Every finding on record at Mission Point Nursing & Physical Rehabilitation Ce

Based on observation, interview, and record review, the facility failed to properly store food product and clean and maintain equipment, resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.Findings Include:On 7/20/26 at 9:16 AM, in the walk-in cooler found two large containers of nutritional shakes dated 7/7 to 8/7 on each container (three dozen chocolate and two dozen strawberry). A review of the shakes found that they are only good for 14 days after thaw. A further review of the walk-in cooler found a container of ravioli dated 7/13 to 7/19 and two opened cartons of almond milk, one not dated and one dated for 7/7. A review of the almond milk containers found the item is only good for 7-10 days after opening. [NAME] M stated that staff typically date items three days out from the date its opened or made.On 7/20/26 at 9:18 AM, the walk-in cooler was observed with a box of raw bacon strips laying on a sheet pan, next to and on top of bowls of ready-to-eat broccoli salads. Further review of the cleanliness of the walk-in cooler found areas of accumulation of debris and yellow staining on the floor under racks and around the floor/wall junction of the cooler.On 7/20/26 at 9:34 AM, a strawberry nutritional shake was observed thawed and not dated in reach in cooler #3.On 7/20/26 at 9:36 AM, [NAME] M stated that the mixer gets used once a week and that the bag covering it means it is cleaned and sanitized. Upon removing the bag from the slicer, accumulation of encrusted debris was evident on the front grate and back shield of the unit.On 7/20/26 at 9:41 AM, the clean pots and pans storage rack was observed with three black carbon encrusted saucepans with metal scrapes on their surface. [NAME] M stated that they spend time scrubbing them, but they don't get much cleaner. Cutting boards on the storage rack adjacent to the saucepans were found with black and yellow staining.On 7/20/26 at 9:43 AM, the clean utensil drawer, containing mechanical scoops, was observed with an accumulation of crumb and dirt debris. One metal scoop was found with dried stuck on food debris. [NAME] M stated she was newer and was not sure of the cleaning frequency of the drawer.On 7/20/26 at 9:45 AM, the storage shelf under the cookline preparation table was observed with a gallon container of soy sauce and a half gallon container of less sodium soy sauce. Both containers only had about 1/3 of their product left. A review of the containers found that they both require refrigeration after opening.On 7/20/26 at 9:50 AM, oven mitts on the convection oven were observed with large wear marks between the thumb and hand portions. [NAME] M stated it has caused issued not having good gloves to grab hot food with.On 7/20/26 at 10:13 AM, the dish machine was observed with a leaking pressure valve coming from the booster heater under the dish line counter.On 7/20/26 at 10:29 AM, the A-side nutrition room refrigeration unit found the following: five nutritional shakes not dated for discard, a yogurt with a best by date of 7/10/26, and a container of cream cheese with a best by date of April 1st, 2026.On 7/20/26 at 10:38 AM, The B-side nutrition room refrigeration unit found two open containers of vanilla med pass supplement with no date to indicate discard. A review of the containers found the supplements are only good for four days after opening.According to the 2022 FDA Food Code:Section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days.Section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) .Section 3-302.11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (1) Except as specified in (1)(d) below or when combined as ingredients, separating raw animal FOODS during storage, preparation, holding, and display from: (a) Raw READY-TO-EAT FOOD including other raw animal FOOD such as FISH for sushi or MOLLUSCAN SHELLFISH, or other raw READY-TO-EAT FOOD such as fruits and vegetables,P (b) Cooked READY-TO-EAT FOOD, P and (c) Fruits and vegetables before they are washed; P.Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.Section 5-205.15 System Maintained in Good Repair. A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair.

Based on observation, interview, and record review the facility failed to ensure food served was palatable and served at a safe and appetizing temperature for 3 of 54 residents (R7, R48, R14) reviewed for palatable food, resulting in the potential for meal dissatisfaction for all residents in the facility. Findings include: On 7/20/26 at 12:10 PM, [NAME] M stated that they switched the menu to tuna sandwiches instead of the tuna melt listed on the menu because they ran out of cheese slices. On 7/20/26 at 12:22 PM, the plate warmer was observed off and not warm to the touch. [NAME] M stated that the plate warmer does not work. When asked if she took temperatures before service, [NAME] M stated that she did not. On 7/21/26 at 10:19 AM, [NAME] M stated that last night's dietary staff forgot to add the meal tickets (for today) on the dinner trays last night, so residents were not able to make decisions on today's meal. [NAME] M stated that dietary staff would go by resident's preferences, likes, and dislikes for today's meals. On 7/21/26 at 11:54 AM, the plate warmer was observed off and not working. On 7/21/26 at 11:58 AM, a test tray was requested for lunch service to be added to [NAME] Hall cart. On 7/21/26 at 12:07 PM, the test tray was plated and added to the [NAME] Hall cart. On 7/21/26 at 12:11 PM, the test tray and hall trays made it to [NAME] Hall. On 7/21/26 at 12:19 PM, all trays on the [NAME] Hall cart were delivered and the test tray was in the conference room with the following temperatures: mechanically altered rib meat was 97F and the rice and broccoli casserole was 117F (when tested with a rapid read digital thermometer). R7 Review of a Face Sheet reflected R7 admitted to the facility with diagnoses that included acquired absence of the left leg below the knee. During an interview on 07/20/2026 at 9:41 AM R7 reported the food is terrible. He showed the surveyor a bowl with 3 hard boiled eggs and two pale sausage links. He food did not look good and the resident said he was going to feed it to the birds. R48 Review of a Face Sheet reflected R48 admitted to the facility with diagnoses that included an unstageable pressure ulcer of the right heel and peripheral vascular disease. During an interview on 07/20/2026 at 10:11 AM R48 reported the food is terrible, they make casseroles with the leftovers, from food that was served 3 days prior, and tastes terrible. R48 reported If you bug them (staff) you can get something else to eat, but it's more of the terrible. R14 Review of a Face Sheet reflected R14 readmitted to the facility after hospitalization for a right femur fracture. Review of a Minimum Data Set (MDS) assessment dated [DATE] reflected R14 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14/15. During an interview on 07/20/2026 at 3:08 PM, R14 reported the food is bad and the menu is hard to understand. R14 wants basic staples for meals. Reports the facility does not offer alternatives, for example, this evening dinner is hamburgers, and the alternate is a hamburger,

Based on observation, interview, and record review, the facility failed to ensure licensed nurses did not delegate treatment orders inappropriately for 1 of 6 residents (R6) reviewed for professional standares of care, resulting in the potential for worsening of R6's skin. Findings include:During an interview on 07/21/2026 at 8:26 AM R6 reported that he has a wound on his bottom. The resident agreed to an observation. Unit manager, Licensed Practical Nurse (LPN) B reported that a wound care nurse rounds for the residents at the facility and will be here at 10AM. During an observation of R6's skin and an interview on 7/21/2026 at 10:00 AM, Certified Nurse Aide (CNA) P reported that she mixes A & D ointment with zinc oxide and applies it to R6's peri area. A tube of zinc oxide was noted on the bedside table. Licensed Practical Nurse (LPN) R reported that the zinc should not be left at the bedside, and only licensed nurses should be applying the zinc oxide because it is considered a treatment. LPN R also reported that R6 did not have a treatment order for zinc oxide to be applied, despite evidence of the zinc oxide paste on R6's coccyx. CNA P reported aides have always applied the zinc, either from the tube left at the bedside or from a medication cup containing the zinc given to aides by the nurse or left at the bedside. Review of a Face Sheet reflected R6 admitted to the facility with diagnoses that included active primary progressive multiple sclerosis and quadriplegia. Review of the July 2026 TAR reflected Zinc oxide was not ordered as a treatment for R6. Review of the May and June 2026 TAR reflected the following order: -Right Buttock & LEFT HIP: Cleanse open area with saline and pat dry, apply zinc barrier cream. every shift for Wound Healing-Start Date 05/22/2026 0700 -D/C (discontinue) Date - 06/02/2026. Nursing staff were documenting the treatment was completed twice a day as ordered between 5/22/26-6/2/2026.-Right Buttock & LEFT HIP: Cleanse open area with saline and pat dry, apply zinc barrier cream. every shift for Wound Healing-Start Date 05/22/2026 0700 -D/C (discontinue) Date - 06/02/2026. Nursing staff were documenting the treatment was completed twice a day as ordered between 5/22/26-6/2/2026.

Based on observation, interview, and record review, the facility failed to appropriately identify, assess, and treat, a wound for 1 resident (R6) out of 1 resident reviewed for quality care, resulting in the potential for the worsening of wounds. Findings include: During an observation and interview on 7/21/2026 at 10:00 AM, Licensed Practical Nurse (LPN) R reported that she was wound care certified. LPN R assessed R6's skin and a scabbed area was noted on R6's right heel. With a gloved hand, LPN R picked the scab away, pulling up a thickened edge of skin when the scab did not just fall away. Review of Weekly Skin Sweeps for the month of July 2026 did not reflect any documentation of a wound on R6's right heel. Review of the July 2026 Medication Administration Record and Treatment Administration Record (MAR-TAR) did not reflect and treatment or monitoring orders for a scabbed area on R6's right heel.During an interview on 07/22/2026 12:02 PM, Physician Assistant (PA) T reported she or the physician should be notified when a new wound is identified so that a treatment can be implemented and interventions are in place. PA T said that if there was a scab that was not obviously loose it would not be appropriate to remove it, rather she would like it to be monitored. During an interview on 7/22/2026 at 12:56 PM, the Director of Nursing (DON) reported there was no evidence staff had identified the scabbed area on R6's heel. The DON reported that the CNAs do a skin sweep with every shower or bath and with cares and they are expected to document by exception in the point of care task documentation that will alert the nurse of a new concern.

Based on observation, interview, and record review, the facility failed to ensure staff implemented and residents followed the facility Smoke Free Environment policy in 1 of 1 resident (R7) reviewed for smoking, resulting in the potential for injury. Findings include:Review of a Face Sheet reflected R7 admitted to the facility with diagnoses that included dementia and acquired absence of the left leg below the knee. Review of a Safe Smoking assessment dated [DATE] at reflected R7 Uses smoking apron for falling ashes.Devices Needed Smoking ApronReview of a Care Plan Report reflected (R7) have been assessed by the IDT (interdisciplinary team) and I am able to smoke independently after I have signed myself out and go off property. I have a history of being non-compliant with providing my smoking paraphernalia to the nurses. Interventions included Offer and encourage a smoking apron to be applied before going outside to smoke. Remove after each occurrence and wipe down with sanitaizing wipes; smoking paraphernalia will be stored at the nurse's station .During an interview on 07/20/2026 at 9:58 AM, Licensed Practical Nurse (LPN) G and LPN S reported there are smokers at the facility. When asked if the nurses lock up the smoking materials, LPN S said it is hit or miss for securing smoking materials. LPN S said some residents have a lock box, and other resident smoking materials are secured in the medication room. LPN S explained that if a resident smokes, they have to sign out and be off the property. During an interview and observation on 07/20/2026 at 9:41 AM R7 wheeled up to the nurse desk and reported he smokes off the property and needs to sign out. R7 pulled a lighter from his pocket, a package of cigarettes was in the cup holder attached to the wheelchair. LPN G wheeled R7 into a parking spot across the street from the building. There was not a fire-retardant cigarette butt container where R7 was set up to smoke. Neither LPN G or LPN S were witnessed retrieving smoking materials for R7 or offering R7 a smoking apron.During an interview and observation on 7/21/26 at 2:00 PM, the Nursing Home Administrator (NHA) reported the smoking situation is a challenge. The NHA reported the residents should not be keeping their smoking materials on their person. During a tour of the outdoor smoking area, residents were observed smoking on facility property. During an interview on 7/22/26 at 9:00 AM the DON reported that the facility is technically non-smoking. Review of a document provided by the facility indicated there are 8 residents currently living at the facility who are smokers. Review of a policy Smoke Free Environment last revied 1/2024 reflected It is the facility's policy to protect the health and safety of our residents, visitors, staff, physicians, and other guests. We recognize the health hazards of tobacco use and as a provider of health care services strongly discourage products that are smoked . 8. Residents who can and want to smoke may do so off premises.c. They must sign out at the clinical care station and request their smoking materials. d. All smoking paraphernalia to be kept at clinical care station including but not limited to, lighters, cigarettes, other paraphernalia.

Based on interview and record review, the facility failed to adequately monitor laboratory values and ensure the resident representative was involved with treatment decisions for 3 residents (Residents #3, #31, and #54) out of 5 residents reviewed for unnecessary medication, resulting in the potential for medical complications for all 3 residents. Findings include:Review of the FDA prescribing information for Clozaril revealed, CLOZARIL treatment has caused severe neutropenia, defined as an absolute neutrophil count (ANC) less than 500/uL. Severe neutropenia can lead to serious infection and death.Recommended Frequency of ANC Testing During CLOZARIL Treatment-Day 1 to Month 6: WeeklyMonth 7 to Month 12: Every 2 weeksMonth 13 and thereafter: Every month (if ANC continues to remain in the normal range). (An ANC can be calculated from a CBC).Resident #3 (R3) Review of an admission Record revealed R3 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: schizoaffective disorder-bipolar type.Review of R3's Order Summary revealed, Clozaril Oral Tablet, 200 mg, one time a day (start date 05/29/2026) AND Clozaril Oral Tablet, 400 mg, at bedtime (start date 05/28/2026).Review of R3's Laboratory Results revealed R3's CBC (complete blood count) was obtained on 4/23/26 and 6/30/26.Review of R3's Annual Wellness Visit Note dated 7/7/26 revealed, . Recent increase in clozapine dose and split dosing after subtherapeutic levels. Weekly CBC and Clozaril level monitoring recommended.Review of R3's Electronic Medical Record revealed no order for a weekly CBC and Clozaril Level. An order dated 6/25/26 revealed, CBC with diff monthly for Clozapine management.Resident #31 (R31) Review of an admission Record revealed R31 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: schizoaffective disorder-bipolar type.Review of R31's Order Summary dated 8/29/25 revealed, cloZAPine Oral Tablet 200 MG 2 tablets bedtime.Review of R31's Laboratory Results revealed R31's CBC was obtained on 1/29/26 and 6/17/26.Review of R31's Order Summary dated 6/30/26 revealed, CBC every month-Long term use of Clozapine.Resident #54 (R54) Review of an admission Record revealed R54 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: schizoaffective disorder-bipolar type.Review of R54's Order Summary dated 9/1/25 revealed, Clozapine Oral Tablet 100 Mg, 3 tablets at bedtime.Review of R54's Psychiatry Follow up note dated 3/11/26 revealed, . Continue monitoring for side effects of antipsychotic and mood stabilizer therapy, including regular CBC and CMP as indicated .Continue monitoring CBC, ANC and CMP.Review of R54's Laboratory Results revealed R54's CBC was obtained on 3/12/26 and 6/11/26.Review of R54's 30-Day Follow-up note dated 6/18/26 revealed, .Clozapine level was elevated at 954, prompting a dose reduction to 200 mg at bedtime on 06/10/2026.Review of R54's Order Summary dated 6/30/26 revealed, CBC Monthly-Long term use of Clozapine.During an interview via email on 7/22/26 at 1:37 PM, the Director of Nursing (DON) stated, We identified in June that the orders for monthly labs had fallen off so we drew labs and put in new orders.During an interview on 07/23/2026 at 9:01 AM, Medical Director (MD) Q reported that for residents prescribed Clozaril, that have been on the medication with stable ANC's, monthly laboratory testing is required. MD Q reported that residents that have been stable on Clozaril long term 3-month testing may be appropriate. MD Q reported that the facility was responsible for ensuring laboratory testing was completed based on the medication prescribed. MD Q reported that the facility nurses and practitioners (Physician Assistants and Nurse Practitioners) were also responsible for ensuring that required laboratory tests were ordered. MD Q reported that there was a need to follow-up with the providers and nurses to ensure they are aware of the requirements. Review of the facility policy, Antipsychotic Reduction Program last reviewed/revised 05/2024 revealed, .Update medication/monitoring orders, as applicable .10. Compliance Monitoring a) Utilize the Unnecessary medications, Psychotropic Medications, and Medication Regimen Review Critical Element Pathway to verify regulatory compliance .Review of the Unnecessary Medications, Chemical Restraints/Psychotropic Medications, and Medication Regimen Review Critical Element Pathway dated 02/2026 revealed, .How do you monitor for adverse consequences (e.g., labs to monitor for adverse events and drug interactions related to use of antibiotics and other high-risk medications)? .Is there documentation to confirm that residents are being adequately monitored and re-evaluated for adverse consequences and the need for tapering?

Resident #12 Review of an admission Record revealed Resident #12 was a female, with pertinent diagnoses which included heart failure, diabetes, chronic pain, depression, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #12, with a reference date of 5/1/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated she was cognitively intact. Further review of Resident #12's MDS assessment, dated 5/1/25, revealed she was frequently incontinent of bowel and bladder. In an interview on 6/23/25 at 10:49 AM, Resident #12 reported long wait times for care. Resident #12 reported staff will often respond to her call light, deactivate the light and say they will be back shortly, then not return which forces her to activate the call light all over again. Resident #12 recalled an instance where this occurred a few weeks ago and resulted in her ultimately waiting almost an hour and a half for staff to come and assist with a brief change after having a bowel movement. Resident #12 reported that when she said something to staff, they instead asked her why she didn't put her call light back on. Resident #12 stated the entire experience was .frustrating . and made her feel like she was the one at fault. Resident #12 reported issues with meal service and described instances where she did not receive all the items ordered. Resident #12 reported instead of retrieving the items from the kitchen, the staff instead asked if she was sure she circled the items and wanted to see her tray ticket. Resident #12 reported the staff frequently will make her feel like she was the one responsible for the missing items. In an interview on 6/25/25 at 11:01 AM, Resident #12 reported with last night's dinner meal, she did not receive her coffee, ranch dressing, or strawberries. Resident #12 reported she knows she circled the items on her tray ticket, and stated .it feels a little disrespectful because I shouldn't have to ask for something I already asked for . Resident #12 recalled an issue with a different meal in the main dining room, and reported everyone else got what they asked for but she was missing her cottage cheese and her salad. Resident #12 reported when she notified the staff member serving of the missing items, that staff member went to the kitchen and the dietary staff immediately asked for Resident #12's slip to see if she actually ordered the items. Resident #12 stated .Why would I say I circled it if I didn't? It's frustrating .It always seems to be my fault when I complain . Based on interview and record review, the facility failed to provide care and services to promote dignity and respect in 2 (Resident #38 and #12) of 5 residents reviewed for dignity/respect, and 5 of 5 residents from the confidential resident meeting, resulting disrespectful treatment by staff, long call light wait times, and the potential for feelings of diminished self-worth, sadness, and frustration. Findings include: Resident #38 Review of a Minimum Data Set (MDS) assessment for Resident #38, with a reference date of 5/29/25 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #38 was cognitively intact. In an interview on 06/23/25 at 09:54 AM, Resident #38 reported that Licensed Practical Nurse (LPN) H has always been very mean and passive aggressive. Resident #38 reported that about a week ago LPN H brought a witness (Certified Nursing Assistant (CNA) E) in her room with her during medication administration, treated Resident #38 like a child, and then called her a b**ch when she left the room. Review of Resident #38's Concern Form completed by Nursing Home Administrator (NHA) A dated 6/20/25 revealed, .(LPN H), my night nurse does not have a great approach when she comes into my room. She does not allow for me to ask her questions and doesn't engage with me when providing care .I would not like her as my nurse. She needs to have better customer service skills .Facility Response: NHA spoke with resident regarding this concern. Resident states that last night she had the nurse come into her room for her medications around midnight. The nurse had another staff member with her and only spoke to the other staff member. While they were in the hallway, the resident could overhear them talking to each other through the night. The nurse was not using appropriate language in the hallway and doesn't want to hear that. Resident states that she feels safe in the facility just doesn't want to hear them talk unprofessionally in the hallway. This nurse and resident has previously had encounters that they did not see eye to eye on. It is felt from the facility that it is best to have the staff member removed from the resident's assignment . Signed In an interview on 06/24/25 at 12:38 PM, LPN H reported that she hadn't ever had issues with Resident #38, except for one time when the resident alleged not receiving her medication. LPN H reported that it was solved by always bringing a witness in the room when LPN H administered medication to that resident. In an interview on 06/24/25 at 01:28 PM, CNA E reported that LPN H treated Resident #38 like a child during medication administration, saying ok .here are your medications .open your mouth .swallow them . CNA E reported that when they were leaving Resident #101's room, LPN H verbalized frustration and said some not so nice words. CNA E reported that Resident #38 heard LPN H refer to the resident as weird and irritating. In an interview on 06/25/25 at 11:59 AM, Unit Manager (UM) D reported that LPN H had a previous issue with Resident #38, therefore she was required to have a witness in the room when she provided care. UM D reported that she had been informed about an inappropriate interaction between LPN H and Resident #38 when she arrived to the facility on the morning of 6/20/25. UM D reported that the resident had said LPN H spoke down to her during medication administration and then called her a bitch. UM D reported the concern to NHA A that same day during the morning meeting. UM D reported that LPN H had not been in the building at all since that day. In an interview on 06/25/25 at 12:13 PM, NHA A reported that he had interviewed Resident #38 immediately after UM D informed him of the concern with LPN H. NHA A reported the resident verified the allegation that LPN H had called Resident #38 a b**ch. NHA A removed LPN H from the schedule investigate, and also had Human Resources involved. NHA A reported that LPN H had not been allowed to return to work. Review of Resident #38 Nursing Progress Note created by LPN H dated 6/20/2025 at 06:20 AM revealed, At approximately 0000 (midnight) hours, resident activated call light requesting pain medication. This nurse retrieved the prescribed PRN (as needed) med and requested a staff member to witness administration in order to prevent potential conflict. Both this nurse and the staff member proceeded to the resident's room, where the medication was administered and witnessed as taken by the resident. Resident was advised to notify nursing via call light if pain worsened or further assistance was needed. Resident verbalized understanding, stating, Okay I will, thank you. This nurse resumed routine treatments and skin assessments. Approximately one hour later, a staff member informed this nurse that the resident wished to speak. This nurse inquired whether the concern was related to pain, medication, or other nursing needs. Staff member stated, She wants to talk about something personal. This nurse accompanied by the staff member, returned to the resident's room to follow up. Upon inquiry, the resident stated, No, its personal .it doesn't have to do with cares or meds. I want to talk to you earlier about something personal. This nurse professionally informed the resident that while all concerns related to cares or medications are welcomed and addressed, personal matters unrelated to medical or nursing care are outside the scope of professional interactions. This nurse then exited the room. The staff member remained present and observed the interaction throughout 7p-7a shift. During a confidential group meeting on 6/24/25 at 2:13 PM it was reported by five of five residents that they do not feel respected and the staff do not treat the facility like it's their home; when they have concerns staff respond in a patronizing way. All five residents also agreed when they report concerns about wrong items on their meal trays, they get responses such as we are not a restaurant or did you circle it on your ticket?

