarm to the charge nurse who would have informed the Director of Nursing. This should never have happened and it will never happen again! The following plan of correction was submitted by the facility to remove the Immediate Jeopardy. 1. Resident # no longer resides in the facility. 6 other residents have been identified for potential for elopement. The clinical records have been reviewed, care guides, care plans, assessments have been reviewed & updated. The Patio Alarm Door was replaced on [DATE]. 6 other door alarms were tested for activation of the alarm, and noted functional. All other Alarms noted function. 2. Immediate head count was completed by nursing staff, all residents were accounted for. All resident's elopement assessment were updated on [DATE] no other residents have been identified as a elopement risk. Patio door alarm was replaced on [DATE] and it is functional, door bell and camera were installed on outside patio on [DATE]. 6 other alarmed doors in the facility were checked and functional. New Security log is being used that includes all alarmed doors, and doorbell in the facility that they are activated and functioning. Resident's will be supervised by staff when going and coming in from patio area. 6 residents who have been identified for high risk for elopement have wanderguard device, wanderguard devices have been checked and they are functioning. Wanderguard system will be checked weekly by Security and Nursing Manager. Elopement drills were conducted with staff with all 3 shifts on [DATE], [DATE] and [DATE]. Nurses will utilize resident roster to document every 2 hours for a head count and visual, C.E.N.A, ADL sheet has been updated to check resident's every 2 hours. Resident Council meeting was held on [DATE] to inform residents of the Door bell and Camera installation. LOA procedure were reviewed with Resident's, no concerns were verbalized. 32 of 64 resided on the first floor. 19 residents with cognition intact were queried about well being and any desires to discharge from the facility. Facility policy regarding LOA's were reviewed & residents were notified to request leaves with the charge nurse. The cognitively impaired residents were checked for any concerns regarding ADL or care. 3. Staff were in-serviced on physically checking residents at a minimum of every two hours, Elopement protocol with the focus on urgency in contacted Administrator/ Director of Nursing with incidents. Elopement drills were completed on each shift. The elopement protocol in-service with focus on response time, thorough search efforts, searching internal & external facility simultaneously. Importance of time in extreme weather conditions were stressed. All Staff were instructed of updates in missing person policy to include, if an alarm noted malfunctioning staff must physically guard the door until repaired, NOTIFY Administrator/Director of Nursing , Maintenance Staff immediately if any alarm malfunctioning. Search team form was added to protocol to expedite search efforts. The elopement policy was updated to include the search team. Memo was posted that no staff who has not been Inserviced on Malfunctioning of alarms, Environmental Hazards, Elopement Protocol can't work until educated. Charge Nurse and certified nursing assistant assigned to Resident #710 on [DATE], were suspended pending termination for failure to Supervise, and check resident. 4. IDT/designee will perform elopement drill twice per week on each shift X 4 week & report findings to Qapi team. The Unit managers will audit nursing supervision on each shift 5 X per week by walking rounds & completed questionnaire. The Director of Nursing will audit each incident report & ensure timely notification per policy. The findings of audits related I/A and Elopement will be forwarded to QAPI Team monthly. Elopement/ discharge audit will be completed weekly by Nursing Manager times 4 weeks, findings will be forwarded to QAPI team. Administrator is responsible for maintaining compliance. Compliance Date [DATE]. ( ) ( ) ( ) ( ) Deficient Practice Statement #2 Based on interview and record review the facility failed to ensure that one of 17 sampled residents reviewed for safe environment was physically present during rounds and failed to implement their missing resident protocol in a timely manner when Resident #710 was not found in the building, resulting in an increased potential for serious injury, harm, or death. Findings include: On [DATE] at 9:00 am, the Administrator and the DON were queried regarding the facility reported incident dated [DATE], regarding Resident #710 when he was not found inside the facility. The DON explained that she had received a phone call from Nurse 'E' around 6:30 am regarding Resident #710. The DON further explained that Nurse 'E' reported that facility staff were not able to find Resident #710 and that the last time they saw him was around 3:00 am on [DATE]. The DON stated, I instructed her to call a 'Code Green' to search for the missing resident because it's cold outside. A Code Green for the facility indicated that a resident was not able to be located and that all staff were to assist in the search for the resident. The DON stated, I spoke to the second floor nurse (Nurse 'I') and he was unaware that Resident #710 was missing which indicated that all facility were not made aware of the Code Green. The DON then stated, I asked him to find (Resident #710) because it was cold outside. The DON and the Administrator stated that