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

Based on interview and record review, the facility failed to maintain complete and accurate medical records for 3 of 15 sampled residents (R3, R51, and R69). Findings include:Resident #51 (R51) A review of R51’s admission Record, dated 07/17/2025, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R51 had multiple diagnoses that included depression, bipolar disease, schizophrenia, and alcohol-induced disorder. R51’s admission Record also revealed they were their own responsible party (in charge of their own medical decisions). A review of R51’s Order Summary Report, dated 7/17/25, revealed R51 had physician orders for Benztropine Mesylate (a medication for Parkinson’s Disease and movement disorders from other diseases or side effects from antipsychotic medications) 0.5 milligrams (mg) twice a day and Bupropion (a medication for depression) 150 mg once a day. In addition, R51’s Order Summary Report revealed R51 was also prescribed Fluphenazine decanoate (an antipsychotic medication for bipolar disease) and Olanzepine (an antipsychotic medication for bipolar disease). A review of R51’s medical record, dated 06/25/2025 to 07/17/2025, failed to reveal any documentation that R51 was made aware in advance of the risks and benefits of a medication, the treatment alternatives or other options and was able to choose the option he preferred prior to the facility administering Benztropine Mesylate and Bupropion to him. During an interview on 07/17/2025 at 10:36 AM, the Director of Nursing (DON) stated R51's psychotropic medications are managed by CMH (Community of Mental Health- an outside agency). The DON stated he would contact them and get something from them to put into R51's medical record documenting that R51 was aware in advance of the risks and benefits of Benztropine Mesylate and Bupropion, the treatment alternatives or other options, and he was able to choose the option he preferred when he was admitted to the facility. During a second interview on 07/17/2025 at 11:30 AM, the DON stated the facility received R51's consent for psychoactive medications (including Benztropine Mesylate and Bupropion) from CMH. The DON stated the facility had done consents (including risks versus benefits of use and the treatment alternatives or other options) for antipsychotic medications (Fluphenazine decanoate and Olanzepine) when R51 had been admitted to the facility. However, the facility did not have any documentation that they had completed any consents for Benztropine Mesylate and Bupropion. Resident # 69 (R69) A review of R69’s admission Record, dated 07/18/2025, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R69’s admission Record revealed they had multiple diagnoses including cervical spinal stenosis, osteoarthritis, and encounter for other orthopedic aftercare. A review of R69’s Discharge Instructions and Recap of Stay form, dated 05/14/2025, revealed that R69 had been admitted to the facility following an elective spinal surgery, progressed well, and was ready for discharge home on [DATE]. However, the “Nursing Services- Recap of Stay- Brief summary of medical stay” revealed, “This resident is in need for skilled services that can only be provided in SNF (Skilled Nursing Facility) on a daily basis for Encounter for Other Orthopedic Aftercare. I estimate the length of stay needed is 14 days.” This statement implied that R69 still needed skilled services that only the facility could provide when she discharged home after only 3 days at the facility. In addition, this statement appeared to be a reason for R69’s admission to the facility and not a summary of their stay. During an interview on 07/17/2025 at 4:00 PM, the DON stated it appeared the nurse manager copied and pasted the information from the hospital discharge summary into her section of R69’s Discharge Instructions and Recap of Stay form. The DON stated he was fine with that since that was the reason that R69 was at the facility. When the DON was informed that the nursing recap of stay at the facility was a summary of what occurred while the resident was at the facility and should be a summary of the resident’s stay and not just the reason for their admission he agreed, but stated he was fine with the nurse manager copying and pasting information from the hospital records into R69’s “Nursing Services- Recap of Stay” section of the Discharge Instructions and Recap of Stay form and did not see anything wrong with her (the nurse manager’s) documentation. During an interview on 07/18/2025 at 9:15 AM, Clinical Care Coordinator (CCC) “C” stated she had been R69’s nurse manager while she (R69) had been at the facility. CCC “C” also stated that she had filled out the “Nursing Services- Recap of Stay” section on R69’s Discharge Instructions and Recap of Stay form. CCC “C” was asked if she copied and pasted her note from any other documentation or if she typed it herself. CCC “C” stated she copied it and pasted it from R69’s “Order Recap Report” (not from R69’s hospital records) under the “Order” tab in R69’s medical record and showed the surveyor that she copied it from the physician order, dated 05/12/2025. CCC “C” stated, “I always copy and paste this (the admission physician order) into the nursing re-cap of stay section of a resident's discharge paperwork. That was what I was trained to do. “Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice… Documentation of nurses’ work is critical as well for effective communication with each other and with other disciplines. It is how nurses create a record of their services for use by payors, the legal system, government agencies, accrediting bodies, researchers, and other groups and individuals directly or indirectly involved with health care. It also provides a basis for demonstrating and understanding nursing’s contributions both to patient care outcomes and to the viability and effectiveness of the organizations that provide and support quality patient care… High quality documentation, however, is a necessary and integral aspect of the work of registered nurses in all roles and settings… Patient documentation frequently is used by professionals who are not directly involved with the patient’s care. If patient documentation is not timely, accurate, accessible, complete, legible, readable, and standardized, it will interfere with the ability of those who were not involved in and are not familiar with the patient’s care to use the documentation. (ANA’s (American Nursing Association) Principles for Nursing Documentation- Guidance for Registered Nurses, 2010, www.nursingworld.org/globalassest/docs/ana/ethics/principles -of-nursing-documentation.pdf, retrieved on 07/22/2025). Resident #3 (R3) Review of the Electronic Medical Record (EMR) reflected R3 admitted to the facility 8/23/2023 with diagnoses that included Quadriplegia (unable to use arms and legs). The EMR reflected R3 was cognitively intact and was able to make his own medical decisions. Review of the EMR Progress Note entry of 6/18/2025 at 12:43 PM reflected that R3 was transported to the hospital when a change of condition was identified. The entry did not reflect that pertinent information about the Resident’s condition was conveyed to the receiving hospital. The entry did not reflect that R3 was provided information on the facility bed hold policy. On 7/17/2025 at 3:46 PM an interview was conducted with the Director of Nursing (DON). The DON reported that when a resident was transferred to the hospital an “Interact” transfer form was completed and contains the documentation of contact with the hospital to convey pertinent resident information and documentation regarding the bed hold policy. The DON reported a review would be conducted for the information for the 6/18/25 event for R3.Review of the EMR index of Interact transfer forms did not reveal this form had been completed for R3 on 6/18/2025 On 7/18/2025 at 10:11 AM the DON acknowledged that an Interact transfer form for R3 on 6/18/25 was not completed and entered into the medical record. This indicated that the medical record did not contain complete documentation to verify that the hospital had been contacted with information pertinent to the change of condition of R3. Additionally, no documentation was included regarding the bed hold policy. urther review of the EMR Progress Notes revealed a “late entry” had been entered on 7/17/25 at 4:01 PM and placed in the Progress Notes time slot for 6/18/25 at 3:49 PM. The entry reflected the hospital had been notified that R3 was “enroute” and the reason for the transfer. The late entry documentation did not include information regarding the bed hold policy.

Based on observation, interview, and record review, the facility failed to ensure resident care plans were reviewed, revised, and implemented for 2 of 15 residents (Resident #40 and #5) reviewed for care plans. Findings: Resident #40 (R40) Review of an admission Record revealed R40 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Muscular Dystrophy and dysphagia (difficulty swallowing). Review of R40’s “Antigravity Team Note” dated 6/12/25 revealed, “Date of Fall: 6/11/25Root Cause(s) of Fall: Rolled from bed…New Interventions: Floor mats added…” Review of R40’s fall “Care Plan” on 7/16/25 at 12:09 PM and on 7/17/25 at 11:02 AM revealed, “I am at an increased risk for falls r/t (related to) muscular dystrophy, muscle weakness, DM II (diabetes type 2), depression, anxiety, chronic pain, scoliosis, history of falls. Date Initiated: 11/23/2023.” There was no intervention for the placement of a floor mat. During an interview on 07/18/2025 at 8:30 AM, Staff Development Coordinator (SDC) “G” reported that R40’s “Care Plans” should reflect her current status and preferences and she would follow up. Review of R40’s fall “Care Plan” on 7/18/25 at 11:15 AM revealed, “…Fall mats at bedside due to risk of rolling from bed.” Review of R40’s nutrition “Care Plan” revealed, “I have the potential for a nutritional/hydration problem r/t DM (diabetes mellitus), CKD (chronic kidney disease), dysphagia, depression, HLD (hyperlipidemia), risk for malnutrition Date Initiated: 12/06/2023…Patient to eat in dining room only, or by nurses' station for supervision. Date Initiated: 11/16/2024…” During an observation and interview on 07/16/2025 at 8:44 AM, R40 was observed eating her breakfast in bed without supervision. R40 reported that she would routinely eat her breakfast and dinner in her bed without supervision. Additionally, there was a fall mat in her room leaning up against the wall. It was not positioned next to the bed. During an observation on 07/17/2025 at 8:49 AM, R40 was observed eating her breakfast in bed without supervision. There was a fall mat in her room leaning up against the wall not positioned next to the bed. During an observation on 07/17/2025 at 10:59 AM, R40 was in bed resting with her eyes closed. There was a fall mat in her room leaning up against the wall not positioned next to the bed. Resident #5 (R5) Review of the Electronic Medical Record (EMR) reflected R5 admitted to the facility 3/11/2018 with pertinent diagnoses that included: Traumatic Brain Dysfunction, Aphasia (inability or difficulty speaking), and Cognitive Communication Deficit. Review of the Minimum Data Set (MDS) dated [DATE] reflected R5 was significantly cognitively impaired. On 7/17/2025 at 11:09 AM Certified Nurse Aide (CNA) “J” reported she had worked at the facility for several years and frequently provided care to R5. CNA “J” reported she often cannot figure out what R5 wants. CNA “J” reported that R5 will point but that she cannot understand the Resident. Review of the Care Plan for R5 revealed a “Focus” of “I have a communication problem (related to) previous traumatic brain injury; my speech may sound garbled at times. I have a communication board. Please encourage me to use it and write out my words” initiated 2/27/2019. The documented “Goal” of this Care Plan was “I will be able to make basic needs known by physical communication on a daily basis…” initiated 2/27/2019. “Interventions” included: “Help me develop a communication tool that I can utilize to communicate my needs” and “Monitor/document frustration level. Allow me time before providing me with words” initiated 2/27/2019. Further review of the Care Plan reflected no new interventions since 2/10/2020. No monitoring documentation or tool was identified in the EMR for the Care Plan intervention of “Monitor/document frustration level” of R5. On 7/17/2025 at 12:51 PM the communication difficulties identified for R5 were discussed with the Director of Nursing (DON). The DON reported a review would be conducted. On 7/17/2025 at 1:30 PM the room of R5 was reviewed. No communication board was found. R5 shook his head “No” when asked if he had a communication board and if he knew what this was.

This citation pertains to intake #1239234:Based on observation, interview, and record review, the facility failed to ensure a clean environment for 2 residents (R7 and R17) reviewed for environmental concerns. Findings include: On 7/11/2025 the Long-Term Care Ombudsman reported that the facility was odoriferous (unpleasant smell) during recent visits. On 7/15/2025 at 11:04 AM a strong smell of urine was noted at and around the Nurse's Station at the South East/West Hall becoming more pronounced down the hall past room [ROOM NUMBER] and continued to room [ROOM NUMBER] before subsiding but still notable. Due to the strong prevalence of the odor in the area the source could not immediately be isolated. Resident #7 (R7) Review of the medical record reflected R7 admitted to the facility 5/3/2024 with pertinent diagnoses that included Need for Assistance with Personal Care. Review of the Minimum Data Set (MDS) dated [DATE] reflected R7 was occasionally incontinent of urine and was not on a toileting program. The Care Plan for R7 reflected the Resident was safe for self-transfers and was ambulatory with a walker. On 7/17/2025 at 11:02 AM an observation and interview were conducted with Certified Nurse Aide (CNA) J in room [ROOM NUMBER] the room of R7. CNA J was asked about the strong smell of urine in the hallway and in room [ROOM NUMBER]. CNA J reported that R7, who resides in bed one, can toilet himself but has trouble urinating into the toilet due to vision problems. CNA J reported R7 urinates on and around the toilet all the time and it was not unusual for the floor around the toilet to be wet with urine. CNA J reported she often checks the bathroom of R7 when she first comes on shift and will contact Housekeeping to ask the urine to be mopped up. Resident #17 (R17) Review of the medical record reflected R17 admitted to the facility with pertinent diagnoses that included Diabetes Mellitus and Benign Prostatic Hyperplasia (enlarged prostate). Review of the Kardex (a summary of the resident's needs and preferences) reflected that R17 was independent for toileting and used a urinal at bedside. On 7/15/2025 at 11:46 AM an observation was conducted in room [ROOM NUMBER] where R17 resided in bed 2. At the head of the bed of R17 two urinals were observed on a towel on the floor. One urinal was full and standing up and the other urinal was empty and laying down. The room had a strong smell of urine as did the hall prior to entering the room. On 7/15/2025 at 1:35 PM, in the room of R17 it was observed that the full urinal remained unemptied and neither urinal had been repositioned on the floor by the bed. On 7/16/2025 at 11:27 AM, in the room of R17 two urinals were observed on the floor at the head of the bed. Both urinals were standing upright. One was completely full, and the other was roughly half filled with urine. A half-filled urinal was observed also hanging but the handle from the wastebasket at bed one. A noticeable urine smell was present in the room. On 7/17/2025 at 10:49 AM, R17 was observed to be asleep in bed two of his room. Two urinals were noted on floor at the head of the bed. One urinal was standing on end half full of urine and the other laying empty on its side. At bed one urinal half-filled urine was hanging on a waste basket half full. The smell of urine was evident in the room. Review of the Resident Council Meeting Minutes dated 2/3/2025 revealed, .Toilets need to be cleaned better after dumping bed pans or urinals.Review of the Resident Council Meeting Minutes dated 4/1/2025 revealed, .Dumping of bed pans/urinals is getting careless and messy.

Based on interview and record reviews the facility failed to notify the responsible party of changes in conditions and treatment for one Resident (R5) of fifteen residents reviewed. Findings Resident #5 (R5) Review of the Electronic Medical Record (EMR) reflected R5 admitted to the facility 3/11/2018 with diagnoses that included: Traumatic Brain Dysfunction, Aphasia (inability or difficulty speaking), and Hemiplegia (weakness or paralysis on one side). Review of the Minimum Data Set (MDS) dated [DATE] reflected R5 was severely cognitively impaired. The EMR admission Record reflected Primary Contact (PC) K was the Guardian for R5. On 7/16/2025 at 11:16 AM a telephone interview was conducted with PC K who reported the facility had not always informed her of changes in status and care for R5. PC K reported several months ago she contacted the facility for an update on R5. PC K reported staff informed her R5 had been sick. PC K reported she contacted the facility a day or two later and was told by the facility R5 had pneumonia and was started on an antibiotic. PC K reported if she did not call the facility she would not have been aware of the condition or treatment of R5. PC K indicated she was not consistently informed of other alterations in status and the care of R5 over time. A review of the EMR was conducted: Review of the Progress Note documented 9/3/2024 reflected R5's blood sugars were evaluated by a Physician Assistant (PA) who implemented a new medication order for Januvia. The documentation did not reflect PC K had been informed of the results of the evaluation and the new medication. Review of the EMR Progress Note of 10/4/2024 reflected a PA again evaluated R5's blood sugars and implemented a medication change. The entry did not reflect PC K was informed of the change. The Progress Note of 10/29/2025 at 2:00 PM reflected R5 was catheterized to obtain a urine specimen that was sent to the lab. The entry did not reflect PC K had been informed of any concerns. Review of the Progress Note dated 11/27/2024 at 10:50 AM reflected R5 presented with a change of respiratory condition and direction to obtain a chest Xray, administer an antibiotic and initiate regular breathing treatments. The entry did not reflect PC K had been notified. The Progress Note dated 12/3/2024 at 11:18 AM reflected a Gradual Dose Reduction (GDR) of a psychotropic medication being conducted. No documentation was identified in the EMR that indicated PC K was aware of this. The Pharmacy Progress Note of 1/28/2025 at 5:55 PM reflected a new order for Norvasc (a medication used in treatment for high blood pressure) had been implemented. No documentation in the EMR was identified that PC K had been informed. Review of the Progress Notes revealed a Dietary Note dated 4/16/2025 at 2:28 PM that reflected R5 was being followed for weight loss over the past month. This and no previous entries were identified that PC K had been informed R5 had experienced a weight loss. The EMR Progress Note dated 4/18/2025 at 9:28 AM revealed a Psychiatry Follow up encounter by a PA. The entry noted the GDR of the psychotropic medication in December of 2024, and that this medication had been discontinued the day of this entry. The documentation reflected facility staff were to discuss the plan of care with the resident's responsible party. However, no documentation was identified in the EMR that reflected PC K was aware of the GDR or the discontinuation of the medication. An EMR Progress Note entry on 6/15/2025 at 12:23 AM reflected R5 had an open area on his penis and an ointment was being applied as a remedy. Neither this entry nor other surrounding documentation was identified that indicated PC K was notified R5 had an open area of skin. On 7/17/2025 at 12:51 PM an interview was conducted with the Director of Nursing (DON). The DON was informed that the Guardian for R5 reported not being informed of changes in the status and plan of care of the Resident over time. The DON was informed that a review of the EMR supported this assertion as documentation was not identified that the Guardian had been notified of changes in condition and treatment for R5. The DON indicated a review would be conducted. As of survey exit no information had been provided by the facility that the Guardian had been informed of the matters noted above.

Based on interview and record review the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews.Findings:Review of the Facility Assessment dated 8/6/24 revealed, .INFORMATION ABOUT OUR STAFF TRAINING/EDUCATION AND COMPETENCIES-Our facility's training program includes an orientation process and ongoing training for all new and existing staff including managers, nursing and other direct care staff, individuals providing services under contractual arrangement, and volunteers consistent with their expected roles. We complete an education needs assessment and develop a curriculum and training plan based on staff need (sic) and resident characteristics.Review of Certified Nursing Assistant (CNA) I's employee file revealed she was hired on 12/18/2023. There were no performance evaluations completed since CNA I's date of hire. Review of CNA I's computerized education/continuing competencies hours revealed:*On 12/30/23, Employee Safety Orientation was completed for 1 hour of education. *On 1/3/24, Code of Conduct was completed but did not count for education hours. No other education was completed until 1/9/25.Review of CNA H's employee file revealed she was hired 10/17/2022. There were no performance evaluations completed for 2023 or 2024.During an interview on 07/18/2025 at 8:58 AM, Nursing Home Administrator (NHA) reported that performance evaluations had not been done in 2024 due to the HR (Human Resources) department putting it on hold in order to streamline the process. NHA reported he was unsure if they had been completed in 2023 as he was not the acting administrator at the time. NHA reported that yearly education was completed by computerized training program, bi-monthly meetings, and the yearly skills assessment/in-service. NHA reported any concerns brought to the attention of management via resident council, staff complaints, or surveys were addressed in the bimonthly meetings with education provided.

Based on observation, interview, and record review, the facility failed to follow professional standards of nursing practice for 2 of 15 residents (Resident #40 and #55) reviewed for medication administration. Findings:Resident #40 (R40) Review of an admission Record revealed R40 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Muscular Dystrophy and dysphagia (difficulty swallowing). The diagnosis of dysphagia was added to her diagnosis list on 12/1/23. Review of R40’s “Care Plan” revealed no entries that R40 could self-administer medications. Review of R40’s “Self-Administration of Medication Evaluation” revealed the assessment for self-administering medications was last completed on 8/10/23 (prior to the dysphagia diagnosis). Review of R40’s “SLP (Speech Language Pathology) Screen” dated 11/27/23 revealed R40 did not have the physical capacity to swallow without difficulty and had difficult/painful swallowing and would cough/choke with meals/medications. During an observation and interview on 07/16/2025 at 8:44 AM, a medication cup full of medications was observed on R40’s tray table next to her breakfast tray. R40 reported that staff “always leave them here” further explaining that she prefers to take them on her own time. R40 reported that she was hospitalized and diagnosed with dysphagia around Thanksgiving of 2023 which resulted in a change of her diet to prevent her from aspirating/choking. During an interview on 07/17/2025 at 2:30 PM, Nursing Home Administrator (NHA) reported that R40 did not self-administer medication and therefore did not have a recent “Self-Administration of Medication Evaluation.” During an interview on 07/18/2025 at 8:30 AM, Staff Development Coordinator (SDC) “G” reported that medications were not to be left on R40’s tray table and licensed nurses were to observe R40 take her medications due to the safety risks present from her dysphagia diagnosis. Review of the facility policy “Resident Rights” last reviewed/revised February 2025 revealed, “…f. The right to self-administer medications if the interdisciplinary team has determined that this practice is clinically appropriate…” Review of the facility policy “Medication Administration” implemented 2/9/25 revealed, “…18. Observe resident consumption of medication…” Resident #55 (R55) Review of the medical record reflected R55 admitted to the facility 6/13/2025 with pertinent diagnoses that included Chronic Obstructive Pulmonary Disease (COPD). Review of the Minimum Data Set (MDS) Section C (cognitive patterns) reflected R15 was cognitively intact. On 7/16/2025 at 8:21 AM an observation, interview, and record review were conducted with Registered Nurse (RN) “L” at the medication cart on the Southeast Hall. RN “L” was observed preparing the morning medication for R55. During this preparation the Medication Administration Record (MAR) was reviewed as RN “L” selected each medication ordered to be administered. The medications reviewed included “Breztri Aerosphere Inhalation Aerosol (a handheld multidose inhaler) 160-9-4.8 MCG/CT 2 puff inhale orally two times a day for COPD” with the direction to “Rinse mouth thoroughly and expectorate after using”. The observation of the medication administration at the above date and time continued. Once prepared, RN “L” carried the medications to the room of R55 who was sitting in a chair eating breakfast. R55 took the medication cup of oral medications from RN “L” and self-administered these without difficulty. RN “L” then handed the Breztri Aerosphere inhaler to R55 who self-administrated two puffs. R55 then handed the Breztri Aerosphere inhaler back to RN “L” and resumed eating breakfast. RN “L” exited the room. On return to the medication cart RN “L” was asked if he should have had R55 rinse her mouth and spit out the water following the self-administration of the Breztri Aerosphere inhaler? RN “L” stated “I’d have to look that up”. This statement indicated the direction on the MAR for this inhaler had not been noted by RN “L”. RN “L” did not re-review the MAR or provide any further clarification of proper use of the Breztri Aerosphere inhaler. A review of the EMR Doctor’s Order of the Breztri Aerosphere confirmed the direction on the MAR to “Rinse mouth thoroughly and expectorate after using”. Review of the manufacturer’s product information sheet/ package insert for the Breztri Aerosphere Inhaler reflected, “Warnings and Precautions”, Candida albicans infection of the mouth and pharynx may occur (a pathogenic overgrowth of a yeast-like fungus that lines the digestive tract). Monitor Patients periodically. Advise the patient to rinse his/her mouth with water without swallowing after inhalation to help reduce the risk”. Review of the facility policy “Medication Administration” implemented 2/9/2025 revealed, “Policy: Medications are administered by licensed nurses or competent medication technicians as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection”. And “12 a. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects”. And “17. Administer medication as ordered in accordance with manufacturer specifications”. And “24. Refer to pharmacy manual for specific medication-related policies and procedures”.

Based on interview and record review, the facility failed to 1.) ensure insulin was administered and monitored following the provider order and 2.) ensure abnormal blood sugar results were reported to the provider for 3 of 15 residents (Resident #40, #10, and #64) reviewed for insulin administration.Findings:Resident #40 (R40) Review of an admission Record revealed R40 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Muscular Dystrophy Review of R40's Order Summary dated 5/3/25 revealed, HumaLOG KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject 4 unit subcutaneously with meals for DM2 In addition to sliding scale insulin. Hold if BS <100 (blood sugar less than 100) or not eating.Review of R40's June Medication Administration Record and Blood Sugar Summary revealed that on 6/24/2025 at 08:06 AM R40's blood sugar was 93 and the 4 units of Humalog was administered. (The sliding scale insulin was not administered due to her blood sugar not falling within range.)Review of R40's July Medication Administration Record and Blood Sugar Summary revealed that on 7/12/2025 at 09:31 AM R40's blood sugar was 94 and the 4 units of Humalog was administered. (The sliding scale insulin was not administered due to her blood sugar not falling within range.)Review of R40's Electronic Medical Record revealed no documentation for the rationale for administering the insulin outside of the ordered parameters. Resident #10 (R10) Review of an admission Record revealed R10 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Type 1 Diabetes. Review of R10's Order Summary dated 4/4/25 revealed, Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro).Call MD (medical doctor) for BS (blood sugar) greater than 500. before meals and at bedtime. To be administered and blood sugars assessed at 8:00 AM, 12:00 PM, 4:00 Pm, and 8:00 PM.Review of R10's Blood Sugar Summary revealed:*On 7/1/2025 at 9:09 PM R10's blood sugar was 525*On 7/3/2025 at 11:12 PM R10's blood sugar was 520*On 7/9/2025 at 4:35 PM R10's blood sugar was 547*On 7/11/2025 at 11:06 PM R10's blood sugar was 553*On 7/15/2025 at 08:55 AM R10's blood sugar was 501*On 7/15/2025 at 10:56 PM R10's blood sugar was 519*On 7/17/2025 at 8:36 AM R10's blood sugar was 524 Review of R10's Electronic Medical Record revealed no documentation that the provider was notified of the blood sugars listed above. During an interview via email on 07/17/2025 at 2:30 PM, Nursing Home Administrator (NHA) reported that the facility provider is notified with high blood sugars no new orders, because (R10 is a) brittle diabetic. During an interview on 07/17/2025 at 9:57 AM, Director of Nursing reported there was no documentation that the provider was notified of the abnormal blood sugar results or that a new order was received. Resident #64 (R64) Review of an admission Record revealed R64 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: type 2 diabetes. Review of R64's Order Summary dated 7/10/25 revealed, QAM (every morning) blood sugar checks for DM2 (type 2 diabetes) one time a day.Review of R64's Blood Sugar Summary on 7/18/25 at 11:30 AM revealed R64's blood sugar was NOT assessed on 7/13/25, 7/14/25, 7/15/25, 7/16/25, or 7/18/25.Review of R64's July Medication Administration Record revealed a check mark for each day (from 7/10/25-7/18/25) indicating the blood sugar assessment had been completed. Review of R64's Electronic Medical Record revealed no documentation that a blood sugar assessment had been completed or a rationale for not obtaining the blood sugar. During an interview on 07/18/2025 at 8:30 AM, Staff Development Coordinator (SDC) G reported that the expectation was for the licensed nurses to follow the physicians orders including the ordered parameters. Review of the facility policy Medication Administration implemented 2/9/25 revealed, .8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters.10. Ensure that the six rights of medication administration are followed.