Based on observation, interview and record review the facility failed to ensure residents received care in accordance with professional standards of practice in 1 (Resident #44) of 15 residents reviewed for quality of care, resulting in lack of monitoring and treatment for Resident #44's Jackson Pratt (JP) drain (a surgical suction drain that draws fluid from a wound to help recover from surgery; the bulb pulls the fluid out when it is squeezed) and the potential for blockage and rehospitalization for infection. Findings include: Resident #44 Review of an admission Record revealed Resident #44 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: colon cancer. During an observation and interview on 06/23/25 at 11:04 AM Resident #44 was sitting in his bed and reported that he was waiting for a nurse. Observed Resident #44's right abdomen with a partially detached gauze dressing with a JP drain. The tubing had brown fluid in it and the bulb was inflated with fluid. Resident #44 reported that he had asked staff for days to help him with the drain. Resident #44 was concerned that the drain was going to get plugged again and he would have to go back to the hospital. Review of Resident #44's Medication Administration Record (MAR) revealed orders for Monitor drain site for increased swelling, redness, abdominal pain .every shift. Start date: 6/11/25. There was no order to empty and measure the drain fluid. There were no orders to monitor the resident's vital signs. In an interview on 06/23/25 at 01:02 PM, Unit Manager (UM) U reported that Resident #44 did not have orders to drain the bulb; the only order in place was to monitor the site of the tube insertion from 6/11/25. UM U reported that the resident had an abdominal procedure done on 6/17/25 due to an abscess (collection of built up pus caused by an infection) and when he returned to the facility he had the tubing and bulb. UM U reported that she had reached out to the hospital and they did not give any orders. In a subsequent interview on 06/23/25 at 01:16 PM, Resident #44 became angry and stated, I need this tube drained .I keep telling everybody and no one is listening! In an interview on 06/23/25 at 01:18 PM, Licensed Practical Nurse (LPN) K reported that she had seen Resident #44 briefly that morning, and that he did not have any orders for the JP drain. LPN K reported that a JP drain only functions if it is emptied and recompressed. LPN K reported that she would go in the room now. In a subsequent interview on 06/23/25 at 01:31 PM, LPN K reported that she drained had just Resident #44's JP and measured the amount of fluid. LPN K reported that there should have been an order to drain it, record the amount of fluid removed, and to monitor the resident's temperature. LPN K reported that anytime the bulb on the JP drain is expanded, it needs to be drained in order to function and suction the fluid out again. Review of Resident #44's Nursing Progress Note dated 6/23/2025 at 1:31 PM revealed, Resident's JP drain remains intact. 45 cc emptied, yellowish/green in color, with a foul odor noted. JP drain compressed again and capped. In an interview on 06/23/25 at 04:32 PM, UM U reported that Resident #44 should have had standard orders to empty and record the amount of fluid from the JP drain every shift and as needed. UM U was not able to report when the JP bulb had been drained last. During an observation on 06/24/25 at 08:37 AM Resident #44 was in his room and reported that he needed someone to come fix his bandage covering the JP tube insertion site on his right abdomen. Observed a large white gauze with multiple pieces of tape on it, but not intact with the skin; the bandage was hanging on the tube and there was no date observed written on the dressing. Resident #44 reported that they are supposed to change it every other day, but it had not been changed in a few days. Review of Resident #44's Treatment Administration Record (TAR) revealed orders Right Flank: cleanse with NS (normal saline), pat dry, skin prep to surrounding skin, apply TAO (triple antibiotic), cover with gauze & secure with transparent film every day shift every other day for according drain dressing. Start date of 6/13/25. The treatment was documented as administered by UM U on 6/23/25. In a subsequent interview on 06/24/25 at 08:47 AM, UM U reported that she had not changed Resident #44's dressing the day before, as the TAR reflected. After reviewing the TAR, UM U reported that she had accidentally signed the order as being administered. In an interview on 06/24/25 at 03:39 PM, Director of Nursing (DON) B Resident #44 had a surgical procedure done on 6/17/25 due to a previous drain site being abscessed, and the resident returned to the facility the same day with the JP drain. DON B reported the resident did not have a JP drain prior to that day, but had previously had a different drain that had been capped on 6/11/25. DON B reported that the facility was aware that the JP drain was there and should have entered new orders on that day. DON B reported that the facility should have implemented at a minimum, standard orders to empty and record the fluid.

This citation pertains to Intake #MI00147517 Based on interview, and record review, the facility failed to maintain professional standards of nursing in 2 of 5 residents (Resident #109 & #110) reviewed for misappropriation of controlled medication, when licensed nurses falsely witnessed to the destruction of controlled medications, resulting in the diversion of narcotic medications for staff personal use. Findings include: Review of a facility reported incident (FRI) submitted on 10/12/24 at 9:30 PM revealed, Perpetrator: (Registered Nurse (RN) M) .Type of Alleged Incident: Misappropriation, Date/Time Incident Discovered: 10/12/24 at 8:40 PM, Incident Summary: At approximately 8:40 PM NHA (Nursing Home Administrator (NHA) A) was notified that the (local police department) notified the Director of Nursing (DON B) that four cards and one bottle were found in the nurse's house with resident names on them, however, did not state the names of the residents and would not release the names of the residents, counts of the medications or the types of the medication to NHA .Employee suspended pending investigation .Full narcotic count of medications in the facility completed, and pain assessments completed for all residents residing in the facility. Review of the police report, obtained by this surveyor on 10/16/24 revealed, .Event occurred from 10/12/24 7:30 PM-10/12/24 9:29 PM .Suspect: (RN M) .located three sheets of prescriptions .All three sheets of prescriptions were prescribed to subjects other than (RN M) .Unprescribed/Stolen Medications: Lorazepam (Ativan) 0.5 mg tablet (sheet): prescribed to: (Resident #109). Prescription # 14275710. 18/60 pills are missing out from the prescription sheet .Oxycodone 5 mg (sheet): Prescribed to: (Resident #110). Prescription #12207906. 44/58 pills are missing out of the prescription sheet. Tramadol HCL (narcotic pain medication) 25 mg (sheet): Prescribed to: (Resident #109). Prescription #14288137. 6/26 pills are missing out of the prescription sheet . In an interview on 10/16/24 at 9:22 AM, Pharmacy Technician (PT) G confirmed that Prescription #14275710 was, Lorazepam prescribed to Resident #109 in March 2024, Prescription #14288137 was Tramadol, prescribed to Resident #109 in June 2024, and Prescription #12207906 was Oxycodone, prescribed to Resident #110 in November 2023. Review of Resident #109's Controlled Substance Proof-Of-Use Record revealed, .RX# (Prescription) 14275710 .Lorazepam 0.5 mg tablet .#60 . The record did not have any doses accounted for and was signed by RN M and witnessed by LPN (Licensed Practical Nurse) K on 7/18/24, indicating that all 60 tablets were destroyed. This was 1 of 2 records for RX# 14275710. Review of Resident #109's Controlled Substance Proof-Of-Use Record revealed, .RX#14275710 .Lorazepam 0.5 mg tablet .#52 . The record indicated that the resident had received 3 doses, and was signed by RN M and witnessed by LPN K on 7/18/24, indicating that 49 tablets were destroyed. This was 2 of 2 records for RX #14275710. Review of Resident #109's Controlled Substance Proof-Of-Use Record revealed, .RX# 14288137 .Tramadol 25 mg tablet .#26 . The record indicated that 2 doses had be administered to the resident. RN M signed to indicate destruction of 24 tablets on 7/18/24 and LPN K signed as a witness to the medication destruction. Review of Resident #110's Controlled Substance Proof-Of-Use Record revealed, .RX# #12207906 .Oxycodone 5 mg tablet .#58 . The record showed zero doses were administered to Resident #110. RN M signed to indicate destruction of 58 tablets on 12/12/23, and RN H signed as a witness to the medication destruction. In an interview on 10/16/24 at 10:09 AM, NHA A reported that LPN K and RN H were both suspended from work, due to their signatures being on the controlled medication records, listed as witness to the destruction of controlled medications that were then located in RN M's home and not destroyed. In an interview on 10/16/24 at 1:29 PM, LPN K reported that she had signed to verifying the destruction of narcotic medication at least 5 times over the past 6 months without visualizing the medication and/or medication card. LPN K reported that RN M would bring her a narcotic medication sheet, saying that she had already destroyed the medications. LPN K reported that she knew the policy was to witness the destruction of narcotic medications, but that she trusted RN M. LPN K reported that she never considered professional standards and/or notifying management regarding the breach of policy. In an interview on 10/17/24 at 12:21 PM, RN H reported that occasionally she would sign that she witnessed the destruction of narcotic medications, without seeing the medication and/or after the first nurse had already popped the pills out of the medication card. RN H reported that there were only a couple of nurses that did it that way, and RN M was the only name she could remember. RN H reported that she knew this was against facility policy but did not report it to anyone. During an observation and interview of medication administration on 10/17/24 at 10:40 AM, the controlled substance proof-of-use binder was reviewed. on B hall. There was a Controlled Substance Shift Inventory record in the front of the binder. The last entry was not dated, indicated a total of 31 RX's were present at the start of the shift, 1 RX was added, and 32 were present at the end of the shift. The entry was signed by an outgoing nurse but was not witnessed by the oncoming nurse. LPN L reported that she had counted that morning when she started her shift, but did not sign the oncoming nurse space, and typically waits to sign until the end of the shift when she counts again. In an interview on 10/17/24 at 10:51 AM, UM C reported that when completing the controlled substance counts at shift change, the outgoing and oncoming nurses should sign at the same time, to ensure the medication counts are witnessed. UM C reported that the re-education related to the controlled substance destruction process did not clarify that the signatures should be recorded at the same time to attest to the count of narcotics. In an interview on 10/17/24 at 10:54 AM, DON B reported that the nurses that count narcotics during shift change should sign the record at that time, to show that they were present, and witnessed the counts. DON B reported that the record for that day was not completed accurately.

This citation pertains to Intake #MI00147517 Based on interview, and record review, the facility failed to prevent the misappropriation of resident medications in 2 of 5 residents (Resident #109 & #110) reviewed for misappropriation of property, when a licensed nurse diverted controlled medications for personal use, resulting in the potential for all residents in the facility to be affected. Findings include: Review of a facility reported incident (FRI) submitted on 10/12/24 at 9:30 PM revealed, Perpetrator: (Registered Nurse (RN) M) .Type of Alleged Incident: Misappropriation, Date/Time Incident Discovered: 10/12/24 at 8:40 PM, Incident Summary: At approximately 8:40 PM NHA (Nursing Home Administrator (NHA) A) was notified that the (local police department) notified the Director of Nursing (DON B) that four cards and one bottle were found in the nurse's house with resident names on them, however, did not state the names of the residents and would not release the names of the residents, counts of the medications or the types of the medication to NHA .Employee suspended pending investigation .Full narcotic count of medications in the facility completed, and pain assessments completed for all residents residing in the facility. Review of a statement from DON B dated 10/12/24, indicated that she had received a call from the local police notifying her that while inside RN M's home, they had discovered narcotic medications that belonged to residents at the facility. Review of a statement from NHA A dated 10/14/24 at 1:22 PM, indicated that he had spoken to the local police department that day and confirmed that they had responded to an incident at RN M's home on 10/12/24. The police department verified the information but was not able to provide any additional details at that time. Review of a statement obtained via phone from RN M dated 10/15/24 revealed, .(RN M) was able to confirm that the medication that was misappropriated was one during the destruction process. (RN M) was also able to confirm that it was around a year ago when their medications were misappropriated. When asked about the resident's names and what medications they were, she stated she was unable to remember the names of the residents and stated that she believes it was Ativan (controlled anxiety medication) and Oxy (Oxycodone: a narcotic pain reliever) that she took from the facility during the destruction process. Review of the police report, obtained by this surveyor on 10/16/24 revealed, .Event occurred from 10/12/24 7:30 PM-10/12/24 9:29 PM .Suspect: (RN M) .located three sheets of prescriptions .All three sheets of prescriptions were prescribed to subjects other than (RN M) .Unprescribed/Stolen Medications: Lorazepam (Ativan) 0.5 mg tablet (sheet): prescribed to: (Resident #109). Prescription # 14275710. 18/60 pills are missing out from the prescription sheet .Oxycodone 5 mg (sheet): Prescribed to: (Resident #110). Prescription #12207906. 44/58 pills are missing out of the prescription sheet. Tramadol HCL (narcotic pain medication) 25 mg (sheet): Prescribed to: (Resident #109). Prescription #14288137. 6/26 pills are missing out of the prescription sheet . In an interview on 10/16/24 at 9:22 AM, Pharmacy Technician (PT) G confirmed that Prescription #14275710 was, Lorazepam prescribed to Resident #109 in March 2024, Prescription #14288137 was Tramadol, prescribed to Resident #109 in June 2024, and Prescription #12207906 was Oxycodone, prescribed to Resident #110 in November 2023. Review of Resident #109's Controlled Substance Proof-Of-Use Record revealed, .RX# (Prescription) 14275710 .Lorazepam 0.5 mg tablet .#60 . The record did not have any doses accounted for and was signed by RN M and witnessed by LPN (Licensed Practical Nurse) K on 7/18/24, indicating that all 60 tablets were destroyed. This was 1 of 2 records for RX# 14275710. Review of Resident #109's Controlled Substance Proof-Of-Use Record revealed, .RX#14275710 .Lorazepam 0.5 mg tablet .#52 . The record indicated that the resident had received 3 doses, and was signed by RN M and witnessed by LPN K on 7/18/24, indicating that 49 tablets were destroyed. This was 2 of 2 records for RX #14275710. Review of Resident #109's Controlled Substance Proof-Of-Use Record revealed, .RX# 14288137 .Tramadol 25 mg tablet .#26 . The record indicated that 2 doses had be administered to the resident. RN M signed to indicate destruction of 24 tablets on 7/18/24 and LPN K signed as a witness to the medication destruction. Review of Resident #110's Controlled Substance Proof-Of-Use Record revealed, .RX# #12207906 .Oxycodone 5 mg tablet .#58 . The record showed zero doses were administered to Resident #110. RN M signed to indicate destruction of 58 tablets on 12/12/23, and RN H signed as a witness to the medication destruction. In an interview on 10/16/24 at 10:09 AM, NHA A reported that LPN K and RN H were both suspended from work, due to their signatures being on the controlled medication records, listed as witness to the destruction of controlled medications that were then located in RN M's home and not destroyed. In an interview on 10/16/24 at 1:29 PM, LPN K reported that she had signed to verifying the destruction of narcotic medication at least 5 times over the past 6 months without visualizing the medication and/or medication card. LPN K reported that RN M would bring her a narcotic medication sheet, saying that she had already destroyed the medications. LPN K reported that she knew the policy was to witness the destruction of narcotic medications, but that she trusted RN M. LPN K reported that she never considered professional standards and/or notifying management regarding the breach of policy. In an interview on 10/17/24 at 12:21 PM, RN H reported that occasionally she would sign that she witnessed the destruction of narcotic medications, without seeing the medication and/or after the first nurse had already popped the pills out of the medication card. RN H reported that there were only a couple of nurses that did it that way, and RN M was the only name she could remember. RN H reported that she knew this was against facility policy but did not report it to anyone. Multiple attempts were made to interview RN M via phone on 10/16/24 and 10/17/24. RN M responded on 10/17/24 at 12:11 PM and declined an interview. In an interview on 10/16/24 at 12:22 PM, Unit Manager (UM) J reported that a controlled substance would be destroyed if a resident discharged , or the medication was discontinued. UM J reported that 2 nurses were required to complete the Controlled Substance Proof-Of-Use record together, indicating the medication destruction was witnessed. Resident #109 Review of Resident #109's Physician Orders for March 2024 revealed, 3 separate orders for Lorazepam 0.5 mg written on 3/14/24, 3/21/24 and 3/27/24. Review of Resident #109's Physician Orders for June 2024 revealed, 1 order for Tramadol 25 mg PRN (as needed) written on 6/14/24. Resident #110 Review of Resident #110's Physician Orders for November 2023 revealed, 1 order for Oxycodone 5 mg written on 11/14/23. In an interview on 10/17/24 at 10:10 AM, DON reported that she had started re-education and was implementing a new policy that would require narcotic medications to be destroyed by only nurse managers, and she would be tracking all narcotics that come into the facility herself going forward. Review of the education log dated 10/15/24 revealed 9 nurses had received re-education on 10/15/24, 4 nurses on 10/16/24, and 1 nurse on 10/17/24. The staff list provided by NHA A indicated a total of 10 nurses employed by the facility and 19 agency nurses. During an observation and interview of medication administration on 10/17/24 at 10:40 AM, the controlled substance proof-of-use binder was reviewed. on B hall. There was a Controlled Substance Shift Inventory record in the front of the binder. The last entry was not dated, indicated a total of 31 RX's were present at the start of the shift, 1 RX was added, and 32 were present at the end of the shift. The entry was signed by an outgoing nurse but was not witnessed by the oncoming nurse. LPN L reported that she had counted that morning when she started her shift, but did not sign the oncoming nurse space, and typically waits to sign until the end of the shift when she counts again. In an interview on 10/17/24 at 10:51 AM, UM C reported that when completing the controlled substance counts at shift change, the outgoing and oncoming nurses should sign at the same time, to ensure the medication counts are witnessed. UM C reported that the re-education related to the controlled substance destruction process did not clarify that the signatures should be recorded at the same time to attest to the count of narcotics. In an interview on 10/17/24 at 10:54 AM, DON B reported that the nurses that count narcotics during shift change should sign the record at that time, to show that they were present, and witnessed the counts. DON B reported that the record for that day was not completed accurately.