they arrived to the facility at approximately 8:00 am. Upon their arrival they continued with the search for Resident #710. The DON added that she did not understand why Nurse 'E' did not initiate the Code Green sooner when staff first identified that Resident #710 was missing at or around the 3 o'clock hour. On [DATE] at 11:30 am, Nurse 'E' was interviewed and explained that she started her shift at 7:00 pm on Sunday, [DATE]. Nurse 'E' reported that she attempted to administer Resident #710's medications at 9:00 pm and at that time he refused them. She then reported that she observed him in bed between 2:00 am and 3:00 am on [DATE]. Nurse 'E' stated, He sleeps with his coat on. I saw his green winter coat on the bed arranged the way he sleeps. I left (Resident #710) alone because he's a bear if you wake him up. I went into his room at 4:30 or 4:45 am and turned the light on. His coat was there but he wasn't there. That is when I realized that I probably did not see him at 3:00 am and that he had been missing (at that time) for over two hours. Nurse 'E' was asked why she did not initiate the Code Green at 4:30 am when she realized that Resident #710 was not in his room. Nurse 'E' explained that she had received training regarding the Code Green protocol but added, I was unclear of when to call the Code Green. I searched for him and asked other staff to help look for him. I realize that when I discovered I had seen his coat and not him at 3:00 am, I should have called the Code Green at that moment. When asked when she officially called the Code Green, Nurse 'E' stated, Around 6:30 am on [DATE]. Nurse 'E' acknowledged that Resident #710 had been missing for nearly four hours before she initiated the Code Green protocol. Review of the timeline provided by the facility noted that Resident #710 was missing approximately two hours before the Administrator and the Director of Nursing were called and was missing approximately five hours before Emergency Medical Services (EMS) were called. On [DATE] at 1:35 pm, Nurse Practitioner (NP) 'H' was interviewed. NP 'H' explained that on [DATE] at 6:00 am she entered the facility and observed the facility staff walking and moving in and out of resident rooms. It looked like they were looking for someone or something. NP 'H' added, I saw staff looking inside the building and outside of the building. I was there for about 45 minutes. When I got ready to leave I asked (Nurse 'E') who were they looking for and she said that they were not able to locate (Resident #710). I had been in the facility for almost an hour and no one asked me if I had seen the resident. (Resident #710) is my resident and no one told me that he was missing. I asked (Nurse 'E') when was the last time she saw him. She told me she went in to administer his inhaler at 4:30 am. I said, 'That was almost two hours ago!' I then asked if they called the Director of Nursing, the Administrator and notified the Police because it was freezing cold outside. It was about 6:45 am or so when I heard her talking to the DON. On [DATE] at 2:05 pm the Director of Nursing was queried regarding Resident #710 missing. The DON explained that as soon as Nurse 'E' identified that Resident #710 was missing at 4:30 am she should have initiated the Code Green. The DON stated, (Certified Nurse Assistant 'M') was (Resident #710's) aide that night and she should have done every two hour checks. That is a standard of practice. She should have looked at him or touched him to ensure he was in the room and not just assumed that he was in the room. On [DATE] at 9:30 am the facility investigation file regarding Resident #710 revealed that the following interviews were conducted: 1. On [DATE] (no time) Certified Nurse Assistant (CNA) 'M', the CNA assigned to Resident #710 on that shift at that time documented, Didn't see Resident (#710) last night on [DATE]. Didn't physically check inside room walked by and glanced through. He was covered under coat. 2. On [DATE] (no time), CNA 'N' indicated that he covered for CNA 'M' at 2:30 am (for a scheduled break) on the morning of [DATE] and, I looked into (Resident #710's room) seen coat on bed (edge). No wheelchair or resident. No one said anything about (Resident #710) until around 5 am. On [DATE] at 5:00 pm, review of facility policies revealed the following: 1. The facility policy titled, Elopement Policy and Procedure dated [DATE], documented, In the event a resident is suspected to have eloped or is otherwise absent without leave from the facility, staff will follow the procedure listed below: -Notify the administrator, Director of Nursing Services, they will give you additional instructions that may include local police notification. -Check the entire building and area to definitely determine that the resident in question is missing. -If the resident cannot be located the Emergency and Elopement policy must be implemented immediately. 2. Facility policy titled, Elopement and Emergency Policy and Procedure dated [DATE] that indicated the any resident missing for more than two hours or any event that resulted in an unnatural or unusual death should be reported to the Administrator, Director of Nursing, and that the local police may be notified. 3. The facility policy titled, Safety-General Guidelines For Resident Safety Policy and Procedures dated ,[DATE], documented, Make routine visits to check on the resident's condition and comfort. Nurse Assistants must know their resident whereabouts at all times. On [DATE] at 11:50 am, clinical record review revealed the following: Per the face sheet Resident #710 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed that according to Resident #710's most recent comprehensive Minimum Data Set ((MDS) dated [DATE], that Resident #710 was able to express his needs, that Resident #710 had impaired cognition, had not exhibited any signs of wandering, was physically able of