Based on observation, interview, and record review, the facility failed to ensure proper care of a Continuous Positive Airway Pressure (CPAP) device for one Resident (R15) of fifteen residents reviewed. Findings: Resident #15 (R15) Review of the medical record reflected R15 admitted to the facility 10/21/2019 with the pertinent diagnosis of Obstructive Sleep Apnea (a condition when breathing stops while sleeping due to a blockage of the windpipe). The medical record reflected that R15 used a CPAP device (the device that consisted of a pressure module that delivered breathable air under pressure via tubing from the device to a mask worn while sleeping to keep the windpipe open) to treat this condition. On 7/16/2025 at 10:09 AM an observation and interview were conducted with R15 in her room. It was observed that R15 had a CPAP device that was not in use and the mask was not stored in a bag. Review of the CPAP filter revealed it was moderately soiled. R15 reported that staff had not cleaned her CPAP in a long time. On 7/17/2025 at 10:53 AM during an observation and interview with R15 in her room it was noted that her CPAP device was not in use and that the mask was not stored in a bag. R15 reported staff had given her a bag a couple of years ago and told her to use it. R15 displayed a folded plastic bag and reported that the current bag was the same bag provided by the facility a couple of years ago. R15 reported that staff did not check daily for proper storage of the mask when not in use and reiterated that staff do not clean her device. Review of the filter revealed that it had not been cleaned or changed and remained moderately soiled as noted on 7/16/2025. Review of the Medication Administration Record (MAR) for July 2025 and the Treatment Administration Record (TAR) for July 2025 did not reflect maintenance of the CPAP device for R15 monitored by Nursing. Review of the Tasks in the EMR for the previous thirty days reflected documentation that staff had cleaned R15's CPAP mask once or twice a day. Additionally, the documentation in tasks reflected the filter was to be changed or cleaned weekly and as needed. The documentation alleged that the filter had last been cleaned or changed on 7/14/2025, two days before the first observation when the filter was noted to be moderately soiled. The policy provided by the facility titled BIPAP-CPAP implemented 11/2009 was reviewed. The policy reflected Procedure: h. Store mask or nasal pillows in mesh bag or other approved storage container approved by the facility when not in use. The policy continued with 5. Cleaning: a. Mask or nasal pillows shall be wiped with an approved disinfecting solution daily per manufacturer's guidelines. And e. Replace mesh bag (or other approved storage device) monthly. And f. Filters cleaned weekly per manufacturer's recommendation.

Based on interview and record review, the facility failed to ensure controlled medications were properly dispensed and documented for 3 of 15 residents (Residents #2, #4, and #25) reviewed for controlled medication administration. Findings:Resident #2 (R2) Review of an admission Record revealed R2 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: osteoporosis. Review of R2's Order Summary dated 5/26/25 revealed, tramadol HCl Oral Tablet 50 MG Give 1 tablet by mouth two times a day for PAIN.Review of R2's Controlled Substance Proof-Of-Use Record revealed that on 7/1/25, 7/2/25, 7/3/25, and 7/14/25 the evening doses of tramadol were documented as dispensed.Review of R2's July Medication Administration Record revealed that on 7/1/25, 7/2/25, 7/3/25, and 7/14/25 the evening doses of tramadol were documented as not administered. Review of R2's Controlled Substance Proof-Of-Use Record revealed that on 7/4/25 there were no doses of tramadol documented as dispensed. Review of R2's July Medication Administration Record revealed that on 7/4/25 the morning dose of tramadol was documented as administered. Review of R2's Electronic Medical Record revealed no documentation as to why the medication was dispensed but not administered. During an interview on 07/17/2025 at 9:57 AM, Director of Nursing (DON) provided a written statement dated 7/16/25 which revealed that the primary nurse for R2 removed the tramadol from the medication cart and wasted (disposed of) the tramadol and a secondary nurse witnessed the waste. DON confirmed the documentation error for the tramadol administration on 7/4/25.Resident #4 (R4) Review of an admission Record revealed R4 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: anxiety disorder. Review of R4's Order Summary with a start date of 3/19/25 and an end date of 4/2/25 revealed, Alprazolam (Xanax) Tablet 0.25 MG Give 0.25 mg by mouth every 6 hours as needed for Agitation for 14 Days.Review of R4's Controlled Substance Proof-Of-Use Record revealed that on 4/10/25 a dose of Xanax was dispensed (without an active order).Review of R4's April Medication Administration Record revealed no documentation that a dose of Xanax was administered. Review of R4's Electronic Medical Record revealed no documentation for the administration of Xanax without a physician order. During an interview on 07/17/2025 at 9:57 AM, DON reported that the provider had given a 1-time verbal order for the use of Xanax, however, the licensed nurse did not transcribe the order into the Electronic Health Record or document the one-time order in the progress notes. Resident #25 (R25) Review of an admission Record revealed R25 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: anxiety disorder. Review of R25's Order Summary dated 7/8/25 revealed, Lorazepam Oral Tablet 0.5 MG (Ativan) Give 1 tablet by mouth every 4 hours as needed for anxiety for 14 Days.Review of R25's Controlled Substance Proof-Of-Use Record revealed:*On 7/14/25 at 4:23 PM a dose of Ativan was dispensed. *On 7/14/25 at 7:01 PM a dose of Ativan was dispensed.*On 7/15/25 at 9:30 AM a dose of Ativan was dispensed.Review of R25's July Medication Administration Record revealed no documentation that the dose of Ativan was administered on 7/14/25 at 7:01 PM or on 7/15/25 at 9:30 AM.Review of R25's Electronic Medical Record revealed no documentation related to the administration of Ativan on 7/14/25 at 7:01 PM or on 7/15/25 at 9:30 AM.During an interview on 07/17/2025 at 9:57 AM, DON confirmed the licensed nurses had not documented the administration of Ativan into the Medication Administration Record.Review of the facility policy Controlled Substances dated June 2019 revealed, .D. Accurate accountability of the inventory of all controlled substances is maintained at all times. When a controlled substance is administered, the nurse administering the medication immediately enters the following information on the controlled substance count sheet and on the Medication Administration Record (MAR):1) Date and time of administration (MAR, controlled substance count sheet)2) Amount administered (controlled substance count sheet)3) Remaining quantity (controlled substance count sheet)4) Initials of the nurse administering the dose (MAR, controlled substance count sheet)E. When a dose of a controlled substance is removed from the container but refused by the resident or not given for any reason, it is not placed back in the container; it must be destroyed according to facility policy, and the disposal must be documented on the controlled substance count sheet on the line representing that dose. The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% for 2 of 6 residents (R52 and R60) observed during the medication administration task, resulting in a medication error rate of 6.66% (2 errors of 30 medications administered).Findings include:R52A review of R52's admission Record, dated 7/18/25, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R52's admission Record revealed multiple diagnoses that included Vitamin D deficiency.During an observation on 7/16/25 at 8:25 AM, Licensed Practical Nurse (LPN) E administered eleven medications to R52, including Vitamin D3 (cholecalciferol) 50 mcg (micrograms) (2000 International Units (IU)).A review of R52's Medication Administration Record (MAR), dated 7/1/25 to 7/18/25, revealed LPN E should have administered cholecalciferol 1000 units on 7/16/25, not cholecalciferol 2000 units.During an interview on 7/16/25 at 12:18 PM, the Director of Nursing (DON) was notified of the medication error. R60A review of R60's admission Record, dated 7/17/25, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R60's admission Record revealed multiple diagnoses that included chronic pain syndrome, back spasm, and neuropathy (nerve damage that can cause symptoms such as pain, weakness, numbness, or tingling).During an observation on 07/15/2025 at 4:35 PM, Registered Nurse (RN) F stated R60's morphine sulfate medication order had been changed earlier in the day. RN F then verbalized the dose they were giving to R60 and administered 40 milligrams (mg) of morphine sulfate oral solution (2 milliliters (ml) of morphine sulfate 20mg/ml) to R60. During an interview on 07/16/2025 at 11:19 AM, RN D stated she just administered 40 mg of morphine sulfate oral solution to R60 for her 11:30 AM dose. A review of R60's MAR, dated 7/1/25 to 7/16/25, revealed RN D and RN F should have administered morphine sulfate 20 mg to R60, not 40 mg. A review of R60's Controlled Substance Proof-Of-Use Record, dated 7/13/25 to 7/16/25, revealed R60 had also received 40 mg of morphine sulfate oral solution on 7/16/25 at 4:54 AM. During an interview on 07/16/2025 at 11:15 AM, the DON was notified of medication errors with R60. The DON stated he would investigate the errors. During a second interview on 07/16/2025 at 3:00 PM, the DON stated he investigated the medication errors and agreed that R60 receiving 40 mg (2 ml) of morphine was an error. The DON reported he had contacted the physician and hospice provider, and both providers acknowledged the errors in morphine dosing, A review of the facility's Medication Administration policy and procedure, dated 2/9/25, revealed, 10. Ensure that the six rights of medication administration are followed. c. Right dosage. 11. Review MAR to identify medication to be administered.

Based on observation and interview, the facility failed to properly label medications in 1 of 2 medication carts (Northeast/ Northwest Split Medication Cart) observed for medication storage.Findings include: During an observation on 07/16/2025 at 8:35 AM, the Northeast/Northwest Split Medication Cart was inspected with Licensed Practical Nurse (LPN) E. The following observations were made: - Incruse Ellipta 62.5 mcg/act discus box labeled with R52's name. However, the discus in the box was not labeled with R52's name and/or any other resident identifying information. - Fluticasone propionate 50 mcg/act nasal spray box labeled with R52's name. However, the nasal spray was not labeled with R52's name and/or any other resident identifying information. During an interview on 07/16/2025 following the inspection of the Northeast/Northwest Split Medication Cart at 8:35 AM, LPN E stated, They (the discus and nasal spray) should be labeled [with the resident's name] so we know if they are in the right box. LPN E also stated the discus, and nasal spray should be labeled with the resident's name, so staff know who the discus and nasal spray belong to in case they fall out of their respective boxes, During an interview on 07/16/2025 at 9:55 AM, Registered Nurse (RN) D stated that staff should label discuses and nasal sprays in the boxes with the residents' names. She stated they do this so we know we're giving the right med (medication) to the right patient (resident). RN D also stated the discuses, and nasal sprays should be labeled with the resident's name in case they fall out of their respective boxes, so staff know who the discus and inhaler belong to.

Based on observation, interview, and record review, the facility failed to safeguard the confidentiality of medical records for 2 of 60 facility residents [R34 and R46), resulting in the potential for unauthorized access to resident medical records and the potential for the loss of resident privacy and confidentiality of their personal health information. Findings include: R46 During an observation on 08/21/24 at 8:25 AM, the computer screen on top of the Southwest Medication Cart was observed open to R46's electronic Medication Administration Record, (e-MAR). R46's personal and health identifying information (i.e., picture, name, room number, physician's name, allergies, recent vital signs, code status, special instructions for medication administration) and medications were visible to anyone walking by the medication cart. No staff were visible within sight of the medication cart. During an interview on 8/21/24 at 8:30 AM, Registered Nurse (RN) E (the nurse assigned to the Southwest Medication Cart) stated she did not see an issue with leaving the computer screen open to R46's e-MAR because I was only two rooms away [administering medications]. She stated she normally closes the computer screen before she walks away from the medication cart. She then indicated that leaving the computer screen open to R46's e-MAR was not an issue because she was only two rooms away from it even though she could not see the cart from inside the resident's room. R34 During an observation on 08/21/24 at 8:40 AM, the computer screen on top of the Southwest Medication Cart was observed open to R34's electronic Medication Administration Record, (e-MAR). R34's personal and health identifying information (i.e., picture, name, room number, physician's name, allergies, recent vital signs, code status, special instructions for medication administration) and medications were visible to anyone walking by the medication cart. During an interview on 08/21/24 at 11:15 AM, LPN F stated the nurses are supposed to close the computer screens before they walk away from the medication carts. She stated the computer screens should not be left open when they are not at the medication carts. During an interview on 08/21/24 at 1:32 PM, RN B stated the nurses are supposed to close the computer screens when they are not at the medication carts. She stated they are supposed close the computer screens because of the Health Insurance Privacy and Portability Act (HIPPA) which protects the confidentiality and privacy of residents personal health information. During an interview on 08/21/24 at 2:06 PM, LPN D stated the nurses are supposed to close the computer screens when they walk away from the medication carts. She stated she closes it to protect the residents' health information. LPN D further stated she had left her computer screen open and walked away from her medication cart twice this morning. You caught me. A review of the facility's HIPPA Security Measures policy, dated 11/01/2023, revealed, It is the facility's policy to implement reasonable and appropriate measures to protect and maintain the confidentiality, integrity, and availability of the resident's identifiable information and/or records that are in electronic format . All workstations that access EPHI (electronic protected health information) will have restricted access .

Based on observation, interview and record review, the facility failed to provide an appropriate size drinking cup to 1 resident (R16) of 1 Resident reviewed for reasonable accommodation of needs. Findings include: Review of R16's face sheet dated 8/19/24 revealed she was an [AGE] year-old female admitted to the facility on [DATE] she had diagnoses that included: Dementia, anxiety disorder, weakness and aphasia (difficulty in communication). R16 was not her own responsible party. R16 was observed in her room on 8/20/24 at 11:45 AM, R16 had a large plastic mug with a straw in it on her bedside table. R16's family member said they have talked to staff several times and reported at her care conferences that R16 does not have the strength to lift a mug that big. R16's family member reports for a week or two after voicing the concern the facility will provide a Styrofoam cup of water. R16's family member said she visits almost daily but will be taking a vacation soon and was worried R16 may get dehydrated as the resident cannot remember to alert staff of her needs. On 8/20/24 at 12:28 PM, R16's family member showed Unit Manager (UM) T that R16 had a large heavy plastic mug in her room and explained she had been asking for an appropriate size water cup for over a year. UM T said she just started last week, and she said she would look into it and address the concern. Review of R16's Kardex (caregiver care plan) dated 8/19/24 revealed. Please do not give me fluids in a big plastic mug. Please put my drinks in a Styrofoam cup or small coffee cup. The smaller cups are easier for me to hold by myself. Please offer me a drink at least once an hour per guardian.

Based on interview and record review, the facility failed to investigate and report an allegation of misappropriation to the state survey agency for 1 of 3 residents (R20) reviewed for abuse and misappropriation, resulting in the potential for abuse and misappropriation to go undetected, underreported, and not investigated. Findings include: A review of R20's Admission Record, dated 8/20/24, revealed R20 was an [AGE] year-old resident admitted to the facility on [DATE]. In addition, R20's Admission Record revealed multiple diagnoses that included dementia and depression. A review of R20's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 5/15/24, revealed R20 had a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15 which revealed R20 was cognitively intact. During an interview on 08/19/24 at 10:45 AM, R20 stated her cell phone came up missing about three months ago (two weeks after she was admitted ). She stated the facility looked everywhere for it but could not find it. R20 also stated about two months ago she had a baggy with 7 quarters in it that came up missing. She stated her cell phone and her quarters were not left out and were out of sight. R20 also stated she was told that the facility does not replace missing money. R20 denied anyone could have come in to visit her and took her cell phone or quarters with them. She stated that she reported to the highest levels that her cell phone was missing. -A review of R20's progress notes, dated 5/8/24 to 8/20/24 revealed the following: - Nursing Progress Note, dated 5/9/24, revealed, Guardian notified via voice message that resident does have a telephone in her room. * No mention that R20 complained that her cell phone and/or money was missing. A review of R20's Resident Personal Belongings Inventory, dated 5/8/24, revealed she had a cell phone, but no cash when she was admitted to the facility. Two people signed the form verifying that she had the cell phone, but no cash when she was admitted to the facility. On 08/20/24 at 01:05 PM, all concerns forms and incident reports (including any follow-up/investigations/supporting documentation, if applicable) for R20 were requested from the Nursing Home Administrator (NHA). During an interview on 08/20/24 at 04:50 PM, the NHA stated they did not have any concern forms or incident reports for R20. During a second interview on 08/21/24 at 08:35 AM, R20 stated she reported her missing cell phone to floor staff, the social worker, and administration. She stated she also reported her missing cell phone to someone from administration two days ago. However, R20 could not remember anyone's names and could not describe the administration person she reported the missing cell phone to two days ago except he was not tall, but not short and he was younger, but not the person I spoke to three months ago. During a second interview on 08/21/24 at 10:15 AM, the NHA stated that he was not aware R20 had made the allegations that her cell phone and quarters were missing. The surveyor reported R20's allegations of her missing cell phone and quarters to the NHA. He stated he would follow-up with her. The surveyor requested that the NHA follow up with them on what the facility is doing and the process that he is following (i.e., start investigation the allegation, reporting the allegation to the state survey agency, etc.). During a third interview on 08/21/24 at 11:15 AM, the NHA stated he spoke with R20. He stated R20 verified that her cell phone and 7 quarters were missing. The NHA stated the plan was he was going to fill out a concern form for R20 about her missing cell phone and money. He stated they are going to search the laundry for the cell phone and continue to look for it. The NHA stated if they cannot find R20's cell phone, then he will start a 5-Day Investigation (report the allegations to the state survey agency and start an investigation). The NHA was asked how long would he look for R20's cell phone before he starts an investigation? He stated if they did not find R20's cell phone by tomorrow morning (8/22/24), then he will start his 5-Day Investigation. A review of the state reporting system for facility reported incidents (FRI's) on 8/21/24 at 03:15 PM (5 hours after R20's allegation was reported to the NHA), failed to reveal that the facility had reported R20's allegation of a missing cell phone and money. In addition, as of the completion of the survey and exit from the facility, the facility failed to provide any documentation that they had initiated an investigation (except for the NHA's statement that he had interviewed R20). A review of the facility's Abuse, Neglect and Exploitation policy, reviewed/revised 6/24, revealed, A. The facility will implement the following . 2. Reporting of all alleged violations to the state agency, adult protective services and all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse .

Based on observation, interview and record review, the facility failed to provide care for 1 (Resident #8) of 2 residents reviewed for Activities of Daily Living (ADL) care. Findings include: Resident #8 (R8) Review of a Face Sheet revealed R8 originally admitted to the facility on [DATE] with pertinent diagnoses of multiple sclerosis, cognitive communication deficit (not interviewable), and contractures. In an interview on 8/19/24 at 2:20 PM, the Guardian of R8 reported he was not being provided with oral care often and the staff are not using the [Brand name of oral moisturizer] gel she provided them with to keep his mouth moist. The Guardian reported she visits every other day and will observe his mouth with caked, dried on secretions that could be avoided if he had routine care with the gel. The Guardian also had concerns R8 was in bed most of the day and not up in his electric wheelchair. R8 enjoys being up in his wheelchair and she had expressed her concerns with the staff. During an observation and an interview on 8/19/24 at 2:42 PM, Certified Nursing Assistant (CNA) I reported she tries to clean R8's mouth every time she comes into the room and showed where his oral swabs were and his oral [Brand name of oral moisturizer] products were. She reported she provided oral care around 1:30 PM when she last seen him. The resident was lying in bed with his mouth wide open and tongue was dry with white strands of dried secretions. His tongue looked dry as well as his lips. CNA I then said she tries to do oral care once a day and left the room without doing oral care. During an observation and an interview on 8/20/24 at 1:55 PM, CNA J and CNA K were in R8's room to reposition him, and his mouth was open and dry. Asked when he was last provided oral care and the CNAs did not know. When asked if his mouth was dry, CNA J took a mouth swab, applied the [Brand name of oral moisturizer] product, and quickly swabbed the open area of his mouth and his tongue. When asked why she did not swab the roof of his mouth or his gums, she grabbed another swab and cleaned the roof of his mouth which had a large amount of dried secretions removed. She then used another swab and cleansed/moistened his gums. In an interview on 8/20/24 at 2:04 PM, CNA L reported she was R8's primary caregiver and said she tries to do oral care on him at least 3 times a shift and she works 12-hour shifts. She then reported she tries to do oral care every time she provides care for him and will sometimes suction his mouth if needed. She reported R8 was not up in his wheelchair this day because she had another aide temporarily care for him and thought they would get him up. Review of the Kardex for R8 revealed: -ORAL CARE AM/HS (morning and night) ROUTINE: (brush teeth, cleanse tongue, clean gums with toothette using [Brand name of oral moisturizer]). Assistance Needed: dependent. - I require total assistance with personal hygiene care. Mouth care should be completed every 4 hours with moistened toothette. -Provide with Routine Oral Care with soft brissle (sic) toothbrush and toothpaste or [Brand name of oral moisturizer] gel twice daily. - Swab my mouth with toothlette every two hours or more, if necessary, as I allow. - Swab oral cavity with ORAL MOISTURIZER [Brand name of oral moisturizer] mother supplies at bed side. (sic) -I would like to be in my high back wheelchair twice a day. Once in the morning and also in the afternoon. Review of a Task List document titled Swab oral cavity with ORAL MOISTURIZER [Brand name of oral moisturizer] mother supplies at bed side retrieved on 8/21/24 for R8 with a 30 day look back revealed most days R8 is documented as receiving oral care 2-3 times a day. In an interview on 8/21/24 at 12:00 PM, Licensed Practical Nurse/Unit Manager (UM) F reported they do provide training for oral care to their staff and residents are to get oral care at least every 2 hours.

Based on observations, interviews, and record review, the facility failed to provide meaningful activities for 2 Residents (R7 and R16) of 2 residents sampled. Findings included: R7 Review of R7's face sheet dated 8/20/24 revealed she was an [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: Dementia, Alzheimer's Disease, major depressive disorder, anxiety disorder and difficulty in walking. R7 was not her own responsible party. R7 was observed sleeping on 8/19/24 at 11:05 AM. R7 was observed sleeping on 8/20/24 at 1:15 PM. During an interview with Certified Nurse Aides (CNA) O and CNA P on 8/20/24 at 1:17 PM, they explained R7 normally sleeps all day, she rarely eats breakfast or lunch. They do attempt to wake her up for breakfast and lunch, but she rarely eats. They were aware she generally wakes up a 5:00 PM. They did not know what her activity or food preferences were as they rarely see her awake long enough to do these activities. During an interview with the Activity Director (AD) Q on 8/21/24 at 10:07 AM. AD Q said she is the only employee in the Activity department. AD Q said she currently has 2 volunteers that work only morning hours and do limited activities with residents. AD Q was not aware R7's normal routine was to sleep during the day and is most alert at night. AD Q was not able to locate any documentation that showed R7 was provided any activities over the last 30 days and currently had no ability to assign any staff to provide activities that were meaningful to this resident during her normal wake hours or on weekends. Review of R7's care plan revealed, I am here for long term care and will be invited to participate in activity program, initiated 10/29/21. Short term goal revealed, I will participate in 1:1 activity 3 day per week. Interventions included, I will enjoy a visit form activity staff. I will enjoy taking a walk within the facility. My life occupation was being a waitress and bartender. R16 Review of R16's face sheet dated 8/19/24 revealed she was an [AGE] year-old female admitted to the facility on [DATE] had diagnoses that included: Dementia, anxiety disorder, weakness and aphasia (difficulty in communication). R16 was not her own responsible party. R16 was observed sleeping in bed on 8/21/24 at 8:45 AM. During an interview with the AD Q on 8/21/24 at 10:07 AM, AD Q said R16 was care planned for activities, but she was down one volunteer and had no documentation to show R16 had received any activities in the last 30 days. During an interview on 8/21/24 at 3:00 PM, R16's family member expressed concern that the facility lacked activities for R16. R16's family member comes in generally 6 days a week. The family member was concerned that when she was not able to be there during vacations or on the weekends, R16 was not having anyone that would read to her or spend quality time with her. Review of R16's care plan dated 1/17/23 revealed, I am here for long term care and will be invited to participate in the activity program. Short term goal included, I will participate in group activities of interest. I enjoy arts and crafts and bingo.