This citation pertains to Intake MI00145186 Based on interview, and record review, the facility failed to ensure residents were free from significant medication errors in 1 of 1 resident (R404) reviewed for medication administration resulting in an Immediate Jeopardy when, beginning on 5/23/2024 at approximately 7:46 AM, R404 was administered another residents medications and was found unresponsive. Resident #404 was hospitalized in the ICU (Intensive Care Unit - provides care and life support for acutely ill/injured patients) on BiPAP (Bilevel Positive Airway Pressure - a device that helps with breathing) with a Narcan drip (a medication used to treat an opioid overdose) and the likelihood of further life-threatening deterioration in his medical condition. Findings include: Review of facility policy, Medication Administration-General Guidelines dated June 2019, revealed, Medications are administered as prescribed in accordance with good nursing principles and practices .The Five Rights (Right Resident, Right Drug, Right Dose, Right Route, and Right Time) are applied for each medication being administered .12. Medications supplied for one resident are never administered to another resident . Review of Licensed Practical Nurse (LPN) WW written statement by proxy of Nursing Home Administrator (NHA) A dated 5/23/24 at 1030 AM, indicated she had dispensed (prepped) and administered morning medications to R404 at approximately 7:30 AM. The resident had been in the Garden room and was noted to be tired with his head on a tray table. At approximately 7:45 AM LPN WW prepped R7's medications and handed the cup of medications to LPN XX and told him the room number. LPN WW stated she was unclear if she had given LPN XX the wrong room number or if he had heard her wrong but at approximately 8:35 AM R7 reported to her that he had not received his 8:00 AM medications. LPN WW informed R7 that he had received his medications, however, R7 continued to insist that he had not. LPN WW asked LPN XX if he had administered R7's to him and LPN XX stated, A bigger guy? LPN WW stated, No, that is not (R7). The medication error was reported to the former Unit Manager/Clinical Care Coordinator (UM/CCC) VV who gave direction to complete an incident report with exact times and to notify the Medical Director (MD). Nurse Practitioner (NP responded with orders to monitor R404's vital signs (VS) every 6 hours x (for) 24 hours. Review of LPN XX written statement by proxy of NHA A dated 5/23/24 at approximately 11:45 AM, indicated he offered to run the medications for LPN WW. When LPN WW handed him the medications for R7 she told him These are for (R7's first name which was the same first name as R404) and when he asked for a room number, LPN WW responded room [ROOM NUMBER]. LPN XX stated when he entered room [ROOM NUMBER], he spoke to a resident and asked if he was the man with the first name he was given. The resident responded to the name. The LPN then informed R404 that he had his medications, and the resident did not dispute taking them. Review of LPN WW written statement by proxy of NHA A dated 5/23/24 at 2:27 PM, gave further clarification on the incident that happened earlier in the day involving R404 and other residents. LPN WW indicated she had prepped medications for three residents with LPN XX administering them. LPN WW stated LPN XX had administered medications to the remainder of the residents on the 300 Hall. LPN WW stated all residents on the 400 Hall she had prepped medications and administered with LPN XX. LPN WW then stated immediately upon identifying the medication error of R404, she and LPN XX the facility stopped having her prepping medications and LPN XX administering them. Review of LPN XX written statement by proxy of NHA A dated 5/29/24 4:01 PM indicated the LPN did not remember if R404 had already received his medications and that he had not given the resident his medications twice. The LPN verified he had shown LPN WW which resident he had given R7's to. Review of LPN WW written statement by proxy of NHA A dated 5/29/24 at 4:06 PM, indicated she verified only LPN XX had administered medications once to R404 She also stated she and LPN XX did walk to R404's room in order to show her which resident he gave medications to. R404 According to the Minimum Data Set (MDS), dated [DATE], R404 scored 15/15 (cognitively intact) on his BIMS (Brief Interview Mental Status). Review of R404's Medication Administration Record/Treatment Administration Record (MAR/TAR) dated 5/23/24 at 8:00 AM indicated Licensed Practical Nurse (LPN) WW documented administration of: -allopurinol 100 mg 1 tablet by mouth for gout -glipizide ER (extended release) 10 mg 1 tablet by mouth -lisinopril-hydrochlorothiazide 10-12.5 mg 1 tablet by mouth for hypertension -multivitamin men 50+ 1 tablet by mouth for supplement -apixaban (blood thinner) 5 mg by mouth for Afib -metformin HCL 1000 mg 1 tablet my mouth for diabetes This indicated Resident #404 had received his ordered morning medications. R7 According to the Minimum Data Set (MDS), dated [DATE], R7 scored 13 /15 (cognitively intact) on his BIMS (Brief Interview Mental Status). Review of R7's MAR/TAR dated 5/23/24 indicated at 8:00 AM, LPN WW indicated documented administration of: -Gabapentin 400 mg 1 capsule by mouth for neuropathy -methocarbamol 500 mg 2 tablets by mouth for muscle spasms/phantom pain -aspirin 81 mg by mouth for prophylaxis (preventative) -lotrel 5-20 mg 1 capsule by mouth for hypertension -Miralax17 grams by mouth for constipation -Apixaban (blood thinner) 5 mg 1 tablet by mouth for prophylaxis -hydromorphone HCL (dilaudid) 4 mg by mouth for chronic pain -levetiracetam 750 mg 2 tablets by mouth for seizure disorder -lidocaine External gel 4% topically for right shoulder pain Review of facility medication administration audit received 7/12/24 at 11:27 AM, indicated on 5/23/24 LPN WW signed out medications with LPN XX having administered them: -7:36 AM to resident in room [ROOM NUMBER] bed 1 -7:41 AM to resident in room [ROOM NUMBER] bed 1 -7:46 AM to R7 (incident involving R404 received the medication not R7) -7:52 AM to resident in room [ROOM NUMBER] bed 1 During an interview on 7/10/24 at 3:38 PM, R7 stated, The facility overdosed the guy in the room across the hall from me a while back. The staff gave him my meds (medications). He was not my roommate. They (nurses/facility) were worried about their own asses and not the man they overdosed. During an interview on 7/11/24 at 2:10 PM, LPN WW stated, I worked at the facility for a little over a month by 5/23/24. I kinda sorta had orientation when I started. It consisted of a walk-through of the facility. There was no orientation on policy. I have been a nurse since 2002. I know the rights of medication (meds) administration. On May 23 rd (2024), I was passing meds with an agency nurse (LPN XX). We were working out of the same med cart. I gave (LPN XX) medications I had pulled to give to (R7). I do not know if I gave the LPN the wrong room number or he heard me wrong, but he gave the wrong person the wrong meds. Once (R7) came to the med cart and said he did not get his morning meds, (LPN XX) and I went looking for the resident that got (R7's) medications. (LPN XX) told me did not give the meds to (R7). I had been pulling meds that morning and (LPN XX) was giving them. I was working behind because the med pass was heavy and falling behind. I delegated the meds to (LPN XX) because I was getting behind, I was a newer nurse to the facility. (LPN XX) just started to work that morning. (LPN XX) was learning the residents and so was I. When a nurse pulls up the MAR it tells you the resident's room number and gives their picture. There was also a printed sheet with resident room numbers. I knew I did wrong by pulling the medications and having the other LPN administer them. The meds were given by (LPN XX) around 8:30 AM. (R7) came to the med cart around 8:30 AM asking for his meds. I told him he already got them, and he argued with me. (LPN XX) said he gave the meds to a bigger guy (R404) and I told him that was not (R7). I gave (R404) his meds at 7:30 AM in the Garden Room. He was drowsy and laying across a bedside table. I had a hard time waking him, he took the meds, and went back to sleep. I left him there. (R404) was not in a wheelchair. He must have walked back to his room where (LPN XX) found him and gave him (R7's) meds. When (R404) was found in his room later that morning by (LPN XX and I. He was sitting in a chair. He was alert and (LPN XX) verified he had given (R7's) medication to (R404). We went immediately to (Unit Manager (UM) VV) reporting the wrong meds had been given to the wrong person. I went back to passing meds at the same med cart. The DON (Director of Nursing) came to see me about 20-30 minutes later and sent me home. During an interview on 7/11/24 at 2:43 PM, LPN XX stated, I am an agency LPN. I have been a nurse for [AGE] years. May 23 rd (2024) was my first day at the facility. I did not get any orientation. The first day I arrived, I was paired up (LPN WW) who was in her orientation process. We decided she would pull meds and I would pass them. (R404) was about the 4th resident we did this together. (LPN WW) would tell me the resident name and room number and I repeated it back to her and she would say yes. After the incident with (R404) we maybe did 5 more residents the same way. (R7) came up to the med cart saying he had not gotten his meds yet that morning. (LPN WW) told him we had given him his meds already. I told her that I had not given medications to (R7). (LPN WW and I found (R404) and she told me he was the wrong resident. We told the Unit Manager right away that we had a med error. The Unit Manager told us to call the doctor who told us to monitor (R404) and do vital signs (VS) every 4 hours. I got a first set a VS on (R404) who was stable. We went back to the med cart and on to the next resident where she passed meds and I watched. The Unit Manager told me to go sit with (R404) and do vital signs every 15 minutes. The second time VS were taken (R404) was slurring his speech and lethargic. I told a CNA (certified nursing assistant) to get the Unit Manager. The doctor came to the room, ordered Narcan, and it was administered. (R404) responded and then started to decline. A second Narcan was ordered and 911 was called. (R404) came around but was confused. EMS (Emergency Medical Services) arrived and gave oxygen. The resident's POX (oxygen level) was in the high 80s. 87-90. I do not know what the medications I gave him. I know the 5 Rights of Medication Administration. I did the best of my ability May 23 rd. I took the meds and went to what I though was (R7's) room. (R404) responded when and went into the room. I did not pull the meds. I watched the MAR as (LPN WW) pulled meds and saw a first name but not a picture in the medical record. I watched the LPN pull a med out of the narcotic (controlled substance) drawer, but I did not look at what med it was or the name on the card. I do not know what meds were pulled. I was told by the Unit Manager the facility normally does have names on room doors or wrist bands. He did not have on a wrist band, a name on the room door, or a picture in medical record. I know better than to administer medications the way I did. A nurse new to a facility should never orient with a nurse that is on orientation too. Ever. During an interview on 7/11/24 at 3:35 PM, R404 stated, I was a resident at the facility in May (2024). I went to the room that was a lounge that morning, was given my medications by a lady, who said she was a nurse then I went back to my room. About 5 minutes later a man nurse came to my room and called out my first name. I said my first name. He did not ask me my last name. He said he had meds for me. I said I got my meds a short time ago by the lady nurse. He said the meds were mine. He said he had been a nurse for about [AGE] years and should know how to pass meds and that he knew they were my meds. He insisted he had my medications. I got tired of arguing with the nurse. He should have checked my ID. I still had the hospital bracelet on from the day before. I took the medications he insisted were mine. The next thing I knew I was in the hospital. I was told I was unresponsive. I was given something to work against the meds. I remember I thought I was in some kind of fantasy world because of the wrong meds. I groped the nurse and that was not me. I apologized to the nurse. Once I got out of the ER (emergency room ) and they put me in ICU (intensive care unit). Then I was sent back to the nursing home for two weeks and finally went home. I originally went to the nursing home because I had Afib. And was sent to rehab at the nursing home. During an interview on 7/12/24 at 9:00 AM, NHA A stated, I do not know all of the medications that (R404) was given. I did not know (R404) got a muscle relaxer that was meant for (R7). During an interview on 7/12/24 at 9:15 AM, Director of Nursing (DON) B stated, I do the staff training. (LPN WW) worked here for almost a month when the incident happened. She had a couple of mentors. I never saw her orientation check list. I do not know what the mentors documented on it about her. She needed more time to learn the flow of the building and. It was not the intention to have (LPN XX) pass medications with her. It was his first day. He was to be doing treatments and new admissions if any came in. He did not have an orientation check list. Agency are on their own when come to work at the facility. Review of R404's Practitioner Progress Note dated 5/23/24 at 1:54 PM, revealed, .called to see new resident urgently this morning due to hypoxia and altered mental status .had inadvertently been given the medication of a different resident. These included dilaudid, Gabapentin, and Keppra (muscle relaxant) .breathing more shallow, less responsive, and diaphoretic (sweating) .was not able to speak .gave Narcan 4 mg nasally .pulse weakened .given second dose of Narcan .lungs with crackles and decreased breath sounds lower half .heart irregular .EMS arrived .transported to ED . Review of R404's ED (Emergency Department) Provider Note dated 5/23/24, revealed, .Patient presented with unintentional medication overdose. Was given Dilaudid and Gabapentin. Was hypoxic (low level of oxygen in body tissues) and required Narcan (medication to treat narcotic overdose) in field. On arrival here, we did give him multiple doses of Narcan. Eventually started on Narcan drip. Was still sleepy. Noted to have hypercapnia (buildup of carbon dioxide in bloodstream). Did require hospitalization .Diagnosis: Acute hypercapnic respiratory failure . mistakenly given another patient's medication .At approximately 8:30 AM, he was given 4 mg of PO (by mouth) dilaudid and 800 mg Gabapentin that was intended for a different patient. Shortly thereafter he became unresponsive and desatted (blood oxygen levels dropped) to 70s Over the course of an hour (R404) became more somnolent (solemn state) and harder to arouse . gave him a total of 2 mg of Narcan .Toxicology was consulted in the emergency department. They recommended to start a Narcan drip .started the drip at 0.4 milligrams/hour, but incrementally increased the dose .ordered a VBG (venous blood gas test) which showed pH of 7.08 (7.32-7.42) pCO2 132 (38-52), bicarb 36.5 (22-32). He was started on BiPAP FiO2 40%. A second VBG approximately 40 minutes later showed minimal improvement. He was transferred to the intensive care unit for further management .Based on last blood pressure taken in the ED of (!) 191/176 .admitted to hospital for acute hypoxic respiratory failure and chest pain. Cardiology believed chest pain was likely type 2 MI (myocardial infarction (heart attack)) .05/23/24 1646 (4:46 PM) INSERT ARTERIAL LINE .CRITICAL CARE ARTERIAL BLOOD GAS - Abnormal; requiring BiPAP -pH, Arterial 7.19 (7.35 -7.45) -pCO2, Arterial 88.1 (35.0-45.0) -Bicarbonate, Arterial 32.7 (20.0-28.0) -Base Excess, 4.5 (2.0 - 2.0) Assumed care from previous physician care at 1:00 pm .Blood gas showed he is significantly acidotic with CO2 retention .Toxicology was consulted .quickly transitioned over to BiPAP and patient was frequently stimulated to try to maintain respirations .required near constant stimulation to keep him awake however and is at high risk for intubation .admitted to the intensive care unit on Narcan drip and BiPAP with close respiratory monitoring, but remains at high risk for decompensation .Critical care time was required due to the life threatening nature of this patient's condition .Heparin gtt (IV drip) started .Lines: Art, PIV .Airways: BiPAP .SUBJECTIVE: Upon presentation to the emergency department the patient was hemodynamically stable but requiring 4 L nasal cannula to maintain appropriate saturations which eventually escalated to BiPAP. The patient received 5 doses of Narcan and subsequently placed on a Narcan drip with some improvement in his mentation. Lab work was significant for a significant respiratory acidosis. The patient was evaluated by toxicology in the emergency department and recommended supportive measures and titratable Narcan in an effort to avoid intubation .Objective .in acute distress .cardiovascular rhythm irregular .Pulmonary .Tachypnea and accessory muscle usage present . Review of R404's Hospital Toxicology Consultation Note dated 5/23/24, revealed, Accidental narcotic ingestion .received total of 5 doses of Narcan and presently is on a Narcan drip .UA not known if the Narcan will be sufficient to return around his respiratory issues and he may require intubation. He remains poorly responsive and requires stimulation to continue participation with the BiPAP. The Narcan may be of little benefit at this point but it will not hurt the patient to increase the dose if attempting to prevent intubation. Care otherwise remains supportive symptomatic. Ingestion includes Neurontin (Gabapentin) and Dilaudid (hydromorphone) .he has severe hypercapnia with a pCO2 of 121 and pH of 7.1. He presently is on BiPAP and a Narcan drip . On 7/11/24, NHA A was notified of the Immediate Jeopardy that began on 5/23/24 due to the facility failing to prevent a serious medication error for Resident #404 requiring hospitalization and admission to the intesive care unit. On 7/11/24, this surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1. Newly hired nurses to only be assigned to follow facility nurses as of 05/23/2024. 2. Medication Administration Guidelines policy was reviewed by the administrator and Director of Nursing and deemed appropriate on 05/23/2024. 3. Medication Administration - General Guideline to be followed at each medication pass. 4. On 5/23/24, daily schedules were reviewed by the DON and scheduler to ensure appropriate nurse orientation practice is occurring. 5. On 5/23/24, education was completed to nurses on medication administration-general guidelines was initiated; any facility staff member and agency staff member who did not receive education by 5/23/24 will receive education prior to the start of their next shift. All facility staff and agency staff who were present at the time of the incident were immediately educated. As of 5/23/24, all facility staff and agency staff have completed the necessary required education. Education is completed for all new hires prior to their first shift. 6. Medication administration audits began the week of 05/23/2024 and were completed weekly x 2 weeks then monthly x 2 months to ensure the Medication Administration Guidelines were being completed. 7. Beginning on 05/23/2024, DON completed daily schedule audits when there was a nurse on orientation to ensure that they are scheduled with a facility nurse - ongoing 8. NHA/designee began to complete resident identifiers audits starting 05/23/2024 to ensure there was a picture uploaded to PCC (electronic medical records) and room is identified with the resident name once weekly x 2 weeks then monthly x 2 months. 9. Results of audits have been reviewed with the QAA committee on May 30th and June 20th to ensure compliance and any further recommendations. During an observation on 7/9/24 at 7:55PM, Resident #15 was observed to have plastic cup with medications left at her bedside. Review of the medical record revealed Resident #15 had a medication administration review on 6/22/2013 that indicated she was unsafe to self-administer medicaitons. This required additional training for nursing on the medication administration policy. 10. Additional education provided on the Medication Administration - General Guidelines policy (2023) to 8 out of 21 licensed nurses, including licensed agency nurses on 07/12/2024. All licensed nurses including agency nurses will have education on the Medication Administration - General Guidelines policy completed prior to the beginning of their next shift. Although the immediate jeopardy was removed on 7/12/24, the facility remained out of compliance at a scope of isolated and severity of actual harm that is not Immediate Jeopardy because education had not yet been completed and sustained compliance had not yet been verified by the State Agency.

This citation pertains to MI00145581. Based on interview and record review, the facility failed to prevent the elopement and ensure the safety in 1 of 2 residents (Resident #305) reviewed for elopements, resulting in an Immediate Jeopardy when on 6/13/2024 at approximately 8:34 PM, Resident #305, who was cognitively impaired exited the facility by facility staff when he was mistaken for a visitor and traveled on foot along a busy road with a speed limit of 40 miles per hour looking for his sister. Resident #305 was found by community members who returned him to facility staff who were searching for him and they brought him back to the facility. This deficient practice placed Resident #305 and other residents identified as at risk for elopement at risk for serious harm, injury, and/or death. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R305 admitted to the facility on [DATE] with diagnoses of mild cognitive impairment and psychomotor agitation (unintentional and purposeless motions and restlessness sometimes accompanied by emotional distress). Brief Interview for Mental Status (BIMS) reflected a score of 5 out of 15 which indicated R305 was severely cognitively impaired (00 to 07 is severe cognitive impairment). Review of the Elopement and Wandering Residents Policy with an Implementation Date of 3/2008 and a Review/Revision Date of 5/2024 revealed Policy Explanation and Compliance Guidelines: 5. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 6. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering: a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay. Review of Agency Licensed Practical Nurse (LPN) II's progress noted dated 6/13/2024 after R305's elopement revealed, At 8:48pm the writer was alerted by staff that the resident mentioned was not in his room and had been let outside of the building around 30 minutes prior. He was seen going north bound in the parking lot towards Forest Hill Ave. The elopement protocol was initiated and the writer vocalized to the staff that she was going to start heading north and go east down Forest Hill Ave while the other staff headed west in search of said resident. Meanwhile the remaining staff accounted for all other residents in the building and did and all clear to ensure that (R305) was the only one unaccounted for. While heading eastbound on forest hill ave the writer spotted the resident on the corner of [NAME] Dr SE and Forest Hill Ave with two individuals. The writer approached the group and identified herself. The individuals stated that he was confused and tried to enter their home. He was able to call his sister from the male's cell phone and the two parties agreed to meet at Forest Hills Food at 9pm. They were heading there when I approached them. The writer thanked them for their help and both the writer and resident returned to the facility. Once at the facility the writer accessed the resident for injuries and pain. The resident denied any pain and reported being hot and tired. In an observation on 7/11/2024 at 4:15 PM, noted the route that R305 took was from the parking lot at the facility going north and uphill to main road which was a busy road with a speed limit of 40 mph. R305 then headed East to where the sidewalk ended approximately 0.25 miles down. R305 walked down to the road approximately 0.6 miles away from the facility unsupervised until community members found him. During an interview on 7/12/2024 at 11:48 AM, Licensed Practical Nurse (LPN) DD stated that on 6/13/2024 she stayed over to complete Relias training (educational training) since she was still in orientation. LPN DD said that she clocked out at 8:34 PM and was getting ready to go out the door when staff sitting at the nurse's station asked her to let 2 gentlemen out of the facility. She stated that she knew one was a resident who was going out to smoke and the other one she didn't know (R305) and assumed he was okay to let out since staff told her to let him out. During an interview on 7/12/2024 at 10:58 AM, Certified Nursing Assistant (CNA) D stated that she came in on 6/13/2024 around 7 PM and around 8:15/8:30 PM, R305 approached her at the nurses' station and asked her to call his sister because he wanted to know if she was coming in later that night. CNA D said she called R305's sister and his sister said she wasn't coming in that night and would be in the next morning. CNA D stated that R305 walked back to his room and that was the last time she saw him. Then, approximately 15 to 20 minutes later a code search was implemented for R305. During an interview on 7/12/2024 at 2:39 PM, CNA BB stated on 6/13/2024 she was doing her Relias training at the nurses' station when R305 went up to her and said he needed to go to the hospital. CNA BB said she thought R305 was a visitor and was going to see family at the hospital. She noticed at that time that LPN DD was leaving and asked if she was leaving and then saw R305 go out with her. During an interview on 7/12/2024 at 3:10 PM, CNA E stated on 6/13/2024 she was doing her Relias training at the nurses' station Relias with CNA BB when she saw LPN DD and a man (R305) leaving with her. CNA E said that she didn't know he was a resident until 30 minutes later when she found out he was a resident and was missing. CNA E stated that R305 was missing for 20 to 30 minutes before anyone realized he was missing. Review of the Admission/Readmission assessment dated [DATE] under Section D. Safety/Fall Risk revealed that R305 had a history of falls and fell in the last month prior to admission at the facility. Under Section E. Elopement Risk Assessment showed that R305 didn't have any elopement attempts at previous residence, didn't have a history of wandering at previous residence and didn't have 1 or more attempts to elope in the last 90 days. Under 6. Behavioral Symptoms, a. Intrudes into other resident rooms. Has delusions, such as need to go out and [NAME] the lawn; Expressions of confusion, Fear, Disorientation; Short attention span; Excessive motor activity; Wanders was checked yes. Under 7. Other Diagnosis Affecting Cognitive Status or Memory, a. Dementia, Depression, Anxiety, Delusional Disorder, mental Illness, Closed Head Injury, Other was checked yes. Under 9. Elopement Risk a. Is the Resident At Risk for Elopement? was checked no. Review of the Elopement Risk assessment dated [DATE] after R305 eloped under 1. History of Wandering and/or Elopement revealed d. Resident has made one (1) or more attempts to elope from either previous or current residence in the last 90 days was checked yes. Under 9. Elopement Risk a. Based upon the assessment above, the resident is determined to be at risk for elopement? was checked yes. Review of the Inpatient Bedside Nurse Warm Handover to Subacute Nurse form that is completed by the nurse for all new admissions prior to admission from discharging facility revealed a section at the bottom titled safety risks. During an interview on 7/12/2024 at 10:04 AM, Registered Nurse (RN) T stated that prior to admission a report is received from the hospital and they fill out the Inpatient Bedside Nurse Warm Handover to Subacute Nurse form to make sure all information is captured prior to admission. RN T said that elopement risk wasn't brought up with R305 from the hospital and hasn't been brought up since she has worked at the facility or with any new admits prior to R305 eloping. During an interview on 7/12/2024 at 2:36 PM, Director of Nursing B stated that she wasn't sure if she could find the Inpatient Bedside Nurse Warm Handover to Subacute Nurse form for R305. DON B also stated that they had wander guards available in the facility prior to 6/13/2024 if they needed to put one on a resident. Review of Practitioner Progress notes dated 6/14/2024 completed by Nurse Practitioner (NP) YY revealed, Patient is seen today by provider following admission to facility. Medications, labs, nursing notes, and plan of care reviewed with patient and nursing. Extensive time spent reviewing patient and plan of care with IDT and nursing. Pt arrived to facility on 6/13/24 and shortly there after eloped from the facility. Pt was found and returned to the facility unharmed. Review of hospital paperwork showed elopement behaviors upon initial arrival to hospital, suspected to be d/t change (due to) of environment, but did not continue throughout hospital stay. During an interview on 7/16/2024 at 9:49 AM, NP YY stated that the day after R305 eloped they had a IDT (interdisciplinary team) and the team was looking into R305's elopement and someone found information about his elopement behaviors at the hospital. NP YY said that elopement risk wasn't on the referral from the hospital since it happened initially at the hospital and not afterwards otherwise, they would have discussed the change of environment at the facility and put interventions into place. During an interview on 7/12/2024 at 2:36 PM, Nursing Home Administrator (NHA) A stated that Social Worker Advocate (SWA) C was the only one in the facility that has access to EPIC (hospital electronic medical record). NHA A stated that SWA C was able to find R305's hospital notes in EPIC regarding his elopement behaviors at the hospital. During an interview on 7/16/2024 at 10:03 A, SWA C stated that she found R305's hospital notes through EPIC the day after R305's elopement since they were discussing R305 at IDT and she started digging into his notes and found that he had elopement behaviors. SWA C said that she looks at EPIC with discharge planning and for her profession only. SWA C stated that the facility has an admissions team off site that gives information to nursing and should be doing a thorough review prior to admitting a resident. On 7/12/2024 at 9:18 AM, NHA A was notified of an Immediate Jeopardy that began on 6/13/2024 when R305 exited the facility when he was mistaken for a visitor. On 7/12/2024, this surveyor verified the facility completed the following to remove the Immediate Jeopardy. The Abatement was accepted on 7/12/2024 at 4:04 PM. 1. R305 was placed on a 1:1 supervision upon return to the facility. - 6/13/24 2. Employee placed on administrative leave. - 6/13/24. Upon return from administrative leave, this staff member was provided 1:1 education on the elopements and wandering residents policy. 3. All newly admitted residents that have a guardian or activated DPOA were identified as being at risk for this deficient practice. - 6/13/24 4. All resident's elopement risk assessments reviewed and any identified elopement risks residents that were currently residing in the facility were reviewed to ensure appropriate interventions were in place. - 6/13/24 5. External door checks were completed by the Administrator. - 6/13/24 6. All-staff re-education was initiated. - 6/13/24 7. On 6/13/24, education was completed to all-staff on elopement and wandering residents policy was initiated; any facility staff member and agency staff member who did not receive education by 6/13/24 will receive education prior to the start of their next shift. All facility staff and agency staff who were present at the time of the incident were immediately educated. As of 6/13/24, all facility staff and agency staff have completed the necessary required education. Education is completed for all new hires prior to their next shift. 8. Administrator/designee audited daily door alarms checks as of 6/13/2024 to ensure proper functioning of the egress and wander guard system. The audits have been conducted weekly for four weeks and then monthly for two months. 9. Elopement drill has been completed on 06/26/2024 and 06/17/2024. 10. Director of Nursing/designee audited new admission elopement risk assessments as of 6/13/2024 to ensure proper interventions have been placed if a resident triggers as an elopement risk and to verify a wander guard is in place for the first 7-days if the resident has a legal decision maker. The audit has been conducted weekly for four weeks and then monthly for two months. During an interview on 7/12/2024 at 1:56 PM, NHA A stated that door alarm checks are supposed to be done daily by maintenance and someone is delegated on weekends/holidays. While reviewing the daily door alarm checks it was noticed that several days were missed and not checked and NHA A said that he audits the door alarm checks weekly and knows there are holes on the sheets. NHA A stated that someone is delegated on weekends and holidays to do door alarm checks, usually a housekeeper who failed to do it and maintenance failed to check and make sure he handed it down to the housekeeper. NHA A was unable to find sheets for the missing days in the maintenance office. Although the immediate jeopardy was removed on 7/12/2024, the facility remained out of compliance with a scope of isolated and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to daily door alarm checks not being completed and sustained compliance had not yet been verified by the state agency.