This citation has multiple deficient practice statements. Deficient Practice #1 Based on observation, interview and record review, the facility failed to provide pain management prior to wound care for two (#s 502 and 504) of four sampled residents reviewed for wound care from a sample 16 residents, resulting in unmanaged complaints of pain. Findings include: On 1/23/14 at 12:45 pm, the Wound Care Nurse was observed to provide wound care to a Kennedy Terminal Ulcer on Resident #504. The Wound Care Nurse described the wound as having a pink base with moderate yellow slough. The wound was approximately the size of a fist and was located at Resident #504's coccyx. The Wound Care Nurse was observed to cleanse the wound with wound cleanser and with each wipe, Resident #504 cried out and "whimpered." The Wound Care Nurse was then observed to apply a gauze which she reported as being "soaked with Dakin's (chlorine) Solution." The Wound Care Nurse then applied the gauze into the wound and Resident #504 began to yell out, but then began to cry. On 1/23/14 at 3:00 pm, the Wound Care Nurse was queried regarding Resident #504's complaints of pain during wound care. The Wound Care Nurse said that she was unaware of Resident #504's complaint of pain, crying, and whimpering and said that she thought it was because of his legs. On 1/23/14 at 3:30 pm, Resident #504's clinical record was reviewed and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] revealed that Resident #504 had severely impaired cognition and required extensive to total assistance for activities of daily living. The Pain Care Plan, dated 12/18/13, revealed that Resident #504 experienced actual pain related to a Skin Ulcer/Wound. The goal was for Resident #504 to "have reduced pain as measured by verbal expression and/or decrease in behaviors associated with pain." The approach listed at the time of the wound care observation noted, "Medicate resident for pain prior to treatments and therapy, if indicated." On 1/24/14 at 2:00 pm, the DON was interviewed regarding Resident #504's complaints of pain during wound care. The DON stated, "I don't know why the resident was not medicated prior to wound care. The Kennedy Ulcer happened so fast that maybe the nerve endings are not dead. The Dakin's Solution may be causing him pain." The DON then said that she reviewed the Wound Care Policy and pain assessment was not included in the policy. On 1/22/2014 at 12:00 p.m., during the observation of resident #502's wound care, performed by the facility's Wound Care Nurse, resident #502 grimaced and said "ouch" when each of three wounds were manipulated. The Wound Care Nurse responded, "I know baby" and continued with the wound care. The Wound Care Nurse described the three wounds observed during the wound care observation as follows: "the first wound is a diabetic ulcer to the left foot...plantar (sole of foot) foot ulcer...6 cm (centimeters) by 3 cm. It is 3 wounds with a bridge. There are necrotic edges and it is slightly malodorous. There is a moderate amount of serosanguinous (slight bloody appearance) drainage. The second wound is a healing stage three (deep tissue injury) sacrum wound. There is no drainage. It is a groove with cicatrix (scar of a healed wound). The third (wound) is a left posterior leg healed wound. It is covered with a dry dressing." When the dry dressing was removed from the posterior left leg, the wound began to bleed profusely. The wound care nurse applied pressure to the wound and applied a pressure dressing. The wound care nurse stated "I'll give you measurements later." The wound appeared to be approximately 4 centimeter (cm) by 4 cm circular wound with pink granulating (develop a grainy surface as part of the healing process) edges. Resident #502 stated "ouch" and grimaced throughout the entire procedure. On 1/23/2014 at 2:00 p.m., review of resident #502's medical record with the wound care nurse revealed the following: Per the medical record face sheet, resident #502 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. physician's orders [REDACTED]." According to the quarterly MDS (minimum data set) dated 11/16/2013 documented resident #502 required pain medication as needed to manage pain. Review of resident #502's MARs (medication administration records) for October 2013, November 2013 and December 2013, failed to reveal documentation that indicated Resident #502 was medicated prior to the dressing changes. Per review of the January 2014 MARs for resident #502, resident #502 was not medicated prior to the dressing changes except for one day, 1/20/2014 at 9:00 a.m. Resident #502's pain care plan, last updated on 12/31/13, did not include the physician's orders [REDACTED]. After the completion of the medical record review, when queried regarding the absence of the administration of pain medication to Resident #502 prior to wound care, the wound care nurse stated "I didn't know there was an order." On 1/24/2014 at 8:40 a.m., review of the facility's policy titled "Pain Management" dated 12/2010, documented: "The nurse will administer pain control medications as ordered by the physician." ( ) Deficient Practice Statement #2 Based on observation, interview and record review the facility failed to follow a physician's orders [REDACTED].