Based on observation, interview, and record review, the facility failed to apply hand splints for 1 (Resident #8) of 1 resident reviewed for contractures. Findings include: Resident #8 (R8) Review of a Face Sheet revealed R8 originally admitted to the facility on [DATE] with pertinent diagnoses of multiple sclerosis, cognitive communication deficit, and contractures. In an interview on 8/19/24 at 2:20 PM, the Guardian of R8 reported he was not wearing his braces/splints on both hands anymore and when he did wear them, the staff was not applying them correctly and the straps would rub his knuckles really hard. During an observation and an interview on 8/19/24 at 2:42 PM, Certified Nursing Assistant (CNA) I repositioned R8 who was laying in bed hugging a couple of pillows. CNA I reported he gets skin breakdown on the inside of his elbows and the pillows help prevent that. He did not have any splints on his contracted hands. When queried about splints for his hand contractures, CNA I reported his splints are in the dresser drawer and left the room without applying the splints. Review of the Splints On? Task List documentation revealed on 8/19/24, R8 was documented as having the hand splints on at 2:31 PM. Review of the Kardex for R8 revealed: - Right hand splint to be on for 3 hours and off for 2 hours. - Splints On for 3 hours, off for 2 hours During an observation on 8/20/24 at 8:45 AM, R8 was observed in bed with no splints on his hands. During an observation on 8/20/24 at 11:26 PM, R8 was observed in bed with no splints on his hands. During an observation and an interview on 8/20/24 at 1:55 PM, CNA J and CNA K were in R8's room to reposition him and he did not have hand splints on. CNA K reported he thought the hand splints were in the dresser drawer. Both CNAs reported they were not R8's primary aides and were helping but did not know the schedule for R8's placement of splints. Review of the Splints On? Task List documentation revealed on 8/20/24 R8 had them on at 12:33 PM. In an interview on 8/20/24 at 2:04 PM, CNA L reported she was R8's primary caregiver this day and was not aware of any braces or splints that needed to be applied on his hands. We went to R8's room and observed two splints in the dresser drawer. Review of an Occupational Therapy Discharge summary dated 11/2/21 for R8 revealed: After cleaning with wash cloth & drying the hand put on splint in [right] hand. In an interview on 8/20/24 at 3:00 PM, Physical Therapy Director (PT) M reported R8 has had some restorative therapy for contractures in his arms and is also to have splints in his hands for his contractures. In an interview on 8/21/24 at 12:00 PM, Licensed Practical Nurse/Unit Manager (UM) F reported according to the Kardex, R8 is to be on a schedule to have his splints off and on. Review of the Splints On? Task List documentation revealed on 8/19/24 R8 had them documented as on 7 times. On 8/20/24, R8 was documented as having the hand splints on twice and documented as refused 3 times. The splint application times do not reflect the 3 hours on and 2 hours off scheduling. Review of the Physician Orders for R8 revealed no orders for splints.

Based on observation, interview, and record review, the facility failed to ensure expired medications were not in 1 of 2 medication carts inspected (Northwest Medication Cart) and failed to secure 1 of 4 medication carts (Southwest Medication cart). Findings include: During an inspection of the Northwest Medication Cart with Licensed Practical Nurse (LPN) A and the Director of Nursing (DON) on 8/19/24 at 5:15 PM, the following observations were made: - An opened 8 fluid ounce bottle of Senna Syrup (a laxative) was observed to have an expiration date of 1/24. - An opened bottle of a multivitamin was observed to have an expiration date of 3/24. - LPN A and the DON verified these findings. During an observation on 8/21/24 at 8:25 AM, the Southwest Medication Cart was observed in the hallway, unlocked, and unattended. There were not any staff within sight of the medication cart. During an interview on 8/21/24 at 8:30 AM, Registered Nurse (RN) E (the nurse assigned to the Southwest Medication Cart) stated she did not see an issue with leaving the medication cart unlocked because I was only two rooms away [administering medications]. She stated she normally locks her medication cart before she walks away from it. She then indicated that leaving the medication cart unlocked and unattended was not an issue because she was only two rooms away from it even though she could not see the cart from inside the resident's room. During an observation on 8/21/24 at 8:40 AM, the Southwest Medication Cart was observed to be in the hallway, unlocked, and unattended. RN E had been observed preparing medications for a resident and had walked away from the medication cart to administer those medications just prior to the observation. During an interview on 08/21/24 at 11:15 AM, LPN F stated the nurses are supposed to lock their medication carts before they walk away from them. She stated the medication carts should not be left unlocked if the nurse is not at the medication cart. During an interview on 08/21/24 at 1:32 PM, RN B stated the nurse is supposed to lock the medication cart when they are not at the medication cart. She stated they are supposed to lock the cart in order to secure the medications. During an interview on 08/21/24 at 2:06 PM, LPN D stated she is supposed to lock her medication cart when she walks away from it. She stated she does this to protect the medications in it from people just taking them. LPN D stated she had left her medication cart unlocked twice that morning when she went to give residents their medication. You caught me. A review of the facility's Medication Storage In The Facility policy and procedure, dated June 2019, revealed, Mediations and biologicals are stored safely, securely, and properly . The medication supply is accessible only to licensed personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access . Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal .

Based on observation, interview, and record review, the facility failed to provide collaborative hospice care for 2 Residents (R4 and R7) of 2 residents reviewed for hospice care. Findings included: Review of R4's face sheet dated 8/21/24 revealed, she was a [AGE] year-old female that admitted to the facility on [DATE] and had diagnoses that included: Parkinson's disease and adult failure to thrive. She was not her own responsible party. R4 was observed on 8/21/24 at 8:49 PM sitting on the edge of her bed with her head down on the mattress on her right side. R4 had vomited on her shirt and her bed. Registered Nurse (RN) E, Certified Nurse Aides (CNA) Q and (CNA) R came in to provide care. They were all aware R4 was in hospice care. None of them were aware of the last time the hospice staff were in to provide service and had no idea of when hospice was scheduled to see R4 again. RN E said at one point hospice kept their schedules in a book at the nursing station. RN E looked at all the books at the nursing station and could not locate any hospice information for any residents on her unit. During an interview with RN N on 8/21/24 at 11:55 AM, she confirmed the facility did not have schedules or documentation the day of hospice service for all of the residents in hospice care. RN N said she had contacted hospice services yesterday and was working with them to get monthly schedules. RN N said all hospice staff are to be charting in the residents' medical records. RN N said they are now working with hospice to improve communication and scheduling. Review of R4's progress notes on 8/21/24 revealed the last progress note in R4's electronic medical record (EMR) was dated 8/21/24 at 9:24 AM, Alert Note. Note Text: Impaired Skin integrity was documented. Resident refused shower for facility staff, prefers hospice to do her showers. The last hospice progress notes in R4's EMR was 8/12/24 at 13:29 (1:29 PM), MSW (Masters Social Worker saw patient for social visit. There was no indication that any hospice staff saw R4 or provided any services between 8/21/24 at 9:24 AM to 8/12/24 at 1:29 PM. It was not clear that R4 had tolerated any showers during this time frame. R7 Review of R7's face sheet dated 8/20/24 revealed she was an [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: Dementia, Alzheimer's Disease, major depressive disorder, anxiety disorder and difficulty in walking. R7 was not her own responsible party. R7 was observed sleeping on 8/19/24 at 11:05 AM. R7 was observed sleeping on 8/20/24 at 1:15 PM. During an interview with Certified Nurse Aides (CNA) O and CNA P on 8/20/24 at 1:17 PM, they explained R7 normally sleeps all day, she rarely eats breakfast or lunch. They do attempt to wake her up for breakfast and lunch, but she rarely eats. They were aware she generally wakes up a 5:00 PM. They did not know what her activity or food preferences were as they rarely see her awake long enough to do these activities. During an interview with Social Worker (SW) S on 8/20/24 at 1:20 PM, the hospice staff schedules for R7 were discussed. SW S could not verify what the hospice schedule was for R7, and she was informed that the current facility staff were not able to locate R7's hospice worker schedule. SW S could not verify hospice was aware of R7's history of sleeping during the day and awake at nighttime. During an interview with RN N on 8/21/24 at 11:55 AM, she confirmed the facility did not have any hospice schedules or documentation indicating the day hospice services were provided prior to yesterday (8/20/24) for all residents receiving hospice services. RN N said she had contacted hospice services yesterday and was working with them to get monthly schedules. RN N said all hospice staff are to be charting in the residents' medical records. RN N said they are now working with hospice to improve communication and scheduling. RN N said they met with hospice and family yesterday and started to make care plan changes. RN N said the hospice nurse was in this morning. RN N said they did not inform hospice of R7's sleep cycle because they had just started a sleep cycle assessment, therefore R7's hospice plan was still set up for care during the daytime. RN N said the only indication in R7's current care plan that R7 had a history of being awake at nights was that she had been a bartender. Review of R7's progress notes revealed that R7's last progress note in her EMR was dated 8/8/24 at 20:53 (8:53 PM). Visit today was a face to face and occurred with visual and audio [Name of hospice doctor] and writer reviewed PT's (patients) declines over the last 2 months. During meeting PT refused to talk or do anything doctor asked. PT has been sleeping more, talking and responding less. PT had a fall on 6/22 that caused bruising on left hips and ribs. Pt use to AMB (ambulate/walk) with walker but now PT refuses to get out of bed but when writer or staff take her to shower room she will sit on walker bench seat. PT is down to 81.5 LBS (pounds) a 3.44% total weight loss in 2 months. The last 14 days PT refused meals 18 times, ate 0% 5 times and averaged 50 % the rest of the meals served. PT BMI is at 19.6 has increased leading to writer making PRN (as needed) Tramadol (pain medication) to scheduled BID (twice a day) with PRN (as needed) available for breakthrough pain. PT's (patients) daughter also stated that she has seen a huge decline in the last 3 months. Last year took PT (patient) to the fair but with her recent declines daughter was scared to try. No new medications changes at this time. No other concerns from facility staff at this time. There were no progress notes located in R7's progress note section to indicate any hospice services were provided since 8/8/24.

Based on observation, interview, and record review, the facility failed to clean a glucometer per the manufacturer's instructions for 2 of 2 residents (R28 and R37) reviewed for blood glucose testing, resulting in the potential for the spread of infection and disease. Findings include: R37 A review of R37's Admission Record, dated 8/21/24, revealed R37 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R37's Admission Record revealed multiple diagnoses that included diabetes. During an observation on 8/19/24 at 4:50 PM, Licensed Practical Nurse (LPN) A was observed cleaning the glucometer machine with a 70% isopropyl alcohol prep pad after checking R37's blood sugar level. LPN A cleaned the machine by quickly swiping it with the alcohol pad. LPN A stated an alcohol prep pad can be used to properly clean and sanitize their glucometer machines. R28 A review of R28's Admission Record, dated 8/21/24, revealed R28 was a [AGE] year-old resident admitted to the facility on [DATE] and readmitted on [DATE]. In addition, R28's Admission Record revealed multiple diagnoses that included dementia. During an observation on 8/20/24 at 8:10 AM, LPN B was observed cleaning the glucometer machine by quickly swiping it with a 70% isopropyl alcohol prep pad after checking R28's blood sugar level. LPN B stated an alcohol prep pad can be used to properly clean and sanitize their glucometer machines. During a second interview on 8/20/24 at 4:35 PM, LPN A stated staff can clean the glucometers with either an alcohol pad (70% isopropyl alcohol) or a [Brand name] Germicidal Bleach Wipe which kills multiple types of spores and viruses, including Hepatitis viruses and HIV. LPN A stated the alcohol pads and bleach wipes can be used interchangeably to clean and sanitize the glucometer machines. During an interview on 8/21/24 at 8:25 AM, LPN D stated the nurses are only supposed to use [Brand name] Germicidal Bleach Wipes to clean and sanitize the glucometers. She stated they are not supposed to use the alcohol pads to clean the machines. During an interview on 8/21/24 at 8:35 AM, Registered Nurse (RN) E stated she only uses the alcohol pads to clean and sanitize the glucometer machines. During an interview on 8/21/24 at 10:38 AM, [NAME] President of Clinical Operations (VPCO) N and Unit Manager F stated staff should not be cleaning the glucometer machines with alcohol pads. A review of the facility's Cleaning and Disinfection of Resident-Care Equipment policy, revised 8/24, revealed, Resident-care equipment can be a source of indirect transmission of pathogens (i.e. bacteria and viruses). Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC (Centers for Disease Control and Prevention) recommendations to break the chain of infection . Use only EPA (Environmental Protection Agency)-registered disinfectants with kill claims for the common organisms found in the facility . Follow manufacturer recommendations for cleaning equipment. A review of the manufacturer's operator and in-service manual for the glucometer machines that the facility uses, dated 2023, revealed only specific disinfecting wipes that are EPA approved and contain bleach and/or a combination of alcohol and another combination of germicidal and bactericidal ingredients (e.g., a quaternary solution) are to be used to clean their glucometer machines. The manufacturer's instructions also indicate that other EPA Registered wipes may be used besides the recommended ones, however they could affect the performance of the machines. The manufacturer's instructions also state that the proper contact time (amount of time the machine must remain wet from the wipe in order to effectively sanitize and disinfect the machine) for the type of wipe used must be followed. A review of the EPA's Registered Anatomic Products Effective Against Bloodborne Pathogens, dated 8/22/24, revealed isopropyl alcohol was only effective against Human Immunodeficiency Virus (HIV), Hepatitis B, and Hepatitis C (viruses common to nursing home facilities) when used in a combination product with another ingredient (e.g., quaternary ammonium). In addition, the combination products that had isopropyl alcohol as an ingredient all had contact times (the amount of time the surface needed to stay wet in order to sanitize and disinfect it) ranging from 0.5 minutes to 10 minutes- not the quick amount of time that the glucometers were dry by with a quick swipe of an alcohol pad). A review of the CDC's Infection Control Chemical Disinfectants Guideline, dated 11/28/23, revealed, Alcohols are not recommended for sterilizing medical and surgical materials principally because they lack sporicidal action and they cannot penetrate protein-rich materials . They also evaporate rapidly, making extended exposure time difficult to achieve unless the items are immersed . A review of the CDC's Injection Safety Considerations for Blood Glucose Monitoring and Insulin Administration web page, dated 8/7/24, revealed, Clean and disinfect blood glucose meters after every use, per the manufacturer's instructions . Blood glucose meters can easily become contaminated during use. When used in healthcare or other group settings, germs and infections can spread if preventive measures are not in place . If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per the manufacturer's instructions, to prevent the spread of blood and infectious agents . If healthcare providers use blood glucose testing or insulin administration devices on more than one patient, equipment and supplies may become contaminated. Unsafe practices during assisted monitoring of blood glucose and insulin administration contribute to the spread of hepatitis B virus, hepatitis C virus, HIV, and other infections

Based on observation, interview and record review, the facility failed to follow physician ordered wound care and provide care to prevent the development of an avoidable unstageable pressure ulcer for 2 residents (Resident #9 and #38) reviewed for alterations in skin integrity, resulting in the development of an avoidable pressure ulcer and the potential for delayed wound healing, infection, and overall deterioration in health status. Findings: Review of the facility policy Wound Treatment Management and Documentation last revised 07/21 revealed, .1. Wound treatments will be provided in accordance with physician orders .c. the facility will follow specific physician orders for providing wound care . Review of the Fundamental of Nursing revealed, Repositioning (turning) patients is a consistent element of evidence-based pressure injury prevention (EPUAP, NPIAP, PPPIA, 2019a). The twofold aim of repositioning should be to reduce or relieve pressure at the interface between bony prominence and support surface (bed or chair) and to limit the amount of time the tissue is exposed to pressure (Maklebust and [NAME], 2016). Elevating the head of the bed to 30 degrees or less decreases the chance of pressure injury development from shearing forces (WOCN, 2016). Change the immobilized patient's position according to tissue tolerance, level of activity and mobility, general medical condition, overall treatment objectives, skin condition, and comfort (EPUAP, NPIAP, PPPIA, 2019a). A standard turning interval of 1.5 to 2 hours does not always prevent pressure injury development; repositioning intervals are based on patient assessment. Some patients may need more frequent position changes, while other patients can tolerate every-2-hour position changes without tissue injury. When repositioning, use positioning devices to protect bony prominences (WOCN, 2016). Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia A.; Hall, Amy. Fundamentals of Nursing - E-Book (p. 1255). Elsevier Health Sciences. Kindle Edition. Resident #9 (R9) Review of a Face Sheet revealed R9 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Minimum Data Set (MDS) assessment for R9, with a reference date of 3/31/22 revealed a Functional Status that R9 required extensive assistance of 2 persons for bed mobility and toileting, and total dependence for transferring. Review of R9's Care Plan revealed, Assist me to turn &/or reposition routinely during CNA rounds while in bed and frequently redistribute my weight if/when I am up in my chair. Date Initiated: 06/30/2022 . During an observation on 07/06/22 at 08:20 AM, R9 was sitting up in a gerichair in the dining room. There were no pressure offloading devices in place. During an observation on 07/06/22 at 10:54 AM, R9 was sitting up in a gerichair near the nurse station. There were no pressure offloading devices in place. During an observation on 07/06/22 at 11:43 AM, R9 was sitting up in a gerichair near the nurse station. There were no pressure offloading devices in place. During an observation on 7/6 at 12:43 PM, R9 was sitting up in a gerichair in the dining room. There were no pressure offloading devices in place. During an observation and interview on 07/06/22 at 01:44 PM, Licensed Practical Nurse (LPN) G reported that R9 was the last resident to get up before meals and the first to be put back to bed after meals because of the pressure ulcer on his buttocks. LPN G verified that the pressure ulcer was facility acquired. R9 was sitting up in a gerichair. During an observation on 07/06/22 at 01:59 PM, R9 was sitting up in a gerichair in his bedroom. R9 had just had a shower and was being placed in bed. During an observation on 07/06/22 at 02:26 PM, R9 was in bed and rolled to his right side for wound care/observation. The wound was on his coccyx and was oblong with well defined edges. The wound bed was observed without slough with a measurable depth. The bottom 1/3rd of the wound was not as deep as the top 2/3rd of the wound. LPN G and Certified Nursing Assistant (CNA) F reported that the wound appeared longer and wider than the previous observations they had made. CNA F reported it was larger than it was 3 days prior. Review of R9's June Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply [MEDICATION(S)] every three days until resolved. every night shift every 3 day(s) for wound management. Review of the checkoff box for 6/27/22 revealed the dressing change was not completed. Review of R9's July Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply [MEDICATION(S)] every three days until resolved. every night shift every 3 day(s) for wound management. Review of the checkoff box for 7/3/22 revealed the dressing change was not completed. Review of R9's Weekly Wound Note dated 6/24/22 revealed, Location/Type/Stage if applicable : coccyx stage 2 pressure Wound Measurements: Length x Width x Depth: 2.5cm x 1cm x 0.1cm . Review of R9's Weekly Wound Note dated 7/3/22 revealed, Location/Type/Stage if applicable : coccyx, pressure stage 2-Wound Measurements: Length x Width x Depth: 2.5cm x 1cm x 0.1cm . Review of R9's Hospice Progress Note dated 7/7/22 revealed, .Wound measurements to coccyx are 3.75x1x0.1cm. Dressing applied to coccyx. Hospice NP, (name omitted), contacted regarding additional wound care needs due to increased length measurement .Collaborated with facility CCC (Clinical Care Coordinator) and SN regarding additional needs regarding patient wound care and interventions to reduce skin breakdown. Further Education regarding prevention of skin breakdown provided to facility CNA's including repositioning every 2 hours and assessing for incontinence every 2 hours. (Indicating the worsening of the wound) During an interview on 07/07/22 at 01:26 PM, CNA E reported that R9 was to be repositioned at least every 2 hours. CNA E reported that R9 was the last to get up for meals and the first to go down after meals. CNA E reported that R9 was not to stay in his gerichair too long in order to prevent and heal his pressure ulcer. Resident #38 (R38) Review of a Face Sheet revealed R38 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for R38, with a reference date of 5/26/22 revealed a Functional Status that R38 required extensive assistance of 2 persons for bed mobility, transferring, toileting and personal hygiene. During an observation and interview on 7/6/22 at 8:36 AM, R38 reported that her buttocks was sore, and the night shift staff notified her of a new area of breakdown on her buttocks. R38 reported she was not repositioned often. R38 had a pillow under her right arm but she was flat on her back. R38's right leg was resting on a pillow and her left heel was resting on the bed. During an observation on 07/06/22 at 11:36 AM, R38's position had not changed, she was laying on her back with a pillow under her right arm. During an observation on 07/06/22 at 01:44 PM, R38's position had not changed, she was laying on her back with a pillow under her right arm. During an observation on 7/7/22 at 7:05 AM, R38 was in bed on her back with a pillow under each arm. The pillows were not offloading pressure on her buttocks. Both heels were resting on the bed. During an observation on 7/7/22 at 10:50 AM, R38 was in bed on her back with a pillow under each arm. The pillows were not offloading pressure on her buttocks. Both heels were resting on the bed. During an observation on 07/07/22 at 01:12 PM, R38 was in bed on her back. There was no pillow offloading pressure on her buttocks. Both heels were resting on the bed. During an observation on 7/7/22 at 1:40 PM, CNA H and CNA F were performing pericare for R38. R38 had a [MEDICATION(S)] dermarite dressing on the right buttocks dated 7/6/22. R38's left buttocks had a large deep ruddy red area on her buttocks that was non blanchable. There was no other barrier cream on her buttocks. Review of R38's July Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply [MEDICATION(S)] every 3 days to reduce risk of impaired skin. every night shift for skin integrity. Review of the checkbox dated 7/1/22, 7/2/22, 7/4/22, 7/5/22, and 7/6/22 revealed the wound care was completed on each of those days (not following the ordered directions for wound care.) Review of R38's Wound Care Notes dated 6/24/22 revealed, .Patient has resolving pressure ulcers of the right sacrum and left calf Recommend [MEDICATION(S)] border to both remaining pressure ulcers. The importance of offloading was stressed to patient .Nutrition requirements of wound healing, including a protein rich diet, as well as supplemental zinc and vitamins C and D3 were encouraged . Review of R38's Physician Orders revealed no order for supplemental zinc, vitamin c or Vitamin D3 nor the change recommended change for wound care following the wound care clinic providers recommendation. During an interview on 07/07/22 at 4:15 PM, Licensed Practical Nurse/Wound Care Nurse (LPN/WCC) I reported that she was the facility wound care nurse but was not certified in wound care. LPN/WCC I verified that R38 was receiving wound care daily with [MEDICATION(S)] dressing and not every 3 days as ordered. LPN/WCC I reported that R38 received wound care consultation at an outside facility, and they created wound care treatment plans.