This citation pertains to MI00145186 Based on observation, interview, and record review the facility failed to follow professional standards of practice for nursing for 1 of 18 residents (R404) reviewed for significant medication errors resulting in R404 receiving another resident's medications including opioids, experienced respiratory failure, and sent to the hospital for life-sustaining treatment. Findings include: R404 According to the Minimum Data Set (MDS), dated [DATE], R404 scored 15/15 (cognitively intact) on his BIMS (Brief Interview Mental Status). R7 According to the Minimum Data Set (MDS), dated [DATE], R7 scored 13 /15 (cognitively intact) on his BIMS (Brief Interview Mental Status). Review of R7's MAR/TAR dated 5/23/24 indicated at 8:00 AM, LPN WW indicated documented administration of: -Gabapentin 400 mg 1 capsule by mouth for neuropathy -methocarbamol 500 mg 2 tablets by mouth for muscle spasms/phantom pain -aspirin 81 mg by mouth for prophylaxis (preventative) -lotrel 5-20 mg 1 capsule by mouth for hypertension -Miralax17 grams by mouth for constipation -Apixaban (blood thinner) 5 mg 1 tablet by mouth for prophylaxis -hydromorphone HCL (dilaudid) 4 mg by mouth for chronic pain -levetiracetam 750 mg 2 tablets by mouth for seizure disorder -lidocaine External gel 4% topically for right shoulder pain Review of Licensed Practical Nurse (LPN) WW written statement by proxy of Nursing Home Administrator (NHA) A dated 5/23/24 at 1030 AM, indicated she had dispensed (prepped) and administered morning medications to R404 at approximately 7:30 AM. At approximately 7:45 AM LPN WW prepped R7's medications and handed the cup of medications to LPN XX and told him the room number. LPN WW stated she was unclear if she had given LPN XX the wrong room number or if he had heard her wrong but at approximately 8:35 AM R7 reported to her that he had not received his 8:00 AM medications. LPN WW informed R7 that he had received his medications, however, R7 continued to insist that he had not. LPN WW asked LPN XX if he had administered R7's to him and LPN XX stated, A bigger guy? LPN WW stated, No, that is not (R7). The medication error was reported to the former Unit Manager/Clinical Care Coordinator (UM/CCC) by both nurses, R404 had received R7's medications. Review of LPN XX written statement by proxy of NHA A dated 5/23/24 at approximately 11:45 AM, indicated he offered to run the medications for LPN WW. When LPN WW handed him the medications for R7 she told him These are for (R7's first name which was the same first name as R404) and when he asked for a room number. LPN XX stated when he entered the stated room, he spoke to a resident and asked if he was the man with the first name he was given. The resident responded to the name. LPN XX then informed R404 that he had his medications. During an interview on 7/11/24 at 3:35 PM, R404 stated, I was a resident at the facility in May (2024). I went to the room that was a lounge that morning, was given my medications by a lady, who said she was a nurse then I went back to my room. About 5 minutes later a man nurse came to my room and called out my first name. I said my first name. He did not ask me my last name. He said he had meds for me. I said I got my meds a short time ago by the lady nurse. He said the meds were mine. He said he had been a nurse for about [AGE] years and should know how to pass meds and that he knew they were my meds. He insisted he had my medications. I got tired of arguing with the nurse. He should have checked my ID. I still had the hospital bracelet on from the day before. I took the medications he insisted were mine. The next thing I knew I was in the hospital. I was told I was unresponsive. Review of LPN WW written statement by proxy of NHA A dated 5/23/24 at 2:27 PM, gave further clarification on the incident that happened earlier in the day involving R404 and other residents. LPN WW indicated she had prepped medications for three residents (R34, R353, and R49) with LPN XX administering them. LPN WW stated LPN XX had administered medications to the remainder of the residents on the 300 Hall. LPN WW stated all residents on the 400 Hall she had prepped medications and administered with LPN XX. During an interview on 7/10/24 at 3:38 PM, R7 stated, The facility overdosed the guy in the room across the hall from me a while back. The staff gave him my meds (medications). He was not my roommate. During an interview on 7/11/24 at 2:10 PM, LPN WW stated, I have been a nurse since 2002. I know the rights of medication (meds) administration. On May 23 rd (2024), I was passing meds with an agency nurse (LPN XX). We were working out of the same med cart. I gave (LPN XX) medications I had pulled to give to (R7) he gave the wrong person the wrong meds. Once (R7) came to the med cart and said he did not get his morning meds. (LPN XX) told me did not give the meds to (R7). I had been pulling meds that morning and (LPN XX) was giving them. I delegated the meds to (LPN XX). I knew I did wrong by pulling the medications and having the other LPN administer them. The meds were given by (LPN XX) around 8:30 AM. (R7) came to the med cart around 8:30 AM asking for his meds. I told him he already got them, and he argued with me. (LPN XX) said he gave the meds to a bigger guy (R404) and I told him that was not (R7). I gave (R404) his meds at 7:30 AM in the Garden Room. He was drowsy and laying across a bedside table. I had a hard time waking him, he took the meds, and went back to sleep. I left him there. He must have walked back to his room where (LPN XX) found him and gave him (R7's) meds. We went immediately to (Unit Manager (UM) VV) reporting the wrong meds had been given to the wrong person. I went back to passing meds at the same med cart. During an interview on 7/11/24 at 2:43 PM, LPN XX stated, I have been a nurse for [AGE] years. The first day I arrived, I was paired up (LPN WW) who was in her orientation process. We decided she would pull meds and I would pass them. (R404) was about the 4th resident we did this together. (LPN WW) would tell me the resident name and room number and I repeated it back to her and she would say yes. After the incident with (R404) we maybe did 5 more residents the same way. The Unit Manager told me to go sit with (R404) and do vital signs every 15 minutes. The second time VS were taken (R404) was slurring his speech and lethargic. The doctor came to the room, ordered Narcan, and it was administered. (R404) responded and then started to decline. A second Narcan was ordered and 911 was called. I do not know what the medications I gave him. I took the meds and went to what I thought was (R7's) room. (R404) responded when I went into the room. I did not pull the meds. I watched the MAR as (LPN WW) pulled meds and saw a first name but not a picture in the medical record. I watched the LPN pull a med out of the narcotic (controlled substance) drawer, but I did not look at what med it was or the name on the card. I do not know what meds were pulled. (R404) did not have on a wrist band, a name on the room door, or a picture in medical record. I know better than to administer medications the way I did. Review of R404's ED (Emergency Department) Provider Note dated 5/23/24, revealed, .Patient presented with unintentional medication overdose. Was given Dilaudid and Gabapentin. Was hypoxic (low level of oxygen in body tissues) and required Narcan (medication to treat narcotic overdose) in field. On arrival here, we did give him multiple doses of Narcan. Eventually started on Narcan drip. Was still sleepy. Noted to have hypercapnia (buildup of carbon dioxide in bloodstream). Did require hospitalization .Diagnosis: Acute hypercapnic respiratory failure . mistakenly given another patient's medication .At approximately 8:30 AM, he was given 4 mg of PO (by mouth) dilaudid and 800 mg Gabapentin that was intended for a different patient. Shortly thereafter he became unresponsive and desatted (blood oxygen levels dropped) to 70s Over the course of an hour (R404) became more somnolent (solemn state) and harder to arouse . gave him a total of 2 mg of Narcan .Toxicology was consulted in the emergency department. They recommended to start a Narcan drip Lab work was significant for a significant respiratory acidosis. The patient was evaluated by toxicology in the emergency department and recommended supportive measures and titratable Narcan in an effort to avoid intubation .Objective .in acute distress .cardiovascular rhythm irregular .Pulmonary .Tachypnea and accessory muscle usage present . Review of R404's Toxicology Consultation Note dated 5/23/24, revealed, Accidental narcotic ingestion .received total of 5 doses of Narcan and presently is on a Narcan drip .UA not known if the Narcan will be sufficient to return around his respiratory issues and he may require intubation . Review of facility policy, Medication Administration-General Guidelines dated 2/2019, revealed, Medications are administered as prescribed in accordance with good nursing principles and practices .The Five Rights .Right Resident, Right Drug . are applied for each medication being administered. A triple check of these five Right Rights is recommended at three steps in the process of preparation of a medication for administration .B. Administration .5) The person who prepares the dose for administration is the person who administers the dose. 6) Residents are identified before medication is administered. Methods of identification include: a. checking a photograph attached to the medical record b. checking an identification band c. asking the resident to verify his/her name d. verifying resident identification with other facility personnel . 12. Medications supplied for one resident are never administered to another resident .the nurse who administers the medication records the administration on the resident's MAR immediately after the medication is given .

This citation pertains to intake: MI00145580 Based on record review and interview, the facility failed to ensure residents recieved care in accordance with residents needs in 2 of 18 residents (Resident #27 and Resident #406) review for quality of care, resulting in Resident #27 not receiving appropriate assessment and treatment for a injury of unknown origin, and Resident #406 not attending follow up appts with surgeon following spinal fusion surgery. Findings include: Resident #27: Review of an Admission Record revealed Resident #27 was a male with pertinent diagnoses which included dementia, abnormal posture (added 5/25/24), pain in right hip (added 6/25/24), pain in right knee (added 6/18/24), stroke, polyneuropathy (damage/disease affecting peripheral nerves on both sides of the body featuring weakness, numbness, and burning pain), dysphagia (damage to the brain responsible for production and comprehension of speech), dorsalgia (back pain), muscle weakness, unsteadiness on feet, lack of coordination, paralysis, cognitive communication deficit (progressive degenerative brain disorder resulting in difficulty with thinking and how someone uses language) and fracture of right hip. Review of current Care Plan for Resident #27, revised on 3/9/23, revealed the focus, .I am at an increased risk for falls r/t (related to) orthostatic hypotension, muscle weakness, polyneuropathy, open area to left foot . with the intervention .Be sure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to all requests for assistance .Enable bar on right side of bed .Ensure that I am wearing non-skid footwear .I need a specialty wheelchair: Regr with pummel cushion and right-side lateral support, and left side arm rest to help reduce my risk for falls. A Device Assessment will be documented per policy to ensure proper use of such equipment (5/21/24) .PT/OT wheelchair /room evaluation .Reduce my risk for falling by cleaning up spills or clutter from my floor, provide glare-free lighting, accessible working call light, bed set at height deemed appropriate by PT/OT/Nurse (as applicable), my personal items within reach .Review information on past falls and attempt to determine cause of falls. Record possible root cause(s) and remove any potential causes as applicable .Staff to check and change resident and offer assistance to use toilet if awake .Fall Interventions: Offer to assist resident to get up in wheelchair for all meals. Bed against wall, enabler bar and fall mat to left side of bed (6/5/24) . Review of Nursing Progress Note dated 5/11/2024 at 7:00 PM, revealed, .Event occurred on 05/11/2024 at 6:50 PM. Resident fell out of wheelchair trying to propel self out of room into the hallway . Review of Nursing Progress Note dated 5/11/2024 at 11:19 PM, revealed, .Resident returned from (Local Hospital) ER department via stretcher by (Transport services). Head CT negative. Left eyebrow laceration glued together and covered with a bandaide. No new orders written, monitor laceration site for s/sx of infection . Review of Practitioner Progress Note dated 5/14/24 at 10:29 AM, revealed, .Pt is 67 y/o male with PMH significant for dementia, hx of CVA, anxiety, depression, HTN, HLD, hx of substance abuse and hemiparesis of L side. Pt is seen today by provider to follow up post ED visit for fall over the weekend. Nursing reports that patient fell out of his wheelchair trying to propel himself down the hallway. He did end up hitting his head and was evaluated in the ED. Pt did sustain a laceration to his left eye brow without need for sutures and head CT was negative for acute changes. Pt reports that he is feeling scared after the fall. He denies any pain or injuries as a result of the fall. I fell out of my wheelchair. He denies headache, neck pain, vision changes, or pain anywhere else. He continues to express that he feels scared as a result of the fall . Review of Nursing: Antigravity Team Note dated 5/15/2024 at 1:24 PM, revealed, .Root Cause(s) of Fall: IDT met and discussed residents most recent fall. Per resident's medical record the resident experienced a fall in the doorway of his room going into the hallway. Resident was unable to express what had happened however interview of staff notes that the resident will frequently use items in his environment to assist with propelling his w/c and it is felt that the resident had used the doorframe of his bedroom in an attempt to pull himself into the hallway ultimately pulling himself out of his w/c. Resident had on proper footwear, the call-light had not been activated due to the resident being in the doorway and the call-light being located on the bed. Assessment of the resident's w/c notes a standard w/c with a standard cushion. Review of resident's diagnoses note a diagnosis of embolic stroke with residual left sided weakness .New Interventions: - seating and positioning eval with noted addition of pummel cushion, right-side lateral support, left side arm rest . Review of Secure Conversation dated 6/14/24, revealed, .HI (first name of NP), resident has been complaining of pain on his right leg. No swelling or injury . Response: .Okay, thank you, please utilize prn (as needed) pain medicine. This is chronic . Review of Medication Administration Note dated 6/18/24 at 08:27 AM, .Give 2 tablets by mouth every 6 hours as needed for PRN (as needed) for pain .Resident requested for Right leg pain . Review of Medication Administration Note dated 6/18/24 at 12:53 PM, .Give 2 tablets by mouth every 6 hours as needed for PRN (as needed) for pain .PRN Administration was Ineffective . Review of Nursing Progress Note dated 6/18/24 at 9:10 PM, revealed, .Resident was slapping his right leg with his hand and yelling out throughout the morning. This nurse spoke with NP (nurse practitioner) in building and requested Right knee x-ray d/t (due to) resident nodding his head to feeling new and sharp pain in right thigh. X-ray resulted with -FINDINGS: Multiple views of the right knee show normal alignment without acute fractures or dislocations .Med staff notified of results and order Voltaren gel to Right knee TID (three times a day) for pain management. This nurse requested something different d/t (due to) resident rubbing leg constantly and being observed rubbing his face throughout the day. Med staff wished to continue with order. Resident declined lunch and dinner. Resident also declined any pain meds d/t him stating, they make me sleepy. This nurse spoke with med staff regarding his most recent return from hospital with no order for his Lyrica that he has been on in the past. Resident allowed this nurse to administer PRN Tylenol this morning with difficulty, with minimal effect. Resident allowed this nurse to apply Lidocaine patches to knee and thigh area of Right leg. This nurse assessed resident after dinner d/t CNA stating resident declined to eat dinner as well. Resident was observed Diaphoretic (sweating heavily), clammy, VS (vital signs) obtained with temp via forehead of 102.6, BP 161/84 P 108 O2 97% RA. Resident was able to be calmed down with reassurance by med staff. This nurse called on call med staff .spoke with her regarding the above and encouraged Voltaren gel be applied and then light weight pants so resident wouldn't touch his leg then his eye/face area. This nurse stated that resident is observed to be in pain r/t facial grimacing and moaning when med staff attempted to reposition him. Med staff ordered UA with C&S, Motrin and encourage ice packs as he allows. This nurse passed on the above to the oncoming nurse. Med staff stated, if he has any change in LOC (level of consciousness), increased pain or becomes non-verbal to call again and speak with on call . In an interview on 07/10/24 at 11:06 AM, Registered Nurse (RN) EE reported Resident #27 had a fall with a fracture of his right hip. Review of Incident Summary dated 6/25/24 at 5:20 PM, revealed, .NHA (Nursing Home Administrator) was notified at approximately 4:37pm that a resident has an intertrochanteric fracture (the area of the body where the hip and thigh meet) of unknown origin in his right hip. Resident was having complaints of pain, an x-ray was ordered, and a fracture was identified. Resident being sent out for further evaluation . Review of interview conducted by facility, revealed, .Spoke to (LPN TT) on 7/1/24 at approximately 1530. Per (LPN TT) she had been working with (CNA N) CENA on Tuesday 6/18/24 and (CNA N) reported that resident (Resident #27) had begun to complain of increased pain around the Thursday/Friday timeframe the week before and that he was experiencing even more pain today (6/18/24). Per (LPN TT), (CNA N) spoke to (NP YY) NP about this resident and (NP YY) assessed and ordered a knee x-ray and other pain interventions. When (LPN TT) was asked if the resident had had any abnormal occurrences or behaviors prior to this day (LPN TT) stated that she did not recall any but she did note that he began smacking his leg more and verbally complaining of increased pain on 6/18/24 . In an interview on 07/16/24 at 09:42 AM, Licensed Practical Nurse (LPN) TT reported Resident #27 had increased pain the last 4-5 days prior to 6/18/24, I went in there and he was hitting his leg. When she asked him about his pain, he indicated his leg hurt from his knee to his hip. LPN TT reported she reported the increase in pain to the nurse practitioner and the CNA reported to her as well. LPN TT reported she felt bad as he had a fractured hip and pain for a week and half at least and the staff were performing cares on him, turning him and attempting to get him up while he had a fractured hip. LPN TT reported he was getting aggressive with his behaviors with staff due to his increased pain. In an interview on 07/12/24 at 10:59 AM, CNA N reported she noticed his pain was more than his normal and reported to the nurse and reported it to the nurse practitioner too that from his knee to his hip was hurting him. CNA N reported she worked with the resident frequently and was familiar with him and she reported she could tell without asking him that he had increased pain by his response to the cares. CNA N reported she wanted him to be comfortable and his pain was not under control. CNA N reported now he had scheduled pain medications and the pain seem to be under better control. CNA N reported they just started the scheduled pain medications on Wednesday (7/10/24). Review of interview conducted by facility, revealed, .Spoke to (CNA N) on 6/28/24 at approximately 1430. Per (CNA N), (Resident #27) has a history of hitting his leg so this behavior was not abnormal for him however a couple of days before the x-ray was taken she had reported to the nurse that touching the residents leg resulted in him expressing a lot of pain. The following day (CNA N) reports that the resident continued to express the same thing however on this day the resident was insistent that he wanted to get up in his chair and they utilized the sit-to-stand to assist with the transfer and this was completed without concern. Per (CNA N), when she returned to work on Tuesday the resident was noted to be grinding his teeth and his facial expressions appeared as if the resident was experiencing increased pain. (CNA N) stated that she notified the NP, (NP YY), of her concern however the resident would not talk to her so (CNA N) asked the resident questions in the presence of (NP YY). (CNA N) asked the resident if his hip hurt and the resident nodded yes, she then asked if his knee hurt and he nodded yes and per (CNA N) she verified with (Resident #27) that he hurt from his hip to his knee and he nodded yes. Further interview of (CNA N) asking if there were any abnormal behaviors or occurrences since resident had returned from the hospital on 6/5/24 resulted in (CNA N) reporting that she had noted that the residents right foot kept dropping off the foot pedal which is new for this resident . Review of Practitioner Progress Notes dated 6/18/24 at 12:39 PM, revealed, .Pt is seen today by provider at the request of nursing. Nursing reports acute on chronic right knee and hip pain. Nursing reports chronic pain to his right thigh with worsening over the last day or so .Upon assessment, pt states that he is having right knee pain. He describes the right knee pain as new and sharp. He reports pain with palpation and movement. He denies recent injury, fall or hearing a popping noise recently. Nursing and nursing aide denies event of injury occurring . In an interview on 07/17/24 at 08:22 AM, Nurse Practitioner (NP) YY reported when she examined Resident #27 she did not perform palpation or assessment of the right hip area as he was seated in his broda chair. NP YY reported she had only performed range of motion on his right knee. When queried if the NP had staff lie the resident down in his bed for a more thorough examination she reported she did not have staff lie him down. NP YY reported she prescribed a lidocaine patch as well as re-prescribed Lyrica for Resident #25. Note: the medication was discontinued at the hospital and not re-prescribed when he returned from the hospital on 6/5/24. Review of interview during investigation revealed, .Spoke to (RN EE) RN on 7/1/24 at approximately 1715 (5:15 PM) via phone .Per (RN EE) she can only recall that staff have been reporting that the resident is noting to be more resistant to turning and that he is grabbing at their arms, being belligerent and agitated when care is being provided and that this started a couple of weeks ago. Resident has been more receptive to taking his medication when (RN EE) notifies him that his pain medications are in with the other medications, and this has been a change in the residents behaviors over the last 2 weeks as well . Review of Nursing Progress Note dated 6/23/24 at 10:15 AM, revealed, .This nurse was notified in shift-to-shift nurse report @0920 a.m. that resident's right knee is very red, warm to the touch and swollen. This writer called the on-call provider number and spoke with (Nurse Practitioner name) NP. Reviewed residents' history and recent right knee xray results as negative. New order received and noted for a uric acid level to be drawn in the a.m. tomorrow, 6/24/24, and administer prn Ibuprofen . Review of eMar - Medication Administration Note dated 6/23/24 at 10:15 AM, revealed, .Behaviors noted r/t (related to) pain . Review of Practitioner Progress Note dated 6/24/24 at 12:48 PM, revealed, .Chief complaint: R knee pain duration unknown .HPI: Pt says his right knee has been painful for 6 months. Worse with movement. Staff reported knee is red, warm and swollen. No fever. No hx gout. Uric acid level was drawn.Review of Systems: was not completed Poor historian .Musculoskeletal: Poor Strength, keep R knee flexed. Tender to palpation. no effusion. not red or warm. He wouldn't let me straighten the knee. no edema or calf tenderness .Diagnosis: M25. 561 - Pain in right knee: I don't see deformity or effusion. Cont. Ibuprofen and voltaren gel and observe for now. consider xray and CBC/WSR. Uric acid pending (ordered by on call provider) . Review of Practitioner Progress Notes dated 6/25/24 at 12:04 PM, revealed, .Chief complaint: Ongoing pain .HPI: Pt is 67 y/o male with PMH significant for dementia, hx of CVA, anxiety, depression, HTN, HLD, hx of substance abuse and hemiparesis of L side. Pt is seen today by provider to f/u to right knee and right hip pain. Uric acid ordered by on call provider resulted as normal at 4. 3. Nursing states that pain continues but ibuprofen does help his pain. Time spent reviewing with IDT. Pt is awaiting sign on to hospice, family is working on ppwk for this transition of care. Right knee xray revealed mild osteo arthritis. Suspect arthritis of right hip as well .Musculoskeletal: Poor Strength, No gross deformities, pain with palpation of right hip .M25. 561 - Pain in right knee: -continue prn ibuprofen and Voltaren gel .New diagnoses: M25. 551 - Pain in right hip .Plan: -suspect osteoarthritis of R hip, obtain xray of hip to r/o fx or dislocation. Low suspicion -continue prn ibuprofen -Add voltaren gel to right hip . Review of Nursing Progress Note dated 6/25/24 at 4:45 PM, revealed, .Resident had been experiencing pain since 6/14/24. Multiple assessments and diagnostic testing completed and 6/25/24 order for right x-ray ordered and noted to be positive .Immediate intervention implemented: Res transfer status changed to total lift, family requested to hospice . Review of Practitioner Progress Note dated 6/26/24 at 11:49 AM, revealed, Pt is seen today by provider to f/u (follow up) to positive hips xray. Pt has been experiencing increased pain to right leg, hip xray completed on 6/25/24 resulting as positive for fx (fracture) .He does endorse pain to right hip .Procedure: Hip RT (right) 2v (views): Findings: Intertrochanteric fracture is demonstrated on the right. Some displacement is seen. No dislocation is noted .Impression: Mildly displaced intertrochanteric fracture on the right .Plan: pt not a surgical candidate, goal to optimize pain and comfort . In an interview on 07/16/24 at 11:08 AM, CNA FFF reported she went to help another CNA with Resident #25. CNA FFF reported the other CNA informed her to be careful as he was in a lot of pain and to go easy on him when they turn him and move him. CNA FFF reported Resident #25 told CNA GGG he was still in pain, and to tell the nurse he had to go to the hospital as the pain was unbearable. CNA FFF reported she believed CNA GGG reported the pain and Resident #25's request to go the hospital but she was not sure what happened after as she was on the other hallway. This writer attempted to contact CNA GGG but was unable to reach them. Review of interview conducted by facility, revealed, .Per (CNA GGG) she could recall working with (CNA FFF) and providing care for (Resident #27) and he was grabbing at her arm and expressing increased pain with movement. (CNA GGG) believed that this increase in behavior and verbalization of pain had occurred around the June 20th timeframe. Per (CNA GGG) when she had asked the resident to rate his pain from 1-10 he stated it was a 20 and he was expressing that he was wanting to go to the hospital. (CNA GGG) stated that it was at this time that she noted that the residents hip was kind of swollen and she reported this to (RN AA), the nurse with the long dark hair. (CNA GGG) stated that she could recall (RN AA) stating that she was aware and working on getting an x-ray . Review of the provided schedule for 6/20/24 revealed, CNA GGG, CNA FFF, and RN AA worked that day. In an interview 07/17/24 at 10:14 AM, UM W reported LPN TT was walking up the hallway and she appeared upset, she was upset the provider did not want to do an xray on Resident #27's upper leg/hip as she did not feel it was clinically necessary. UM W reported she went to speak to the provider and NP YY reported to her she felt there was nothing to clinically support that she had examined him and did not see anything that would warrant further unnecessary testing. UM W reported the NP indicated him slapping his leg was not unusual for him. UM W reported when she went to examine Resident #27, who was in bed at this time, she attempted to straighten his leg a little bit and he said No and started slapping his leg. UM W reported she had maybe lifted it a couple of inches. UM W reported she did not observe the NP perform her examination on Resident #27. In an interview on 07/17/24 at 10:20 AM, Unit Manager (UM) W reported pain assessments were completed on every shift in the medication administration record (MAR). UM W reviewed the documented pain levels in mid-June 2024 for Resident #27's and his pain levels were documented in the range of 4-5 on a scale from 0-10 with 10 being the worst. UM W reported when she went to assess Resident #27 originally, she was barely able to lift his right leg up 2 inches and Resident #25 yelled No and appeared to be in extreme pain. UM W reported with the expression of his pain she observed the documentation of a range of 4-5 appeared to not be correct unless he was not moved at all when assessed and he had had pain medication administered. Resident #406: Review of an Admission Record revealed Resident #406 was a female with pertinent diagnoses which included spinal stenosis (space inside the bones of the spine get too small), wedge compression fracture of fifth lumbar vertebra (spinal compression fracture that occurs when the front of a vertebra collapses, but the back does not), wedge compression fracture of first lumbar vertebra, fusion of spine (surgical procedure that permanently joins two or more vertebra together so there is no movement between them), muscle weakness, difficulty in walking, unsteadiness on feet, and lack of coordination. Review of Care Conference Summary dated 5/28/2024 at 2:59 PM, revealed, .Summary of Discussion: Initial care conference held to discuss admission, goals, and discharge planning. Resident admits into subacute rehabilitation post hospitalization at (Local Hospital) r/t spinal stenosis (L4-5) and compression fracture of L5. Resident is s/p orthopedic surgery and TOC states to follow up with OAM in 2 weeks . In an interview on 07/17/24 at 10:00 AM, Health Information Coordinator (HIC) M reported urogynecologist indicated they do not need to see Resident #406 with no explanation to this writer. HIC M was queried whether Resident #406 was scheduled to see a gastroenterologist and HIC M reported she was unsure and she would need to take a look and reported she was not scheduled to see the gastroenterologist. When queried whether Resident #406 was scheduled to see the spinal surgeon, HIC M reported she had contacted them on Monday (July 15, 2024) and today but had not returned a phone call back to her. When queried when the resident returned from the hospital, it was reported she returned on 7/2/24 and had been back in facility for approximately 2 weeks. When queried if it was HIC Ms responsibility to follow up on scheduling appointments for residents, she stated, Sure. When queried if Resident #406 had seen the spinal surgeon since her admission, HIC M reported she would have to refer to her notes and when she looked she did not have a note in reference to the appointment. When asked if she had scheduled an appointment for Resident #406 to see the spinal surgeon on 6/8/24 per the discharge instructions from the hospital she reported she did not schedule the appointment. In an interview on 07/17/24 at 12:01 PM, Therapy Director (TD) PP reported there was no order for changes to the spinal precautions and the staff should be following the precautions until otherwise changed by the spinal surgeon. The spinal surgeon would be the provider who would discontinue the precautions for Resident #406. In an interview on 07/17/24 at 12:17 PM, Director of Nursing (DON) B reported the HIC M would be the staff member to follow up and initiate the scheduling of appointments with the spinal surgeon and other discharge appointments.