#511) of seven sampled residents reviewed for pain from a total sample of 16, resulting in increased anxiety and pain. Findings include: On 1/22/14 at 2:00 pm, Resident #511 was observed seated in her wheelchair in her room. Resident #511 was observed to occasionally hold and rub her stomach (abdomen) and said, "I have been having problems with my stomach. It hurts. I am in pain right now. I was supposed to have an abdominal X-ray and that hasn't happened yet. I don't know what's taking them (nursing staff) so long." On 1/23/14 at 12:00 pm, Resident #511 was observed in bed. Resident #511 stated, "I can't eat my lunch. My stomach hurts so bad. Maybe I have gall-stones or kidney stones. I have been throwing up for two days. I didn't have an X-ray yet, I don't know what is wrong with me. I don't think they (nursing staff) even care." When asked to rate her pain on a scale of one to 10 with 10 being the worst pain ever, Resident # 511 shouted, "Eight!" Resident #511 was then observed to rub her stomach and became teary eyed. On 1/23/14 at 12:15 pm, Nurse 'W' was queried regarding the complaints of pain and the follow-up abdominal X-ray that was ordered by the physician. Nurse 'W' stated, "I was going to call to see what the hold-up (delay) was." Nurse 'W' telephoned the Diagnostic technician. The technician stated, "We did not get the order for the follow-up." Nurse 'W' was unable to explain why the X-ray was not ordered. On 1/23/14 at 4:15 pm, the Director of Nursing and the Administrator were queried regarding Resident #511's complaints of pain and staff's failure to order the follow-up abdominal X-ray as ordered by the physician. The Director of Nursing and the Administrator were unable to offer a verbal explanation of why the physician orders [REDACTED]. On 1/24/14 at 8:00 am, Resident #511's clinical record was reviewed and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), dated [DATE] revealed that Resident #511 was cognitively intact and had denied having any pain during the assessment. A pain care plan for Resident #511, dated 12/2/13, did not address abdominal/stomach pain. An abdominal X-ray dated 1/16/14 revealed, "Mild small bowel ileus (intestinal obstruction) in the midline central abdomen." A physician's orders [REDACTED]. On 1/24/14 at 2:30 pm, the facility policy titled "Pain Management" dated 12/2010, documented, "If it is identified that the resident is experiencing pain that is not controlled by current interventions, the physician will be contacted and made aware and additional physician orders [REDACTED].

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO TAKE THE APPROPRIATE MEASURES TO PREVENT THE DEVELOPMENT OF A PRESSURE ULCER FOR ONE (#303) OF FIVE RESIDENTS REVIEWED FOR PRESSURE ULCER OF A TOTAL SAMPLE OF 16, RESULTING IN A FACILITY ACQUIRED PRESSURE ULCER. FINDINGS INCLUDE: ON 1/19/12 AT 1:00 P.M., WOUND CARE FOR RESIDENT #303 BY TREATMENT NURSE "A" WAS OBSERVED. RESIDENT #303 WAS ALERT AND ORIENTED. THE RESIDENT WAS SEATED IN WHEELCHAIR, AND WAS DEPENDANT ON STAFF TO MOVE HER LEGS. WHEN QUERIED, THE RESIDENT STATED SHE NEEDED STAFF ASSISTANCE FOR REPOSITIONING. THE RESIDENT WAS NOT WEARING HEEL PROTECTORS AND DID NOT HAVE ANY PILLOWS TO ELEVATE HER FEET OR PROTECT BONY PROMINENCES. OBSERVATIONS REVEALED RESIDENT #303 HAD A CIRCULAR, DIME SIZED, STAGE III PRESSURE ULCER (FULL THICKNESS SKIN LOSS INVOLVING DAMAGE TO UNDERLYING LAYERS OF SUBCUTANEOUS TISSUE) ON THE LATERAL MALLEOLUS (OUTER ANKLE BONE). THE WOUND HAD RAISED PALE EDGES AROUND A PALE PINK , MOIST BASE, WITH MODERATE SEROSANGUINOUS (BLOOD AND TISSUE FLUID) DRAINAGE. WHEN QUERIED, TREATMENT NURSE "A" REPORTED THAT RESIDENT #303'S STAGE III PRESSURE ULCER WAS ACQUIRED IN THE FACILITY. ON 1/19/12 AT 2:00 P.M., RESIDENT #303'S CLINICAL RECORD WAS REVIEWED WITH TREATMENT NURSE "A" AND REVEALED THE FOLLOWING: REVIEW OF RESIDENT #303'S FACE SHEET REVEALED AN ADMISSION INto the facility on [DATE]. [DIAGNOSES REDACTED]. REVIEW OF THE ADMISSIONS MINIMUM DATA SET ASSESSMENT (MDS), dated [DATE] REVEALED RESIDENT #303 HAD COGNITIVE IMPAIRMENT (DEMENTIA) AND NEEDED EXTENSIVE STAFF ASSISTANCE FOR MOBILITY IN BED, WAS DEPENDENT ON STAFF FOR TRANSFERS TO THE WHEELCHAIR AND ACTIVITIES OF DAILY LIVING (ADLS), DID NOT WALK, AND WAS INCONTINENT OF BOWEL AND BLADDER. THE MDS ALSO DOCUMENTED THAT RESIDENT #303 WAS AT RISK FOR DEVELOPING PRESSURE ULCERS. THERE WAS NO DOCUMENTED EVIDENCE THE RESIDENT HAD A PRESSURE ULCERS AT THAT TIME. REVIEW OF THE ADMISSION NURSING SKIN ASSESSMENT, DATED 9/2/11 NOTED THAT RESIDENT #303 HAD SCARS FROM PREVIOUS SKIN GRAFTS ON THE LOWER EXTREMITIES (LEGS). WHEN QUERIED, WOUND CARE NURSE "A" STATED THAT THIS INDICATED THAT RESIDENT #303 HAD HAD PREVIOUS PRESSURE ULCERS, AND THUS WAS AT HIGH RISK FOR DEVELOPING PRESSURE ULCERS AGAIN. THE NURSING AND WOUND CARE ADMISSION ASSESSMENTS DATED 9/2/11 DOCUMENTED RESIDENT #303'S WAS AT RISK FOR DEVELOPING PRESSURE ULCERS. REVIEW OF THE "PRESSURE ULCER RISK ASSESSMENT SUMMARY", DATED 9/2/11, PERFORMED BY THE WOUND CARE/TREATMENT NURSE, NOTED THAT RESIDENT #303 WAS AT HIGH RISK FOR DEVELOPING PRESSURE ULCERS DUE TO INCONTINENCE, POOR MOBILITY, DECREASED PHYSICAL ACTIVITY, LEFT SIDED WEAKNESS, HEALED SCARS, AND END STAGE [MEDICAL CONDITION]. THE ASSESSMENT NOTED, "POTENTIAL FOR BREAKDOWN (PRESSURE