This Citation pertains to Intake Number MI 421. Based on observation, interview and record review, the facility is placed in Immediate Jeopardy for its failure to use an Automated External Defibrillator (AED) device as part of the Cardio Pulmonary Resuscitation (CPR) process during separate [CONDITION(S)] events for two residents (Resident #4 and Resident #16) in violation of facility CPR Policy and the Basic Life Support (BLS) Standards of Care of the American Heart Association (AHA) as adopted by the facility. Both Resident #4 and Resident #16 expired at the facility. This deficient practice places all residents, who are designated as a Full Code and who suffer [CONDITION(S)] or are found unresponsive, at risk for serious harm and/or death. Immediate Jeopardy: Immediate Jeopardy began on [DATE]. Immediate Jeopardy was identified on [DATE]. NHA was notified of the Immediate Jeopardy on [DATE] at 1345 hours. Immediate Jeopardy was abated or removed on [DATE]. The Immediate Jeopardy began on [DATE] at 5:35 PM, when, per interview done on [DATE] at 3:43 PM, Certified Nurse Assistant (CNA) J stated that on [DATE] at 4:30 PM, Resident #4 had a low blood pressure and was not acting right. CNA J stated that she notified Registered Nurse (RN) B of the low blood pressure, but did not see RN B go to Resident #4's room. On [DATE] at 5:35 PM, CNA J took an evening meal tray into Resident #4 and found the resident to be unresponsive. CNA J notified RN B who went to the room, called 911 and went to notify Licensed Practical Nurse (LPN) T from the North Nursing Unit of the cardiac emergency for Resident #4. An interview on [DATE] at 11:31 AM with Registered Nurse (RN) B revealed that she was not sure what to do in a code or where stuff was. A second interview on [DATE] at 3:00 PM with RN B, revealed that she did not stay in the room once LPN T arrived and that she left to walk to the other end of the building to get an oxygen tank while LPN T got the crash cart. RN B stated that she then went to the nursing desk, printed off transfer paperwork, and notified the family of the event for Resident #4. LPN T performed compressions and oxygenation for Resident #4. At 5:55 PM EMS arrived and placed a 3-lead ECG monitor on Resident #4. Resident #4 expired in the facility. An interview on [DATE] at 11:50 AM with the Director of Nursing (DON) revealed that he had checked the facility AED on [DATE] (the day after [CONDITION(S)] event) and the AED had not been used for the [CONDITION(S)] event of Resident #4. The facility held a Quality Improvement and Assurance Program meeting on [DATE] and did not address the event and no nursing education was initiated related to the use of the AED. Resident #16: In an interview on [DATE] at 4:10 PM, the Director of Nursing (DON) stated, when asked about any [CONDITION(S)] or emergent events in the past three months, that there was a [CONDITION(S)] event for Resident #16 on [DATE] and that the facility AED had not been used. On [DATE] Resident #16 was found unresponsive at 10:00 PM by a staff member. A [CONDITION(S)] code was initiated, and staff performed compressions and oxygenation. The facility AED was not used. In both events the outside services of EMS or fire department personnel upon arrival placed an AED on both of the residents. Both Resident #4 and Resident #16 expired at the facility. Record review of both [CONDITION(S)] events revealed that no crash cart documentation forms were used and no facility AED was used. The Immediate Jeopardy was identified on [DATE]. The Administrator and Director of Nursing were notified on [DATE] at 1:45 PM of the Immediate Jeopardy that began on [DATE] at 5:35 PM, due to the facility's failure to implement the use of the facility's Automated External Defibrillator (AED) during a [CONDITION(S)] event for Resident #4 on [DATE] and for Resident #16 on [DATE]. Findings include: Resident #4: Record review of Resident #4's Face sheet, advance directive form and care plans from the closed medical record on [DATE] revealed that the resident's signed choice on [DATE] was to be CPR Full- Resuscitation. The physician signed the resident's choice form on [DATE]. In an interview on [DATE] at 3:43 PM, Certified Nurse Assistant (CNA) J stated that on [DATE] at 4:30 PM, Resident #4 had low blood pressure (90 over something), a high heart rate in the 120's and was not acting right. CNA B stated that she notified Registered Nurse (RN) B of the low blood pressure and the high heart rate, but did not see RN B go to Resident #4's room. On [DATE] at 5:35 PM, CNA J took an evening meal tray to Resident #4 and found the resident to be unresponsive. CNA J notified RN B who went to the room, called 911 and went to notify Licensed Practical Nurse (LPN) T from the North Nursing Unit of the cardiac emergency for Resident #4. Record review of Resident #4's progress notes, dated [DATE], revealed that there was a pharmacy progress note on [DATE] and not another nursing progress note until [DATE] at 7:06 PM that noted the following: -Staff brought meal tray into room at 5:35 PM and resident was unresponsive. -Last set of vitals and rounds done at 4:30 PM. Vital signs ,d+[DATE], 92% Room air, 18, 69, 97.6 temporal (temperature). -Code started at 5:39 PM. - 911 called at 5:41 PM. -EMS (Emergency Medical Services) arrived at 5:56 PM. -PA, wife, DON notified of condition. -EMS called [NAME] (Time of Death) at 6:22 PM. -ME (Medical Examiner) notified and released the body to the funeral home. There was no documentation that the facility's AED was used nor a time documented that an AED was placed on the resident by facility staff. Record review of the Emergency Medical Services (EMS) run sheet, dated [DATE], for Resident #4, revealed that EMS placed a 3-lead cardiac monitor at 5:55 PM. (20 minutes after the resident was found unresponsive). An interview on [DATE] at 11:50 AM with the Director of Nursing (DON) revealed that he had checked the AED on [DATE], the day after Resident #4's [CONDITION(S)] event, and stated that neither the AED nor the pads had been used for the event. In an interview on [DATE] at 12:00 PM, the Nursing Home Administrator (NHA) and the Director of Nursing (DON), both reviewed the AED sticker. The AED was pulled from the wall case by the DON. The DON stated that that it was not used during Resident #4's code. The NHA and DON both stated that the facility does not have an AED policy. The DON stated that it is taught in BLS (Basic Life Support) training every 2 years which all nursing staff are required to take and pass. There was no past nursing education presented to the surveyor in regard to the AED or [CONDITION(S)] codes during the survey. In an interview on [DATE] at 12:20 PM, the NHA revealed that she looked and there is no AED policy on its use. It is in the Cardiopulmonary Resuscitation (CPR) policy. The NHA was asked about staff education. The NHA replied that the facility could not find any. BLS cards are renewed every 2 years. The NHA further stated that the facility was getting another AED from another building, Record review of the facility nursing skills competency check list of 2019 (2020 was on a Relias computer program with no hands on) provided by the facility revealed that the Cardiac Section discussed the disease, sodium diet, signs and symptoms of a heart attack, heart failure treatment, cardiac assessment, cardiac medication class and anticoagulation monitoring. Record review and interview on [DATE] at 3:15 PM with the DON of the South Nursing Unit crash cart and binder revealed the following: -Emergency Cart Equipment List Check Sheet form did not list the AED machine. -Record review of the crash cart inspect daily form for the month of [DATE] revealed that out of 31 days in the month, the cart was checked 11 days. -February 2021 daily check forms revealed out of 28 days in the month only 17 days were checked. -February 4th, 2021 was not checked, which was the day of Resident #4's cardiac event. Record review of the 'Cardiac-Respiratory Arrest Documentation' form (undated), located in the front of the crash cart binder, revealed the following: -the name of resident, date, time, AED used yes/no, Time AED pads placed, shock advised, Time shock given, and pertinent documentation related to an emergent situation. This form was not used, per the DON, for Resident #4's [CONDITION(S)] event on [DATE]. The DON stated that the facility uses the nursing resource, Nursing Clinical Skills, Perry, Potter and Ostendorf, 9th edition 2014 copyright, for all nursing procedures and services for resident care. Record review of the 'Nursing Clinical Skills, Perry, Potter and Ostendorf, 9th edition 2014, Chapter 28-Emergency Measures for Life Support, Page 739, Skill 28.2- Using an Automatic External Defibrillator noted the following: The AED (Automatic External Defibrillator) is a defibrillator that incorporates a rhythm analysis system. The device attaches to a patient by two adhesive pads and a connecting cable. Most AED's are stand-alone boxes with a very simple three-step function and verbal prompts to guide the responder. All AED's offer automatic rhythm analysis, whereby the rhythm is compared to thousands of other rhythms stored in the AED computer software. On rhythm identification, some AED's automatically provide the electrical shock after a verbal warning . Page 740 clinical decision point: If the AED is immediately available, attach it to patient as soon as possible. The faster defibrillation is delivered the better survival rate (Kleinman et al. 2015). An interview was conducted on [DATE] at 10:00 AM with the Director of Nursing to review the Quality Assurance and Performance Improvement meeting agenda for the meeting held on [DATE]. The review revealed that the facility had Process Improvement Plans (PIPS) for falls, pressure ulcers, Infection Control, Dietary meal temperatures, room changes and compliance. There was no reference item for the failure to use the facility's AED for the [CONDITION(S)] event of [DATE]. Resident #16: On [DATE] at 4:10 PM the State surveyor was notified by the DON that another [CONDITION(S)]/emergency situation had occurred on [DATE] involving Resident #16. The DON stated that the AED was not used on the resident at that time either. No code form documentation from the crash cart was used. The DON did state that the 5-lead (cardiac monitor) was applied by EMS at 10:21 PM. The State Surveyor asked why staff waited for outside EMS to place an AED? No response to the question was received. Record review of Resident #16's nursing progress notes, dated [DATE] at 10:00 PM, revealed that the resident was unresponsive and cardiopulmonary resuscitation was initiated, but the facility AED was not documented as having been used. The interview with the DON revealed that no AED device was used for Resident #16. Record review of the American Heart Association Basic Life Support (BLS) 2020 book was reviewed. On Page 6, Figure 4, Adult [CONDITION(S)] Algorithm, [DATE].) Give oxygen, attach monitor/defibrillator . Page 4. noted that fewer than 12% have an Automatic External Defibrillator applied before EMS arrival . Record review of Resident #4's Emergency Medical Services (EMS) run sheet dated [DATE] noted that the facility staff stated that the patient was last seen alive and well at 4:30 PM when his vitals we taken, which were as follows: -BP ,d+[DATE], pulse 127, oxygen 92% room air. -The patient was alone from 4:30 PM- 5:38 PM, when staff brought him his dinner at 5:38 PM the found him unresponsive on his bed -Manual compressions were started at 5:40 PM. Defibrillator-no. Record review of Resident #16's Emergency Medical Services (EMS) run sheet, dated [DATE], noted that the local fire department was doing CPR and had attached the resident to an AED. The facility's Cardiopulmonary Resuscitation (CPR)-Adult Policy states, Mission Point Health Systems has set American Heart Association as our standard of BLS care. The Policy also states under the Policy Explanation and Compliance Guidelines: 1. In the event a resident is identified unresponsive and upon a thorough assessment determines that there is no pulse or respiratory activity and the resident has declared a full-code status, a licensed staff member will: . f. Identify a member of the response team to be responsible for documenting the time of each intervention and resulting response. Documentation should include but not limited to: 1) Date and time of arrest and name(s) of person(s) assisting with CPR, including the recorder. 2) Medications given 3) Treatments performed 4) Results of resuscitation 5) Time AED was placed and whether or not shock advised. (Emphasis added) 6) Date and time family and doctor notified 7) Assessment done 8) Where resident was transferred to (i.e. EMS Agency or Mortuary). 9) A debriefing with staff involved in the code response as needed. In addition, content and training modules for the Basis Life Support (BLS) standard of care for the American Heart Association from their web site, which the facility had adopted, includes a training module entitled, Importance of early use of an AED and a training module involving an AED skill demonstration. The facility set the American Heart Association as their standard of BLS care and the use of an AED in providing CPR is outlined in the facility CPR policy. In both instances of [CONDITION(S)] for Resident #4 and Resident #16, the facility did not follow the American Heart Association standard of Basic Life Support care nor their own CPR-Adult Policy, both of which involved using an AED in the event of a cardiac event or if a resident was found unresponsive. Facility nursing staff were trained in AHA Basic Life Support, which mandated use of an AED for CPR, if available. An AED was present in the hallway for use and was functional. It was not used in either cardiac event on [DATE] or [DATE] where CPR was performed and the AED was available, but not used. The Immediate Jeopardy was abated on [DATE], based on confirmation during interviews conducted on [DATE] at 3:45 PM, that the facility had implemented the following to remove the immediate jeopardy. 1.) On [DATE]: Identified 17 Residents as having Full Code orders. Verified (AED) batteries are not expired. Verified electrodes (pads) are not expired. 2.) Actions to prevent re-occurrence: Licensed Nurses re-educated on the use of an AED (Automated External Defibrillator). An AED was obtained from a sister facility on [DATE] with an up-to-date sticker indicating completion of an annual inspection. Facility Cardiopulmonary Resuscitation (CPR) Adult' policy was reviewed and deemed appropriate by the Nursing Home Administrator. 3.) The Crash carts' documents and emergency equipment list updated to include an AED. 4.) The Director of Nursing is responsible for monitoring ongoing compliance. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope and severity for potential for more than minimum harm that is not Immediate Jeopardy, pending completion of Inservice Training by all staff who have not yet in-serviced and the facility's ability to sustain compliance as verified by the State Agency.

This Citation pertains to Intake Number MI 421. Based on observation, interview and record reviews, the facility failed to prevent facility- acquired pressure ulcers (PU) for two residents (Resident #1 & Resident #3), resulting in Resident #1 developing a facility-acquired, Stage IV pressure ulcer that required hospitalization and surgical debridement, Resident #3 developing a facility-acquired, Stage III pressure ulcer to the mid-back, Findings include: Record review of the facility 'Wound Treatment Management and Documentation' policy, dated 12/2020, revealed that to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment. Facility utilizes the Perry & Potter Clinical Nursing Skills/Techniques and National Pressure Ulcer Advisory Panel. Record review of the 'Clinical Nursing Skills & Techniques' book, Perry, Potter and Ostendorf, 9th edition, copyright 2014, Chapter 39- Pressure injury prevention and care, pages 990-997, revealed the following: Pressure injuries occur from unrelieved prolonged soft tissue compression, which interferes with the blood flow to the tissues. If this compression continues for a prolonged period of time, the tissue dies from lack of blood flow, or tissue ischemia. Ischemia develops when pressure inside the vessels, causing the vessels to collapse and decreasing tissue perfusion. Staging of Pressure Injuries: Stage 1- Pressure injury: Non-blanchable [CONDITION(S)] of intact skin. Stage 2- Pressure injury: Partial-thickness skin loss with exposed dermis. Stage 3- Pressure injury: Full-thickness skin loss. Stage 4- Pressure injury: Full-thickness skin and tissue loss. Resident #1: Record review of Resident #1's annual Minimum Data Set (MDS), dated [DATE], noted an elderly male with severe cognitive impairment, never or rarely made decisions. Section G: Functional status noted the resident needed 2 people to assist him with bed mobility, transfers, dressing and toileting. Active medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section M: skin conditions noted that resident was at risk for pressure ulcer injuries and had one Stage II pressure ulcer, and one unstageable deep tissue injury. In an interview on 3/12/2021, Licensed Practical Nurse (LPN)/Clinical Care Coordinator/Wound Care Nurse A, revealed that Resident #1's wounds started as in-house acquired. Record review of monthly wound measurements for Resident #1 revealed that on 1/23/2021 the right buttocks developed a stage II pressure ulcer measuring 3.4 cm length X 3.4 cm width X 0.1 cm depth. The wound measurements on 3/3/2021 noted the same wound to have grown to measure: 4.5 cm length X 4.1 cm width X 4.3 cm depth with large amount of purulent drainage with a strong odor noted by the wound physician. Noted wound was deteriorating with large amount of brown foul-smelling purulent drainage. Record review of the Wound Physician's note, dated 2/3/2021, revealed a right buttocks Stage 3 pressure ulcer measuring 2.5 cm X 2.5 cm X 0.1 cm. A second wound was discovered on 2/3/2021 to the left buttocks, a Stage 3 pressure ulcer measuring 0.5 cm length X 2.6 cm width X 0.1 cm depth, with serosanguineous drainage noted. Record review of the Wound Physician's note, dated 2/10/2021, revealed a right buttocks Stage 3 pressure ulcer measuring 5 cm X 3.5 cm X 0.6 cm. The left buttocks Stage 3 pressure ulcer measured 0.6 cm length X 1.1 cm width X 0.1 cm depth, with serosanguineous drainage noted. A third wound was discovered on 2/10/2021 to the right heel measuring 3.1 cm X 3 cm X 0 depth noted as deep tissue pressure injury. A persistent non-blanchable, deep red, maroon, or purple discoloration was noted. Record review of the Wound Physician's note, dated 3/3/2021, revealed a right buttocks Stage 4 pressure ulcer measuring 4.5 cm X 4.1 cm X 4.3 cm, deteriorating with strong odor and purulent large amount of drainage noted- signs of infection present. Record review of Resident #1's progress notes, dated 3/3/2021, revealed that the resident was sent out to the hospital for surgical debridement. Closed record reviewed. Resident #3: Record review of Resident #3's admission Minimum Data Set (MDS), dated [DATE], noted an elderly female with a Brief Interview of Mental Status (BIMS) score of 12 out of 15, able to make decisions. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section M: skin conditions noted Resident #3 to be at risk of pressure ulcers with no unhealed pressure ulcers at assessment. Observation and interview on 3/12/2021 at 10:30 AM with the Licensed Practical Nurse (LPN)/Clinical Care Coordinator/Wound Care Nurse A, revealed that Resident #3 pressure and deep tissue injury wounds were acquired in the facility. Observations were made of Resident #3 seated in her room in a wheelchair looking out the window with bilateral blue puff boots on. LPN A removed the boots. Observation was made of the left foot outer heel with black eschar noted and measuring 0.5 cm X 0.6 cm X 0 depth. The left lateral mid-heel had eschar measuring 1.1 cm X 1 cm X 0 depth. The left back heel with a deep tissue injury measured 2.7 cm X 4.6 cm X 0 and was facility-acquired. An observation of the right inner heel was made, measuring 1.5 cm X 2.0 cm X 0 depth. Observation was made of a middle-of- back pressure ulcer and revealed a white dressing with no date or time that it was applied and no staff initials. LPN A stated that it should have a date when changed and by whom. LPN A peeled back the dressing to expose a Stage III wound packed with calcium alginate. LPN A acknowledged that the wound was facility-acquired.

Past Non-Compliance was determined appropriate by the State Agency for this citation. Plan outlined below. Based on observation, interview and record review, the facility failed to provide adequate supervision and functioning safety devices to ensure the safety and prevent the elopement of one resident (Resident #1) out of 3 residents reviewed for being at risk for elopement, resulting in an Immediate Jeopardy (IJ) that began on 5/25/2020, as a result of the facility's failure to prevent a resident elopement from the facility on Monday May 25, 2020 sometime after last being observed at 10:45 AM. This deficient practice has the high likelihood to affect all residents in this facility potentially resulting in harm, serious injury or death. Findings include: According to a facility face sheet dated 6/16/2020, Resident #1 was an [AGE] year-old admitted to the facility on [DATE] with the Diagnoses: [REDACTED]. Resident #1 according to a Minimum Data Set quarterly assessment dated [DATE], had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 indicating Resident #1 was cognitively impaired. Review of a facility elopement assessment dated [DATE], Resident #1 scored a 2 for risk of elopement. Anything over a 1 was at risk for elopement. Resident #1 wore a wander guard device/bracelet on his person that deactivated opening of doors when the device was near a wander guard protected door thus assisting in the prevention of elopement. According to a facility investigation dated 6/1/2020 at 3:30 PM, Incident Summary Facility was passing lunch and identified that a resident (Resident #1) was not in his room and charge nurse was notified and immediately started a search. During the search, facility received a phone call from the central (law enforcement/emergency) dispatch that inquired if we had a resident by the name of (Name of Resident #1), facility stated yes. Central dispatch stated that they had received a phone call from a local restaurant that (Name of Resident #1) was there. (Name of Resident #1) was returned to facility uninjured . This investigation continued, Incident type Elopement (Name of Resident #1) on Monday May 25, 2020 at approximately 10:45 AM, resident (Name of Resident #1) was observed by Clinical Care Coordinator (CCC) A positioned at the facility's north nurse's station. Shortly before noon, CNA (Certified Nurse's Aide) B was delivering meal trays to resident rooms and identified (Name of Resident #1) was not present in his room. CNA B notified CCC A who immediately initiated a 'code search' head count per facility policy. It was identified that (Name of Resident #1) was the only unaccounted for resident. At 12:10 PM, the (Name of the City) Department of Public Safety phone the facility and spoke to CNA C to notify staff of (Name of Resident #1) location at a local restaurant approximately 0.5 miles from the facility. CNA D was instructed to retrieve (Name of Resident #1) from his location, and they returned to the facility at 12:30 PM . During an interview and observation of all the facility doors and their operations with Maintenance Staff E on 6/15/20 at 9:20 AM, it was observed that only the facility entrance had a wander guard alarm. All other exits had a 15 second egress alarm and release and keypad, including the employee entrance. Upon pushing on the employee entrance door, a tone was emitted and when the door released in 15 seconds, a very loud squeal was emitted. This sound could be disabled at the keypad or at the two nurses station alarm annunciators. During an observation and interview with the facility Administrator (NHA) on 6/15/2020 at 10:00 AM, she stated 5/25/2020 (Monday) was Memorial Day and management staff was not present. She stated she was notified of Resident #1 elopement and came to the facility right away. NHA stated that earlier in the day, a food delivery truck had come and by interviews she had found that the employee entrance door alarm sound had been de activated at the nurse's control panel at the nurse's station and the alarm sound had never been turned back on for the employee entrance door. She had never had an employee admit that they had de activated the alarm. A walk of the potential path that Resident #1 took during his elopement was made with the NHA from the employee entrance, around the back of the facility on a sidewalk that ended at the south end hall of the facility. She stated that Resident #1 used a 4 wheeled walker for ambulation. From there, there was a large expanse of lawn that she said there was wheeled walker tracks in she could follow from the sidewalk behind the building to the sidewalk in front of the facility property. NHA stated it had rained earlier, and the wheeled walker tracks were easy to see. As this path was walked with the NHA, it was observed that the lawn area was very uneven, and Resident #1 had to walk a long way to the next sidewalk on this wet lawn. NHA could not say if the lawn had been mowed before this occurrence. At the front of the facility property was a sidewalk that went down a side city street. This sidewalk either went up a slope or down a slope depending on Resident #1's path. It was unsure which path from there Resident #1 had taken but the local restaurant he was in was on a very busy city street near a main intersection. NHA stated it was very warm on 5/25/2020, about 80 degrees Fahrenheit. She stated Resident #1 had on a shirt, pants, and soled slippers. During an interview on 6/15/20 at 10:48 with Dietary Manager (DM) L, she stated she was at the facility working on 5/25/20. She revealed a food truck driver had come and she had let him in at 7:30 AM on 5/25/2020. DM L stated it was a normal process for the delivery to come in through back door (employee entrance). The delivery truck driver had put a magnet in the employee entrance door so it would not close. Since COVID-19, the facility disabled the code pad outside at the employee entrance so the delivery truck driver could not use it to gain entrance to the facility. DM L stated it took approximately ½ hr. to 45 min for the delivery to be completed. DM L revealed she had never heard the alarm on the employee entrance door go off and it did not go off that day. She denied disabling the alarm. She revealed alarms go off at the nurse's stations if the employee entrance was opened with the keypad. Since the occurrence, DM L stated she must let the delivery truck driver in and out of the employee entrance each time, keypad him out and in. DM L stated she stayed at the door. DM L stated she did not find out Resident #1 had eloped until later that evening. DM L stated she was not part of the procedure to locate Resident #1. DM L was asked if there was a code search was everyone was to be involved? DM L stated that no code was called that day. During an interview on 6/15/2020 at 11:15 AM with CNA B, she revealed she saw Resident #1 on 5/25/2020 and on that day he was exit seeking, wanting to go to work, go to the bank. CNA B revealed he was not pushing on doors but going to doors. CNA B stated she kept redirecting Resident #1. CNA B stated that she took her lunch break at 11:00 AM and came back at 11:30 AM. She said she had sat at desk charting. She told a resident lunch was in 15 minutes. When she went to deliver Resident #1 his lunch tray, she had put his tray down (he was usually in the bathroom and usually answered, he did not). Realizing Resident #1 had not answered, she went back, and Resident #1 was not in the bathroom. At approximately 11:55 AM CNA B asked CCC A if she had seen Resident #1. CCC A said Resident #1 was looking to leave so they had better find him. CNA B stated she last saw Resident #1 between 10:00 and 10:30 AM. CNA B stated she did not hear any alarms. CNA B stated she did see two lights on at the Zone Annunciator (door alarm box). Usually there was only one light on, and it was on for the front door. CNA B confirmed that no one made an announcement or code on the overhead. She confirmed they were supposed to call a code. She stated they then started to search bathrooms/rooms for Resident #1 and that was when dispatch called that Resident #1 had been found. When Resident #1 got back, he was tired and hot. CNA B revealed Resident #1 was wearing two t shirts, sweatpants, black shoes. She stated she thought he had left with a coat or sweater on but was not wearing it. She stated Resident #1 had a wheeled walker and when returned he had on one shoe and was sweating really bad. They gave him water. During an interview on 6/15/2020 at 11:33 AM, CNA H confirmed she had worked 5/25/20. She stated she was Resident #1's aide. CNA H stated Resident #1 was more energetic for the 2 days before hand. She revealed Resident #1 was usually in room. but in the past two days he was moving a lot. CNA H stated when Resident #1 came out of his room that day, he said he was going to pick up his wife. She stated she last saw Resident #1 at 10:30 AM at nursing station. When staff realized he was missing was when the facility received a phone call informing them where Resident #1 was. CNA H confirmed there was no page overhead that Resident #1 was missing. CNA H stated when Resident #1 came back, he was fine but tired. There was dirt on his walker and clothes like he fell . CNA H did not hear any alarms sounding during the time Resident #1 was gone. During an interview and observation of Resident #1 in his room on 6/16/20 at 1:00 PM, Resident #1 was sitting on the right side of his bed. This surveyor tripped the door motion sensor alarm upon entering Resident #1's room. An attempt was made to interview Resident #1 however he was not able to remain on topic. When asked, he did not seem to remember leaving the facility. When asked about his wander guard bracelet on his left wrist he said his watch was getting loose and pointed out the blinking light on it. The blinking light indicated that the wander guard was operational. Resident #1 was pleasant and smiling. A blue four wheeled walker was observed under his window to the right head of his bed. During an interview on 6/16/20 at 11:05 AM with Social Worker (SW) K, she stated she was on vacation when Resident #1 eloped from the facility. She confirmed she knew Resident #1, that he had delusions and hallucinations. Resident #1 was thinking his parents were alive, and he is living in (Name of City). She stated Resident #1 was confused when family was last seen. His hallucinations centered around TV shows. She confirmed that Resident #1 had verbalized intermittently that he needed to leave the facility. SW K stated a few months after he admitted in July 2019, Resident #1 tried to elope from the facility. This need to elope was added to Resident #1's behaviors to monitor. SW K stated she did follow up visits several times after his elopement on 5/25/2020 and that Resident #1 does not remember the elopement. SW K confirmed that Resident #1 was at his baseline, no changes in activities of daily living or psychosocial status. Review of staff written statement (no date noted) by CNA O reflected, On Monday (5/25/20), I came to work at 9:30 (AM), after I clocked in (Name of Resident #1) asked me to let him out the door, I told him that I couldn't. He said okay and walked away. After that he was just walking around. The last time I saw him was between 10:00 AM and 10:30 AM. CNA O was called for an interview but did not answer or return the call by survey exit on 6/16/20 at 1:00 PM. Review of a staff written statement dated 5/27/20 (no time noted) by Staff P reflected, On the day of May 25th, 2020 (Name of Resident #1) came up to me at approximately 9:50 AM to 10:00 AM asking if I can let him out to go home. I replied no and told him that I (sic) not let him out. I've tried several times afterwards to redirect him (Resident #1) to the North Hall where his room and other nurses and CNA's are located where they can relocate him to anywhere but outside. As I was doing this, I got to his level and way of thinking so I can have him listen better. But as I tried, he walked back to the side door (employee entrance) by the time clock where I was located after the time of meet up. So I started to walk with him to the North desk when another nurse walked and I handed him over to her letting her know what was happening. Review of a facility progress note for Resident #1 reflected, 5/25/20 12:00 PM Nursing Progress Note: Late entry .Resident (#1) exited facility with walker unattended. Responsible party notified, physician notified, Administrator notified, DON (Director of Nursing) notified. Immediate intervention implement 1:1 (one on one) staff observation. Wander guard device replaced. Review of a facility care plan for Resident #1 dated reviewed 5/28/20 reflected, Focus: I am at risk for elopement. I have a history of wandering and exit seeking behaviors. Prior to admission, I had instances of elopement from my home. I am severely cognitively impaired and am typically not oriented to time, place or situation. I will pace/walk the hallways and sit by the front doors. I have a history of pushing on the doors as an attempt to leave. I will talk about needing to go to work or visit with my parents, which is an indicator that I will begin exit seeking. I may report needing to work on my car, which is another indicator I am looking to leave. 5/25/2020 I exited the facility unsupervised and returned with no injury . Review of a facility policy titled, Elopements and Wandering Residents dated reviewed (handwritten notation with the NHA initials) on 5/25/20 reflected, This facility ensure that resident who exhibit wandering behavior and/or are risk for elopement received adequate supervision to prevent accidents and receive care in accordance with their person centered care plan addressing the unique factors contributing to wandering or elopement risk. Wandering is a random or repetitive locomotion that may be goal-directed (e.g. the person appears to be searching for something such as an exit) or non-goal directed or aimless. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e. an order of discharge or leave of absence) and/or any necessary supervision to do so. The facility may be equipped with door locks and/or alarms to help avoid elopements. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 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 risk, implementing interventions to reduce hazards and risk and monitoring for effectiveness and modifying interventions when necessary. Monitoring and Managing Residents at Risk for Elopement or unsafe Wandering .adequate supervision will be provided to help prevent accidents or elopements. Staff will monitor the implementation of interventions, response to interventions, and document accordingly .Procedure for locating missing resident. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol . Review of submitted training of facility staff, No Title to the document or date reflected, Key Points: If a resident is exit seeking .what do we do? Make 1:1 if persists after diversion. Elopement policy- follow if can't be located. No bypassing alarms. Keyed box going to be over buttons. Check placement and function of wanderguard (every) shift for those at risk. There is a list in each elopement binder of those that have been identified. Night shift nurse to check ALL exit doors every night and complete checklist located in elopement binder. Please leave checklists in this book when full and start a new one . Review of a facility document titled, Elopement Procedure no date noted reflected, When a resident cannot be located, this protocol should be immediately initiated. Step 1: Locating a resident. Page resident's name overhead 3 times (1 time every 30 seconds to a total time and no more than 90 seconds). If resident is not located Call a code search overhead announcing residents name repeating 3 times in a row (Code Search(NAME)Doe, Code Search(NAME)Doe, Code Search(NAME)Doe) . Review of a facility document titled, Audible Alarm, no date noted reflected, When you hear an audible alarm go to annunciator panel, which is located at each nurse's station on the wall. There will be a light flashing (red) to corresponding door. You must go to that door and complete a walk around the building. North and South will complete a head count using the census sheet, which is located in the census book at each nurse's station. Review of a facility document titled, Tips for Prevention of Elopements (no date noted) reflected, Involve the family in the prevention strategy by supervising resident during key risk times. Room placement for easy observation. React to statements such as 'I want to go home. Observed for aimless wandering, fear or anxiety about the surroundings. Involve the activities department in the prevention strategy .review physical plant to be sure door alarms are working and that unauthorized areas are properly locked to prevent resident entry. Consider a chain of custody for high risk residents; develop a schedule for periodic checks on the resident .Never assume everyone knows the resident is a wanderer; make it clear to .whoever is involved in resident's care even for a short period of time. Consider use of color-coded wristbands as an alert to staff. Consider use of a personal alarm for the resident . The Nursing Home Administrator and the Director of Nursing (DON) were informed on 6/15/20 at 2:49 PM of a past noncompliance Immediate Jeopardy (IJ) that began on 5/25/20 at 10:45 AM, after the facility failed provide adequate supervision and functioning safety devices to ensure the safety and prevent the elopement of one resident (Resident #1) who was actively exit seeking and eloped from the facility on 5/25/20. This deficient practice has the high likelihood to affect all residents in this facility. On 6/16/20, the surveyor verified the facility implemented the following to remove the high likelihood the identified deficient practice would occur again: 5/25/20 -Resident #1 assigned to 1:1 staff supervision immediately upon return -Administrator, DON, Maintenance Director, CCC arrived in building and checked all exit doors -Elopement and Wandering Residents Policy reviewed by NHA and deemed appropriate -Elopement risk assessment conducted on all 69 facility active residents -Care Plans reviewed for those residents identified as elopement risk were reviewed and revised -All residents assigned wander guard devices were reviewed to ensure they have the active task to check placement and function of the device -All 7 of 69 residents that were identified as elopement received new wander guard bracelets -Elopement books were updated to reflect current residents that were identified at risk of elopement -Staff education initiated on Elopement and Wandering Residents and Wander guard Policies and procedures -Night shift nurses were assigned an audit tool to verify all exit doors to ensure proper working order every shift -Upon NHA and DON review of staffing patterns, additional CNA added to 3rd shift base schedule 5/26/20 -Maintenance door audit completed on all exit doors to ensure secure and alarms functions. This audit completed daily. -Elopement Risk Audit Tool developed. Regional clinical director to complete random record reviews of 10% census weekly -Plastic cover placed over Annunciators - Only Nurse, Maintenance, DON, CCC and NHA have key access -Facility conducted in house employee education on elopement; those on leave of absence were completed upon return. 100% of active staff re educated on this date; 94 active staff/97 total staff (three staff members on Leave of Absence) Education included: 1. Elopement binders 2. Elopement policy 3. Discussed what to do if a resident is exit seeking 4. Discussed cover that was placed over annunciator panel, who has keys 5. Check placement and function of wander guards 6. Elopement procedure 7. Discussed procedure for audible alarm 8. How to activate a wander guard device 5/27/20 -Frequent checks initiated on resident and 1:1 resolved -Motion sensor placed on door of resident's (#1) room to alert staff to his movement -Elopement drill conducted on 2nd shift -Elopement PIP (Process Improvement Plan) will be presented to QAPI (Quality Improvement) meeting in June 2020 5/28/2020 -(Name of food service) visit following 5/25/20 education provided to driver, no further concerns -As a precautionary measure, nursing was educated that at no time is anyone to deactivate a wander guard device to active risk residents, walkie talkies are to be utilized outside with staff, and resident at risk for elopement are not to go outside alone 5/31/20 -Elopement Education Validation tool modified. CCC to complete weekly staff audit to validate staff understanding On 6/16/20 this surveyor reviewed documentation, conducted interviews, and made observations the preceding interventions were completed prior to the abbreviated survey. A determination of past non-compliance was approved by the State Agency as of 5/26/20.