This citation pertains to intake: MI00142051 Based on observations, interview and record review, the facility failed to employ an Activity Director with the required qualifications resulting in the potential for unmet met psychosocial needs, feelings of boredom and a lack of person-centered activities. This citation has the potential to impact all 54 who reside in the facility. Findings include: In an interview on 07/16/24 at 10:13 AM, Certified Nursing Assistant (CNA) P reported she had been filling in, while on light duty, as an activities aide. She reported she does not have attendance sheets and any activities she does with the residents she would go into the electronic medical record and document in the appropriate task section. CNA P reported she does not have any prior experience in activities as she worked as a CNA at the facility prior to being placed on light duty. In an interview on 07/17/24 at 10:27 AM, revealed, the facility not had an Activities Director since mid-May 2024. Administrator A reported the facility had been using a light duty certified nursing assistant (CNA) to complete activities for the residents.

Based on interview and record review the facility failed to maintain an effective training program, which included trainings in resident rights, abuse, neglect, and exploitation, quality assurance, infection control, compliance and ethics, and communication for all new, existing, and contractual nursing department employees resulting in the potential for decreased resident safety for all residents who resided in the facility. Findings include: Review of Education Spreadsheet 2024 provided by Director of Nursing (DON) B revealed categories of education included abuse, compliance, infection control, QAPI (quality assurance, performance improvement), resident rights, and communication, total of 44 nursing department employees, the date that each education was assigned, and the completion date for each employee. The Education Spreadsheet 2024 revealed no recorded completion date for 10 employees under abuse, no recorded completion date for 15 employees under compliance, no recorded date of completion for 12 employees under infection control, no recorded completion date for 23 employees under QAPI, no recorded completion date for 18 employees under resident rights, and no recorded completion date for 13 employees under communication. Review of Course Completion History dated 7/12/24 provided by DON B revealed 5 Certified Nurse Assistants (CNA) of 5 (CNA H, CNA I, CNA O CNA P, CNA ZZ) had not completed the assigned required training categories. CNA H had not completed any trainings as assigned. CNA I completed 4 of 6 assigned required trainings. CNA O had completed 1 of 6 assigned required trainings. CNA P completed 2 of 5 assigned required trainings. CNA ZZ had not completed any trainings as assigned. In an interview on 7/16/24 at 1:56 PM., DON B reported that required annual training were not completed by nursing department staff. In an interview on 7/17/24 at 9:21 AM., DON B reported that annual trainings were assigned upon hire and then yearly. DON B reported that there was no staff member in the role of staff development, and no one was tracking employee completion of required assigned trainings. In an interview on 7/17/24 at 9:23 AM., Nursing Home Administrator (NHA) A reported that the training was computer based and expected to be completed by employees inside the building, while clocked in, but not while assigned to residents to provide care. NHA A reported that there was no staff member in the role of staff development. NHA A reported that required trainings should be part of the new hire orientation, specifically on day 2 during in person facility training. NHA A reported that day 2 orientation training was not being completed as expected by the facility staff. In an interview on 7/17/24 at 9:30 AM., DON B reported that an email was sent to employees when a training was assigned and available to be completed. DON B reported that she had received emails notifying her that she had trainings to complete. In an interview on 7/17/24 at 10:03 AM., CNA X reported that she has not done any required trainings that were assigned, and she was notified by email that she had courses to complete. In an interview on 7/17/24 at 12:16 PM., CNA ZZ reported that she has not done any required trainings that were assigned, and she was notified by email that she had courses to complete.

This citation has two DPS statements DPS 1 Based on observation, interview, and record review, the facility failed to follow infection prevention standards of practice for 1.) wound dressing change labeling and dating for 1 resident (R7), 2.) disinfecting resident-shared equipment, 3.) appropriate use of indwelling catheter cover for one resident R27, 4.) appropriated use of personal protective equipment (PPE) for EBP (enhanced barrier precautions residents for 2 residents (R7 and R23) of 18 residents reviewed for infection control, resulting in the potential of cross-contamination of blood-borne pathogens, and disease transmission to a vulnerable population. Findings include: R7 According to the Minimum Data Set (MDS), dated [DATE], R7 scored 13 /15 (cognitively intact) on his BIMS (Brief Interview Mental Status) with diagnoses that included a pressure injury to right elbow. Review of R7's Order Summary dated 6/3/24, revealed, 'Right elbow .wrap with kerlix daily and PRN if soiled. Review of R7's Care Plan dated 5/8/24, indicated the resident required enhanced barrier precautions (EBP) due to the wound on his right elbow. The goals was to use EBP to minimize the risk of MDRO transmission using interventions that included clean/disinfect reusable medical equipment after every use .gown/gloves should be worn during high-contact resident care activities . During an observation and interview on 7/9/24 at 7:30 PM, Licensed Practical Nurse II stated, (R7) has a wound on his right elbow. Day shift does the wound dressing. I'm working 2nd shift. I do not look at it unless an aide tells me I need to. Observed on 7//9/24 at 9:15 PM, R7 to have a dressing to his right elbow that was not labeled or dated. During an observation and interview on 7/10/24 at 4:10 PM, observed dressing to R7's right elbow that was not labeled or dated. Resident stated, They (referring to nursing staff) never write on it. During an observation and interview on 7/10/24 at 4:15 PM, Registered Nurse (RN) T stated, The dressing on (R7's) right elbow should be labeled and dated to other staff know when it was changed for infection control. There is no label or date on this dressing so there is no idea when it was done. During an interview and record review on 7/17/24 at 11:22 AM, Corporate Clinical Consultant (CCC) KK stated, The facility uses the nursing resource, [NAME] and [NAME], for dressing changes, it directs that wound dressings should be labeled with dressing with date, the nurse's initials and time of dressing to provide a record to determine when to next change the dressing for infection control purposes. Review of R7's Order Summary dated 5/15/24 revealed, I require Enhanced Barrier Precautions related to wound to my right elbow. In an interview and observation on 7/9/24 at 07:20 PM, R7 had a bandage on his right elbow with no date on it, with an open wound under his right elbow that had a light scab on it, like a film. During an observation and interview on 7/09/24 at 7:30, R7 had Enhanced Barrier Precautions signage on the wall next to his room's door. LPN II stated, (R7) has a wound on his right elbow. Observed with the LPN, a cupped elbow pad with dime size serosanguinous (bloody drainage) on it lying on the floor across room from resident's bed. The LPN looked at it and left the room without addressing it. During an interview and observation on 7/10/24 at 4:15 PM, RN T entered R7's room and looked at an elbow pad on the resident's floor in the same spot as morning observation and day prior. RN stated, That should not be on the floor with blood on it. If housekeeping was in here, they should have notified nursing or CNA (certified nursing assistant) to bag it and throw it away and get the resident a new one. It is an infection control issue. During an interview on 7/10/24 at 4:50 PM, Director of Nursing (DON) B and Infection Control Preventionist (IPC)/Regional Consultant KK stated, Any item that is soiled or has blood on it should be handled immediately and taken care of for infection control issues. (R7) does wear an elbow pad and does have a wound on his right elbow. During an interview on 7/10/24 at 04:10 PM, CNAs X and I stated regarding R7, Housekeeping cleaned his room while he was at an appointment today. Neither one of us know anything about a bloody item on the floor. We have been in his room today. During an observation and interview on 7/11/24 at 9:40 AM Housekeeping OO stated, If blood is found in a resident's room, housekeeping is to notified nursing or CNAs to pick it up and then housekeeping cleans it with bleach. Review of facility policy, Cleaning and Disinfection of Resident-Care Equipment, date revised 2/22, revealed, Policy: Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC recommendations in order to break the chain of infection . Disinfection is a process of eliminating microorganisms, except spores, from inanimate objects, usually by chemical means .Staff shall follow established infection control principles for cleaning and disinfecting reusable, noncritical equipment . Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident . During an observation on 7/17/24 at 9:38 AM, LPN Q took a resident-shared vital sign machine from a hallway and went into a resident room to take a blood pressure prior to administering medication. The resident was in the bathroom sitting in her wheelchair, waiting to be transferred to the toilet. After the blood pressure was used on the resident, the LPN took the machine back out into the hall, did not clean it, and continued to her medication cart to prep medications for administration. During an interview on 7/17/24 at 10:00 AM, Unit Manager (UM) G stated, Resident-shared equipment should be cleaned after use on each resident. There are disinfectant wipes all over the facility including the medication and treatment carts. The facility does not keep disinfectant wipes on equipment any longer for safety reasons. During an observation and interview on 7/17/24 at 10:05 AM, LPN Q stated while looking in her medication cart, I do not have disinfectant wipes in this cart. Where would I put them in here? There is no room. I did not know staff had to come to the nurses at medication carts to get the disinfectant wipes. When asked if the nurse cleaned the vital sign machine after using on the resident, the nurse stared at the surveyor and did not give an answer. During an interview on 7/17/24 at 11:22 AM, the DON (Director of Nursing/ICP) and CCC KK stated, Resident-shared equipment should be cleaned after used on each resident for infection control purposes. The disinfectant wipes should be hung in a bag on each piece of equipment. 41424 Resident #27: Review of an Admission Record revealed Resident #27 was a male with pertinent diagnoses which included wound on left foot, dementia, altered mental status, history of foot abscess. Review of Orders revealed no order for an external urinary catheter. Review of current Care Plan revealed no focus for an external urinary catheter. Review of Treatment Administration Record (TAR) revealed no monitoring of external urinary catheter. During an observation on 07/09/24 at 07:44 PM, Resident #27 was lying in his bed and he had a catheter bag in a privacy bag on the floor under his bed frame. There was no personal protective equipment (PPE) noted in the room and there was not a sign on the door or wall at entry to indicate the resident was on enhanced barrier precautions. During an observation on 07/10/24 at 10:58 AM, Resident #27 was observed lying in his bed and the catheter bag was in a privacy bag lying on the floor under his bed. During an observation 07/11/24 at 01:00 PM, Resident #27 was lying in his bed and the catheter bag was on the floor in a privacy bag. In an interview on 07/11/24 at 01:28 PM, CNA reported he had a new mattress, not put it on yet as the hospice nurse was coming to change his catheter from a condom type catheter to a foley as he had pain when the staff move him and doing that to prevent pain for him. During an observation on 07/11/24 at 01:53 PM, Resident #27 was lying in his bed, he had his legs up over a pillows, in supine position, the catheter bag was scrunched under the bed on the floor. In an interview on 07/16/24 at 01:48 PM, Unit Manager (UM) W reported the external catheter would not stay on and it was too distressing for when especially when he had to be turned and the pulling on it it would come off, Resident #27 would ask for it to be removed, he was miserable with it on. UM W reported the catheter bag in a privacy bag should not be on the floor as this can increase infection susceptibility. UM W reported staff should have placed a barrier under it or placed it in a basin. Resident #23: Review of Centers for Disease Control and Prevention (CDC) dated March 20,2024, revealed, .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities .EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .EBP are indicated for residents with any of the following: o Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or o Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO .Effective Date: April 1, 2024 . Review of an Admission Record revealed Resident #23 was a male with pertinent diagnoses which included paralysis on left side, contracture, abnormal posture, pressure ulcer other site, contracture of left knee, and pressure ulcer of left ankle. Review of current Care Plan for Resident #23, revised on 5/31/24, revealed the focus, .I require Enhanced barrier precautions d/t (due to) increased risk of MDRO acquisition due to my wound . with the intervention .Enhanced barrier precautions: Gown/gloves should be worn during high-contact resident care activities (Dressing, bathing, transferring, hygiene, linen changes, toileting/brief changes, device or wound care) . During an observation on 07/09/24 at 09:44 PM, Licensed Practical Nurse (LPN) TT entered the room and she had donned gloves to assist Resident #23. She proceeded to remove the blankets and attempted to shift his right leg over a little bit, the left leg was contracted up under his right leg and was underneath his right buttock/back thigh area. Resident #23 reported he wanted the green boot of his right leg. LPN TT loosed and opened up the boot and left his right foot inside the opened boot. Observed the inside of the green boot was heavily soiled. Resident #23 had splatters of larger and smaller red marks up and down his right shin. He had a pillow under his right knee but resident reported it was not supportive enough and was causing pain for him as it was pulling his knee down and he can't straighten his right knee. LPN TT was holding Resident #23's right leg up some to prevent more pain. Resident #23 requested another pillow under his right leg and his left leg. LPN TT was asking the resident if they could leave the boot for his heel as she did not want it to be on the bed with nothing underneath it and having the heel break open. Certified Nursing Assistant (CNA) O came back to the room and she had an additional pillows for Resident #23's right and left legs. Both LPN TT and CNA O were attempting to reposition Resident #23's right leg to a comfortable position for him. CNA O placed the pillow under his left knee with no gloves or PPE on. The blue circular pad for his left foot/ankle was not preventing his foot off of the bed. CNA O took the green boot which had been on his right foot and placed it in the closet. LPN TT had not donned a gown prior to providing care to Resident #23. CNA O had not donned gloves or a gown before providing care to Resident #23. In a interview on 07/09/24 at 09:59 PM, LPN TT reported she did not don a gown prior to providing hands on care to Resident #23. This writer and the nurse reviewed the sign on the wall outside of Resident #23's room for enhanced barrier precautions and when the PPE was required. In an interview on 07/16/24 at 01:17 PM, Unit manager (UM) W reported Resident #23 was on enhanced barrier precautions as he had chronic wounds due to his contractures. She reported the red spots on his right shin were from scabs he had on his leg and were opened when a CNA showered him and removed the bathing blanket and the scabs came off and left those spots to heal. They were healed but red spots now left behind. 38905 DPS 2 Based on interview and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing. Findings include: During an interview with Environmental Services Manager (ESM) L, at 2:10 PM on 7/10/24, it was found that the facility does not currently sample for Legionella or track disinfectant levels within the domestic water supply. When asked if there were ongoing control limits being maintained, ESM L stated no. During an interview with ESM L, at 2:25 PM on 7/10/24, it was asked if he regularly meets with a team to talk about or review the water management plan, and he stated No. A record review of the facilities Legionella Water Management Program policy, dated 11/2017, found that, a Water Management Team should be established and the considerations of team members should be followed, .Consider who among your employees, partners, and outside experts can provide these skills so that you can develop the most effective program possible. a. Those who might be part of your water management program team include: o Infection control staff who may choose to use their facility's routine surveillance for healthcare- associated Legionnaires' disease to validate their program. Important to look for healthcare-associated cases and histories for all patients with diagnosed Legionnaires' disease .Administrator, DON, Safety Committee chair, Environmental Services Manager, Employee Health, Registered Dietitian, City Water Personnel. b. Review the elements of the program at least once per year. Further review found that, .Your written program should include at least the following: a. Program team, including names, titles, contact information, and roles on the team .d. Control measures, including points in the system where critical limits can be monitored and where control can be applied .

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include: During the initial tour of the kitchen on 7/09/2024 at 7:11 PM the following was observed in the reach in refrigerator: 4 salami sandwiches on white bread on tray with parchment paper on top, not sealed, no label and date Lettuce and tomato slices were on top of the parchment paper, not covered, no label and date 1 blue pitcher with some type of juice in it, no label and date The following was observed in the walk-in refrigerator: Macaroni noodles in a container, no label and date 2 aluminum pans with BBQ pork , top on but not sealed, no label and date 1 deep metal pan with small cups of sour cream, no label and date 1 tray with waffle fries spread out, open to air, no label and date During an interview on 7/10/2024 at 2:05 PM, Dietary Manager (DM) CC stated that when they have leftover food staff is supposed to put a label and date of what it is, when it was made and the expiration date. DM CC said she has to constantly remind her staff to label and date foods. According to the 2017 FDA Food Code revealed: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Review of the Food Storage Policy with an Implementation Date of 5/25/2007 and a Reviewed/Revised Date of 1/2024 revealed, Policy Explanation and Compliance Guidelines 3. 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 5. Ready to eat food can be stored by expiration date, until opened, then labeled with open and use-by date if not discarded. 7. Food items that are opened shall be put into sealable container or bag, labeled and dated with open and use by-date. 38905 During a tour of the A side pantry, at 9:31 AM on 7/10/24 it was observed that eight, individually packaged yogurts were founded with manufacture best by dates of July 4, 2024. When asked how often staff should be coming down to check and stock the pantries, RD EEE stated they should come down once a day. During a tour of the B side Pantry, at 9:40 AM on 7/10/24, it was observed that the following items were found in the refrigeration unit: two containers of potato salad dated for 7/5, a grocery bag with an open container of bologna salami dated opened on 6/23, a grocery bag with a bbq take out plate (ribs/mac and cheese) and a steak sandwich with no dates to indicate discard, and a four pack of yogurt with a best by date of July 4, 2024. At this time, an interview with Regional Dietitian (RD) EEE found that staff are supposed to come down daily and check the units. When asked how long food from outside sources are kept, RD EEE stated that they go by manufactures expiration dates or 3 days for leftovers. According to the 2017 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) . During a tour of the kitchen, at 9:02 AM on 7/10/24, it was observed that gray chipping paint was found inside of the metal drawer of the clean utensil scoops. When asked if she could see the debris accumulation at the back of the drawer, RD EEE stated yes. After the scoops were removed from the drawer it was observed that paint chips were coming off as metal scoops slide back and forth in the drawer. During a revisit of the kitchen, at 9:09 AM on 7/10/24, it was observed that leaking condensate was observed on the overhead ventilation system. Observation found three ventilation grates that are pushing air cold air into the kitchen food service area and slowly dripping water on the floor. During a revisit to the kitchen, at 11:35 AM on 7/10/24, it was observed that there was cracks and open pits on the floor around and near the three-compartment sink. During a tour of the dish machine area, at 11:40 AM on 7/10/24, it was observed that the temperature gauge on the dish machine was found with a broken lens and a shard of glass holding the dial stuck. An interview with RD EEE found that staff use a thermometer to check the temperature to make sure it works properly. According to the 2017 FDA Food Code section 6-501.11 Repairing. PHYSICAL FACILITIES shall be maintained in good repair.

Based on interview and record review the facility failed to ensure 12 hours of in-service education was completed in 5 reviewed certified nurse assistants (CNA) (CNA H, CNA I, CNA O, CNA P and CNA ZZ) of 5 resulting in the potential for performance concerns and decreased resident safety for all residents who resided in the facility. Findings include: Review of Education Spreadsheet 2024 provided by Director of Nursing (DON) B revealed categories of education included abuse, compliance, infection control, QAPI (quality assurance, performance improvement), resident rights, and communication, total of 44 nursing department employees, the date that each education was assigned, and the completion date for each employee. The Education Spreadsheet 2024 revealed no recorded completion date for 10 employees under abuse, no recorded completion date for 15 employees under compliance, no recorded date of completion for 12 employees under infection control, no recorded completion date for 23 employees under QAPI, no recorded completion date for 18 employees under resident rights, and no recorded completion date for 13 employees under communication. Review of Course Completion History dated 7/12/24 provided by DON B revealed 5 Certified Nurse Assistants (CNA) of 5 (CNA H, CNA I, CNA O CNA P, CNA ZZ) had not completed the assigned required training categories. CNA H had not completed any trainings as assigned. CNA I completed 4 of 6 assigned required trainings. CNA O had completed 1 of 6 assigned required trainings. CNA P completed 2 of 5 assigned required trainings. CNA ZZ had not completed any trainings as assigned. In an interview on 7/16/24 at 1:56 PM., DON B reported that CNA 12-hour in-services that were assigned were not completed. In an interview on 7/17/24 at 9:21 AM., DON B reported that annual training was assigned upon hire and then yearly. DON B reported that there was no staff member in the role of staff development, and no one was tracking CNA 12-hour in-service completion. In an interview on 7/17/24 at 9:23 AM., Nursing Home Administrator (NHA) A reported that the facility assigned training was computer based and included training/topics that would count towards CNA 12-hour in-service requirements. NHA A reported that these trainings were to be completed by the facility on day 2 of new hire orientation and then assigned yearly. NHA A reported that day 2 orientation was not being completed as expected by the facility staff and the trainings were not being completed by newly hired CNAs. In an interview on 7/17/24 at 9:30 AM., DON B reported that an email was sent to employees when a training was assigned and available to be completed. DON B reported that she had received emails notifying her that she had trainings to complete. In an interview on 7/17/24 at 10:03 AM., CNA X reported that she has not done any required in-services that were assigned, and she was notified by email that she had courses to complete. In an interview on 7/17/24 at 12:16 PM., CNA ZZ reported that she has not done any required trainings that were assigned, and she was notified by email that she had courses to complete.