ULCER): UNAVOIDABLE", AND DOCUMENTED "ALL POSSIBLE INTERVENTION AND TREATMENT WILL BE INITIATED." WHEN QUERIED, THE WOUND NURSE WAS UNABLE TO PROVIDE DOCUMENTATION OF INTERVENTIONS AND TREATMENT INITIATED TO PREVENT THE PRESSURE ULCER FROM DEVELOPING ON RESIDENT #303'S ANKLE. RECORD REVIEW REVEALED A BRADEN SCALE SKIN ASSESSMENT FOR RESIDENT #303, DATED 9/2/11, DOCUMENTED THAT RESIDENT #303 WAS NOT AT HIGH RISK FOR DEVELOPING PRESSURE ULCERS WITH A SCORE OF 13. WHEN QUERIED, THE WOUND NURSE STATED THAT FEWER PREVENTATIVE INTERVENTIONS WOULD BE NEEDED FOR A RESIDENT WITH A BRADEN SCORE OF 13. WHEN QUERIED, NURSE "A" WAS UNABLE TO EXPLAIN THE DISCREPANCY BETWEEN PRESSURE ULCER RISK ASSESSMENTS FOR RESIDENT #303, AND WAS ALSO UNABLE TO EXPLAIN WHY STAFF HAD NOT COMMUNICATED WITH EACH OTHER TO ENSURE IMPLEMENTATION OF APPROPRIATE INTERVENTIONS TO PREVENT PRESSURE ULCERS, BASED ON AN ACCURATE ASSESSMENT OF RESIDENT #303'S RISK FACTORS. REVIEW OF THE NURSING CARE PLAN FOR "POTENTIAL FOR SKIN BREAKDOWN", DATED 9/2/11 CONTAINED THE FOLLOWING INTERVENTIONS: 1. "CHANGE AND REPOSITION A MINIMUM OF EVERY 2 HOURS" 2. "ASSESS FOR ADEQUATE NUTRITION AND PROVIDE NUTRITIONAL SUPPLEMENTS AS NEEDED." 3. "FLOAT HEELS ON PILLOW AS NEEDED" 4. "USE PRESSURE REDUCING DEVICES" 5. "PROTECT BONY PROMINENCES BY USING PILLOWS AS NEEDED (PRN)" WHEN QUERIED, TREATMENT NURSE "A" WAS UNABLE TO EXPLAIN WHEN THESE INTERVENTIONS WERE IMPLEMENTED, AND WHAT "AS NEEDED" MEANT. REVIEW OF THE physician's orders [REDACTED]. HEEL PROTECTORS." WHEN QUERIED THE WOUND NURSE WAS UNABLE TO PROVIDE DOCUMENTATION THAT RESIDENT #303'S HEELS WERE FLOATED, THAT DEVICES TO REDUCE HEEL AND ANKLE PRESSURE WERE IMPLEMENTED, OR THAT BONY PROMINENCES (ANKLE BONES) WERE PROTECTED WITH PILLOWS PRIOR TO THE DEVELOPMENT OF THE PRESSURE ULCER ON 12/7/11. OBSERVATION OF RESIDENT #303'S BED, AND OF RESIDENT #303 IN THE WHEELCHAIR WITH NURSE "A", REVEALED NO ADDITIONAL PILLOWS OR HEEL BRIDGE DEVICE FOR USE IN FLOATING HEELS AND PROTECTING BONY PROMINENCES. OBSERVATION WITH NURSE "A" AT THIS TIME ALSO REVEALED THAT THE RESIDENT WAS NOT WEARING HEEL PROTECTORS, AND THE WOUND CARE NURSE WAS UNABLE TO LOCATE ANY IN THE RESIDENT'S ROOM UPON REQUEST. WHEN QUERIED ABOUT WHY RESIDENT #303 WAS NOT WEARING HEEL PROTECTORS AS ORDERED (PRESCRIBED) BY THE PHYSICIAN, THE WOUND NURSE STATED, "THEY'RE PROBABLY IN LAUNDRY BEING WASHED." REVIEW OF THE NURSING NOTES DATED 12/7/12 REVEALED THE FOLLOWING "AREA OF CONCERN NOTED TO LEFT ANKLE. NOTED WAS A STAGE III ULCER MEASURING 1.0 CENTIMETERS (CM) BY 1.0 BY 0.4 CM. " REVIEW OF LABORATORY (LAB) BLOOD TEST RESULTS FOR RESIDENT #303 REVEALED NO BLOOD TESTS WERE PERFORMED PRIOR TO THE DEVELOPMENT OF THE PRESSURE ULCER.. WHEN QUERIED ABOUT THIS, THE TREATMENT NURSE WAS UNABLE TO EXPLAIN WHY LAB BLOOD TESTS WERE NOT DONE TO ASSESS FOR NUTRITIONAL STATUS PRIOR TO THE DEVELOPMENT OF A PRESSURE ULCER, PER THE NURSING CARE PLAN. A LAB TEST RESULT, DATED 1/11/12, DOCUMENTED THAT RESIDENT #303 HAD A LOW BLOOD [MEDICATION NAME] (PROTEIN) LEVEL OF 3.0 GRAMS PER DECILITER (G/DL)(NORMAL RANGE, 3.5 G/DL TO 5.2 G/DL). REVIEW OF THE DIETARY PROGRESS NOTES AND LAB RESULTS REVEALED A DIETARY NOTE DATED 12/16/11, DOCUMENTING THAT THE DIETARY MANAGER WAS UNAWARE THAT RESIDENT #303 HAD DEVELOPED A PRESSURE ULCER, "NO PRESSURE ULCERS. CONTINUE WITH CARE PLAN." NO DIETARY SUPPLEMENTS TO PROMOTE WOUND HEALING OR TO CORRECT NUTRITIONAL DEFICIENCIES WERE ADDED IN DECEMBER. NO LAB TESTS WERE ORDERED IN DECEMBER TO ASSESS RESIDENT #303'S NUTRITIONAL STATUS, AND RISK FOR FURTHER SKIN IMPAIRMENTS AND DELAYED HEALING OF THE EXISTING PRESSURE ULCER. ON 1/18/12 AT 2:45 P.M., THE CERTIFIED DIETARY MANAGER (CDM) "N" WAS INTERVIEWED REGARDING RESIDENT #303. THE CDM REPORTED RESIDENT #303 DID NOT RECEIVE ANY NUTRITIONAL SUPPLEMENTS TO HEAL PRESSURE ULCERS UNTIL JANUARY 2012, AS SHE WAS UNAWARE THE RESIDENT HAD DEVELOPED A PRESSURE ULCER. WHEN QUERIED, CDM "N" REPORTED THAT NO LAB TESTS WERE DONE TO ASSESS RESIDENT #303'S NUTRITIONAL STATUS PRIOR TO 1/11/12. WHEN QUERIED, THE CDM WAS UNABLE TO EXPLAIN HOW RESIDENT #303'S NUTRITIONAL STATUS COULD BE ACCURATELY assessed with [REDACTED].#303'S LOW BLOOD [MEDICATION NAME] TEST RESULT ON 1/11/12 INDICATED THAT THE RESIDENT WAS AT INCREASED RISK FOR DELAYED WOUND HEALING AND THE DEVELOPMENT OF PRESSURE ULCERS. THE CDM WAS UNABLE TO STATE WHETHER RESIDENT #303'S BLOOD [MEDICATION NAME] LEVELS WERE LOW PRIOR TO 12/7/11, AND WOULD HAVE INCREASED THE RESIDENT'S RISK OF DEVELOPING A PRESSURE ULCER. ON 1/19/12 AT 12:00 P.M., THE ASSISTANT DIRECTOR OF NURSING (ADON) WAS INTERVIEWED ABOUT RESIDENT #303'S FACILITY ACQUIRED STAGE III PRESSURE ULCER, AND REPORTED THAT RESIDENT #303 WAS AT HIGH RISK FOR THE DEVELOPMENT OF PRESSURE ULCERS DUE TO MULTIPLE COMORBIDITY (DISEASE PROCESSES). THE ADON COULD NOT EXPLAIN WHY THE RESIDENT'S BRADEN SCALES CODED THE RESIDENT AS NOT AT HIGH RISK. THE ADON STATED THAT THE WOUND NURSE SHOULD HAVE ENSURED THAT THE BRADEN SCALE ASSESSMENTS ACCURATELY REFLECTED THE RESIDENT'S RISK FOR DEVELOPING PRESSURE ULCERS, AND SHOULD HAVE ENSURED THAT APPROPRIATE INTERVENTIONS TO PREVENT PRESSURE ULCERS WERE IMPLEMENTED. THE ADON STATED THAT STAFF NURSES SHOULD HAVE ENSURED THAT IMPLEMENTED INTERVENTIONS WERE ADDED TO THE TREATMENT RECORD AND DOCUMENTED AS IMPLEMENTED. THE ADON STATED THAT RESIDENT #303 SHOULD HAVE RECEIVED DEVICES TO ELEVATE HER HEELS WHEN IN BED, AND SHOULD HAVE HAD LABS DONE TO DETECT NUTRITIONAL DEFICIENCIES, AND NUTRITIONAL SUPPLEMENTS ADDED TO CORRECT ANY NUTRITIONAL DEFICIENCIES PRIOR TO THE DEVELOPMENT OF A PRESSURE ULCER, OR AT LEAST IMMEDIATELY AFTER ONE DEVELOPED, BUT COULD NOT EXPLAIN WHY THIS HAD NOT BEEN DONE. A POLICY ON PRESSURE ULCER PREVENTION WAS REQUESTED BUT NOT PROVIDED. ( )