Based on observation, interviews, and record review, the facility failed to prevent, monitor, treat and promote the healing of pressure ulcers for 1 of 4 residents (Resident #65) reviewed for pressure ulcers. The deficient practice resulted in Resident #65 developing a facility acquired stage 3 pressure ulcer to the right heel and the worsening of, and lack of healing of, multiple pressure ulcers. Findings include: The facility provided a copy of the policy/procedure for Skin Care and Wound Management dated 8/11/2006 with a revision date of 1/2018 for review. The policy reflected, The facility staff strive to prevent resident/patient skin impairment and to promote the healing of existing wounds. The disciplinary team works with the resident/patient and family to identify and implement interventions to prevent and treat potential skin integrity issues. The interdisciplinary team evaluates and documents identified skin impairments and preexisting signs to determine the type of impairment, underlying condition contributing to it, and description of impairment to determine appropriate treatment .Components of skin care and wound management program include but are not limited to the following: .C. weekly monitoring of resident/patient skin status .E. Interdisciplinary review of identified skin impairments. F. Care plan for identified risk areas. G. Monitoring for consistent implementation of interventions and effectiveness of interventions. H. Review and modification of treatment plans, as applicable. I. Analysis of facility pressure ulcer data for quality improvement opportunities . Resident #65 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #65 was a [AGE] year-old male, who was admitted to the facility on [DATE] and readmission date of [DATE], with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), reflected a score of 14 out of 15 which represents Resident #65 was cognitively intact. Resident #65 required staff assistance with all activities of daily living. The facility provided a copy of the CMS-802 MDS Resident Matrix with a print date of 6/4/18. The form reflected that Resident #65 had a facility acquired pressure ulcer(s) (any stage) and had worsened pressure ulcer(s) (any stage). The facility provided a copy of the admission assessment dated [DATE] that reflected the following wounds (not limited to): Sacrum 11 x 6.2 cm (was noted as pressure area but no depth or stage was documented) Left ischial (on the buttock) pressure 7 x 2 (no depth or stage noted) Right ischial pressure 7.5 x 4 cm (no depth or stage noted) Right heel pressure 4 x 3 cm (no depth or stage noted) According to the nursing notes Resident #65 was transferred to the hospital and admitted on [DATE] treated for [REDACTED].#65 was readmitted to the facility. The facility provided a copy of wound consult done by a physician (during the hospital stay) that was dated 4/18/18 at 9:12 PM. The record reflected the following wounds (not limited to): Sacrum 1.9 x 8.1 x 0.1 cm, stage 4 pressure ulcer Left ischial 9.2 x 3.1 x 1.6 cm, stage 4 pressure ulcer Right ischial 2.9 x 11.6 x 1.2 cm, stage 4 pressure ulcer Right heel 0.9 x 2.2 x partial thickness and 0.6 x 0.9 x 0.2 cm, stage 3 pressure The facility provided a copy of the Treatment Administration Record (TAR) for (MONTH) (YEAR) with a print date of 6/5/18 at 2:37 PM. The TAR reflected a treatment order to change the dressing to the sacrum and ischial three times daily. The record reflected no dressing changes for day shift on 6/1, 6/2, 6/3 and no dressing change for the night shift on 6/4. The treatment for [REDACTED]. The treatment to the groin was ordered for three times daily and was not signed out for day shift on 6/1 and 6/2 and for the night shift on 6/4. An interview and record review was conducted on 6/5/18 at 3:30 with the DON B. The (MONTH) (YEAR) TAR was reviewed with the DON B and Surveyor asked if all of the nurses have access to the electronic health record to chart the dressing changes were done for Resident #65 and DON B stated that all nurses have access and should document in the TAR as completed before the end of their shift. An observation, interview and record review of a wound dressing change was conducted with RN R, CNA C and Resident #65 on 6/5/18 at 11:00 AM. Resident #65 stated that he does not have feeling in and around the wounds and they did not cause him discomfort. Resident #65 was asked about the pressure ulcers and reported that the staff usually measure them weekly, and reports that he has been told they are healing. When asked if the physician evaluates the pressure ulcers, Resident #65 stated he did not think so. When asked what the goal was for the pressure ulcers, for example complete closure or healing, Resident #65 stated, No one has ever said that I guess. I hope they close. As RN R and CNA C positioned Resident #65 unto his left side a large dressing was noted to the sacral and buttock area. The dressing was labeled and dated as, 6-10 4/04/18 (initials of Nurse EE. RN R stated, It was changed on the 6 PM - 10 PM shift. The date was should have been 6/4/18 and the nurse put their initials. This observation of the dressing label reflects the same as the TAR and reflects that the dressing was not changed on the midnight shift as the order directs. RN R confirmed that the Nurse EE worked the afternoon shift and not the midnight shift. RN R was observed as the dressing was removed, and the wounds were cleansed to the sacral area, left ischial and right ischial areas. RN R stated that he also has wounds to the groin and heel. As RN R applied the ointment to the sacral wound, the applicator was then placed back into the ointment container and with the same applicator proceeded to apply ointment to the right ischial pressure ulcer. RN R returned the applicator to the ointment container and with the same applicator applied ointment to the left ischal pressure ulcer. RN R then placed a dressing over the pressure ulcers. On 6/5/18 at 5:11 PM, the DON B provided a copy of the dressing change procedure that she stated the facility used. The procedure was reviewed with DON B. When asked for cross contamination purposes if the staff should use the same medication applicator for all three wounds, DON B stated, No, I would expect the nurse to use a separate one for each wound. A follow up interview was conducted on 6/06/18 at 9:16 AM with RN R. RN R came to the conference room and stated that she received education that she should have used 3 separate medication applicators for the application of the ointment to the different wounds during the dressing change. RN R stated that she was under the impression that she could use the same applicator because all three wounds were essentially under one large dressing but was advised by the DON B to use a clean one for each wound. On 6/5/18 at 4:15 PM, RN CCC U stated that the right heel was healed on 12/26/17 and it reopened on 1/18/18 (stage 3) and the left groin/testicle (stage 3) was first noted on 1/10/18. RN CCC U stated that both wounds were facility acquired pressure ulcers and documentation of the documented facility root cause analysis (per facility policy) could not be located. A written request for copies of the following items was requested on 6/5/18 at 2:25 PM: (MONTH) and (MONTH) TAR's, wound measurements and skin assessments from 5/1/18 - current. An interview and record review was conducted with DON B and RN CCC U on 6/6/18 at 1:00 PM of Resident #65's multiple pressure ulcers. The weekly skin assessments from 5/1/18 - 5/29/18 were reviewed. The following inaccuracies were noted: 5/1/18 the wound to the groin was not noted, 5/8/18 and 5/15/18 the wound to the right heel was not noted, 5/22/18 the wound to the groin was not noted, and 5/29/18 the wounds to the groin and right heel was not noted. The DON B stated that the weekly skin assessments were not accurate and should reflect all skin issues as the facility policy states. According to the most recent wound measurements and assessments for the pressure ulcer to the groin and the sacral was dated 5/22/18. The RN CCC U provided an assessment dated [DATE] at 3:08 PM for the sacral for review (after the request for documents was made on 6/5/18 at 2:25 PM). The RN CCC U stated that the groin had healed but did not provide an assessment for review. The most recent measurement and assessment for the left ischial, and right ischial was documented on 5/22/18 (15 days ago). There was only one print out from the electronic health record (EHR) (from 5/1 - 6/5) for the right heel which was dated 6/5/18 at 3:07 PM (after the request for documents was made on 6/5/18 at 2:25 PM). There were no other measurements available in the EHR for the facility acquired pressure ulcer to the right heel. The DON B and the RN CCC U stated that there were no other measurements found in the EHR to review. The facility failed to follow the policy to measure and assess all wounds weekly. The RN CCC U stated that she is responsible for measuring the wounds weekly and did not do them last week. When asked about if there were root cause analysis done for the facility acquired pressure ulcers the DON B and RN CCC U stated that another CCC was overseeing that unit at the time and they could not be located for review. The onset of the facility acquired pressure ulcer was noted as 1/10/18 and 1/18/18. The facility could not provide documentation before the exit of this survey supporting that the two stage 3 pressure ulcers to the groin and right heel were avoidable.

Based on interview and record review, the facility failed to document and act upon a change of condition for 2 (#1 and #4) of 4 sampled residents, resulting in Resident #1 having episode of shortness of breath with sweatiness and complaint of dizziness reported to the nurse, and Resident #4 having [MEDICAL CONDITION] activity with unresponsiveness to monitor closely and with no documentation. Findings: Record review of facility Change in Condition' policy, dated 6/2017, revealed it is the policy of this facility to inform residents/legal representative, attending physician or designee of a change in the resident's condition. Definition- An acute change in condition means deterioration in health, mental or psychological status in either life threatening conditions or clinical complications. Record review of facility 'Charge nurse' job description (undated) revealed knowledge and abilities of a thorough knowledge of general nursing principles and procedures and understanding of the concepts of aging and the needs and concerns of the elderly population and those with terminal illness. Knowledge of state and federal health regulations and clinical standards of nursing practice . (A.)(7.) Performs comprehensive and focused nursing assessments in conjunction with changes in clinical conditions and in accordance with scheduled programs. (A.) (15.) Assures completion of daily, weekly and monthly documentation requirements in the patient clinical record are performed. (E.) (2.) Timely performance of focused assessments related to change in condition. Resident #1: Record review of Resident #1's Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year-old male with Brief Interview of Mental Status (BIMS) of 15 out of 15, cognitively intact. Resident #1's medical [DIAGNOSES REDACTED]. Record review of Resident #1's 'Medical Treatment Decision Form', dated 11/8/17, revealed that Resident #1 was full resuscitation with yes to hospitalization noted. Record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's Activity of Daily Living care plan, dated 11/8/17, revealed shortness of breath with activity intolerance. Resident #1's anti-anxiety care plan, date initiated 11/22/17, noted anxiety contributes to my feelings of shortness of breath and fear of dying. Interventions included: Assess resident's symptoms to insure anxiety is not due to actual change in condition. There was no care plan for respiratory treatments, respiratory assessment, or respiratory hygiene, or advanced directive care plan. Record review of Resident #1's 'Progress notes', dated 11/22/17 at 1:43 AM, [MEDICATION NAME] was given for anxiety and SOB (shortness of breath). (No [MEDICATION NAME] treatment was given for shortness of breath). 11/22/17 at 3:54 AM, Resident pleasant. Continues with constant cough, occasionally productive. Lung sounds with slight rhonchi anteriorly, apical regular. Resident complained of shortness of breath throughout the night hours and PRN (as needed) [MEDICATION NAME] administered and resident noted sitting up in bed with eyes closed 11/22/17 at 7:26 AM [MEDICATION NAME] solution 3 ml inhale orally every 4 hours as needed for shortness of breath, nurse to document nebulizer/inhaler note. 11/22/17 at 7:44 AM [MEDICATION NAME] antianxiety med given. 11/22/17 at 8:34 nurse noted meds effective. 11/22/17 at 2:27 PM Resident uses call light to report difficulty breathing. Certified Nurse Assistant (CNA) instructed to obtain a set of vital signs. Upon returning to the room resident is lying on bed unresponsive, this nurse notified. No pulse palpated, chest compressions initiated. (There was no assessment by nursing when notified of sweaty and complained of dizziness at 10:30 AM) An interview on 12/19/17 at 12:17 PM with Licensed Practical Nurse (LPN) F revealed that on 11/22/17 in the morning Resident #1 had asked to go to the hospital and that she told the Director of Nursing (DON). LPN F stated that she wrote a hand written statement in ink (not typed) and gave it to the DON (after the incident of [MEDICAL CONDITION]). An interview on 12/19/17 at 1:55 PM with Social services staff E revealed that the week of 11/22/17 Resident #1 had verbally reported increase in anxiety and that the physician assistant increased the anti-depressant and the anti-anxiety medications at the same time. Staff E stated when asked that the facility had a morning meeting at 9:00 AM every day and discussed the Resident #1 and the changing of the medications and that the resident had requested to go to the hospital for difficulty breathing and that the DON stated that she had spoken to the Resident #1 about re-hospitalization . Social service staff E was asked does a resident have a right to request hospitalization . Response was yes, it's a residents right. An interview on 12/19/17 at 2:00 PM with Clinical Care Coordinator (CCC) D revealed that on 11/22/17 in the morning around 8:00 AM Resident #1 had asked about going to the hospital and we didn't send him. The CCC D stated that she went with the DON B to speak with the Resident #1. The CCC D stated that she stepped out of the room and that the DON spoke with the resident, but that she was not aware what was said. An interview on 12/20/17 at 8:50 AM with CCC D revealed that the DON B met with Resident #1 about his request or stated wanting to go to the hospital and that she (the CCC D) heard the DON ask Resident #1 Why do you want to go? What can they do there that we can't do here? And that Resident #1 stated, suctioning, that if he could get deep suctioning it would help. The CCC D stated that the DON started talking and that's when she was called out of the room. The CCC D stated that she did not hear the words you can't go to the hospital but has heard statements of there's no medical reason. The CCC D stated that residents do have the right to go to the hospital. Record review of Resident #1's 'Physical Therapy Treatment Encounter Note', dated 11/22/17, revealed: (Resident) performed bed mobility with sbax1 (Stand by assist times 1 person). Resident complained about inability to breath. Oxygen and heart rate monitored, 96% and 112. Resident's cough reflex appears to be weak. Huffing and coughing techniques. Resident ambulated 15 feet, 10 feet with 2 wheeled walker with cgax1 (Contact guard assist times 1 person). Resident's oxygen 91% and heart rate 62. Resident was sweaty and complained of dizziness. Resident's blood pressure 125/81, resident on 2 liter oxygen continuous. Nurse notified and resident was left in day room under observation. An interview via phone on 12/20/17 at 11:57 AM with Physical Therapy staff H revealed Resident #1 was having difficulty breathing on 11/22/17 and the day prior. Resident #1 Complained of sweating and dizziness, and I monitored him in therapy session and wrote a note. He complained of not able to breath. I put him in the day room and I told Licensed Practical Nurse (LPN) F about it. He was afraid to do more. Constantly complained of not being able to breath, that was about 10:30 AM that we (therapy) were working with him. A phone interview on 12/20/17 at 12:44 PM with the attending physician I, revealed that the physician saw the Resident #1 upon admission and that the physician assistance (PA) also saw him. Physician I was asked if he was aware on 11/22/17 that Resident #1 had asked or requested to go to the hospital? Physician I stated 'No, not aware of hospital request, but that Resident #1 was seen by a PA that day. Record review of Resident #1's 'Practitioner Short Progress Note', dated 11/22/17 at 11:12 AM, revealed that anxiety increased, on [MEDICATION NAME] for depression, has increased anxiety after having [MEDICAL CONDITION] and now the new [MEDICAL CONDITIONS] [MEDICATION NAME] was ordered and suggested for him to have [MEDICATION NAME] increased social work and nursing approve of this change feel that increasing [MEDICATION NAME] will take 2 to 4 weeks before we'll start seeing effects in the meantime use [MEDICATION NAME] 0.25 mg every 8 hours as needed for anxiety. Benefits outweighs risk due to his increased anxiety affecting his breathing. Record review of the facility's summary report related to the Resident #1's incident on 11/22/17 revealed that there were only typed staff statements with no signatures of the Licensed Practical Nurse (LPN) and Certified Nurse Assistant (CNA) staff. There were no hand written statements by the staff received by the state surveyor Resident #4: Record review of Resident #4's Minimum Data Set, dated dated [DATE], revealed a [AGE] year-old male with history of falling with [MEDICAL CONDITION], with surgical repair with staples. Record review of Resident #4's 'Progress Notes', dated 9/27/17 at 5:51 AM, while seated at the nurses station around 3:00 AM the nurse noted Resident #4 began to shake, head fell back, resident was not responding. Resident came to and became alert again after 20-30 seconds, was still confused but responding to his name only, and unaware of where he was. Vital signs 121/77, 89, 17, 98.5 & 97% on room air. Blood sugar 131. Doctor notified of current change in status. New order to monitor closely throughout the night and doctor will see him in the AM. Record review of Resident #4's orders revealed that there was no order written 'To monitor closely'. Record review of Resident #4's 'Progress Notes', dated 9/27/17 at 11:07 AM, noted the nurse was called to the day room at 10:40 AM where Resident #4 was sitting in wheelchair, resident was shaking arms and head fell back, residents upper body still shaking. Resident #4 did not respond for approximately 10 seconds. When resident did respond, he knew his name. The doctor was notified. Record review of Resident #4's 'Progress Notes', dated 9/27/17 at 11:25 AM, noted resident was being assessed, had two concurrent episodes and was sent to the hospital. An interview on 12/20/17 at 1;00 PM with staff CCC D who looked for and could not find an order to monitor closely, how often and what to monitor, revealed that the nurse should have done an SBAR (Situational Background Assessment Recommendation) form on 9/27/17 at 3:00 AM. CCC D stated that there was not one done until Resident #4 was sent out to the hospital later in the day at 11:30 AM. The CCC D stated that Resident #4's hospital nurse called to update her stating Resident #4 was going into asystole making him unresponsive.