Based on interview and record review the facility failed to develop person centered care plans in 3 (Resident #34, Resident #49, and Resident #6) of 18 residents reviewed for person centered care plans resulting in staff not monitoring for side effects of an anticoagulant medication and not monitoring a known skin condition. Findings include: Resident #34 Review of an Admission Record revealed Resident #34 had pertinent diagnoses which included: dementia, atrial fibrillation (a-fib - an irregular rate of the heart that could cause blood clots to form) and cerebral infarction due to unspecified occlusion (a blockage of an artery interrupting blood flow to the brain, stroke). Review of a Minimum Data Set (MDS) assessment for Resident #34, with a reference date of 4/11/2024 revealed a Brief Interview for Mental Status (BIMS) score of 9/15 which indicated Resident #34 was cognitively intact. Review of Physician Orders for Resident #34 revealed . Xarelto tablet 20 mg give 20 mg by mouth one time a day for A-fib .ordered on 3/19/24 . Review of Physician Order for Resident #34 revealed no order to monitor for side effects of anti-coagulant- bleeding/bruising. Review of Care Plan for Resident #34 revealed no developed person-centered care plan related to the use of anticoagulant medication. Resident #49 Review of an Admission Record revealed Resident #49 had pertinent diagnoses which included: atrial fibrillation (irregular heart rate that could cause blood clots to form), fracture of the right lower leg, and compression fracture of T11-T12 vertebra (fracture of the middle spine) . Review of a Minimum Data Set (MDS) assessment for Resident #49, with a reference date of 6/20/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #9 was cognitively intact. Review of Physician Orders for Resident #49 revealed . Apixaban oral tablet 5 mg give 1 tablet by mouth tow times a day for hx (history) of DVT (deep vein thrombosis (blood clot in the leg)), a fib . ordered on 3/19/24 .monitor for side effect of anti-coagulant (preventing the clotting of blood) i.e. bruising/bleeding . ordered on 3/19/24 . Review of Care Plan for Resident #49 revealed no developed person-centered care plan related to the use of anticoagulant medication. In an interview on 7/11/24 at 1:10 PM., Unit Manager/Licensed Practical Nurse (UM/LPN) W reported that Xarelto and apixaban are both anticoagulant medications. UM/LPN W reported that the expectation was to have a care plan in place for any resident that was taking an anticoagulant medication, and the care plan should include interventions to monitor for bleeding. 41027 Resident #6 Review of an Admission Record revealed Resident #6 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: other specified disorders of nose and nasal sinuses. During an observation on 07/09/24 at 08:05 PM in Resident #6's room, the resident was lying in bed and there was a large black crusted lesion noted on her nose. Review of Resident #6's Care Plan for information related to the skin condition on her nose. There was no problems, goals, or interventions related to the lesion on her nose. Review of Resident #6's Practitioner Progress Notes dated 6/20/2024 revealed, .Physician regulatory visit .no longer under hospice care. The lesion on her nose is chronic and sometimes bleeds. The guardian has declined treatment for this and pt has been uncooperative for treatment. In an interview on 07/10/24 at 03:12 PM, Certified Nursing Assistant (CNA) Z reported that she did not know what the spot on Resident #6's nose was, and did not know if she was receiving any treatments for it. In an interview on 07/12/24 at 01:31 PM, Unit Manager (UM) W reported that Resident #6 had the lesion on her nose for years. UM W reported that is was a chronic wound due to an untreated skin cancer, and does open up at times. UM W reported that Resident #6's guardian had declined further treatment. In an interview on 07/12/24 at 03:01 PM, Licensed Practical Nurse (LPN) R reported that Resident #6 had the chronic wound on her nose for years, and at times the crust falls off or gets scratched off and starts to bleed. LPN R reported that the last time the wound bled was about a month ago, and that nursing applied an antibiotic ointment to the area until it scabs back over. In an interview on 07/17/24 at 12:06 PM, Director of Nursing (DON) B reported that Resident #6's nose wound is a chronic skin cancer, and that there should be orders and a care plan in place. DON B reported that in addition to orders to monitor for signs and symptoms of infection, ideally there wound also be a monthly wound note indicating the wound status.

This citation pertains to intake number MI 570. Based on interview and record review, the facility failed to prevent the elopement of 1 sampled resident (Resident #100) of 3 residents reviewed for elopement, resulting in an Immediate Jeopardy when Resident #100 who had been assessed as an elopement risk and wore a Wanderguard bracelet eloped from the facility on 3/21/2020 at approximately 9:30 AM unbeknownst to facility staff and was found 0.2 miles away at a (name of store) after being alerted by the police. This deficient practice placed Resident #100 and 5 other residents who were assessed as being at risk for elopement, at risk for serious harm, injury, and or death from hazards outside the facility. Findings include: Review of the Elopements and Wandering Residents Policy reviewed 3/21/20, revealed that This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factor contributing to wandering or elopement risk .3. The facility may be equipped with door locks and/or alarms to help avoid elopement. 4. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. Review of the Incident Report dated 3/21/2020 at 10:28 AM, revealed Resident (#100) exited facility between approximately 9:30 and 10:23 am. (name of Sheriff department) contacted facility at 10:23 AM and informed staff that resident was at the (name of store) down the street from the facility. This writer and (Certified Nursing Assistant (CNA) H) transported resident back to the facility at 10:28 AM. Remaining staff performed code search and all other residents were accounted for. Resident (#100) was clothed in jacket, jeans, button up shirt, baseball cap, socks and shoes. Witness (CNA D) reported; He was at station A between 9 and 10. He asked (Licensed Practical Nurse (LPN) E) where his home was. She pointed down hall 2 and said its that way. Then he went down hall 2. I didn't hear any alarms. Witness (LPN E) reported she was at the desk charting around 9:30/10 am when (name of resident) came and asked me where home was. I pointed him down hall 2 and told him his room was (room #). At about 10:30 am I heard the code called over the intercom and called (a phone #), I called Nursing Home Administrator to notify her. (LPN G and CNA H) then walked up and went to get (name of resident). When they came back I notified family and on call physician. Witness (LPN G) reported 0930 resident approached me asking I want to go home, how do I get out of here. Cares and emotional support were provided. Continued to be agitated. Administered as needed [MEDICATION NAME] tablet. Resident was cooperative and continued down the hallway towards the front lobby while in his wheelchair. 10:28 AM a code search was called and I was informed that 911 had called the facility. We were notified that resident was at the (name of store) on (name of 4 lane divided 45 mile per hour road). Myself and another staff member took a vehicle down to the store and retrieved (name of resident). (Name of resident) was brought back to the facility. Skin and vital signs assessed. No injuries noted. Wanderguard in place and functioning. Assisted resident to bed to rest. Administered [MEDICATION NAME] due to pain in bilateral lower extremities. I (name of staff member Dining Aid (DA) C) was walking down hall three between 9- 9:30 AM and heard the alarm. It was going off for a while, I took the key and turned it into the door by station B. (SIC) During an interview on 6/30/2020 at 2:15 PM, DA C reported that she was coming from the kitchen going towards B hall to use the printer after delivering the breakfast trays. DA C reported that residents were in their rooms and still eating, she could hear the door alarm going off by the desk and was looking for a nurse, but could not find the nurse or any other staff before she took it upon herself to turn off the alarm. DA C reported that she had seen other staff take the key down that hung up by the door and turn off the alarm, so she turned off the alarm when not finding any staff after 5-10 minutes. DA C reported that she did not look outside the door for any residents or inform anyone that she had turned off the alarm. DA C reported that she was not aware of the abuse procedures for wandering residents until after lunch when the Nursing Home Administrator informed her. Review of a Admission Record revealed Resident #100 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 7/11/2019 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #100 was severely cognitively impaired for daily decision making skills. Review of the Elopement Care Plan dated 7/5/18, revealed I am at risk for elopement related to cognitive impairment .Interventions: I have a Wanderguard device on my right wrist. Date Initiated 7/5/2018, Distract me by including be in any activities that are appropriate. I like to visit with other people and socialize. Date Initiated: 7/9/2018. Review of the Elopement Evaluation dated 1/23/2020, revealed (Resident #100) scored a greater than 1 = At Risk for Elopement. A yes answer to any question identified with an asterisk identifies a risk for elopement. Resident #100 was a yes to all 4 questions with an asterisk. Review of the Elopement Evaluation dated 2/24/2020, revealed (Resident #100) scored a greater than 1 = At Risk for Elopement. A yes answer to any question identified with an asterisk identifies a risk for elopement. Resident #100 was a no to all questions. Review of the Skin Sweep dated 3/21/2020 at 10:45 AM, revealed skin intact, hydration screen, mucous membranes moist, pink, and skin turgor, normal. During an interview on 6/30/2020 at 11:30 AM, Director of Nursing (DON) B reported that they knew the alarm was turned off on the North hall door by a staff member and figured it was the only door (Resident #100) could have exited the building. DON B reported that he had called the building next door because they have cameras out on their parking area that can see the street in front of the building and possibly the side of his building for the time frame they knew the resident was gone, but they did not have any showing him. DON B stated that he figured (name of resident) went left on the sidewalk out the exit door and then he went up to the street (name of 2 lane street) he did not cross in front of the facility or at least was not seen in any of the video from the facility next door. He went from there to the (name of store) and we were called by 911 at 10:23 am. During an observation on 6/30/2020 at 11:45 PM Surveyor walked out the exit door on the North hall turned left on the side walk which was smooth and continued approximately 270 feet to the parking lot which ended by the trash cans on my right and cars on turn left, there was no side walk about 125 feet I crossed the road in front of the building to a side walk then walked up the hill approximately 250' to (a 2 lane road with a turning lane), turned left for just over 2000 feet to enter the driveway to (name of the store) which was uphill and (on a 4 lane divided highway with a turn lane). On 6/30/2020 at Nursing Home Administrator (NHA) A was notified of an Immediate Jeopardy that began on 3/21/2020 when Resident #100, who was identified as an elopement risk, eloped from the facility, unbeknownst to facility staff. On 7/2/2020 ad 7/3/2020, this surveyor verified the facility completed the following to remove the Immediate Jeopardy: On 3/21/20 after 10:23 AM staff members went to get resident #100 and brought him back to the facility at 10:28 AM. On 3/21/20 after 10:23 AM call a code search (head count) was completed in the building to account for residents. On 3/21/20 when Resident #100 was returned to the building a nursing assessment, including skin inspection was completed. On 3/21/20 Resident #100 was assigned frequent checks for increased staff supervision. On 3/21/20 all exit door were checked, facility door code, alarm and magnetic lock system were all functioning appropriately. On 3/21/20 the DON verified the Resident's WanderGuard device and the transmitter were in place and functioning, did an additional physical assessment and pain assessment. Staff education initiated on 3/21/20 Elopement and Wandering Residents, Responding to Door Alarms and WanderGuard policies and procedures. On 3/21/20 key codes for all exit doors were changed, with louder annunciator installed at 3 fire exit doors, (including the door identified as resident's likely exit). On 3/21/20 maintenance door audit completed on all exit doors to ensure secure and alarms functions. This audit is completed daily. On 3/23/20 the social worker completed supportive visit with resident. On 3/23/20 Care Plans for those residents identified a elopement risk were reviewed and revised as applicable. On 3/23/20 Interdisciplinary Team (IDT) reviewed all elopement UDA's (assessments), elopement care plans and deemed appropriate. On 3/23/20 Elopement Drills started and continued 3/24, 3/26, 3/37. 3/31, 4/1, 4/3, 4/6, 4/9, 4/17, 4/20, 4/24, 4/28, 5/4, 5/29, 6/5 On 3/23/20 Elopement PIP created and was presented to Quality Assurance and Performance Improvement (QAPI) April 15, 2010. Performance improvement Plan to include random elopement and door alarm drills to be performed weekly. On 3/23/20 facility finished in-house employee education on elopement; those on leave of absence were completed upon return. 100% of active staff re-educated by 3/23/20. (Education included A. elopement policy and procedure B. Elopement binders C. Discussed what to do if a resident is exit seeking D. Check placement of WanderGuards E. Discussed procedure for audible alarms. On 3/2420 Engineering system inspected performance of door alarm system. On 3/24 20 all keys used to disable door alarms were removed and given to specific staff members. On 3/24/20 charge nurses and management education initiated regarding door key use and expected procedure.' The facility was granted a Past Non-Compliance at the time of exit with a compliance date of 3/24/20. Therefore, no plan of correction will be required.

This citation pertains to MI 533, MI 248 and MI 164 Based on interview and record review, the facility failed to assess and treat one resident (Resident #3) for an acute change in condition, out of 2 residents reviewed for a change in condition, from a total sample of 13 residents, resulting in hospitalization for acute [MEDICAL CONDITION] (a condition characterized by change in brain function) and [MEDICAL CONDITION] due to [MEDICATION NAME] (a medication muscle relaxer) toxicity and resulting placement on hospice care. Findings include: According to a facility face sheet dated 6/21/17 at 10:06 a.m., Resident #3 was a [AGE] year old female admitted into the facility on [DATE] with the cumulative Diagnoses: [REDACTED]. A hormone producing body that regulates calcium and phosphorus in the body) and abnormal weight loss. Review of an acute care facilities document titled, Physician ED (Emergency Department) Report dated 4/29/17 (no time noted) reflected, History of Present Illness: The patient is a [AGE] year old female with a history of coronary [MEDICAL CONDITION] (heart vessels are obstructed), [MEDICAL CONDITION] stage 4, chronic pain, comes in today from her nursing home where she lived for increasing weakness. [MEDICATION NAME] was just started yesterday for muscle spasm. She is given 10 mg (milligrams) t.i.d. (three times a day). She received all 3 doses yesterday and 2 doses today. Last dose was at 1 p.m. I talked to her nurse at the facility where she lives and she told me that this morning she was acting fine, was speaking and then was talking at lunchtime, and then after she received the 1 p.m. [MEDICATION NAME] dose. I do not know how she was but at 5 p.m., at dinner she was not arousable . Review of progress notes for Resident #3 dated 4/29/17 at 10:47 a.m. reflected, Res(ident) in the early a.m. was noted to be very stiff, lethargic, with little response. VSS (vital signs stable) 157/86 (blood pressure), pulse 73, temperature 97.1 (degrees Fahrenheit), respirations 16, O 2 (oxygen) saturation 99% (percent). Res(ident) was repositioned and monitored. Manager was notified and as I was speaking on the phone with him another nurse who just came in from res(ident) room stated she was alert and oriented, had some conversation, response appropriate, squeezed both hands. Staff continuing to monitor . This progress note was signed by Licensed Practical Nurse (LPN) L. There was no documentation about notifying the physician. In an interview on 6/21/17 at 3:40 p.m., LPN L confirmed she was the nurse caring for Resident #3 the morning of 4/29/17. LPN L was asked if she gave Resident #3 [MEDICATION NAME] 10 mg at 8:00 a.m. on 4/29/17. LPN L stated, I can't recall oh yes! It (the [MEDICATION NAME]) was becoming a problem. (Resident #3) was not used to it. sleeping more, not as alert . LPN L was asked if she called the physician about the drowsiness of Resident #3. LPN L stated she did not that the physician usually came in during the day and he would be informed. LPN L again stated Resident #3 was experiencing lethargy because of the [MEDICATION NAME]. In an interview on 6/20/17 at 12:59 p.m., Family Member R stated they had come into the facility to visit on 4/29/17. She was unsure of the time. Family Member R stated she had found Resident #3 unresponsive. Family Member R stated she got conflicting reports about Resident #3's condition from staff members. Family Member R stated they do not remember the names of who they spoke with. The facility nurse they did speak to had told her she'd (Resident #3) been like that all day. Family Member R wanted Resident #3 to be sent to the hospital. Family Member R stated Resident # 3 was, holding herself stiff, snoring, not responding. Family Member R stated an African American woman came in and agreed Resident #3 needed to go to the hospital. In an interview with Registered Nurse (RN) M on 6/21/17 at 4:05 p.m., RN M was asked if she cared for Resident #3 on 4/29/17. RN M confirmed that she had. RN M stated she came into work at 11:00 a.m RN M stated, I remember. The [MEDICATION NAME] issue. RN M stated she floated (moved from area to area as the facility needs) and was on Resident #3's area every couple of weeks. She (Resident #3) was tired. I thought it was her (they way the resident normally was). RN M stated that nothing abnormal had been given by the previous nurse in the shift change verbal report. RN M stated Resident #3's daughter came in and requested that she (Resident #3) be sent out (to the hospital). RN M stated the doctor was called by Licensed Practical Nurse (LPN) T. RN M stated that the [MEDICATION NAME] dose had been changed to (lowered to 5 mg instead of 10 mg) by the physician. RN M was asked when the decision was made to transfer Resident #3 to the hospital. RN M stated it was a few hours. RN M couldn't remember when Resident #3 was transferred to the hospital but she stated it was at the end of the shift. RN M worked the second shift, 4/29/17, 11:00 a.m. to 11:00 p.m. Review of a facility document titled, Discontinue Order for Resident #3 dated 4/29/17 at 6:48 p.m., the order reflected that the physician was called at 6:48 p.m. and [MEDICATION NAME] tablet 10 mg three times a day for muscle spasms had been discontinued. Reason for discontinuation: New dosage for [MEDICATION NAME]. Review of a facility document titled, Discontinue Order for Resident #3 dated 4/29/17 at 8:23 p.m., the order reflected, Give [MEDICATION NAME] 5 mg by mouth three times a day related to Hypertensive [MEDICAL CONDITION] with Stage 1 through out Stage 4 [MEDICAL CONDITION] .per family/guardian request. Review of a facility progress note for Resident #3 dated 4/29/17 at 21:17 p.m. reflected, B/P (blood pressure) 172/100. Per on call physician Nitro ([MEDICATION NAME]) 0.4 (milligrams) given. B/P 97/63 after Nitro. Daughter came in after dinner and asked to have resident sent to ER (emergency room ) for lethargy. Explained to daughter that resident was put on [MEDICATION NAME] 4/28(17). Per on call physician D/C'd (discontinued) [MEDICATION NAME] 10 mg. Ordered [MEDICATION NAME] 5 mg t.i.d (three times a day). D/C Tylenol prn (as needed). Ordered Tylenol arthritis 650 mg every 4 hours prn. Per guardian resident was sent to (name of acute care facility) ER at 9:00 p.m. via (by) stretcher. On call nurse was notified and report given to ER (name of local acute care hospital). This progress note was signed by Registered Nurse (RN) M. There is no documentation that the physician was notified about the lethargy, the stiffness or the unresponsiveness of Resident #3, just the family request for the [MEDICATION NAME] to be changed resulting in a change in [MEDICATION NAME] order by the physician. Review of a document from the acute care facility for Resident #3 titled, Discharge Summary dated 5/7/17 and signed at 12:22 p.m. reflected, Hospital Course: [MEDICATION NAME] was just started Wednesday for muscle spasms. She (Resident #3) is given 10 mg (milligrams) t.i.d. (three times a day). She received 3 doses yesterday and 2 doses today. Last dose was at 1:00 p.m. The morning of admission she was acting fine, was speaking and then was talking at lunchtime, and then after she received the 1:00 p.m. [MEDICATION NAME] dose. But at 5:00 p.m., at dinner she was not arousable. Today when patient was visited at there nursing home by her (family member), the patient was not responding and was 'stiff as a board'. The patient (Resident #3) was transported to the ED (emergency department) for additional workup and evaluation. Patient was severely altered, arousable only to strong sternal (breast bone in center of the chest) rub and then would only open (her) eyes This report goes on to reflect, In the ED .she (Resident #3) was having rhonchorus (snoring) breathing nasally (by nose) with good oxygen saturation .She was admitted for possible [MEDICATION NAME] toxicity. Continued review of a document from the acute care facility for Resident #3 titled, Discharge Summary dated 5/7/17 and signed at 12:22 p.m. reflected, Toxicology (blood test for medications in the blood) was consulted and when they saw her she was interactive and no longer obtunded (having diminished arousal), however approximately 1 hour later she was obtunded, rigid and myclonic ([MEDICAL CONDITION] of most of the muscles of the body) jerking .The most likely [DIAGNOSES REDACTED]. Given her CKD4 ([MEDICAL CONDITION] stage 4, end stage), we monitored her for several days to see if she improved as [MEDICATION NAME] was metabolized (body processed the medication and excretes it. In this case [MEDICATION NAME] is metabolized and excreted by the kidneys and Resident #3 had end stage kidney disease) She did show some mild improvement, but did not return to her baseline (Resident #3's usual cognitive and health state). Patient was discharged in stable condition back to her living facility with hospice on 5/5(17) Resident #3 had been experiencing an acute change in condition on 4/29/17 since 10:47 a.m. There is no documentation that the physician was notified about the lethargy, intermittent stiffness or the unresponsiveness of Resident #3 through out the day, just the family request for the [MEDICATION NAME] to be changed resulting in a change in [MEDICATION NAME] order by the physician and the increased blood pressure. Resident was transferred to an acute care facility on 4/29/17 at 9:00 p.m., 10 hours after Resident #3 had started to experience an acute change in condition. The Professional Standards of Quality for Staff Roles and Responsibilities in Monitoring Patients with Acute Changes of Condition for the nurse includes recognizing condition change early and assessing the patient's symptoms and physical function and document detailed description of observations and symptoms. (Process Guidelines for Acute Change of Condition, AMDA Clinical Process Guidelines, 2003).

This citation pertains to MI 728 Based on interview and record review, the facility failed to perform wound care as recommended by the wound clinic for 1 (Resident #11) of 1 reviewed for wounds, from a total sample of 9 residents, resulting in [MEDICAL CONDITION] (bacterial skin infection) of Resident #11's leg and hospitalization [MEDICAL CONDITION] (life-threatening illness caused by the body's response to an infection). Findings include: Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #11 was a [AGE] year old male, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #11 scored 9 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). Review of the complaint intake MI 728, revealed the facility staff failed to assess and treat the resident legs wounds for a week 12/28/16 to 1/5/17 when (name of the wound clinic) ordered dressing changes every day on 12/28/16. The wound clinic was distressed when the resident came in and the dressing had not been changed at all and the wound was now infected. Review of the wound clinic Physician order [REDACTED].#37 Right, Lateral Lower Leg apply silver calcium alginate, cover with ABD pad cover with ABD pads and roll gauze, change dressing once daily and Wound #41 Right, Lateral, Superior Lower Leg apply [MEDICATION NAME] blue ready to wound beds, cover with ABD pads and roll gauze, change dressing once daily. Review of the physician's orders [REDACTED].#11's right leg wounds. Review of the Treatment Administration Record Dated 12/29/16 through 1/4/17, revealed no documentation that daily dressing changes were performed for Resident #11's right leg wounds. Review of the Physician Consultation Form dated 1/5/17, revealed Dressings on right leg to be changed daily . Review of the wound clinic notes dated 1/5/17, revealed Your provider has ordered a medication for you .[MEDICATION NAME] 100 mg (milligrams) PO BID (by mouth twice daily) x 10 days for [MEDICAL CONDITION] of the right leg . Other Activity instructions revealed check right foot and leg twice daily for increased redness, warmth and swelling. If there is any worsening, recommend evaluation in Emergency Department to receive IV (intravenous) antibiotics. In an interview on 1/27/17 at 11:00 am, Licensed Practical Nurse (LPN) P reported usually Resident #11 came back with paperwork from the wound clinic. She reported she was the nurse on duty on 12/29/16, after Resident #11's wound clinic appointment and the escort reported placing the paperwork on the desk. LPN P reported she was unable to locate the paperwork (with new wound care orders) on 12/29/16. When asked if she could have called the wound clinic for instructions, LPN P stated yes .I dropped the ball. LPN P reported on 1/5/17, she received a phone call from Resident #11's wound clinic asking if Resident #11's dressings to his right leg were being changed daily. When asked if Resident #11's dressings were changed daily, LPN P stated no. When asked why not, LPN P stated there wasn't an order in there (electronic medical record) for it to be changed every day. LPN P reported Resident #11 came back from the wound clinic on 1/5/17, with an infection of his leg. In an interview on 1/27/17 at 11:20 am, Director of Nursing (DON) B reported Resident #11's wound care was not being performed as ordered by the wound clinic on 12/29/16. DON B reported Resident #11's dressings had always been ordered to change at his wound clinic appointment, but on 12/29/16, the wound clinic changed the orders to daily and it wasn't noted and they weren't done. Review of the Nursing Progress Note dated 1/9/17, revealed spoke with nurse at (hospital name); resident has been admitted to med/surg with acute kidney injury,[MEDICAL CONDITION].