This Citation pertains to Intake Number MI 316 Based on observation, interview, and record review the facility failed to prevent the elopement and ensure the safety in 1 of 8 sampled residents (Resident #104), from a total sample of 8 residents, resulting in an Immediate Jeopardy when Resident #104, who had been identified as an elopement risk, had a history of [REDACTED]. These deficient practices place 8 additional residents, identified as an elopement risk, at risk for serious harm, injury, and/or death. Findings include: Resident #104: Resident #104 was a current resident at the facility at the time of the investigation on 8/10/2011. Resident #104 was admitted to the facility on [DATE] according to Facility physician progress notes [REDACTED]. According to the clinical record, Resident #104 was identified as an elopement risk on 2/24/11. According to the MDS (minimum data set), dated 5/21/11, Resident #104 sometimes understood others, sometimes was able to make himself understood, had both long and short term memory problems and had modified independence in making decisions regarding daily life. Resident #104 was able to walk independently in his room and corridor, required limited one person assistance with dressing, personal hygiene and physical assistance with bathing, was continent of bowel, and occasionally incontinent of bladder. Review of Facility Elopement Risk Assessment, dated 2/24/11 and written by the previous facility Social Worker, stated "Resident is deemed an elopement risk at this time. Will continue to monitor". On 3/22/11 "no change to elopement status, will continue to monitor". No documented interventions were put in place. In a review of Facility Medical Records, dated from 5/31/11 to 7/12/11, no elopement risk evaluations were found. Review of Facility incident/accident occurrence reports revealed on 6/11/11 at 1:50 AM Resident #104 got on the 2nd floor elevator without staff knowledge and went to the basement of the facility to a non-resident care area. According to the incident/accident occurrence report he encountered a staff member who did not intervene and ensure he returned to his room on the 2nd floor, but left Resident #104 unattended in the basement, got on the elevator, and returned to the unit. Upon returning to the unit, the staff member asked if Resident #104 "made it up stairs". A door alarm sounded (time unknown) and Resident #104 was found outside "wanting to smoke". There were no new interventions implemented. The report was signed by the Administrator, Director of Nurses, and Physician. Review of Facility incident/accident occurrence reports revealed on 6/13/11 at 12:20 AM Resident #104 got onto the 2nd floor elevator without staff knowledge, went to the basement, opened the door which activated the alarm, and exited the building. The documented intervention on the incident/accident occurrence report was "assigned CNA to monitor whereabouts". Review of Facility incident/accident occurrence reports revealed on 6/13/11 at approximately 9 PM Resident #104 again got onto the 2nd floor elevator without staff knowledge, went to the basement, and exited the building. Facility staff were unable to locate Resident #104. Staff immediately began to search for Resident #104 inside the facility, on the facility grounds, and in the surrounding neighborhood. Resident #104 was located approximately 2 blocks from the facility. Resident #104 was returned to the facility by staff members at 10:40 PM. Interventions noted "1:1 supervision until lock unit could be located wanderguard applied". The report was signed by the Administrator, Director of Nurses and Physician. Accompanied by Certified Nurse Aide (CNA) #4 on 8/11/11 at 11:45 AM this surveyor walked up 2 flights of stairs from the basement , exited from the West 1st floor door, descended 2 steps, turned right and was in the parking lot. No audible alarm sounded. Upon returning to the building, Security guard #8 stated "It has a silent alarm. You set if off when you went out. I had to reset it. I saw you on the monitor too". Review of the facility document titled: "Resident Monitoring Log Sheet" Note: enter the location code at the time resident monitored in the specific location and initial", dated 6/13/11 and beginning at 12 AM, revealed that the times from 10 PM to 12 MN were blank with no signatures present, indicating the whereabouts of Resident #104 was unknown. Review of the Facility document titled "Safety Check Log Check All Elopement Risk Residents", dated 6/13/11, included instructions to "complete this sheet on the identified resident. Turn in with rounds form to the Administrator daily. Response and address all concerns immediately. Complete until date line was blank." This surveyor noted that the times for 8 PM and 9 PM "resident room" was signed by staff in the signature column and the time for 10 PM to 6 AM was left blank. Review of Facility "Safety Check Log Door Alarm Log" ,dated from 6/2/11 to 6/13/11, revealed blank times at 7 AM to 8 AM and 9 PM to 10 PM. An interview with Security Guard #13 was conducted on 8/22/11 at 4 PM. When shown the "Safety Check Log Door Alarm logs" and asked what the blank areas meant, Security Guard #13 stated "that's