Based on interview and record review, the facility failed to document and act upon a change of condition for 2 (#1 and #4) of 4 sampled residents, resulting in Resident #1 having episode of shortness of breath with sweatiness and complaint of dizziness reported to the nurse, and Resident #4 having [MEDICAL CONDITION] activity with unresponsiveness. Findings: Record review of facility use of the 'Clinical Nursing Skills & Techniques' Perry/Potter/Ostendorf, 8th edition, 2014 clinical resource book located at the nursing station, revealed that on page 47, chapter 4, Documentation and Informatics. Nursing documentation ensures continuity of care, provides legal evidence, and evaluates patient (resident) outcomes .Your documentation provides a detailed account of a patient's plan of care, important assessment, and treatment, which must be an accurate and timely evaluation of information. Record review of facility Change in Condition' policy, dated 6/2017, revealed it is the policy of this facility to inform residents/legal representative, attending physician or designee of a change in the resident's condition. Definition- An acute change in condition means deterioration in health, mental or psychological status in either life threatening conditions or clinical complications. Resident #1: Record review of Resident #1's Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year-old male with Brief Interview of Mental Status (BIMS) of 15 out of 15, cognitively intact. Resident #1's medical [DIAGNOSES REDACTED]. Record review of Resident #1's 'Medical Treatment Decision Form', dated 11/8/17, revealed that Resident #1 was full resuscitation with yes to hospitalization noted. Record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's Activity of Daily Living care plan, dated 11/8/17, revealed shortness of breath with activity intolerance. Resident #1's anti-anxiety care plan, date initiated 11/22/17, noted anxiety contributes to my feelings of shortness of breath and fear of dying. Interventions included: Assess resident's symptoms to insure anxiety is not due to actual change in condition. There was no care plan for respiratory treatments, respiratory assessment, or respiratory hygiene, or advanced directive care plan. Record review of Resident #1's 'Progress notes', dated 11/22/17 at 1:43 AM, [MEDICATION NAME] was given for anxiety and SOB (shortness of breath). (No [MEDICATION NAME] treatment was given for shortness of breath). 11/22/17 at 3:54 AM, Resident pleasant. Continues with constant cough, occasionally productive. Lung sounds with slight rhonchi anteriorly, apical regular. Resident complained of shortness of breath throughout the night hours and PRN (as needed) [MEDICATION NAME] administered and resident noted sitting up in bed with eyes closed 11/22/17 at 7:26 AM [MEDICATION NAME] solution 3 ml inhale orally every 4 hours as needed for shortness of breath, nurse to document nebulizer/inhaler note. 11/22/17 at 7:44 AM [MEDICATION NAME] antianxiety med given. 11/22/17 at 8:34 nurse noted meds effective. 11/22/17 at 2:27 PM Resident uses call light to report difficulty breathing. Certified Nurse Assistant (CNA) instructed to obtain a set of vital signs. Upon returning to the room resident is lying on bed unresponsive, this nurse notified. No pulse palpated, chest compressions initiated. (There was no assessment by nursing when notified of sweaty and complained of dizziness at 10:30 AM) An interview on 12/19/17 at 12:17 PM with Licensed Practical Nurse (LPN) F revealed that on 11/22/17 in the morning Resident #1 had asked to go to the hospital and that she told the Director of Nursing (DON). LPN F stated that she wrote a hand written statement in ink (not typed) and gave it to the DON (after the incident of [MEDICAL CONDITION]). An interview on 12/19/17 at 1:55 PM with Social services staff E revealed that the week of 11/22/17 Resident #1 had verbally reported increase in anxiety and that the physician assistant increased the anti-depressant and the anti-anxiety medications at the same time. Staff E stated when asked that the facility had a morning meeting at 9:00 AM every day and discussed the Resident #1 and the changing of the medications and that the resident had requested to go to the hospital for difficulty breathing and that the DON stated that she had spoken to the Resident #1 about re-hospitalization . Social service staff E was asked does a resident have a right to request hospitalization . Response was yes, it's a resident's right. An interview on 12/19/17 at 2:00 PM with Clinical Care Coordinator (CCC) D revealed that on 11/22/17 in the morning around 8:00 AM Resident #1 had asked about going to the hospital and we didn't send him. The CCC D stated that she went with the DON B to speak with the Resident #1. The CCC D stated that she stepped out of the room and that the DON spoke with the resident, but that she was not aware what was said. An interview on 12/20/17 at 8:50 AM with CCC D revealed that the DON B met with Resident #1 about his request or stated wanting to go to the hospital and that she (the CCC D) heard the DON ask Resident #1 Why do you want to go? What can they do there that we can't do here? And that Resident #1 stated suctioning, that if he could get deep suctioning it would help. The CCC D stated that the DON started talking and that's when she was called out of the room. The CCC D stated that she did not hear the words you can't go to the hospital but has heard states of there's no medical reason. The CCC D stated that residents do have the right to go to the hospital. Record review of Resident #1's 'Physical Therapy Treatment Encounter Note', dated 11/22/17, revealed: (Resident) performed bed mobility with sbax1 (Stand by assist times 1 person). Resident complained about inability to breath. Oxygen and heart rate monitored, 96% and 112. Resident's cough reflex appears to be weak. Huffing and coughing techniques. Resident ambulated 15 feet, 10 feet with 2 wheeled walker with cgax1 (Contact guard assist times 1 person). Resident's oxygen 91% and heart rate 62. Resident was sweaty and complained of dizziness. Resident's blood pressure 125/81, resident on 2 liter oxygen continuous. Nurse notified and resident was left in day room under observation. An interview via phone on 12/20/17 at 11:57 AM with Physical Therapy staff H revealed Resident #1 was having difficulty breathing on 11/22/17 and the day prior. Resident #1 Complained of sweating and dizziness, and I monitored him in therapy session and wrote a note. He complained of not able to breath. I put him in the day room and I told Licensed Practical Nurse (LPN) F about it. He was afraid to do more. Constantly complained of not being able to breath, that was about 10:30 AM that we (therapy) were working with him. A phone interview on 12/20/17 at 12:44 PM with the attending physician I, revealed that the physician saw the Resident #1 upon admission and that the physician assistance (PA) also saw him. Physician I was asked if he was aware on 11/22/17 that Resident #1 had asked or requested to go to the hospital? Physician I stated 'No, not aware of hospital request, but that Resident #1 was seen by a PA that day. Record review of Resident #1's 'Practitioner Short Progress Note', dated 11/22/17 at 11:12 AM, revealed that anxiety increased, on [MEDICATION NAME] for depression, has increased anxiety after having [MEDICAL CONDITION] and now the new [MEDICAL CONDITIONS] [MEDICATION NAME] was ordered and suggested for him to have [MEDICATION NAME] increased social work and nursing approve of this change feel that increasing [MEDICATION NAME] will take 2 to 4 weeks before we'll start seeing effects in the meantime use [MEDICATION NAME] 0.25 mg every 8 hours as needed for anxiety. Benefits outweighs risk due to his increased anxiety affecting his breathing. Record review of the facility's summary report related to the Resident #1's incident on 11/22/17 revealed that there were only typed staff statements with no signatures of the Licensed Practical Nurse (LPN) and Certified Nurse Assistant (CNA) staff. There were no hand written statements by the staff received by the state surveyor Resident #4: Record review of Resident #4's Minimum Data Set, dated dated [DATE], revealed a [AGE] year-old male with history of falling with [MEDICAL CONDITION], with surgical repair with staples. Record review of Resident #4's 'Progress Notes', dated 9/27/17 at 5:51 AM, while seated at the nurses station around 3:00 AM the nurse noted Resident #4 began to shake, head fell back, resident was not responding. Resident came to and became alert again after 20-30 seconds, was still confused but responding to his name only, and unaware of where he was. Vital signs 121/77, 89, 17, 98.5 & 97% on room air. Blood sugar 131. Doctor notified of current change in status. New order to monitor closely throughout the night and doctor will see him in the AM. (There were no documentation for 'closely monitor' presented to the state surveyor). Record review of Resident #4's orders revealed that there was no order written 'To monitor closely'. Record review of Resident #4's 'Progress Notes,' dated 9/27/17 at 11:07 AM, noted the nurse was called to the day room at 10:40 AM where Resident #4 was sitting in wheelchair, resident was shaking arms and head fell back, residents upper body still shaking. Resident #4 did not respond for approximately 10 seconds. When resident did respond he knew his name. The doctor was notified. Record review of Resident #4's 'Progress Notes', dated 9/27/17 at 11:25 AM, noted resident was being assessed, had two concurrent episodes and was sent to the hospital. An interview on 12/20/17 at 12:20 PM with CCC D revealed that she could not find a monitor closely order for Resident #4. The CCC D stated that she would have clarified with the doctor how often to monitor and what to monitor. An interview on 12/20/17 at 1:00 PM with staff CCC D who looked for and could not find an order to monitor closely, how often and what to monitor, and revealed that the nurse should have done an SBAR (Situational Background Assessment Recommendation) form on 9/27/17 at 3:00 AM. CCC D stated that there was not one done until Resident #4 was sent out to the hospital later in the day at 11:30 AM. The CCC D stated that Resident #4's hospital nurse called to update her stating Resident #4 was going into asystole making him unresponsive. An interview on 12/20/17 at 12:10 PM with the Registered Nurse Consultant C on what does 'closely monitor' mean, revealed that the consultant would recommend that the nurse clarify the order and write an order.

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO TIMELY IMPLEMENT INTERVENTIONS IN ORDER TO PREVENT A PRESSURE SORE FROM DEVELOPING FOR ONE OF FIVE RESIDENTS (#1) REVIEWED FOR PRESSURE ULCERS, FROM A TOTAL SAMPLE OF FIFTEEN RESIDENTS, RESULTING IN THE RESIDENT DEVELOPING AN AVOIDABLE STAGE IV PRESSURE ULCER THAT NECESSITATED ANTIBIOTIC THERAPY AND WAS PAINFUL. FINDINGS INCLUDE: ACCORDING TO THE ADMISSION RECORD DATED 12-6-2011, RESIDENT #1 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE] AND RE-admitted on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #1'S QUARTERLY MINIMUM DATA SET (MDS) 3.0 ASSESSMENT, DATED 5/24/12, REFLECTED THAT RESIDENT #1 WAS TOTALLY DEPENDENT UPON STAFF FOR POSITIONING NEEDS WHILE IN BED. REVIEW OF RESIDENT #1'S "WEEKLY SKIN SWEEP" DATED 8/7/2012, 8/14/2012 AND 8/21/2012 REVEALED: "SKIN INTACT" TO LEFT BUTTOCKS. REVIEW OF THE "WEEKLY SKIN SWEEP" FOR RESIDENT #1, DATED 8/28/2012, REVEALED: "SKIN IMPAIRED, LEFT BUTTOCK PRESSURE, 1.6 (CENTIMETERS) (BY) 1.8 (CENTIMETERS), STAGE II." ACCORDING TO THE STATE AGENCY'S CLINICAL PROCESS GUIDELINE FOR "PREVENTION AND MANAGEMENT OF PRESSURE ULCERS" (02/24/03), A STAGE 2 (II) PRESSURE ULCER IS DEFINED AS A SUPERFICIAL WOUND CHARACTERIZED BY PARTIAL THICKNESS SKIN LOSS. REVIEW OF RESIDENT #1'S "WEEKLY SKIN SWEEP" DATED 9/23/12 REVEALED HER LEFT BUTTOCK PRESSURE SORE DETERIORATED FROM A STAGE II TO A "STAGE IV" THAT WAS MEASURED AS 2 CM (CENTIMETERS) IN LENGTH BY 2 CENTIMETERS IN WIDTH. NO DEPTH WAS DOCUMENTED. THE PROCESS GUIDELINE FOR "PREVENTION AND MANAGEMENT OF PRESSURE ULCERS" (02/24/03) DEFINES A STAGE 4 (IV) PRESSURE ULCER AS A WOUND WITH FULL THICKNESS SKIN LOSS AND EXTENSIVE TISSUE DESTRUCTION AND/OR NECROSIS THAT CAN EXTEND AS DEEP AS BONE. ON 9/25/12, THE "WEEKLY SKIN SWEEP" FOR RESIDENT #1 REVEALED THE LENGTH OF HER ULCER WAS NOW 3.0 CM (ONE CM LARGER), THE WIDTH WAS 2.0 CM AND THE DEPTH WAS 4.5 CM; AND, THE WOUND WAS A STAGE "IV". THE DOCUMENTATION IN THE FACILITY'S MEDICAL RECORD FOR RESIDENT #1 WAS NOT CONSISTENT REGARDING THE HISTORY OF HER PRESSURE ULCER DEVELOPMENT. THE NURSE SKIN/WOUND PROGRESS NOTE FOR RESIDENT #1, DATED 9/1/2012, REVEALED: "LEFT BUTTOCKS WITH OPEN AREA, NECROTIC (DEAD) TISSUE NOTED." THE NURSE SKIN/WOUND PROGRESS NOTE DATED 9/12/2012 DESCRIBED THE WOUND AS: "ULCER NOW A STAGE FOUR WITH MODERATE SEROSANGUINOUS DRAINAGE", BUT THERE WAS NO DOCUMENTATION TO INDICATE WHETHER THE NECROTIC TISSUE DESCRIBED ON 9/1/12 WAS STILL EVIDENT. THE "SKIN GRID-MEASURABLE WOUND ASSESSMENT" FOR RESIDENT #1, DATED 9-5-12, DESCRIBED RESIDENT #1'S WOUND AS FOLLOWS: "SITE-LEFT BUTTOCK, TYPE-PRESSURE, LENGTH-1.9 CENTIMETERS, WIDTH-1.5 CENTIMETERS, DEPTH-0.5 CENTIMETERS, STAGE-II." THIS LAST ENTRY WAS DOCUMENTED FOUR DAYS AFTER THE 9/1/2012 ENTRY THAT DESCRIBED THE WOUND AS "NECROTIC", AND THE CHANGE THAT WAS SUGGESTED BY THE TWO DIFFERENT PROGRESS NOTES WOULD NOT HAVE BEEN POSSIBLE. RESIDENT #1'S "SKIN GRID-MEASURABLE WOUND ASSESSMENT" DATED 9/26/2012 DESCRIBED THE WOUND AS A LEFT BUTTOCK PRESSURE ULCER, WITH A LENGTH OF 3.0 CENTIMETERS, WIDTH OF 2.0 CENTIMETERS AND DEPTH OF 4.5 CENTIMETERS THAT WAS A STAGE IV WOUND. THE "RESIDENT ASSESSMENT INTERVIEW FOR PAIN" FOR RESIDENT #1, DATED 5/24/2012, REVEALED: "PAIN PRESENCE" AS A ZERO WITH A LINE THROUGH IT, INDICATING NO PAIN. RESIDENT #1'S NURSES NOTES, DATED 7/17/12, REVEALED: "SKIN INTACT & (AND) DENIES PAIN." HOWEVER, AFTER THE DEVELOPMENT OF THE PRESSURE ULCER ON HER LEFT BUTTOCK, RESIDENT #1'S "PRN (AS NECESSARY) PAIN MANAGEMENT FLOW SHEET", DATED 9/17/12 AT 1600 (4:00 PM), REVEALED: "LOCATION OF PAIN - L (LEFT) BUTTOCK, DESCRIPTION OF PAIN - MOANING, CRYING OUT, CURRENT INTENSITY - 5/10 FACES (MEANING, SCORED AS 5 OUT OF 10 TOTAL POSSIBLE POINTS AND INDICATING MODERATE PAIN USING FACIAL EXPRESSIONS AS THE INDICATOR) CAUSATIVE FACTORS (FOR THE PAIN) - WOUND." PHYSICIAN ORDER [REDACTED].O. (ORAL) 30 MIN (MINUTES) BEFORE L (LEFT) BUTTOCK TX (TREATMENT), INDICATION-DX - PAIN." THE NURSES NOTES DATED 9/30/12 DOCUMENTED THAT RESIDENT #1 WAS EXPERIENCING PAIN DURING HER DRESSING CHANGE: "DRESSING TX (TREATMENT) DONE AS ORDERED. RESIDENT TOLERATED POORLY, REPEATING "NO, NO, I'M GOING TO TELL YOUR MOTHER" AND GRIMACING AS IF IN PAIN." REVIEW OF PHYSICIAN ORDERS [REDACTED].#1'S PRESSURE ULCER. THE ORDER READ: "CLARIFICATION: [MEDICATION NAME] (ANTIBIOTIC) & (AND)[MEDICATION NAME](ANTIBIOTIC) FOR DX (DIAGNOSIS) OF WOUND INFECTION." ON 10/27/12, ANOTHER PHYSICIAN ORDER [REDACTED]." BASED ON REVIEW OF RESIDENT #1'S CLINICAL RECORD, THERE WAS NO DOCUMENTED EVIDENCE TO SHOW THAT PREVENTATIVE INTERVENTIONS HAD BEEN IMPLEMENTED TIMELY, IN ACCORDANCE WITH THE PLAN OF CARE. REVIEW OF PHYSICIAN ORDERS [REDACTED]." REVIEW OF RESIDENT #1'S CARE PLAN FOR "RISK FOR ALTERATION OF SKIN INTEGRITY R/T (RELATED TO) BRADEN SCALE RESULTS" (DATE INITIATED: 8/1/2012) REVEALED: "AIR MATTRESS TO BED FOR PRESSURE REDUCTION, DATE INITIATED: 11/1/2012." THE 11/1/2012 DATE WAS APPROXIMATELY ONE AND A HALF MONTHS AFTER THE PHYSICIan order for [REDACTED]. FURTHER REVIEW OF PHYSICIAN ORDERS [REDACTED]." THE ORDER WAS WRITTEN AFTER RESIDENT #1'S LEFT BUTTOCK PRESSURE ULCER DEVELOPED AND THEN DETERIORATED TO A STAGE 4 ULCER. FURTHERMORE, REVIEW OF RESIDENT #1'S CARE PLAN FOR "SKIN INTEGRITY R/T (RELATED TO) EXTERNAL PRESSURE TO LEFT BUTTOCKS" (DATED 8/23/12) STATED "...I NEED AN AIR MATTRESS WHILE IN BED" DATE INITIATED: 9/12/2012. THIS DATE WAS INCONSISTENT WITH THE INITIATION DATE OF THE MATTRESS THAT WAS DOCUMENTED ON THE OTHER CARE PLAN. REVIEW OF RESIDENT #1'S "ADL (ACTIVITIES OF DAILY LIVING) SELF CARE PERFORMANCE DEFICIT" (DATED 11/1/12) REVEALED AN INTERVENTION FOR: "...SKIN INSPECTION: I REQUIRE SKIN (IN CAPITAL LETTERS) INSPECTION DAILY." HOWEVER, THIS SURVEYOR WAS UNABLE TO LOCATE ANY DAILY SKIN INSPECTION NOTES IN RESIDENT #1'S ELECTRONIC RECORD, AND NO SKIN INSPECTION RECORD WAS PROVIDED BY THE FACILITY. DURING AN INTERVIEW, ON 11-15-12 AT 8:30 A.M., THE FACILITY ADMINISTRATOR AND UNIT MANAGER "A" FOR RESIDENT #1 WERE ASKED TO EXPLAIN HOW RESIDENT #1'S PRESSURE ULCER MAY HAVE BEEN UNAVOIDABLE. NO INFORMATION WAS PROVIDED, AND NO EXPLANATION WAS PROVIDED TO SHOW THAT THE PRESSURE ULCER WAS UNAVOIDABLE OR INTERVENTIONS WERE PUT INTO PLACE TIMELY TO PREVENT THE PRESSURE ULCER FROM DEVELOPING AND THEN DETERIORATING. DURING AN OBSERVATION IN RESIDENT #1'S ROOM, ON 11-15-12 AT 9:15 A.M., THE RESIDENT'S PRESSURE ULCER DRESSING CHANGE WAS OBSERVED AS COMPLETED BY MEDICATION NURSE "I". THE DRAINAGE FROM THE PRESSURE ULCER PACKING WAS OBSERVED TO BE A GREENISH SERO-SANGUOUS (WATERY-BLOODY) DRAINAGE WITH NO ODOR. THE WOUND BED WAS REDDISH PINK IN COLOR WITH NO SLOUGH NOTED. DURING AN INTERVIEW CONDUCTED AT THE TIME OF OBSERVATION, NURSE "I" WAS ASKED HOW RESIDENT #1'S PRESSURE ULCER HAD DEVELOPED. NURSE "I" SAID THAT SHE DID NOT KNOW. NURSE "I" SAID THAT RESIDENT #1 HAD EXPERIENCED PAIN WITH THE DRESSING CHANGE, BUT RECEIVED MEDICATION A HALF HOUR PRIOR TO THE DRESSING CHANGE THAT WAS HELPING. DURING A FOLLOW-UP INTERVIEW ON 11-15-12 AT 10:45 A.M., UNIT MANAGER "A" WAS ASKED IF THERE WAS ANY ADDITIONAL INFORMATION THE FACILITY COULD PROVIDE RELATED TO RESIDENT #1'S PRESSURE ULCER, AND UNIT MANAGER "A" RESPONDED, "NO". UNIT MANAGER "A" WAS ALSO ASKED IF RESIDENT #1 HAD BEEN NON-COMPLIANT WITH TURNING (REPOSITIONING). UNIT MANAGER "A" SAID, "NO." DURING THE INTERVIEW, UNIT MANAGER "A" SAID THAT THE PRESSURE ULCER AREA HAD STARTED AS A RED AREA AND DEVELOPED FURTHER. ( )

This citation pertains to intake #MI 022 and MI 304 Based on observation, interview, and record review, the Facility failed to provide adequate supervision (appropriate positioning and handling during care), and assistive devices (halos), to prevent a fall in 1 of 4 sampled Residents (#501), resulting in Resident #501 falling out of bed onto the floor, while having her brief changed on 2/10/12 and sustained a fractured Left arm diagnosed by an Orthopedic Physician on 2/24/12. Findings include: Review of the clinical record revealed Resident #501 was a [AGE] year old woman admitted to the facility on [DATE]. Review of the Minimum (MDS) data set [DATE] revealed Resident #501's [DIAGNOSES REDACTED]. Review of the Brief Interview of Mental Status (BIMS) score revealed 15 which indicated Resident #501 was cognitively intact. Review of the Minimum (MDS) data set [DATE] revealed Resident #501's BIMS score was 15 indicating she was cognitively intact. Review of the Facility Fall Risk assessment dated [DATE], revealed Resident #501 was a risk for falls with 6 of 12 categories checked. Review of the care plan for Resident #501 under "potential for injury due to falls" and also the care plan for "Requires assistance with Activity of Daily Living due to right side Hemiparesis, Decreased Mobility, Obesity..." revealed no assistive devices such as mats next to bed to cushion a potential fall, no halo or partial side rail to assist in turning and repositioning in bed and no instructions to assure staff do not let go of Resident #501 when she is turned to prevent her from falling off the bed. Review of the Facility incident report (IR), dated 2/10/12 at 7:40 PM revealed Resident #501 rolled out of bed onto the floor and sustained abrasions and a hematoma on her left arm and an abrasion on her right leg. Certified Nurse Assistant (CNA) #4 and CNA #8 were present during the accident. According to the IR, Resident #501 was not taken to the hospital and was not seen by a Physician, but a Physician was called. Ice was applied to her left elbow and under the section titled, "Immediate steps taken to prevent recurrence and to ensure resident's safety", was written, "... move resident to 3/4 side of bed when turning, needs Bariatric bed larger. When turn to side make sure to start on far side, turn to middle of bed. ?Halo bar to bed." which indicated a questionable need for a halo (a quarter size side rail used by residents to assist in rolling or turning in bed). In an interview on 6/13/12 at 1:00 PM, when asked if she ever fell out of bed, Resident #501 said, "yes". When asked if anyone was with her Resident #501 said, "yes the aides" and named CNA #4 and CNA #8. Resident #501 said, (named CNA #8) "walked away". Resident #501 said she injured her left arm and it happened about 3 months ago. In an observation on 6/13/12 at 3:45 PM, Resident #501 was in bed with only a few inches bilaterally of the bed not filled by Resident #501. The mattress width of the bed measured 42 inches. There were only approximately 4 inches on either side of Resident #501 that did not occupy the bed, when she laid on her back. There were no halos (quarter side rails), on either side. CNA #11 and CNA #12 were in the room providing care for Resident #501. the height of the bed from the floor to the mattress measured approximately 27 inches and there were no matts on the tiled floor to cushion Resident #501 if she were to fall out of bed again. CNA #11 and CNA #12 were observed rolling Resident #501 from side to side and back again. Both CNA's used their hands to hold her and their bodies to support the weight of Resident #501 and prevent her from falling out of the bed. The waste basket was located on Resident #501's left side, near the bed side table, opposite the window. Resident #501 right and left hands were clenched shut, however she was able to easily open her left hand which could grasp a halo when turned with assistance, to assist in maintaining her position.. The Administrator said, in an interview on 6/13/12 at 12:30 PM, CNA#4 did not work a the facility anymore and CNA#8 worked at the Facility approximately once a month. During a telephone interview on 6/13/12 at 12:30 PM, CNA #4 said she and CNA #8 were changing the soiled brief of Resident #501 on 2/10/12 at about 7:40 PM. CNA #4 said she stood on the left side of Resident #501 and CNA #8 stood on Resident #501's right side. They turned Resident #501 toward the window, (right side),where CNA #8 was standing, and changed Resident #501's brief. CNA #4 said CNA #8 let one hand go that was holding Resident #501 to dispose of the soiled brief and Resident #501 rolled off the right side of the bed onto the floor. CNA #4 said if Resident #501 had a halo she could have used it with her left hand and helped to keep her from falling out of the bed possibly. CNA #8 could not be reached after 4 attempts were made with messages left on an answering machine. In an interview on 6/14/12 at 2:35 PM, Licensed Practical Nurse (LPN) #10 said he worked on the East side on 2/10/12 and was called to Resident #501's room where he saw her face down, on the floor, complaining of pain. LPN #10 said Resident #501 kept saying her shoulder hurt (it was her left shoulder). LPN #10 said both CNA #4 and CNA #8 said they were providing care and had rolled Resident #501 toward CNA #8 and Resident #501 rolled off the bed. When asked if any one assessed Resident #501 for injuries and LPN #10 said Resident #501 said her left shoulder and hand hurt and she kept saying, "I'm in pain, I'm in pain", so we just rolled her over onto her back and about 5 of us lifted her with the Hoyer (mechanical lift) onto her bed. When asked why didn't he call Emergency Medical Services (EMS), LPN #10 responded, "That's a good question" and had no further response. Review of the mobile x-ray dated 2/10/12 (no time), under Findings revealed "no evidence of fracture or dislocation" for Resident #501. In an interview on 6/14/12 at 1:00 PM, Unit Manager/Registered Nurse (RN) #3, when asked why Resident #501 did not have a halo on her bed, stated she was not aware CNA #8 took her hand off Resident #501 when she was rolled toward her on 2/10/12 at 7:40 PM, during care. RN #3 said both hands should have been kept on Resident #501 when she is rolled toward them and other CNA could clean her. When asked if that information was in the care plan for Resident #501, RN #3 said she thought it was a "standard" (2 hands on a Resident who is rolled toward you, while care is provided). When asked if Resident #501's fractured left arm was a result of the fall on 2/10/12, RN #3 said, "it had to be". RN #3 explained that after Resident #501's fall on 2/10/12 the mobile x-rays showed no fractures and when the Lidocaine medication did not relieve the pain, we kept going over it and finally decided to send her to an Orthopedic Physician and got the referral on 2/15/12. Review of the Physician order [REDACTED].#501 to an Orthopedic Physician, administer Lidoderm gel topically to left shoulder every day and Physical Therapy evaluation and treatment to left shoulder. Activity Aide (AA) #6 , in an interview on 6/13/12 at 3:20 PM, said she went with Resident #501 on the van heading for the Orthopedic Physician office on 2/17/12 when Resident #501 started to slip out of her wheelchair while in the van. AA #6 instructed the driver to stop and she called the Facility and 4 people arrived to help reposition Resident #501 to stop her from falling out of her wheelchair. AA #6 said she used her entire weight to hold Resident #501 back from falling out of her chair. AA #6 said they took Resident #501 back to the Facility and did not call another service to take Resident #501 to her appointment with the Orthopedic Physician. Review of the nurse's notes dated 2/17/12 at 1:00 PM, revealed the following was written, "Reported this AM, 2 small bruises noted on back by Aides, Resident had an appointment today, left on dial-a ride, Resident was sliding out of wheelchair. Staff went to aide and help Resident. Staff repositioned in wheelchair and brought back to Facility. Appointment canceled and to be rescheduled. Skin sweep done and no red marks, bruises on back related to recent incident." Review of all incident reports for Resident #501 revealed 2/10/12 as the only incident report completed in Feb. 2012 by the Facility. Review of the Orthopedic Physician's note dated 2/24/12 (no time), under "History" was written, "This is a [AGE] year old female who is a long-term resident of" (named facility), "nursing home. She has had severe stroke and also has insulin-dependent diabetes. About two weeks ago she fell and injured her left shoulder. She is now here for evaluation. Patient is totally dependant and has no useful function in her upper and lower extremities". Under "Physical Examination" was written, "The left shoulder shows tenderness and pain on attempted motion. Both hands show stiffness and contracture but capillary refill is brisk and sensation is intact." Under "Imaging" was written, "Limited x-rays of the left shoulder are obtained in the office today. There appears to be a completely displaced fracture of the surgical neck of the humerus." Under "Plan" was written, "Under the present circumstances I do not recommend any surgical intervention. Patient is advised to avoid excessive motion of the arm. Order are written down so that the arm can be positioned in the most comfortable manner. The hand can be exercised. I do not think a sling is practical since she is recumbent most of the time. We will obtain x-rays of the left shoulder in 3 to 4 weeks's time and send them to me for review. Transporting her from the nursing home is a challenge in itself and I do not think she needs to be seen again unless there is a specific issue." Review of the Physician order [REDACTED]. Ice should be applied to her left shoulder, and Tylenol as needed for pain. Re-x-ray shoulder in 4 weeks in the Orthopedic Physician's office. Physician order [REDACTED]. Review of the nurse's notes dated 2/24/12 at 3:25 PM was written Resident #501 returned from the Orthopedic Physician's office and the X-rays did show a Fracture which "was unmistakable on the film". According to the nurse's notes the Attending Physician requested the follow up films (x-rays), be done in the Orthopedic office". Review of the Facility's CNA Care Plan for Resident #501 revealed new instructions dated 2/10/12 that were written, "Positioning put body on far side of the bed, then turn on side so in middle of bed for care. Head of Bed to be down when changing her." #