Based on observation, interview and record review the facility failed to use mechanical lift slings in good condition for 1 resident (#4) who fell from the mechanical lift sling and failed to maintain mechanical lift slings in good repair and ensure appropriately sized mechanical lift slings are applied for 2 residents (#1, 17 and 32) from a sample of 10 residents reviewed for the use of mechanical lift slings and transfers from a total sample of 16 residents resulting in a fractured clavicle (collar bone) for resident (#4). This resulted in an immediate jeopardy with harm for Resident #4 and placed Residents #1, 17 and 32 in an immediate risk for potential injury or death since the facility had no procedure in place for the safe use of mechanical lift slings and safe transfers. The facility Administrator was notified of the immediate jeopardy on 11/07/2013 at 11:54 am. The immediate jeopardy began on 11/04/2013 at 11:53 when resident (#4) fell during a mechanical lift transfer. The immediate jeopardy was removed on 11/7/2013 at 4:50 PM, but not corrected, when the the corrective action plan was accepted to remove the immediate jeopardy. Although the immediate jeopardy was removed, the deficient practice continued to be isolated at a harm level with ongoing facility staff training and the continued monitoring for the safe use of mechanical sling transfers in their Quality Assurance Committee. Findings include: Review of the Face Sheet dated 11/04/2013 reflected Resident #4 was admitted to the facility 05/06/2006 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] and review of Resident #4's "Fall" care plan dated 07/25/2013 indicated Resident #4 was totally dependent on staff for all transfers using a mechanical lift. The MDS indicated Resident #4 had a Brief Interview for Memory Score (BIMS) of 6/15 (severe cognitive impairment). Review of the Nursing Progress Note, dated 11/04/2013 at 11:53 PM reflected Resident #4 was being transferred by being lifted and suspended in the air with the mechanical lift from her wheel chair to her bed when the leg straps that connected the lift sling to the mechanical lift broke on both sides resulting in Resident #4 falling to the floor. Review of the nursing "Progress Notes" dated 11/05/2013 at 1:36 PM, noted Resident #4 complained of left shoulder pain and an xray was ordered. At 2:25 PM the same day, the nursing "Progress Notes" reflected "...(Resident #4) will not raise arm up due to c/o (complaint of) pain". Review of the xray report from 11/05/2013 reflected a non displaced fracture of the left clavicle (left collar bone). During an interview with the Director of Nursing (DON) on 11/06/2013 at 12:30 PM, the DON provided the Surveyor with the names of the two staff members involved in the mechanical lift incident involving Resident #4's fall and fracture on 11/04/2013. During a telephone interview with LPN "I" on 11/06/2013 at 1:15 PM, LPN "I" stated that CNA "H" asked for assistance transferring Resident #4 from her wheel chair to her bed. CNA "H" had Resident #4's (mechanical lift) sling under her and LPN "I" stated that she did not inspect the integrity of the sling before assisting with the transfer. LPN "I" stated that she heard a strap break and added, "The straps kept breaking". Resident #4 fell to the floor and ended up on her left shoulder, face down. LPN "I" stated the straps by Resident #4's head had broken first. Observation of the broken mechanical sling revealed there were 3 broken sling straps; all 3 were leg straps. The Manufacturer's application directions (undated) reflect the sling should have been applied to the Resident's leg region. However, LPN "I" stated that the broken strap was applied at the Resident #4's head. The application did not follow the manufacturer's specification. LPN "I" stated that she did not have any training from the facility on mechanical lift transfers or slings, including how to appropriately size the sling to the individual resident. It was unclear whether the size of the sling was appropriate to the size of resident #4 who had the [DIAGNOSES REDACTED]. During an interview with LPN "I" on 11/06/2013 at 2:45 PM, LPN "I" was asked to demonstrate how the mechanical lift sling was placed on Resident #4 and she could not recall how the sling was placed, but recalled the straps that had broken were at Resident #4's head. During a telephone interview with CNA "H" on 11/06/2013 at 1:30 PM, CNA "H" stated that LPN "I" was assisting her transfer Resident #4 on 11/04/2013 between approximately 7:30 - 8:00 PM. CNA "H" stated the (mechanical lift) sling straps under Resident #4's legs "...broke in half and (Resident #4) fell to the floor ". CNA "H" stated that she looked at the sling but did not do an inspection of the sling's condition prior to using the sling to lift and transfer Resident #4. Review of the facility policy and procedure for Hydraulic Lift, revised date of 02/02/2006, reflected under "IV. General Guidelines", item #4 "Never use a torn or damaged sling ". It was noted during surveyor observation of the mechanical lift sling used on 11/04/2013 with Resident #4 that 3 of the 14 straps on the mechanical lift sling were completely broken and 6 of the remaining 14 straps had a reduction in the width/thickness and/or distortions of the weave pattern to the webbing. Review of the facility policy and procedure for Lift Slings dated 10/21/2010, reflected under, "III. Procedure" #6 "After each laundering inspect the sling for wear, tears, and loose stitching". and #7 "Bleached, torn, cut, frayed, or broken slings are unsafe and could result in injury. Remove from service by giving the sling to the Environmental Services Supervisor ". Interviews were conducted on 11/06/2013 between 11:05 and 11:20 am with housekeeper/laundry personnel "G", "L", and "M". All three staff members stated that they do not inspect the mechanical lift slings and had not been educated by the facility to do so. An interview was conducted on 11/06/2013 at 11:10 am with the facility's District Manager "K" for the contracted housekeeping/laundry services. District Manager "K" stated his expectation would be "...for our staff (laundry) to inspect them (the mechanical lift slings) before washing and when they (the mechanical lift slings) came out (of the washer)". District Manager "K" stated, "We should make sure it's a double check process, laundry and the CNA's". During an interview with the Administrator on 11/05/2013 at 4:30 PM, the Administrator stated that the facility did not have any type of tracking or inspection system in place prior to the incident involving Resident #4 on 11/04/2013. The Administrator stated, "We didn't have anyone specifically assigned to check the (mechanical lift) slings for integrity". On 11/06/2013 at 11:25 am, the Administrator stated that her expectation was that the slings would be checked for flaws, holes, rips, before the CNA's would lift a resident. It was noted during surveyor observation of the mechanical lift sling involved in the incident with Resident #4 on 11/04/2013 that the labels were worn and could not be read. An observation of the manufacturer inspection label on a new mechanical lift sling by the same manufacturer and model indicated the sling must be quality checked and passed every 6 months by a competent and authorized official or by the manufacturer's dealer. This was not followed. ( ) In an observation conducted 11/6/13 at 10:30 AM , an inspection of a new mechanical lift sling was conducted. The sling was removed from the packaging and revealed a label attached to the sling titled "Inspection Label" (undated). On this "Inspection Label" a written directive was observed and read as follows, "Please Note: All slings must be inspected before use and application to a patient. The sling must also be checked and passed every six months by a competent and Authorized Official or by (the dealer)". Also on the "Inspection Label" was observed a template titled, "6 Month Inspection Record" with 6 blocks indicating; "Inspection 1", "Inspection 2", etc. through "Inspection 6" with space to record the dates of inspection of the mechanical sling. On 11/6/13 at 11:00 AM, an observation and inspection of the mechanical lift slings currently in service were conducted. The observation of sling #3 (Resident #32) revealed that the "Inspection Label" was in place but was washed out and did not indicate any history of 6 month inspections. An inspection of sling #7 (Resident #1) revealed that the "Inspection Label" was in place but was washed out, and did not indicate any history of 6 month inspections. In an interview conducted 11/6/13, at 4:30 PM, Certified Nurse Aide (CNA) "N" stated that he had received in-service instruction on the use of the mechanical lift slings on the night of 11/5/13. CNA "N" stated that he had been instructed on inspecting the slings for fraying and tearing prior to use (on 11/5/13). CNA "N" stated that he did not receive training on selecting the proper size sling for a resident. CNA "N" stated that he would "guess" on the proper size to use for a resident. ( ) During an interview with CNA "J" on 11-6-13 at 11:00 AM, CNA "J" said that he had just received training that morning at 6:45 AM about using mechanical lift slings. The Surveyor asked CNA "J" to demonstrate his training. CNA "J" went to Resident #17's room and located Resident #17's sling. CNA "J" could not locate the manufacturer label on the sling or any indication of the size or style of the sling. CNA "J" said that he could not follow his in-service instruction because the sling was missing the information. CNA "J" went to the nurse's station to get additional information on the sling for Resident #17's safety, handed the sling to the DON and said he was not able to locate the size or type of sling since there was no label. The Surveyor asked the DON what size and type of sling Resident #17 had care planned. The DON was unable to locate a care plan for Resident #17 that indicated the size or type of sling to be used. ( ) Review of the mechanical lift manufacturer's general care and instruction record sheet reflected under "Care and Maintenance Record" (undated) that a "Record Card/Sheet" (undated) was supplied with the sling and that the condition of the sling needed to be recorded at least every 30 days and the product needed to be checked prior to every use. Upon inspection damaged sling should be instantly rejected. The lack of a system to identify unsafe slings utilized in resident transfers using a mechanical lift was not identified as an area of concern by the Quality Assurance Committee prior to the incident on 11/04/2013 involving Resident #4. There was no plan put in place to address identification and education of staff related to the use of unsafe and inappropriately sized mechanical lift slings utilized in resident transfers. This lack of a facility wide policy and procedure contributed to resident #4's fall with harm. The corrective action plan to remove the immediate jeopardy was accepted on 11/ 7/2013 at 4:50pm. The following are the corrections: 1) All mechanical lift slings currently in use have been numbered. Any new mechanical lift slings were dated with the date put into use and numbered. Ongoing all new mechanical lift slings will be numbered and dated upon initiation of use. 2) Mechanical lift slings will be inspected for wear, tears and loose stitching by laundry staff after each washing, prior to return to residents use. Inspection will be documented on the "Lift Sling Inspection Log" using the number assigned on the sling. Any sling showing wear, tears, or loose stitching will be double checked by the Administrator and or Maintenance Director. Any sling considered unsafe will be discarded. 3) Lift slings in use will be inspected by the Administrator/Designee on a weekly basis. This will be documented on the "Lift Sling Inspection Log". Any sling considered unsafe will be discarded. 4) Licensed nurses and or (sic) nursing assistants will inspect the slings for wear, tear and loose stitching prior to each use. If any safety issue is noted the sling will be removed from service, placed in the soiled utility room and management staff notified. 5) Upon admission of a resident utilizing a mechanical lift or determination of new need for mechanical lift a licensed nurse will determine size and inspect sling for good condition. Sizing will be care planned and placed on Kardex. The system for inspection of mechanical lift slings has been added to the orientation and annual competency checks. This plan was accpeted to remove the immediate jeopardy on 11/7/13. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND ASSISTIVE DEVICES TO PREVENT FALLS FOR 1 OF 1 RESIDENTS WITH A KNOWN HISTORY OF FALLS (#101), OUT OF A TOTAL OF 3 SAMPLED RESIDENTS RESULTING IN SERIOUS HARM FOR RESIDENT #101 WHO HAD FALLEN OUT OF BED ON 7/7/13 AND NO INTERVENTIONS WERE PUT IN PLACE, fell OUT OF BED A SECOND TIME ON 7/8/13 AND SUSTAINED A FACIAL LACERATION REQUIRING TREATMENT IN AN EMERGENCY DEPARTMENT OF A HOSPITAL FOR 10 SUTURES AND THE POTENTIAL FOR DEATH DUE TO A FALL. FINDINGS: REVIEW OF THE CLINICAL RECORD FACE SHEET FOR RESIDENT #101, REVEALED SHE WAS A [AGE] year OLD WOMAN, admitted to the facility on [DATE]. REVIEW OF THE MINIMUM DATA SET (MDS), dated [DATE], REVEALED HER [DIAGNOSES REDACTED].. REVIEW OF THE FACILITY'S NURSES NOTES AND INCIDENT/ACCIDENT REPORT DATED 7/7/13 AT 2:45 P.M. REVEALED RESIDENT #101 WAS FOUND ON THE FLOOR, NEXT TO HER BED, ON HER RIGHT SIDE. REDNESS WAS NOTED ON RIGHT HIP AREA, ABLE TO MOVE HER RIGHT LEG WITHOUT SIGNS OF PAIN. ACCORDING TO THE INCIDENT REPORT, RESIDENT #101 had a history of [REDACTED]. REVIEW OF THE CARE PLAN FOR FALL PREVENTION, DATED AS INITIATED ON 7/23/12 REVEALED RESIDENT #101 WAS " A HIGH RISK FOR FALLS RELATED TO UNAWARE OF SAFETY NEEDS, CONFUSION, POOR COMMUNICATION, DECONDITIONING, VISION/HEARING PROBLEMS, GAIT/BALANCE PROBLEMS AND INCONTINENCE." THERE WERE NO NEW INTERVENTIONS IMPLEMENTED AFTER RESIDENT #101 fell OUT OF BED ON 7/7/13. THE FOLLOWING INTERVENTIONS WERE NOT IMPLEMENTED UNTIL 7/24/13, "PERIMETER MATTRESS AND SAFETY MAT NEXT TO HER BED". THERE WERE NO INTERVENTIONS SUCH AS SENSOR PAD ALARMS TO BED TO ALERT STAFF. IN AN INTERVIEW ON 8/22/13 AT 2:35 PM, REGISTERED NURSE (RN#6), SAID ON 7/7/13 AT 2:45 PM, SHE FOUND RESIDENT #101 ON THE FLOOR, ON HER RIGHT SIDE. A RED, RIGHT HIP WAS THE ONLY INJURY. RN#6 SAID RESIDENT #101 DID NOT HAVE A PERIMETER MATTRESS, OR BED RAILS, OR ALARMS OR A MAT ON THE FLOOR ON 7/7/13. REVIEW OF THE FACILITY'S NURSES NOTES AND INCIDENT/ACCIDENT REPORT DATED 7/8/13 AT 2:35 A.M. REVEALED RESIDENT #101 WAS FOUND, "LYING ON THE FLOOR, NEXT TO HER BED, FACE DOWN. THERE WAS A POOL OF BLOOD BY RESIDENT'S HEAD. NURSE NOTED A LACERATION ABOVE HER RIGHT EYE APPROXIMATELY 3 CM LONG...ABOUT 0.5-1 CM DEEP...ORDER RECEIVED TO SEND TO HOSPITAL. " RESIDENT #101 WAS OBSERVED ON 8/22/13 AT 1:00 PM, IN THE DINING ROOM, SITTING IN A GERI-CHAIR STARING AT THE CEILING. THERE WERE NO FACIAL WOUNDS NOTED. RESIDENT #101 WAS NOT ALERT AND NOT ABLE TO BE INTERVIEWED DUE TO SEVERE COGNITIVE DEFICITS. REVIEW OF THE NURSE'S NOTES DATED 7/8/13 AT 5:00 AM REVEALED RESIDENT #101 "RETURNED FROM THE HOSPITAL WITH 10 SUTURES NOTED ABOVE HER RIGHT EYE, FACIAL BRUISING NOTED AROUND RIGHT EYE". REVIEW OF THE NURSE'S NOTES DATED 7/8/13 AT 9:26 PM REVEALED RESIDENT #101 ' S RIGHT EYE WAS, "VERY BRUISED AND SWOLLEN. BANDAGE INTACT OVER RIGHT. " REVIEW OF THE NURSE'S NOTES DATED 7/10/13 AT 1:12 PM REVEALED RESIDENT #101'S FAMILY CAME IN TO VISIT. RESIDENT #101 WAS NOTED TO HAVE AN ABRASION ON HER LOWER RIGHT LEG FROM THE FALL. ACCORDING TO THE NURSE'S NOTE, THE AREA WAS 5X6CM AND WAS CLEANSED AND TRIPLE ANTIBIOTIC OINTMENT WITH A BANDAGE WAS APPLIED. IN AN INTERVIEW ON 8/22/13 AT 4:05 PM, THE UNIT MANAGER (RN#5), SAID THE FAMILY OF RESIDENT #101 BROUGHT IT TO THE NURSE'S ATTENTION THAT RESIDENT #101 HAD AN ABRASION ON HER LOWER RIGHT LEG. THE ABRASION WAS NOT COVERED WITH A DRESSING AND NOT ON THE TREATMENT ADMINISTRATION RECORD UNTIL 7/11/13. #

This citation pertains to MI 619 Based on observation, interview, and record review the facility failed to maintain the highest practicable physical well-being (perform adequate Cardio [MEDICAL CONDITION] Resuscitation (CPR) correctly on a resident with a [MEDICAL CONDITION] (tube surgically placed in the neck for breathing)) in 1 of 5 sampled residents (Resident #101), resulting in an Immediate Jeopardy for Resident #101, who on [DATE] at approximately 2:30 a.m. was found unresponsive and facility staff performed incorrect ventilation breaths for Resident #101. Resident #101 subsequently died . This deficient practice places all residents admitted with a [MEDICAL CONDITION] at risk for serious harm, injury, and/or death. Findings include: Review of the Face Sheet revealed Resident #101 was a [AGE] year-old male admitted to the facility on [DATE]. Review of the Physician's Admission Order Sheet revealed Resident #101 was diagnosed with [REDACTED]. Review of the facility incident report, dated [DATE], revealed that Resident #101 "at approximately" 2:20 a.m. on [DATE] was found by Licensed Practical Nurse (LPN) #9 and Certified Nurse Aide (CNA) #12 "without any audible breath sounds or palpable pulses." The staff started Cardio [MEDICAL CONDITION] Resuscitation and notified 911. Emergency Medical Services arrived at 3:00 a.m. and continued resuscitative efforts until 3:15 a.m. at which time Resident #101 "was pronounced expired." Review of the Medical Treatment Decision Form, dated [DATE], revealed Resident #101 had requested "that in the event my heart and breathing should stop, I am given resuscitating measures." The Medical Treatment Decision Form was signed by Resident #101's guardian/spouse. In an interview on [DATE] at 7:10 a.m., CNA #12 reported she went into Resident #101's room on [DATE] at approximately 2:20 a.m. to care for his roommate and noted Resident #101 was not breathing well and had mucous on the washcloth below his [MEDICAL CONDITION]. CNA #12 stated she went to get LPN #9. CNA #12 returned with LPN #9 at approximately 2:30 a.m. and found Resident #101 unresponsive. CNA #12 stated Resident #101's color "was different, grayish" and Resident #101 was not making any sounds (no breathing). CNA #12 stated LPN #9 stated, 'oh no' and told her to get LPN #11 and CNA #10. In an interview on [DATE] at 8:50 a.m., LPN #9 stated, on [DATE] at 12:30 a.m., CNA #12 came and told her Resident #101 sounded "rattley (noisy breathing)". LPN #9 stated she went into Resident #101's room and suctioned his [MEDICAL CONDITION]. LPN #9 stated on [DATE] at 2:20 a.m., CNA #12 came and told her Resident #101 was "breathing loud". LPN #9 stated she went in at 2:30 a.m. with CNA #12 into Resident #101's room and found him not breathing and without a heartbeat. LPN #9 stated she, LPN #11, CNA #12, and CNA #10 lowered Resident #101 onto the floor and she started doing chest compressions and "mouth to mouth" (not mouth to [MEDICAL CONDITION]) rescue breathing. LPN #9 stated Resident #101's chest rise was "not really, not much" when she was providing mouth to mouth resuscitation. In an interview on [DATE] at 8:06 a.m., CNA #10 stated, on [DATE] at "around" 2:30 a.m., CNA #12 came and told her Resident #101 was not responding. CNA #10 went into Resident #101's room and found him "in his bed." CNA #10 stated she, LPN #9, LPN #11 and CNA #12 lowered Resident #101 off his bed and onto the floor. CNA #10 stated LPN #11 began performing chest compressions and LPN #9 gave mouth to mouth resuscitation (not effective rescue breathing for a patient with a [MEDICAL CONDITION]). CNA #10 stated LPN #11 stopped chest compressions and went out to call 911 and get "supplies." CNA #10 stated LPN #9 resumed chest compressions on Resident #101 when LPN #11 stopped. In an interview on [DATE] at 6:07 a.m., LPN #11 stated, on [DATE] at approximately 3:00 a.m., CNA #12 called her on the phone and stated ,'we need you over here right now.' LPN #11 went to Resident #101's room and found him laying in his bed with LPN #9 standing at the head of his bed. LPN #11 stated LPN #9 "was standing there waiting for me to come in." LPN #11 stated LPN #9 said "we need to do CPR, he (Resident #101) has no respiratory and no pulses." LPN #11 stated she did not give any rescue breaths and did not witness any rescue breaths given to Resident #101 at this time. LPN #11 stated LPN #9, CNA #12 and CNA #10 placed Resident #101 onto the floor and then LPN #11 started chest compressions. LPN #11 stated, "I got tired so LPN #9 took over (chest compressions)." LPN #11 stated she went to call 911 (call was made at 2:37 a.m. on [DATE]) and then went to the supply closet and grabbed an "ambu-bag (bag valve mask used to deliver positive pressure ventilations of air and oxygen (if attached to an oxygen tank) by pressure into a person not breathing), oxygen tank, and some tubing." LPN #11 returned to Resident #101's room, attached the ambu-bag and tubing to the oxygen tank and turned on the oxygen flow to 2 liters/minute. LPN #11 stated CNA #10 took the ambu-bag and was squeezing it into the [MEDICAL CONDITION]. LPN #11 stated she and LPN #9 continued providing chest compressions for Resident #101 until Emergency Medical Services (EMS) arrived (at patient at 2:48 a.m.). An observation of Unit "B" revealed Resident #101's room was approximately 120 feet from the supply closet. The supply closet was a locked room located behind the nurses desk of Unit "B". Review of Emergency Medical Patient Care Report, dated [DATE], revealed the 911 call was placed at 2:37 a.m. on [DATE] (7 minutes after Resident #101 was found unresponsive). In an interview on [DATE] at 12:35 p.m., Paramedic #19 stated, upon arrival to the facility on [DATE], she entered Resident #101's room and noted the ambu-bag was "not hooked up correctly." Paramedic #19 stated CNA #10 had the ambu-bag's "port (exhaust) to the patient (the exhaust port is used for exhausting exhaled air and provides no positive pressure ventilation to the patient)." Review of Emergency Medical Patient Care Report, dated [DATE], revealed the ambulance arrived at the facility at 2:45 a.m. and was "at patient" at 2:48 a.m. In an interview on [DATE] at 2:05 p.m., Fire Fighter (FF) #17 stated on [DATE] at approximately 2:49 a.m., he entered Resident #101's room. FF #17 reported that Paramedic #19 stated he should help facility staff with the use of ambu-bag for Resident #101. FF #17 stated the ambu-bag was not being used properly. FF #17 stated CNA #10 was attempting to fit exhaust port of the ambu-bag to Resident #101's [MEDICAL CONDITION]. FF #17 stated to use an ambu-bag in this manner "would do no good." FF #17 stated the face mask was still attached to the ambu-bag (the face mask is used to cover the mouth of a patient when using an ambu-bag to give positive pressure ventilation to the mouth from the ambu-bag and the face mask must be removed from the ambu-bag to allow attachment of the ambu-bag to a [MEDICAL CONDITION]). FF #17 stated, "the chest was not rising (indicating ineffective use of the ambu-bag and no effective rescue ventilations of Resident #101 for 19 minutes). FF #17 stated he "took the mask off and started using it (the ambu-bag)" and then "the chest was rising." Review of facility Policy and Procedure CPR- Adult, dated ,[DATE] and revised [DATE], revealed there were no instructions documented for how facility staff should perform CPR on a resident with a [MEDICAL CONDITION]. In an interview on [DATE] at 11:00 a.m. and on [DATE] at 4:15 p.m., Assistant Director of Nursing (ADON) #14 stated, "We don't specifically check off [MEDICAL CONDITION] care" for new staff personnel. ADON #14 stated staff had to "give me a verbal step by step for ambu-bag use." This Surveyor asked for documentation and instructions of ambu-bag use and ADON #14 reported there was no documentation of the aforementioned verbal training. Administrator #1 was notified on [DATE] at 1:05 p.m. of the Immediate Jeopardy that was identified on [DATE] and began on [DATE] as a result of the facility's failure to maintain the highest practicable physical well-being for Resident #101, when Resident #101 was found unresponsive without a pulse or respirations and facility staff failed to provide rescue breathing to his [MEDICAL CONDITION] for approximately eight minutes. On [DATE] the Surveyor confirmed the facility staff completed the following to remove the Immediate Jeopardy: 1. a) On [DATE], the Administrator and the Director of Clinical Services discussed over the phone with the Director of Respiratory Services and reviewed the CPR guidelines for an adult with [MEDICAL CONDITION], that were going to be in the policy delivered [DATE]. The Administrator then directed the Assistant Director of Nursing (ADON) as to what the additional guidelines and policy were going to be. The ADON developed an in-service training outline and the ADON began facility training at 2:45 p.m. of 13 of 49 CNA's and 10 of 29 Licensed Nurses concerning CPR of a resident with a [MEDICAL CONDITION]. Training included appropriate resuscitation procedures with an ambu-bag to the [MEDICAL CONDITION] and chest compressions. All nursing staff will complete a post test to verify competency following training. b) As of [DATE] at 2:00 p.m. 21 of 29 Licensed Nurses have been trained and 31 of 49 CNA's have been trained. All Nurses and CNA's who have worked since [DATE] at 2:45 p.m. have been trained before they began working. All other nurses and all CNA's prior to starting their shift will receive the training and this will continue until all nursing staff have been trained. c) Nursing management personnel were assigned to provide training throughout the weekend. 2. a) The facility has reviewed the policy and procedure for CPR of an adult. The last revised date was [DATE], which indicates Metron Integrated Health Systems had set the American Heart Association as the standard for basic life support care. These standards are based on the American Heart Association 2010 guidelines. The Director of Respiratory Therapy provided in written policy format on [DATE], what he had verbally communicated on [DATE] to the ADON concerning additional guidelines for CPR of an adult with a [MEDICAL CONDITION], which was to be added to the current policy and procedure based on standard of practice. Once the written policy was received, the ADON and the Director of Nursing (DON) reviewed with staff on a one-to-one basis the policy for CPR with an adult with a [MEDICAL CONDITION]. This included staff, who had previously been in-serviced. b) The ongoing practice for all Metron licensed personnel is to be certified in basic life support once every two years. This training is offered every month. Employees, therefore, have different certification dates. Two weeks prior to the certification or re-certification staff are provided with American Healthcare Association BLS (basic life support) for Healthcare Providers student manual for professionals to review. Currently, all 29 licensed staff have received re-certification at different times. All staff certification has been done from [DATE] to current. 3. Adult CPR for an individual with a [MEDICAL CONDITION] education will be repeated monthly for three months then quarterly thereafter. The ADON will report these outcomes to the QA (Quality Assurance) committee. In addition the facility added this education on [DATE] to new hire orientation and a competency checklist for verification of the licensed nurses' and CNAs' understanding. 4. Currently there are no residents with a [MEDICAL CONDITION] in the facility. Although, the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, due to the fact that sustained compliance had not been verified by the State Agency and all staff had not yet been in-serviced.