when we were doing 6 hours and no one was there to check, no one was here" The surveyor asked, "so the blanks mean there was no security here then?" Security Guard #13 replied "yes". Review of Staff Educational In-services, dated 6/14/11, revealed an in-service for 66 staff members was conducted on the topic of "Elopement". Objectives included: 2.) Review which residents are at risk and how those residents can be identified by use of orange color arm bands. Resident #104 was observed by this surveyor on 8/11/11 at 11:30 AM ambulating with staff in the hall. Resident #104 had a shuffling gait. When this surveyor asked how are you feeling today, he replied "boy" and kept walking. Resident #104 was groomed with clean clothing, hair combed and no body odors noted. There was no color identification band noted on Resident #104. Review of the Facility Policy Statement "Wander-Guard/Wandering/Elopement Risk Resident", dated October 2010, Section #3, "the resident's care plan will be modified to indicate the resident is at risk for elopement episodes and wanderguard system will be put in place according to the following procedure: A. Wanderguard bracelet will be placed on the resident's wrist and on ankle if needed. B. The wanderguard will be checked on a weekly basis to ensure functional accuracy. C. The resident will be walked through the alarmed area by the assessor/monitor to ensure it functions properly. D. In the event a wander guard does not function properly, it will be replaced and tested to ensure proper working condition before the resident returns to the unit. E. If a resident, who has been identified as a wanderer, is found to have a missing wander guard during the check, a new bracelet will be issued and placed. Section # 6 indicated: "If a resident repeatedly wanders off the unit, a monitoring schedule will be implemented to ensure resident safety. The resident's care plan will be documented as to the implementation of the monitoring schedule." Review of Resident #104's Nursing Care Plan "Potential for elopement/wandering related to stroke, confusion & wandering into the rooms of others frequently", dated 2/8/11, revealed the goal was to have decreased, or absence of elopement attempts. Interventions included: 1) To attempt to determine the cause of elopement/wandering attempts such as boredom, looking for something or someone; 2) To assess for elopement on admission and as needed; 3) To place wanderguard (personal location security device) on resident and monitor and 4) Maintain I.D. (identification) bracelet on resident also noted on 2/8/11 "has been placed with a wanderguard". Review of Resident #104's Nursing Care Plan "alternation in communication" (no date) revealed the long term goal "effective conveyance of needs. Resident #104 was aphasic (unable to speak) could only say two words "boy & OK". Approach: use communication board or have patient to write. Encourage resident to speak slowly and allow time to complete statements. Evaluate effectiveness of reorientation as cognitive level allows. Review of Resident #104's Nursing Care Plan "Neurological status altered related to seizure disorder history of TIA"s (mini strokes), dated 2/8/11, revealed interventions which included that Resident #104 was to be protected from injury (due to seizures), if a seizure occurred stay with the resident, signal for help, note the time of the onset, duration, type of movement, location of and body parts involved. Review of Resident #104's Nursing Care Plan "potential for injury and trauma", dated 2/8/11, revealed that on 3/8/11 and 3/16/11 Resident #104 became dizzy lost his balance and fell with no injury sustained. Interventions included "to maintain a hazard free environment" and to "acknowledge his ability and desire to function independently". Facility staff were to provide frequent observations. Review of Resident #104's Nursing Care Plan "Non-compliant with ADL's (activities of daily living)", dated 6/10/11, revealed Resident #104 was "noted attempting to get onto elevator". The goal was for Resident #104 to "not ride elevator without staff assistance". In an interview on 8/10/11 at 11:50 AM, Security Guard #8 stated that on an hourly basis security physically goes to check the location of residents at risk for Elopement "to go and see where they are 24/7. We talked about it yesterday, getting a way to track them. We have 10 people we keep track of now. I don't check to see if they physically have them on (the wanderguard's) or check if the alarms works, just where the residents are. There is no log of who has a wanderguard, which number, nothing like that I know of". Noted on the security guard's desk by the front entrance were 2 monitor's one on the desk and one on the wall facing the 1st floor nurses station. Security Guard #8 stated the focus of the monitor was on the parking lot, front entrance and the side of the facility by the fence facing north. On 8/10/11 at 2:00 PM this surveyor requested a Wanderguard Check list for checking function, location of wanderguard use, and a current list of wanderguard's currently in use from Maintenance Staff #7. Maintenance Staff #7 stated, "we don't do that or have one". In an interview on 8/10/11 at 2:10 PM with Licensed Practical Nurse (LPN) #5 when asked about tracking & usage of Wanderguard's replied "we don't have a system to document wanderguard's never have that I know of". In an interview on 8/10/11 at 2:10 PM, LPN # 9 reported there was an "elopement risk list" and