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT AN ELOPEMENT OUTSIDE OF THE FACILITY FOR ONE AGITATED, COGNITIVELY IMPAIRED RESIDENT (#110) OF THREE RESIDENTS REVIEWED FOR ELOPEMENT RISK OUT OF A SAMPLE OF TWELVE RESIDENTS FROM A TOTAL RESIDENT POPULATION OF 66. THE FACILITY'S DEFICIENT PRACTICE RESULTED IN RESIDENT #110 ELOPING FROM THE FACILITY THROUGH A WINDOW DURING THE DARK NIGHT HOURS, TO A WEEDED AREA APPROXIMATELY 80 YARDS FROM THE FACILITY, PLACING HIM IN IMMEDIATE JEOPARDY TO HIS HEALTH AND SAFETY. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 3/15/12 AT 2:00 P.M. ON 3/15/12. THE IMMEDIATE JEOPARDY BEGAN 3/14/12, AT APPROXIMATELY 9:45 P.M., WHEN NURSE AIDE "B" ENTERED RESIDENT #110'S ROOM TO HELP HIM PREPARE FOR BED AND NOTED THAT RESIDENT #110 WAS MISSING. TEN MINUTES LATER, AT 10:00 P.M. ON 3/14/12, A CHECK OF THE INTERIOR FACILITY FAILED TO LOCATE RESIDENT #110; AND, AT APPROXIMATELY 10:20 P.M., THE FACILITY CALLED 911. ACCORDING TO NURSING NOTES DATED 3/14/12 AT 2225 (10:25 P.M.): "SEARCHES CONTINUED INSIDE AND OUT AND MAINTENANCE NOTED A TORN SCREEN...AND A TABLE KNIFE AND WINDOW LATCH...FOUND RESIDENT (#110) IN BACK OF BUILDING IN A WEEDED AREA ON THE HILL." PRIOR TO ELOPING FROM THE FACILITY UNDETECTED ON 3/14/12, RESIDENT #110 HAD, ACCORDING TO NURSING NOTES, TOLD THE FACILITY THAT HE WAS WORRIED ABOUT HIS MONEY, WANTED TO LEAVE, AND WAS GOING TO LEAVE. THE FACILITY ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY AT 4:45 P.M. ON 3/15/12. THE IMMEDIATE JEOPARDY WAS REMOVED AT 3:50 P.M. ON 3/16/12 AFTER THIS SURVEYOR VERIFIED THAT THE FACILITY HAD IMPLEMENTED THE FOLLOWING: - ON 3/15/12, ALL RESIDENT WINDOWS AND COMMON AREAS WERE EQUIPPED WITH A DEVICE TO PREVENT THE WINDOWS FROM OPENING MORE THAN 6 INCHES. AND, ON 3/16/12, ALL OF THE OTHER WINDOWS IN THE FACILITY HAD A DEVICE PLACED TO PREVENT THE WINDOWS FROM OPENING MORE THAN 6 INCHES. THESE MODIFICATIONS WERE VERIFIED BY THIS SURVEYOR WITH OBSERVATIONS BEGINNING ON 3/16/12 AT APPROXIMATELY 3:05 P.M. - ON 3/15/12, FACILITY STAFF WERE DIRECTED TO REMOVE FINISHED MEAL TRAYS FROM THE HALLWAYS AND RESIDENT ROOMS, AND PLACE THE TRAYS IN THE MEAL CART AFTER MEALS, TO ENSURE THAT RESIDENTS WOULD NOT TAKE AND KEEP TABLE KNIVES. - ON 3/15/12, THE FACILITY'S INTERDISCIPLINARY TEAM (IDT) UPDATED RESIDENT #110'S CARE PLAN WITH AN INTERVENTION TO ENSURE THAT HE WOULD ONLY RECEIVE PLASTIC SILVERWARE WITH HIS MEALS. STAFF WERE DIRECTED TO ASSIST HIM IF HE NEEDED HELP TO CUT HIS FOOD. - ON 3/15/12, EVERY RESIDENT IN THE FACILITY WAS ASSESSED FOR ELOPEMENT RISK. THE CARE PLANS AND ELOPEMENT BOOK WERE UPDATED AS NEEDED. EXCEPT FOR ONE RESIDENT WHO WAS NEWLY admitted to the facility on [DATE], NO ADDITIONAL RESIDENTS WERE IDENTIFIED AS BEING "AT RISK" FOR ELOPEMENT. - RESIDENT #110 WAS CONTINUED WITH 1:1 SUPERVISION. - THE IDT WOULD REVIEW RESIDENTS WITH ELOPEMENT RISK AND EXIT SEEKING BEHAVIORS DURING MONDAY-FRIDAY MORNING MEETINGS. - ON 3/15/12, THE FACILITY'S CORPORATE CONSULTANT (A LICENSED SOCIAL WORKER) COMPLETED A PSYCHOSOCIAL ASSESSMENT, WHICH INDICATED THAT RESIDENT #110 had a history of [REDACTED]. - AT APPROXIMATELY 2:00 P.M. ON 3/15/12, RESIDENT # 110'S ROOM WAS SEARCHED AND DANGEROUS OBJECTS (RAZORS, SHOE LACES, CALL LIGHT CORDS AND BREAKABLE OBJECTS) WERE REMOVED. RESIDENT # 110'S CARE PLAN AND ADL (ACTIVITY OF DAILY LIVING) GUIDE WERE UPDATED TO REFLECT SAFETY INTERVENTIONS. - ON 3/15/12, THE PROCESS TO GET EMERGENCY GUARDIANSHIP FOR RESIDENT #110 WAS INITIATED. - STARTING ON 3/15/12, ALL STAFF PROVIDING 1:1 OBSERVATION WERE PROVIDED AN OBJECTIVE FOR THE 1:1 WITH SPECIFIC INSTRUCTIONS, AND EACH STAFF WERE REQUIRD TO SIGN THE OBJECTIVE SHEET SHEET. - ON 3/15/12, SEVENTEEN OF 30 LICENSED STAFF AND IDT MEMBERS WERE INSERVICED REGARDING CARE PLAN REVIEWS AND THE DOCUMENTATION THAT WAS REQUIRED FOR UPDATING AND DISCONTINUING INTERVENTIONS ON CARE PLANS. THE REMAINING STAFF WERE TO BE INSERVICED PRIOR TO THEIR NEXT SCHEDULED SHIFT. - AS OF 10:30 P.M. ON 3/15/12, TWENTY-SEVEN OF 89 FACILITY STAFF RECEIVED AN INSERVICE, PRIOR TO STARTING THEIR SCHEDULED SHIFT, REGARDING HOW TO IDENTIFY STATEMENTS OR BEHAVIORS THAT COULD INDICATE A RESIDENT'S ELOPEMENT RISK AND/OR SUICIDAL IDEATION, THE APPROPRIATE INTERVENTIONS TO PUT INTO PLACE, AND THE PROPER IMPLEMENTATION OF ALARMS. ALL OTHER STAFF WERE TO RECEIVE THIS INSERVICE PRIOR TO STARTING THEIR SCHEDULED SHIFTS. - A PLAN WAS IMPLEMENTED TO RANDOMLY INTERVIEW A MINIMUM OF THREE STAFF MEMBERS IN EACH DEPARTMENT ON EACH SHIFT REGARDING THEIR KNOWLEDGE OF RESIDENTS' ELOPEMENT RISK, SUICIDAL RISK AND APPROPRIATE USAGE OF ALARMS. THIS RANDOM SAMPLING WOULD CONTINUE UNTIL ALL STAFF IN EACH DEPARTMENT HAD BEEN QUESTIONED AND RESPONDED APPROPRIATELY. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 3/16/12, THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED, AND CONTINUES AT AN ISOLATED LEVEL WITH THE POTENTIAL FOR MORE THAN MINIMAL HARM, PENDING THE FACILITY'S ABILITY TO: - COMPLETE THE INSERVICE EDUCATION FOR ALL STAFF. - CORRECTLY IDENTIFY ANY RESIDENTS AT RISK FOR ELOPEMENT AND PROTECT THEM FROM EXITING THE BUILDING UNSUPERVISED. - SUSTAIN COMPLIANCE AS VERIFIED BY THE STATE AGENCY. FINDINGS INCLUDE: ACCORDING TO THE ADMISSION ORDER SHEET DATED 1/14/12, RESIDENT #110 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. NURSING NOTES ENTERED AT 7:45 P.M. ON 1/14/12 (DATE OF ADMISSION) INDICATED THAT RESIDENT # 110 HAD "SENSOR ALARMS ON BED AND W/C (WHEELCHAIR) FOR SAFETY" AND WAS "A & O X 1" (ALERT AND ORIENTED TO PERSON ONLY), WAS A POOR HISTORIAN AND WAS "UNABLE TO STAY ON ONE THOUGHT VERY LONG." ACCORDING TO A "BIMS (BRIEF INTERVIEW FOR MENTAL STATUS) EXAM" DATED 1/23/12, RESIDENT #110 SCORED "8" POINTS OUT OF 15 POSSIBLE POINTS, INDICATING THAT HE WAS MODERATELY COGNITIVELY IMPAIRED. (A SCORE OF "0 TO 7" INDICATED SEVERE IMPAIRMENT.) THE DEPRESSION ASSESSMENT/MOOD INTERVIEW, WHICH WAS CONDUCTED BY THE SOCIAL WORKER ON 1/23/12, SCORED RESIDENT #110 AS MINIMALLY DEPRESSED. THE FOLSTEIN MINI-MENTAL EXAM, CONDUCTED BY THE SOCIAL WORKER ON 1/23/12, CONTAINED A SECTION FOR STAFF TO ADDRESS "SUICIDAL/IDEATION AND /OR PLAN", BUT NO ENTRY WAS DOCUMENTED UNDER THAT SECTION ON THE FORM. ON 2/20/12, AT 1:00 P.M. NURSING NOTES DOCUMENTED: "RESIDENT (#110)PLACED ON ELOPEMENT RISK D/T (DUE TO) TRYING TO GET OUT THE FRONT DOOR. CALLING WIFE AND TELLING HER TO COME GET HIM..." ON 2/20/12 AT 4:00 P.M., NURSING NOTES DOCUMENTED: "RESIDENT (#110) WAS QUITE AGITATED EARLY THIS AFTERNOON AFTER (HIS) WIFE LEFT. BEGAN PACKING CLOTHES (AND) HEADING FOR THE FRONT DOOR. YELLING, PUNCHING DOOR. STATES...HE WANTS TO GO HOME....WAS PLACED ON 30 MINUTE CHECKS..." ON 2/21/12 AT 2:46 A.M. NURSING NOTES DOCUMENTED: "RESIDENT (#110)ATTEMPTED TO CLIMB OUT OF BED. MOVED TO ROOM (NUMBER OF ROOM) FOR SAFETY CLOSER TO THE NURSES' DESK." ON 2/23/12 AT 9:00 A.M. NURSING NOTES DOCUMENTED: "RESIDENT (#110) IS (UP) WALKING WITH WALKER. REFUSING ASSISTANCE. STATES 'I HAVE RIGHTS, I'M NOT A PRISONER'... RESIDENT HAS COAT (AND) HAT ON. STATES HE IS GOING TO WALK SIX MILES TO HIS NEPHEW'S HOUSE OR GO TO THE HOSPITAL WHERE THEY WILL GIVE HIM 'TREATMENT'." ON 2/26/12 AT 5:30 A.M., NURSING NOTES DOCUMENTED THAT RESIDENT #110 WAS: "...(UP) WALKING AROUND ROOM, WITHOUT ASSISTANCE, PUTTING HIS COAT AND SHOES ON. STATES HE IS GOING TO THE BANK. GETTING UPSET (AT) ALARMS (AND) BEING 'FOLLOWED'. (UP) WALKING (WITH) WALKER ERRATICALLY. WILL SIT FOR A COUPLE MINUTES THEN GET BACK UP (AND) WALK..." ON 2/27/12 AT 6:15 A.M., NURSING NOTES INDICATED THAT RESIDENT #110 WAS AGITATED AND YELLING THAT HE HATED THE ALARMS STATING, "GET THESE DAMN NOISES OFF OF ME." ON 2/27/12 AT 4:00 P.M., NURSING NOTES DOCUMENTED THAT THE COUNTY POLICE ARRIVED AT 8:40 A.M. TO SERVE RESIDENT #110 WITH DIVORCE PAPERS. ACCORDING TO THE NOTES: "...RESIDENT BECAME VERY UPSET. PUT HAT (AND) COAT ON AND WAS "GOING TO THE BANK BEFORE SHE RIPS ME OFF'." THE NOTES STATED THAT THE RESIDENT WAS "ENCOURAGED TO ATTEND ACTIVITIES DURING THE DAY", BUT NO OTHER MONITORING OR SAFETY INTERVENTIONS WERE DOCUMENTED IN THE NOTES. THE NOTES STATED THAT THE PHYSICIAN WAS IN TO SEE RESIDENT #110, AND MEDICATION CHANGES WERE MADE. BASED ON REVIEW OF THE SOCIAL SERVICE NOTES IN RESIDENT #110'S CLINICAL RECORD, THERE WAS NO SOCIAL SERVICES FOLLOW-UP TO RESIDENT #110'S MOOD STATE THAT DAY. THERE WERE NO SOCIAL SERVICE NOTES DOCUMENTED IN RESIDENT #110'S CLINICAL RECORD ON ANY DATE BETWEEN 2/13/12 AND 3/2/12. ON 2/28/12 AT 4:00 P.M., NURSING NOTES DOCUMENTED: "RESIDENT (#110)...CONTINUES TO MAKE STATEMENTS WISHING TO GO TO BANK..." ON 2/29/12 AT 12:30 A.M., NURSING NOTES INDICATED RESIDENT # 110 WAS "DOWN" ABOUT HIS DIVORCE. THE NURSING NOTES DOCUMENTED: "(RESIDENT) WANTS TO GO TO THE BANK SO HE CAN TAKE HIS MONEY OUT SO HIS WIFE CANNOT TAKE IT...RES(IDENT) IS ONE-ON-ONE FOR SAFETY R/T (RELATED TO) WALKING (WITH) WALKER AND NO ALARM." ON 2/29/12 AT 1:30 P.M., NOTES DOCUMENTED: "RESIDENT IS OWN PERSON (AND) REQUESTS ALARMS TO BE DISCONTINUED. RESIDENT IS GETTING FRUSTRATED AND READY TO THROW ALARMS. ALARMS DC'D (DISCONTINUED) ON REQUEST OF RESIDENT." BASED ON REVIEW OF THE RESIDENT'S "POTENTIAL FOR ELOPEMENT CARE PLAN", INITIATED 2/20/12, NO ADDITIONAL MONITORING INTERVENTIONS WERE DOCUMENTED AS HAVING BEEN ADDED TO THE CARE PLAN UNTIL 3/15/12, AFTER RESIDENT #110 HAD SUCCESSFULLY ELOPED. ON 3/2/12 AT 9:15 A.M., NURSING NOTES INDICATED THAT RESIDENT #110 WAS: "...UP TO NURSES STATION (WITH) HAT AND COAT ON, PUSHED WALKER TO SIDE. TALKING VERY LOUDLY. WANTS TO GO TO THE BANK. STATES HE CAN WALK TO THE BANK 'IT'S ONLY 5 MILES'. REMINDED THAT 5 MILES IS A LONG WAY (AND) IT'S COLD OUT. STATES "I DON'T GIVE A DAMN'. STOOD AT FRONT DOOR FOR A WHILE (WITH) STAFF CLOSE BY THEN SAT DOWN IN CHAIR." ON 3/2/12, SOCIAL SERVICE NOTES DOCUMENTED: "TODAY (AT) APPROXIMATELY 10:00 A.M. (RESIDENT #110) WENT OUT THE FIRST SET OF DOORS OUT INTO THE LOBBY. HE WAS UPSET (AND) WANTED TO TALK ABOUT HIS RIGHTS...HE THEN AGREED TO COME BACK INTO THE MAIN PART OF THE BUILDING. (HE) NEVER LEFT SIGHT OF STAFF AND DID NOT MAKE IT OUT OF THE BUILDING...STAFF REPORTS THAT (RESIDENT #110) FOLLOWED A VISITOR OUT THE DOOR. HE WAS UNABLE TO TYPE IN CODE TO OPEN THE DOOR ON HIS OWN..." THE NOTES DESCRIBED RESIDENT #110'S COGNITION AND BEHAVIORS AS "FLUCTUATES DAY TO DAY." DURING AN INTERVIEW CONDUCTED AT 11:58 A.M. ON 3/15/12, FACILITY SOCIAL WORKER "A" SAID THAT SHE HAD CALLED THE BANK ON BEHALF OF RESIDENT #110 AND HAD FOUND OUT THAT ONLY RESIDENT #110'S NAME WAS ON THE ACCOUNT, NOT THE WIFE'S. SOCIAL WORKER "A" SAID THAT SHE HAD SHARED THIS INFORMATION WITH RESIDENT #110, AND FOR AWHILE HE HAD SEEMED CALMER. DURING AN INTERVIEW CONDUCTED ON 3/15/12 AT 10:24 A.M., THE FACILITY'S ADMINISTRATOR SAID THAT RESIDENT #110 HAD ATTEMPTED TO LEAVE THE FACILITY ON 3/2/12 IN ORDER TO SECURE HIS PERSONAL FUNDS BECAUSE HE THOUGHT HIS WIFE WAS STEALING FROM HIM. THE ADMINISTRATOR SAID THAT THERE WAS NO INCIDENT REPORT FILLED OUT, BUT THE RESIDENT CARE PLAN WAS UPDATED ON 3/2/12. BASED ON REVIEW OF RESIDENT #110'S "POTENTIAL FOR ELOPEMENT CARE PLAN", THERE WAS A REVIEW DATE OF 3/2/12 WRITTEN IN THE LEFT MARGIN OF THE CARE PLAN, BUT THERE WERE NO NEW INTERVENTIONS DATED AS HAVING BEEN ADDED TO THE CARE PLAN BETWEEN 2/20/12 AND 3/15/12. AN UNDATED INTERVENTION ON THE CARE PLAN TO "INITIATE RESIDENT CHECKS" EVERY 30 MINUTES HAD A LINE DRAWN THROUGH IT. THE DOCUMENTATION ON THE CARE PLAN REFLECTED THAT RESIDENT CHECKS HAD BEEN CONDUCTED EVERY 30 MINUTES, THEN CHANGED TO EVERY 15 MINUTES, THEN CHANGED BACK TO EVERY 30 MINUTES, BUT THERE WERE NO DATES OR INITIALS ON THE CARE PLAN TO INDICATE WHEN THE CHANGES WERE MADE, OR BY WHOM. ACCORDING TO A "STATEMENT OF ABILITY/INABILITY FOR DECISION MAKING", SIGNED BY ONE PHYSICIAN ON 3/6/12, AN "X" WAS MARKED IN THE BOX NEXT TO THE STATEMENT: "RESIDENT (#110) IS UNABLE TO MAKE HER/HIS OWN DECISIONS." ALTHOUGH physician progress notes [REDACTED].#110'S "POTENTIAL FOR ELOPEMENT CARE PLAN." ON 3/7/12 AT 6:50 P.M., NURSING NOTES DOCUMENTED THAT RESIDENT #110 WAS ANXIOUS AND "WANTING TO GO HOME" AND "HAD COAT AND HAT ON." ON 3/8/12 AT 11:50 P.M., NURSING NOTES DOCUMENTED: "RESIDENT (#110) GOT VERY ANXIOUS AND CONFUSED TODAY AND WANTED TO GO HOME. STATES HE WALKED ALL THE WAY TO (NAME OF DESTINATION) AND HIS KNEES ARE HURTING." ON 3/12/12, A SECOND PHYSICIAN/PSYCHOLOGIST SIGNATURE WAS OBTAINED ON THE "STATEMENT OF ABILITY/INABILITY FOR DECISION MAKING" AND CORROBORATED WITH AN "X" NEXT TO THE STATEMENT: "I AGREE WITH THE FINDINGS ABOVE"..."RESIDENT (#110) IS UNABLE TO MAKE HER/HIS OWN DECISIONS." NO NEW SAFETY INTERVENTIONS WERE DOCUMENTED ON THE "POTENTIAL FOR ELOPEMENT CARE PLAN" OR IN THE NURSING NOTES FOR THAT DATE. ON 3/14/12 AT 2145 (9:45 P.M.) NURSING NOTES DOCUMENTED THE FOLLOWING: "...CENA (NURSE AIDE "B") IN HALLWAY AND GETTING SNACKS FINISHED UP AND EVERYONE TO BED NOTED RESIDENT (#110) NOT IN ROOM." ON 3/14/12 AT 2200 (10:00 P.M.) NURSING NOTES DOCUMENTED: "ALL ROOMS ON NORTH WERE CHECKED INCLUDING BOTH BATHROOMS, CLOSETS AND UNDER BEDS. SOUTH STATION WAS NOTIFIED AND THEY ALSO BEGAN A SEARCH OF ROOMS. MAINTENANCE CHECKING DOOR ALARMS AND ROOMS WITH KEY ENTRY...UNABLE TO FIND RESIDENT (#110)..." ON 3/14/12 AT 2220 (10:20 P.M.) NURSING NOTES DOCUMENTED THAT 911 WAS CALLED. ON 3/14/12 AT 10:25 P.M., NURSING NOTES DOCUMENTED THAT THE SEARCH CONTINUED INSIDE AND OUT OF THE FACILITY AND MAINTENANCE STAFF NOTED A TORN SCREEN AND A TABLE KNIFE IN THE ROOM ADJOINING RESIDENT #110'S ROOM. THE NURSING NOTES DOCUMENTED AT 10:25 P.M. ON 3/14/12 CONTINUED: "RECEIVED A PHONE CALL FROM (NAME) THAT THEY HAD FOUND RESIDENT #110 IN THE BACK OF BUILDING IN A WEEDED AREA ON THE HILL. NURSING NOTES AT 10:30 P.M. DOCUMENTED: "RESIDENT WAS ASSISTED BACK INTO BUILDING WITH ASSIST OF SEVERAL STAFF MEMBERS...VITALS TAKEN AND (TEMPERATURE) 99.5, PULSE 100, RESPIRATIONS 28, B/P (BLOOD PRESSURE) 180/88. RESIDENT COOPERATIVE BUT STATES HE IS BACK IN PRISON AND NOT FREE. ONE TO ONE STARTED AS SOON AS RESIDENT BACK IN BUILDING." ON 3/14/12 NURSING NOTES DOCUMENTED AT 11:15 P.M. INDICATED THAT RESIDENT #110 WAS TAKEN TO THE SHOWER ROOM AND ALL OF HIS CLOTHES REMOVED TO ALLOW ASSESSMENT. THE NOTES DOCUMENTED: "SKIN CLEAR, DENIES PAIN OR DISCOMFORT." ACCORDING TO THE "POST FALL INVESTIGATION WORKSHEET" INVOLVING RESIDENT #110, DATED 3/14/12 (ITEM #24), STAFF HAD IDENTIFIED THE FOLLOWING EVENT AS THE "FACTOR THAT MAY HAVE CONTRIBUTED" TO THE INCIDENT: "WIFE SERVED PT (PATIENT) WITH DIVORCE PAPERS LAST WK (WEEK)." ACCORDING TO THE "POTENTIAL FOR ELOPEMENT CARE PLAN" (INITIATED BY THE FACILITY ON 2/20/12), THE RISK FACTORS THAT HAD BEEN IDENTIFIED AS INCREASING RESIDENT #110'S RISK FOR ELOPEMENT WERE: PAIN OR OTHER CONDITIONS CAUSING RESTLESSNESS OR WANDERING, INDEPENDENT MOBILITY, WANDERING AND EXPRESSING A WISH TO LEAVE THE FACILITY, AND A [DIAGNOSES REDACTED].#110'S PERSISTENT WORRIES REGARDING HIS DIVORCE AND BANK ACCOUNT AS FACTORS POTENTIALLY INCREASING HIS ELOPEMENT RISK. THE CARE PLAN GOAL WAS FOR RESIDENT #110 TO REMAIN SAFE WITHIN THE PREMISES OF THE FACILITY. THE CARE PLAN INTERVENTIONS INCLUDED REPORTING BEHAVIORS/STATEMENTS THAT REPRESENTED AN INCREASED RISK FOR ELOPEMENT (SUCH AS: "I WANT TO GO HOME, "I'M LEAVING") TO THE ADMINISTRATOR, DIRECTOR OF NURSING (DON) AND CHARGE NURSE AND DOCUMENTING THAT INFORMATION ON THE FACILITY'S 24 HOUR (REPORT) SHEET. BASED ON COMPARATIVE REVIEW OF RESIDENT #110'S ELOPEMENT RISK CARE PLAN WITH FACILITY NURSING NOTES (DATES 2/20/12, 2/23/12, 2/26/12, 2/27/12, 2/28/12, 2/29/12 AND 3/2/12), THERE WAS NO DOCUMENTATION TO REFLECT THAT THE BEHAVIORS AND/OR STATEMENTS MADE BY RESIDENT #110 ON THOSE DATES, INDICATING THAT HE WANTED TO LEAVE OR WAS PREPARING TO LEAVE THE FACILITY, WERE REPORTED TO THE FACILITY'S ADMINISTRATOR OR DIRECTOR OF NURSING. ACCORDING TO THE FACILITY'S "IMMEDIATE JEOPARDY REMOVAL PLAN", DATED 3/15/12, THE PROCESS TO SECURE EMERGENCY GUARDIANSHIP FOR RESIDENT #110 WAS NOT STARTED UNTIL 3/15/12, AFTER THE INCIDENT OF ELOPEMENT ON 3/14/12. ACCORDING TO A "SOCIAL WORK CONSULT", DATED 3/15/12, RESIDENT #110 WAS ASSESSED COMPREHENSIVELY BY SOCIAL SERVICES ON 3/15/12, AFTER THE ELOPEMENT HAD OCCURRED ON 3/14/12. RESIDENT #110 REPORTED DURING THEIR INTERVIEW THAT HE had a history of [REDACTED]. ( ) RESIDENT #110 WAS OBSERVED IN HIS ROOM, AT 10:55 A.M. ON 3/16/12, WITH HIS EYES CLOSED, AND AGAIN AT 12:09 P.M. PLAYING CARDS, WITH ONE-TO-ONE SUPERVISION PROVIDED BY STAFF. AN ATTEMPT TO INTERVIEW RESIDENT #110 WAS MADE AT 2:30 P.M. ON 3/16/12. DURING THE INTERVIEW, RESIDENT #110'S FACIAL EXPRESSION WAS CONFUSED. DURING THE INTERVIEW, RESIDENT #110 SAID, "THEY WON'T LET ME OUT'A HERE." RESIDENT #110 THEN SAID, "I THINK THEY WANT ME TO THINK I'M CRAZY." ( )