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE MEDICAL JUSTIFICATION FOR AN INDWELLING URINARY CATHETER FOR 1 OF 4 RESIDENTS (#3) WITH CATHETERS AND FAILED TO ASSESS AND IMPLEMENT NURSING INTERVENTIONS FOR 1 OF 4 RESIDENTS (#1) REVIEWED FOR URINARY TRACT INFECTION [MEDICAL CONDITION] FROM A TOTAL SAMPLE OF 18 RESIDENTS, RESULTING IN A LOSS OF NORMAL BLADDER FUNCTION, CATHETER RELATED PAIN, BLEEDING AND URINARY TRACT INFECTION FOR 1 RESIDENT (#3) AND DEVELOPMENT OF CATHETER RELATED URINARY TRACT INFECTIONS AND COMPLICATION FOR 1 RESIDENT (#1). FINDINGS INCLUDE: RESIDENT #3 WAS AN [AGE] year OLD MALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE RESIDENT RECENTLY HAD A VISIT TO emergency room RELATED TO [MEDICAL CONDITION] ON 2/17/11 AND RETURNED WITH AN INDWELLING CATHETER. THE NURSING NOTE DATED 2/20/11 REELECTED THAT THE RESIDENT COMPLAINED OF PAIN AT THE CATHETER INSERTION SITE. THERE WAS A YELLOW THICK DRAINAGE AROUND THE CATHETER. THE PHYSICIAN WAS NOTIFIED AND AN ORDER TO START THE ANTIBIOTIC (KEFLEX) WAS RECEIVED. THE PHYSICIAN HAD INDICATED THAT HE WOULD EVALUATE THE CULTURE FROM THE DRAINAGE AND URINE SPECIMEN THAT WAS SENT OUT. HOWEVER, NO URINALYSIS OR CULTURE REPORT COULD BE FOUND. THE NURSING NOTE LATER IN THE SAME DAY (10:00 P.M.) REFLECTED THAT RESIDENT WAS FOUND SHIVERING, COMPLAINED OF BEING COLD AND HOT, KICKING COVERS OFF. THE URINE WAS FOUND TO HAVE DARK BLOOD (MAY HAVE BEEN CAUSED BY THE RESIDENT'S MANIPULATION). THE NURSING NOTES DATED 10/15/10 THROUGH 3/3/11 REFLECTED THAT THE RESIDENT FREQUENTLY REFUSED MEDICATIONS AND HE WAS UNCOOPERATIVE WITH HIS CARE. THE MINIMUM DATA SET ((MDS) dated [DATE] REFLECTED THE RESIDENT WAS ALWAYS INCONTINENT OF BOWEL AND BLADDER. THE RESIDENT DID NOT VERBALIZE NEED TO VOID, WAS RESISTIVE OR REFUSED STAFF'S EFFORT TO ASSIST HIM TO TOILET. THE NURSING NOTE DATED 1/27/11 6:30 P.M. REFLECTED THAT THE RESIDENT ATTEMPTED TO TRANSFER SELF TO BATHROOM ALTHOUGH HE HAD BEEN TOILETED AT 5:30 P.M. ONE HOUR AGO. THE RESIDENT HAD NO OBVIOUS INJURY WITH SELF TRANSFER, BUT HE HAD INCREASED CONFUSION AND REFUSED TO HAVE VITAL SIGNS TAKEN. THE ORDER TO OBTAIN URINALYSIS WAS RECEIVED AND THE STRAIGHT CATHETERIZATION WAS ATTEMPTED WITH MUCH RESISTANCE AND COMBATIVENESS, THUS WAS UNSUCCESSFUL. AFTER THE RESIDENT HAD NOT VOIDED THROUGH THE NIGHT SHIFT HE WAS SENT TO THE HOSPITAL AND RETURNED WITH AN INDWELLING CATHETER IN PLACE. THE emergency room (ER) PATIENT EDUCATION MATERIAL PROVIDED TO THE RESIDENT UPON DISCHARGE CONTAINED INFORMATION ABOUT ACUTE [MEDICAL CONDITION] RELATED TO EITHER THE ENLARGED PROSTATE OR CERTAIN MEDICATION. THE TREATMENT IN THE emergency room INCLUDED "ONE TIME" CATHETERIZATION TO EMPTY THE BLADDER. THE URINALYSIS PERFORMED IN ER WAS NOT INDICATIVE FOR URINARY TRACT INFECTION. THE RESIDENT WAS REFERRED TO A UROLOGIST FOR FURTHER EVALUATION AND TREATMENT. THE UROLOGIST REPORT DATED 2/7/11 REFLECTED THAT THE RESIDENT EXPERIENCED [MEDICAL CONDITION] ON 1/28/11, RESULTING IN OVER 600 ML OF URINE WHEN THE CATHETER WAS INSERTED IN THE emergency room . THE REPORT CONTINUED SAYING THAT THE RESIDENT HAD NEVER TAKEN MEDICATIONS OR UNDERGONE surgery for [REDACTED]. UNDER THE HEADING OF REVIEW OF [MEDICAL CONDITION] SYSTEM THE UROLOGIST DOCUMENTED, "RESIDENT ADMITS INCONTINENCE BUT DENIES [MEDICAL CONDITION], DAYTIME FREQUENCY, NOCTURIA (NIGHT TIME VOIDING), DYSURIA (DIFFICULTY VOIDING), URINARY HESITANCY, DECREASED STREAM, CHANGE IN URINE COLOR, HEMATURIA (BLOOD IN URINE), POST-VOID DRIBBLING AND ERECTILE DYSFUNCTION." HOWEVER, THE UROLOGIST'S TREATMENT PLAN INCLUDED LEAVING THE CATHETER IN PLACE INDEFINITELY, AFTER DISCUSSING OPTIONS WITH THE RESIDENT'S NURSE AIDE, BECAUSE OF DIFFICULTY WITH INTERMITTENT CATHETERIZATION. THERE WAS NO EVIDENCE THAT THE UROLOGIST REVIEWED MEDICATIONS OR TRIED MEDICATION TO TREAT SIGNS AND SYMPTOMS OF PROSTATE ENLARGEMENT. THE RESIDENT WAS NOT SCHEDULED TO RETURN TO THE OFFICE FOR FURTHER ASSESSMENT OR EVALUATION FOR THE CONTINUED USE OF THE CATHETER. [MEDICAL CONDITION] IS THE INABILITY TO COMPLETELY EMPTY THE URINARY BLADDER BY VOIDING. THE URINARY BLADDER CONSISTS OF SMOOTH MUSCLE (DETRUSOR MUSCLE) THAT CONTRACTS WHEN THE BLADDER CHAMBER IS FILLED WITH URINE AND THE PRESSURE RISES INSIDE THE CHAMBER. FOLLOWING AN INDWELLING CATHETERIZATION THE BLADDER LOSES MUSCLE TONE AND DOES NOT RETURN UP TO APPROXIMATELY 7 DAYS. LEAVING THE CATHETER IN FOR AN EXTENDED PERIOD OF TIME WITHOUT JUSTIFICATION WILL LEAD TO LOSS OF DETRUSOR MUSCLE TONE, THUS ABILITY TO CONTRACT. THE physician's orders [REDACTED]. HOWEVER, 2 DAYS LATER ON 2/22/11 THERE WAS ANOTHER ANTIBIOTIC ORDER FOR [MEDICATION NAME] 1 GRAM INTRAMUSCULARLY FOR 7 DAYS. BOTH ANTIBIOTICS WERE PRESCRIBED FOR [DIAGNOSES REDACTED]. ON 3/2/11 AT 9:45 A.M., THE UNIT NURSE, (STAFF " G") EXPLAINED THAT THE RESIDENT WAS REFUSING THE ORAL ANTIBIOTIC, THUS IT WAS SWITCHED TO AN INJECTABLE ANTIBIOTIC. ON 3/2/11 IN THE MORNING, THE UNIT MANAGER, (STAFF "A") STATED THAT THE RESIDENT HAD NO PREVIOUS EPISODES OF [MEDICAL CONDITION] AS LONG AS HE HAD BEEN IN THE FACILITY (SINCE 2007), ALTHOUGH HE WAS ALWAYS INCONTINENT. THE RESIDENT'S CLINICAL RECORD CONTAINED NO EVIDENCE TO SUPPORT THE USE OF AN INDWELLING CATHETER. NO ASSESSMENT OR DOCUMENTED POST VOID RESIDUAL VOLUME IN DETERMINING URINARY RETENTION. IN ADDITION, NO NURSING CARE PLAN WAS IN PLACE TO MANAGE INCONTINENCE, PREVENT COMPLICATIONS RELATED TO USE OF AN INDWELLING CATHETER AND ITS CARE, PUTTING THE RESIDENT AT RISK FOR A DECLINE IN NORMAL BLADDER FUNCTION, SKIN EROSION, PAIN AND AVOIDABLE URINARY TRACT INFECTIONS. ( ) RESIDENT #1 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. THE RESIDENT ASSESSMENT PROTOCOL (RAP) DATED 4/5/10 REFLECTED THAT THE RESIDENT HAD A SUPRA PUBIC CATHETER PLACED ON 10/18/2007. CATHETER WAS CHANGED MONTHLY, BAG CHANGED WEEKLY, CATHETER SITE WAS CLEANSED WITH SOAP AND WATER DAILY WITH DRESSING AROUND THE SITE. RECEIVED DAILY IRRIGATION WITH ACETIC ACID AND RECEIVED FLUID THOUGH TUBE FEEDING. THE RESIDENT WAS DEPENDENT ON ALL AREAS OF ACTIVITIES OF DAILY LIVING, INCLUDING FEEDING AND ELIMINATION. REVIEW OF THE NURSING NOTES DATED 8/30/10 THROUGH 2/3/11 REFLECTED THAT THE RESIDENT HAD MULTIPLE hospitalization S RELATED TO CARE OF BOTH FEEDING TUBE AND CATHETER RELATED COMPLICATIONS. FOR EXAMPLE, THE NURSING NOTE DATED 8/30/10 REFLECTED, "...NOTIFIED (DOCTOR'S NAME)...CONCERNED BRIEFS SATURATED WITH URINE, CLOTHING UP TO HEAD...DRIED BLOOD PRESENT ON SUPRAPUBIC CATHETER TUBING NEAR ABDOMEN...MAY NEED NEW CATHETER..." THE NURSING NOTE DATED 12/3/10 REFLECTED, "...BLEEDING AT SUPRAPUBIC CATHETER SITE...THERE IS A PIECE OF TISSUE RED, FLESHY PROTRUDING AT THE CATHETER SITE..." THE NURSING NOTE DATED 1/17/11 REFLECTED , "...SUPRAPUBIC CATHETER CHANGED DUE TO LEAKING URINE IN BRIEF... SUPRAPUBIC CATHETER WAS VISUAL IN VAGINAL OPENING...READJUSTED WITHOUT OUTPUT...(DOCTOR'S NAME) WAS NOTIFIED..." THE NURSING NOTE DATED 11/21/10 REFLECTED, "...FEEDING TUBE PULLED OUT...RESIDENT UPSET, REFUSED TO EAT OR DRINK..." ON 3/3/11 AT 8:30 A.M., BOTH FEEDING TUBE SITE AND SUPRAPUBIC CATHETER WERE OBSERVED IN THE RESIDENT'S ROOM. THE SKIN AROUND BOTH SITES WAS RED AND HAD A SMALL AMOUNT OF DARK BROWNISH DRAINAGE. URINE LOOKED CLEAR BUT HAD LARGE AMOUNT OF WHITE SEDIMENTATION. THE NURSING CARE PLAN RELATED TO USE OF SUPRAPUBIC CATHETER DATED 7/15/10 REFLECTED THAT THE RESIDENT WAS AT RISK FOR INFECTION, WOULD ENCOURAGE FLUID, IRRIGATE CATHETER DAILY, CHANGE CATHETER MONTHLY, CHANGE BAG WEEKLY, MONITOR SIGNS AND SYMPTOMS OF URINARY TRACT INFECTION AND EMPTY BAG EVERY SHIFT. ON 3/2/11 AT 12 NOON, THE UNIT MANAGER, (STAFF "A") STATED THAT THE FACILITY NORMALLY DID NOT MONITOR INTAKE AND OUTPUT WITH TUBE FED RESIDENTS, UNLESS THEY HAD RECENTLY BEEN hospitalized OR IF PHYSICIAN HAD ORDERED FLUID MONITORING. HOWEVER, THERE WAS NO FLUID MONITORING WHENEVER SHE WAS RETURNED FROM THE HOSPITAL (10/9/10, 11/10/10, 11/23/10). IN ADDITION, NO FLUID MONITORING COULD BE FOUND EVEN WHILE THE RESIDENT'S FEEDING TUBE GOT PULLED OUT FOR 3 DAYS (FROM 11/21/10 TO 11/23/10), PUTTING THE RESIDENT AT RISK FOR DEHYDRATION. DURING A SAME INTERVIEW, STAFF "A" WAS ASKED HOW TO MANAGE DEHYDRATION THAT MAY BE A CAUSE OF THE RESIDENT'S UTI WITHOUT MONITORING FLUID STATUS. SHE SAID THE RESIDENT WAS TOO LITTLE (RESIDENT WEIGHED APPROXIMATELY 130 POUNDS) TO GIVE TOO MUCH FLUID. HOWEVER, THERE WAS NO MEDICAL RATIONALE THAT THE RESIDENT NEEDED TO HAVE FLUID RESTRICTION. THE ESSENTIALS OF GERONTOLOGICAL NURSING, AUTHORS: A.S. STAAB AND L.C. HODGES, 1996 STATES THAT ADEQUATE FLUID INTAKE MAINTAINS DILUTE URINE AND HELPS PREVENT URINARY TRACT INFECTION. ( )

This citation pertains to intake MI 398 Based on observation, interview and record review, the facility failed to provide safety devices (transfer belt or mechanical lift) and supervision to prevent falls in 1 (101) of 4 sampled residents resulting in resident 101 falling and fracturing her left leg, and the potential for a fall when resident 101 was rolled away from a staff member to the far side of the bed with the bed in the high position and nothing in place to prevent her from falling out of bed. Findings include: Review of Resident 101's medical record revealed a [AGE] year old female who was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 101's Minimum Data Set ((MDS) dated [DATE] revealed that she had modified independence with cognitive skills for daily decision making, her long-term and short-term memory were intact, she was totally dependent for transferring, dressing and bathing, and required extensive assistance with personal hygiene. In an observation on 9/23/10 at 11:00 am, staff #13 was observed standing next to resident 101's bed, assisting resident 101 with dressing. Resident 101 was lying on the bed, and the bed was in the high position. There was one assist bar (partial hand rail near the head of the bed approximately 8 inches long) on the right side of the bed. Staff #13 stood on the left side of resident 101's bed and rolled resident 101 away from her (staff #13) toward the right side of the bed, and pulled the left side of resident 101's pants up. Staff #13 then walked to the right side of the bed and rolled resident 101 away from her (staff #13) toward the left edge of the bed and attempted to pull the right side of her pants up. There was not another staff member in the room. The surveyor did not observe anything to be in place to prevent resident 101 from rolling off from the left side of the bed and onto the floor. Staff #13 was unable to completely pull resident 101's pants up. Staff #13 left the bed in the high position with resident 101 lying slightly on her left side, exited resident 101's room, leaving resident 101 unattended, and shut the door to the room. Staff #13 returned approximately 1 minute later with staff #15. Resident 101's plan of care identified her to be at risk for falls with intervention dated 4/4/10 as "mechanical lift". Resident 101's plan of care also documented a decline in physical function due to a fracture of left ankle dated 9/7/10. An xray report with a documented exam date of 8/23/10 stated a left ankle xray revealed soft tissue swelling and Avulsion of the medial malleolus. Hospital discharge instructions for Resident 101 dated 9/2/10 stated that resident 101 had an avulsion fracture and described an avulsion fracture as "chips of bone pulled off by muscle tendons and ligaments. Hospital emergency department physician notes for resident 101 with a documented date of service as 9/2/10 stated that resident 101 fell approximately 1 week ago and landed on her left ankle and listed a [DIAGNOSES REDACTED]. A facility incident report dated 8/23/10 stated that resident 101 was lowered to the floor by two CNA's (certified nurse aides) while transferring her (resident 101) off the commode (portable toilet). The facility incident report also documented an injury to resident 101's left ankle. In an interview on 9/22/10 at 11:00 am, resident 101 stated that she was dropped by staff on 8/23/10 during a transfer. Resident 101 stated two staff members were holding her under her arms and trying to transfer her to the commode (portable toilet) and they dropped her. Resident 101 stated the two staff members did not use a "belt" on her at the time she was dropped. Resident 101 stated "when I was dropped, screamed and screamed" (pointed to her left leg) after she was on the floor. Resident 101 stated she continued to have bad pain in her left leg, which she told surveyor was an 11 on a scale of 1 to 10, and that she kept telling the nurses about her pain. Resident 101 stated the nurses gave her medicine for pain but it didn't work and she continued to have pain. Resident 101 stated an xray was done of her left ankle at the facility, but the nurse told her xray said it wasn't broken. Resident stated her leg was "big, big" and she continued to complain of pain and requested to be sent to the hospital on [DATE]. Resident 101 stated the doctor at the hospital did an xray and found that her left leg was broken, and the doctor gave her a shot for the pain, which helped. Resident 101 stated they put a brace on her leg at the hospital. At the time of the interview, resident 101 was observed in her room, sitting in a motorized wheelchair, with her left foot and lower leg in a half cast with a wrap around the cast and her left foot and lower leg. Resident 101 stated she was a refugee from Africa, and spoke broken English, but was not difficult to understand. Resident 101's nephew was in the resident's room at the time of the interview and assisted the surveyor with communication when needed. In an interview on 9/22/10 at 12:45 pm, staff #12 stated she was helping staff #11 transfer resident 101 from her wheelchair to the commode. Staff #12 stated resident 101 was leaning back too far in the commode and they (staff 11 and staff 12) did not want the commode to tip over, so they lowered resident 101 to the floor. Staff #12 stated she had her arm under resident 101's arm and staff #11 had her arm under resident 101's other arm during the transfer and when resident 101 went down to the floor. Staff #12 stated resident 101 screamed as they were getting her up from the floor and while they were getting resident 101 off from the floor, resident 101 complained the entire time of pain in her leg. Staff #12 stated that she and staff #11 did not have a gait belt on resident 101. In an interview on 9/22/10 at 2:45 pm, staff #11 stated that her and staff #12 held resident 101 under each arm and transferred her to the commode. Staff #11 stated that resident 101 was leaning back and sliding out of the commode, so she (staff #11) and staff #12 lowered resident 101 to the floor. Staff #11 stated that resident 101 hollered, "my leg, my leg" while they (staff #11 and staff #12) lowered resident 101 to the floor. Staff #11 stated she couldn't do anything about resident 101's leg because "she is a big lady". Staff #11 stated she went and got the nurse and it took 5 staff members to get resident 101 back into her bed. In an interview on 9/22/10 at 1:00 pm, staff nurse #9 stated staff #11 and staff #12 stated resident 101's knees had buckled and they had lowered resident 101 to the floor. Staff nurse #9 stated she thought in the process of lowering resident 101 to the floor her ankle got twisted. Staff nurse #9 stated resident 101 was placed back into bed and she (staff nurse #9) assessed resident 101's left ankle and found it to be swollen. Staff nurse #9 stated resident 101 did complain of pain in her ankle and she (staff nurse #9) put ice on resident 101's ankle, called the physician and an xray was ordered. #