showed it to this surveyor. The "elopement risk list" was last updated on 2/1/11. Resident #104 was not on the list and 2 of the 5 residents listed no longer resided at the facility. The same list was also obtained from the 2nd floor nurses station. Only Resident #103 was listed. In an interview on 8/10/11 at 2:20 PM, CNA #6 stated "we check to see if they (wanderguard's) are on but there is no place to write it down, not since 1988, that's how long I've been here". In an interview with on 8/10/11 at 2:30 PM, LPN #2 stated, "I don't know of any process we have about that who checks location, if it works or even on the resident". In an interview on 8/11/11 at 10:25 AM, CNA #4, when asked what the process was for residents to get a wanderguard placed, stated staff call for a wanderguard. CNA #4 reported the wanderguards are located in the Director of Nurses' (DON's) office. CNA #4 stated, "I activate it by placing the wanderguard on a box, press the button, a light comes on and it is activated. I then go check 2 doors to make sure an alarm sounds, only 2 doors the north and east front door have alarms, I put it on the resident, and tell the Security guard. I don't know of any system in place to record who has what wanderguard, if any identification number is connected to which resident, we have no logs about wanderguard. We know which residents wander so we just watch them, I just know about 4 Residents who have them now". In an interview on 8/11/11 at 1:30 PM, the Assistant Director of Nurses (ADON) #3 stated that the employee who got on the elevator, while leaving Resident #104 in the basement on 6/11/11 at 1:50 AM, was no longer employed by the facility. ADON #3 was unable to explain how Resident #104 exited the building on 6/13/11 at 12:20 AM. and why no interventions were done by staff. ADON #3 stated, "we now have nothing in place to check if it's (the wanderguard) on the person and working. I don't know if Resident #104 had a wanderguard on until after he left the 3rd time". In an interview on 8/11/11 at 10 AM, Maintenance staff #7 stated that only 2 doors on the 1st floor have wanderguard alarms, the North door and West front door. On the 2nd floor the North door has a numbered key pad and wanderguard alarm, the other exit door directly across from Room 206 has a numbered key pad alarm system and no wanderguard alarm. In a phone interview on 8/24/11 at 5:45 PM, LPN #1 stated that on 6/13/11 the last time she remembered seeing Resident #104 was at approximately 8:30 PM. LPN #1 stated that security does rounds, but was unable to remember if security was there on 6/13/11. LPN #1 stated before she began passing her 9 PM medications "something just came over me to check" on Resident #104. LPN #1 stated facility staff were unable to locate Resident #104 and a search was started. LPN #1 was unable to recall exactly which staff left the facility in their own cars to find him "not everyone could leave and go search. He was found 2 blocks from the facility and returned with no apparent injury." This surveyor read the documentation LPN #1 had entered into the Nurse's Notes on 6/13/11 at 10:40 PM. LPN #1 stated, "If that's the time I wrote then that's the time. I would write the precise time down, if that's what I wrote that's the time". The Administrator, DON and ADON were notified on 8/16/11 at 9:55 AM of the Immediate Jeopardy that began on 6/13/11 when Resident #104, who had been identified as an elopement risk, had a history of [REDACTED]. These deficient practices place 8 additional residents, identified as an elopement risk, at risk for serious harm, injury, and/or death. On 8/23/11 the Surveyor confirmed that the Facility implemented the following to remove the Immediate Jeopardy: 1. On 8/10/11, all residents at risk for elopement had wanderguards applied. 2. On 8/11/11, all wanderguards were tested for placement and functionality by the MDS coordinator. 3. On 8/10/11, all residents at risk for elopement were reassessed and their care plans reviewed and updated as needed. 4. On 8/18/11, all residents in the facility were assessed for elopement risk. 5. On 8/18/11, the code to the stairwell doors was changed. 6. As of 8/18/11, the Nursing department will be responsible to do random head counts during rounds. Security, as of 6/13/11, continues to maintain a daily log to make rounds hourly to determine whereabouts of residents at risk for elopement. 7. Continuing as of 6/13/11, door alarms are tested daily to ensure they are working. Any negative findings are to be reported to the Maintenance department and/or Administrator. 8. On 8/11/11, 5 of 5 security staff were in-serviced on wanderguard monitoring. 9. On 6/14/11, 48 of 74 staff were in-serviced on elopement procedures. All other staff will be in-serviced by 8/19/11. 10. On 6/11, 40 nursing staff were in-serviced on "Understanding Difficult Behavior". On 8/18/11, 6 remaining staff were in-serviced on "Understanding Difficult Behavior". 11. Beginning 8/19/11, nurses are responsible to check wanderguards for placement and function every shift and record results on the Medication Administration Record. 12. Beginning 8/11/11, a list of residents at risk for elopement will be placed at each nurse's station and the security desk. Although the Immediate Jeopardy was removed on 8/19/11 at 2 PM, the Facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to the fact that all in-services had not been completed and sustained compliance had not been verified by the State Agency.