This citation pertains to intake numbers MI 844 and MI 956. Based on observation, interview, and record review, the facility failed to: 1) prevent the elopement in 1 of 5 sampled Residents (Resident #101) reviewed as at risk for elopement, from a total sample of 7 residents, resulting in an Immediate Jeopardy when Resident #101, who had been identified as an elopement risk, eloped from the facility on 11/7/11 at approximately 3:30 PM into the facility parking lot, unbeknownst to facility staff, and was returned to the facility at approximately 3:35 PM escorted by staff. This deficient practice placed a total of 5 residents, identified as an elopement risk, at risk for serious harm, injury, and/or death, and 2) ensure the safety to prevent falls in 1 of 7 sampled residents (Resident #105) from a total sample of 7 residents, resulting in a head laceration requiring emergency medical care after a fall for Resident #105. Findings include: Resident #101: Review of the face sheet revealed Resident #101 was a [AGE] year old male admitted to the facility on [DATE]. According to the admission medical assessment, dated 8-31-11, Resident #101 had a history of [REDACTED]. Resident #101's Brief Interview for Mental Status (BIMS) score, dated 9/5/11, was 0/15 which indicated Resident #101 had severe cognitive impairment. Review of the Nurse's Notes, dated 8/30/11 at 9:45 PM, revealed Resident #101 was "exit seeking and went out front door when door was improperly shut". Review of the Nurse's Notes, dated 8/31/11 at 11:00 AM, revealed an Elopement Care plan was put in place for Resident #101. Review of the Elopement Care plan, dated 8-31-11, revealed Resident #101 was at risk for elopement due to pain or other condition, causing restlessness or wandering, a history of elopement attempts, a history of wandering, and [DIAGNOSES REDACTED]. Interventions to prevent elopement included to administer pain medications as ordered, initiate and document on the Behavior Tracking Log, keep elopement book updated, direct supervision while outside, encourage activity participation, and to initiate missing resident procedure as needed. Review of the Nurse's Notes, dated 9/1/11 at 11:00 PM, revealed Resident #101 "continues to seek exit doors and tries to go outdoors. Sits by front door and wait (sic) for someone to go out then tries to push open door before it closes. Mood very changeable." There was no documentation of an increase in supervision for Resident #101. Review of the Nurse's Notes, dated 10/30/11 at 10:25 PM revealed Resident #101 refused nursing care, was "yelling out and pointing at the door". Review of the Nurse's Notes dated 11/4/11 at 6:35 PM, revealed Resident #101 eloped through the employee door and that the door alarm sounded. Resident #101 was agitated but redirected back into his room. Facility staff implemented every 15 minute checks for Resident #101. Review of the Incident/Accident (I/A) Report, dated 11/4/11 at 6:05 PM, revealed documentation that an "Employee door alarmed. Staff checked door - Resident (Resident #101) noted in wheel chair in employee back parking lot. Resident redirected back into building." The I/A Report reflected an intervention put in place to prevent recurrence was to place Resident #101 on every 15 minute checks. Review of the Nurse's Notes, dated 11/6/11 (late entry for 11/5/11 at 4:00 PM), revealed Resident #101 was witnessed exiting the facility through the back employee door. There was no documentation of an increase in supervision for Resident #101. Review of the Nurse's Notes, dated 11/6/11 at 11:15 AM, revealed Resident #101 was witnessed by writer to be going out back employee door. There was no documentation of an increase in supervision for Resident #101. Review of the Nurse's Notes, dated 11/6/11 at 11:25 AM, revealed Resident #101 was witnessed by a Certified Nurse Assistant (CNA) to be going out back employee door. There was no documentation of an increase in supervision for Resident #101. Review of the Nurse's Notes, dated 11/7/11 at 3:35 PM, revealed Resident #101 noted "outside front of building in parking lot rolling back towards facility in w/c (wheelchair). Resident (Resident #101) brought back inside and placed on 1:1 with staff." Review of the I/A Report, dated 11/7/11 at 3:35 PM, revealed Resident #101 "was noted outside in front parking lot. Eloped out front door while Emergency Medical Staff was bringing (different) Resident." There was no documentation that the door alarm sounded. The I/A Report reflected an intervention put in place to prevent recurrence was to place Resident #101 on 1:1 supervision. Review of a typed document (no title) provided by the facility, dated 11/7/11, revealed the facility believed Resident #101 went through the alarmed door prior to it closing when ambulance staff had brought a stretcher in through the doors with a new admission. The document reflected the nurse had returned to the desk to answer a telephone when the new admission arrived. In an interview on 11-10-11 at 9:45 AM, Certified Occupational Therapy Assistant (COTA) #1 said she was leaving work on 11-7-11 at approximately 3:35 PM when she observed Resident #101 in the parking lot headed up a hill to the road and went back into the facility to get the nurse to help bring Resident #101 back into the facility. In an interview on 11-10-11 at 8:55 AM, Licensed Practical Nurse (LPN) #1 said she was at the front desk on 11-7-11 when COTA #1 came in the door and told her that Resident #101 was out in the parking lot. LPN #1 said she did not hear any door alarms prior to Resident #101 being found outside. LPN #1 said Resident #101 did not have any injuries and thought that he must have left the building when the emergency medical technician brought a new resident into the building. LPN #1 said she did not see anything because she had her head down doing paper work at the desk. In an interview with Registered Nurse (RN) #1 on 11-10-11 at 11:10 AM, RN #1 said she last saw Resident #101 at approximately 3:30 PM when she gave him his medications and she did not see him leave the building after giving his medications. In an interview on 11-10-11 at 10:00 AM, CNA #2 said she was doing 15 minute checks on Resident #101 on 11-7-11. CNA #2 said she weighed him at approximately 3:15 PM and returned him back down his hall after weighing him. CNA #2 said she was in the process of looking for him when she heard someone say he was outside. In an interview on 11-10-11 at 3:40 PM, CNA #3 said on 11-7-11 at approximately 3:35 PM he was in a room with a new Resident. CNA #3 stated he became aware that Resident #101 was out in the parking lot about 4 PM and he was assigned to provide 1:1 care with Resident #101. An observation on 11/10/11 beginning at 8:00 AM during the initial tour revealed all doors with alarms in the facility were found to be armed and functional. During an observation and interview on 11/10/11 at 1:30 PM, Resident #101 was noted to be in his room, in bed, with his covers on. A facility staff member was located in a chair outside the door of Resident #101's room. Resident #101 answered "ya" to all questions asked by this surveyor but was unable to provide any additional information regarding the incident. The Director of Nursing provided the Surveyor with a book of Residents listed as an elopement risk. The surveyor reviewed the elopement book and it contained information on 5 Residents. The Administrator was informed on 11-10-11 at 4:55 PM of the Immediate Jeopardy that was identified on 11-10-11 and began on 11-7-11 when Resident #101, who had been identified as an elopement risk, eloped from the facility on 11/7/11 at approximately 3:30 PM into the facility parking lot, unbeknownst to facility staff, and was returned to the facility at approximately 3:35 PM escorted by staff. On 11-15-11 this Surveyor confirmed that the facility implemented the following to remove the immediate jeopardy: 1. On 11/7/11, Resident #101 was escorted back to the building by CNA #1 and LPN #1 without difficulty and placed on 1:1 during waking hours and every 15 minute checks while asleep in bed with a sensor alarm to notify staff of attempts to get out of bed. 2. On 11/7/11, Resident #101 was assessed by RN #1 and no injuries were found. Resident #101's demeanor was within normal limits. No signs of distress facially or through body movements.. 3. On 11/7/11, the increased supervision and the need to inform nursing staff of any potential harmful activities was added to the Certified Nurse Aide care guide for Resident #101. 4. On 11-7-11, the Interdisciplinary team (IDT) reviewed and updated Resident #101's care plan interventions with the 1:1 added. 5. On 11/8/11, the Regional CTRS (Certified Therapeutic Recreational Specialist), CBIS (Certified Brain Injury Specialist) met with IDT to review the established TBI (traumatic brain injury) interventions for Resident #101 to ensure the appropriate interventions were in place. Resident #101's Nursing Care Plan was updated to add 1:1 while awake and every 15 minute checks while asleep. 6. On 11/14/11, 58 of 83 employees were in-serviced on the "Need to Know" form to reinforce the one-on-one instruction and inform them of their responsibilities in providing one on one supervision of Resident #101, on the elopement policy and procedure, and the Nursing Care Plan. No staff will be allowed to work prior to receiving the in-service. 7. On 11-14-11, all residents in the building were reassessed for their elopement risk. No additional residents were identified as at risk for elopement. 8. On 11-14-11, the Elopement polity and procedure was reviewed and no changes made. 9. During the Capital Budget Process for Fiscal Year 2012, funds were approved for installation of Mag-loc on the facility front entrance. First bid was received on 10-21-11 and is awaiting Fire Marshall approval. 10. On 11-15-11, the 1:1 assigned to Resident #101 stopped. Facility staff were reassigned to observe the front entrance 24/7 to prevent elopement until the Mag-Loc on the front entrance door is installed to ensure no residents exit the facility through the door in the event it does not close properly or is left open by someone entering the building. While Immediate Jeopardy was removed on 11-15-11, the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not Immediate Jeopardy due to injuries sustained by Resident #105. ( ) Resident #105: Review of the face sheet revealed Resident #105 was an [AGE] year old male admitted to the facility on [DATE]. According to his hospital consult physician note, dated 11-2-11, Resident #105 had a history of [REDACTED]. Review of the Incident/Accident Report, dated 11-12-11 at 2:30 AM, revealed, "Resident (Resident #105) observed laying on the floor on back next to bed, bleeding from back of head. Resident asked 'did I roll out of bed?'" Resident #105 received first aid then was sent to the hospital via emergency medical system. Immediate steps taken to prevent recurrence were documented as, "wing mattress, sensor alarm, and floor mats." Review of the Emergency Department Record, dated 11/12/11, revealed Resident #105 arrived at the hospital with a laceration to the back of his head that required 5 staples. Resident #105 was discharged back to the facility on [DATE] at 4:00 AM. In an interview on 11-16-11 at 12:50 PM, Hospice Registered Nurse (HRN) #1 reported that she was the Hospice Nurse who did the admission on Resident #105 at the facility on 11-11-11 and had completed a fall risk assessment. HRN #1 reported that just prior to leaving the facility on 11-11-11, she reported to Registered Nurse (RN) #2 and Certified Nursing Assistant (CNA) #4 and explained to them that Resident #105 was a high risk for fall. Review of the Hospice Admissions Record, dated 11-11-11, revealed that Resident #105 was given a fall risk score of 16 (indicating a high risk). On Page 24 of the Hospice Admission record it was documented, "discussed with staff (RN #2 and CNA #4) re (regarding) plan of care and safety plan for patient, (physician name) recommended holding Roxanol (narcotic pain medication) for excessive sedation due to fall risk." In an interview on 11-15-11 at 10:45 AM, Licensed Practical Nurse (LPN) #1 reported she helped get Resident #105 settled in his room on 11-11-11 just prior to leaving at 8:00 PM. The Surveyor asked LPN #1 what was the facility procedure for assuring the safety of a resident that was known to be a high risk for falls. LPN #1 explained that the residents who are at high risk for fall are usually provided safety equipment (low bed, mat on floor and alarm) LPN #1 said there was no safety equipment in place for Resident #105 when she left at 8:00 PM. In an interview on 11-15-11 at 11:00 AM, Registered Nurse (RN) #2 said she started working on 11-11-11 at 4:00 PM and helped get Resident #105 in bed at 7:30 PM when he arrived. RN #2 stated that HRN #1 was at the facility meeting with Resident #105 and doing paper work as soon as Resident #105 arrived. RN #2 said she met with the HRN #1 between 8:30 PM - 9:00 PM, when HRN #1 was about to leave, and recalled talking about comfort measures. She did not recall any safety concerns. RN #2 said she left the facility at approximately 2:00 AM and had not completed the facility fall risk assessment on Resident #105 prior to leaving the facility. In a telephone interview on 11-15-11 at 3: 55 PM, CNA #4 stated she cared for Resident #105 on 11-11-11 and that Resident #105 was very restless prior to her leaving at 10:30 PM. CNA #4 said she reported Resident #105's restless behaviors (throwing feet over edge of bed, sitting him self up at the edge of bed, saying his oxygen tubing was a snake) and told RN #2 that Resident #105 many need a sensor pad on his bed". CNA #4 said no safety equipment was in place when she left at 10:30 PM, however she reported to CNA #5 when she left, that Resident #105 "may need something for safety." In an interview on 11-15-11 at 12:00 PM, CNA #5 stated she was caring for Resident #105 on 11-11-11 when he fell and lacerated his head. CNA #5 said she started work at 10:30 PM on 11-11-11, and after report, went to check on Resident #105. CNA #5 said Resident #105 was awake and playing with his oxygen tubing frequently when she checked on him. CNA #5 said her normal procedure, when working nights, is to check on all her residents every 15 to 20 minutes and she checked on Resident #105 the same as the rest of her residents. CNA #5 said she was 2-3 rooms away when she heard a crash in Resident #105's room. CNA #5 reported and demonstrated (in Resident #105's room) where Resident #105 was, when she found him on the floor bleeding at 2:00 AM. CNA #5 demonstrated that Resident #105 was 1/2 between his bed and the bathroom, on his back, with his head bleeding. CNA #5 said LPN #2 came to assess Resident #105, provided first aid and then sent him to the hospital. This Surveyor asked CNA #5 what the facility does to protect a resident who are a fall risk and CNA #5 responded that they usually give them pads on the floor or alarms. CNA #5 said Resident #105 did not have floor pads or an alarm on when he fell , but he did have a yellow wrist band which meant he was a fall risk. Review of the Nurse's Notes, dated 11-14-11 at 6:25 AM, revealed Resident #105 had "No heart rate, no respirations, no pulse and no blood pressure." According to nursing notes dated 11-14-11 at 08:45, "Hospice nurse and medical examiner here." In a telephone interview on 11-15-11 at 11:45 AM, the Funeral Home Director (FHD) #1 was asked to read the cause of death listed on the Death Certificate for Resident #105. FHD #1 stated, "Severe [DIAGNOSES REDACTED] for 1 year, Congestive heart failure for 1 year, Coronary artery disease, Diabetes II and Pulmonary hypertension. ( )

This citation pertains to MI# 417 Based on observation, interview, and record review the facility failed to provide supervision and assistive devices to prevent accidents in 1 of 11 sampled residents (#101), resulting in an Immediate Jeopardy for Resident #101, who had a history of [REDACTED]. These deficient practices placed 7 additional residents, for whom the facility did not ensure appropriate safety devices were in place, at risk for serious harm, injury, and/or death. Findings include: Record review of facility accident/incident reports for resident #101 revealed that the resident sustained [REDACTED]. The incident report revealed that the resident was witnessed to be holding the foot of the bed and her knees buckled. A personal/tab alarm was placed to bed and wheelchair at that time. Record review of facility accident/incident report for resident #101 dated [DATE] revealed the resident was found by staff lying on the floor next to her bed and chair. A hand written note on back of accident/incident form revealed that the call light was on and the alarm was sounding but could not be heard until the staff got into the residents room. Record review of resident #101's accident/incident report dated [DATE] revealed that the resident was forgetful and was heard calling out for help, resident was noted on the floor, call light was not on, the resident stated she was on the phone and needed an address, instead of putting on the call light she got up to get it herself. She fell and landed on back, could not deny hitting head. A personal/tab alarm was placed due to noncompliance of call light. Record review of the southwest nurse 24 hour report dated [DATE] revealed that the resident #101 was noted to be very demanding, takes alarms off, ambulating in room, noncompliant. Record review of resident #101's accident/incident report dated [DATE] at 2:15 AM revealed that the resident was confused and had an unwitnessed fall in her room. The accident/incident report revealed that: "(nurse) was called to room by certified nurse assistant (CNA), noted resident lying face down on floor in front of bathroom, call light off, alarm silenced by heavy blanket covering pad. After checking for injuries/obvious deformities, log rolled unresponsive resident onto back, noted face/head was purple/cyanotic in color and respirations were blowing type. Resident then log rolled onto side-lying position. Pressure applied to approximately 7 centimeter round lump with gash to back of head, with sterile gauze. 911 was called by CNA at 2:17 AM, ambulance/EMT personnel arrived at 2:26 AM and took over charge of scene. Resident never was responsive". An interview on [DATE] at 11:10 AM with CNA #10 revealed: "No, the alarm did not go off. I was in the hall and I heard a noise, like something got knocked over. I went down the hall, past her room, looked in and saw her lying on the floor; she was right in front of the bathroom door, lying on her back. No, I didn't touch her at that time. I yelled for the nurse. The nurse wasn't at the desk, so I ran down the hall and yelled for CNA #8. CNA #8 came out of a room. I asked her where (nurse #14) was, she was on break. Nurse #14 smokes and goes outside for her breaks. I told CNA #8 to go get nurse #14 because Resident #101 was on the floor. I went back to resident #101's room, when I got back, she had rolled to her side and I saw blood on the floor, it was a puddle under her head. I stayed in the room with her. Resident #101 did talk to me she said she had been walking, still no alarm was sounding. ...Nurse #14 came to the room...told me to take blood pressure, no pressure, couldn't hear anything, nurse #14 took her pulse, oxygen saturation, respirations was normal, then (respirations) slowed and she started blowing breaths, by the time the nurse (#14) came she wasn't responding at all". An interview on [DATE] at 11:29 AM with nurse #14 revealed: "Resident #101 was ill. She was noncompliant. She would get up and move about room. Started walking to the bathroom. She would get up and just start walking. The alarm would let us know she was moving. She didn't use the call light; she was more resistant to using it. She was active more frequently, confused at times. I did the midnight medication pass, I did pulse oxygen saturation. I found her sitting on the very edge of her recliner. Her legs and feet were so swollen. I hooked the call light to her chair and I and CNA #10 helped her sit back further in the chair. I went out finished med pass/pulse ox, and then charted talking to resident #101. It was after 2:00 AM, I'm a smoker, I went out side to smoke, out back pass the southwest hall into the smoking area....I smoked a half cigarette when I heard "Dee", I looked around didn't see anyone, I just saw employee (entrance) door close, I opened the door and saw CNA #8....she said resident #101 was on the floor. I walked to the room, saw resident #101 on the floor on her stomach, I sat beside her and asked if she was OK, she didn't respond. Respirations were a blowing (type), lips moved, blowing little bubbles, lots of saliva, rolled her over, face was purple. No alarm sounding in the room, none. When I walked in the room a large puddle of blood by her head, at least 200 milliliters, it was a lot. We turned her over, she didn't respond. We turned her onto her side, and then I got vital signs. Respirations ,[DATE], pulse ox 98%, pulse with machine was 100.....the pulse ox amazed me because of her color and slow respirations, but it was good". Upon further interview nurse #14 revealed: "Nurse #6 came to the room, gauze to resident #101's head for pressure, laceration on right midway (to head) a large 8 centimeter round lump, bleeding profusely....EMT's took over. I said to CNA #10 why wasn't alarm sounding? I asked if it was sounding when she came into the room. CNA #10 said no. We went to the chair and lift up the blanket; it didn't sound when was lifted, so CNA #10 put her hand on the pressure pad and lifted her hand up, it then sounded. Resident #101 was on the very edge of her chair, she was a large woman, some part of her should have been on the pad, but it didn't sound. No, I don't know how long she was down on the floor; it didn't sound (alarm). I can't say how long she was on the floor before we got to her, no one witnessed her fall. History of shutting off her alarms, she had been shutting off her alarms. CNA #15 had told me she hide the alarms so resident #101 wouldn't turn them off. Resident #101 had been becoming more noncompliant with her alarms, her diet, everything. Recently started walking. I have 52 people/residents a night to care for; I'm in (resident) rooms ,[DATE] times a night with meds. Ask CNA #15. An interview on [DATE] at 12:15 PM, CNA #15 revealed: "Alarms-Resident #101 would shut off them off. First tab alarm, she would unclip it then get up all the time. I put a pressure pad alarm in her chair and hide the alarm box back behind her chair, so she couldn't reach it. She was a smart lady, she would watch us shut it off behind the chair, so she would pull the cord till the box got to her hands and she would shut it off. I've seen her shut it off. Seen her with the box in her hands trying to shut it off. I've caught her up in room by herself after she shut off her alarms. She used to walk at night to the bathroom with walker. On nights when she was short of breath, she would use the bedside commode. No, there were no 15 minute checks, no monitoring done on her. She had only used the pressure alarm for a week before she fell the last time. The pressure pad worked, she would stand up, turn off the alarm, walk to the bathroom, return to her chair, turn it back on, and set the alarm box on the floor next to her chair. I watched her from the doorway, it was a fact, and she shut it off. ,[DATE] times a week she would be found up in room wandering around her dresser and then back to her chair. ,[DATE] times a week I'd catch her doing it, I'd tell her not to because she'd fall. When she got Ativan every 4 hours, she'd get drowsy, not awake, she'd start moving around. She insisted she get Ativan every 4 hours for shortness of breath, she'd get up and not know what she was doing". An interview on [DATE] at 4:00 AM with nurse #6 revealed that she was called to the resident #101's room to assist nurse #14. Nurse #6 stated, "I went to the room, resident #101 was on the floor with a lot of blood from her head injury, it coagulated quickly, I picked up estimated 200 cc at least....I could see where she fell and hit the back of her head, it was low in back of head/high neck area, was crushed, bleeding heavy. I used wash clothes and 4 X 4 gauze; they soaked through". Record review of resident #101's nurse notes dated [DATE] at 00:45 AM revealed: 'Upon entering room at 24:00 to perform oxygen saturation measurement, observed resident sitting on very edge of her recliner. SPO2 96% on 2.5 liter per nasal cannula. Resident confused, able only to state her name and that she is in Michigan. Encouraged resident to sit back in the chair and put her feet up as they are grossly edematous, non-pitting. Alarm intact to chair. CNA assisted resident to sit back and raise the foot rest. Resident immediately lowered it again. Encouraged to allow us to assist her onto bed and she again refused. At this time is sitting in chair with footrest down. Call light in reach, reminded to use call light for assistance and she verbalizes understanding. Record review of resident #101's nurse note dated [DATE] at 3:00 AM revealed that the resident was found on the floor parallel to the bathroom door, she was incontinent of urine, with approximately 200 cc bright red blood around her head, non-responsive to verbal or tactile stimuli.....respirations 12 and blowing. A large lump was noted to the back of head with profuse bleeding. An interview on [DATE] at 8:23 AM with the county emergency medical responder revealed that when he entered the room the nurse was sitting on the floor at the residents head, blood on towels, and nurse holding pressure to the back of residents head on the right side. The EMS person received a report of un-witnessed event. The mechanism of injury-trauma point to head, neck brace applied and resident was rolled to a long board and strapped on.....not conscious, breathing irregular and very, very slow, cardiac was still ok, felt a pulse. Respiratory rate decreased and an airway was placed, assisted with ventilation with a bag valve mask, cardiac monitored. When the EMS was coming up the hallway with the resident on the gurney, EMS were advised by facility staff of resident #101's DNR (Do Not Resuscitate) status (which does not apply when related to a emergent situation) and resident #101 went into V-fib and expired later, while still in the facility. Record review of resident #101's physician monthly orders dated [DATE]-[DATE] revealed Resident #101 was on Plavix 75 milligrams daily (anti-blood clotting), Aspirin 81 milligrams daily, was to be monitored for side effects of blood thinning each shift, and was to have a personal (tab) alarm on when in wheelchair, the recliner, and bed. Record review of the facility 'Fall Reduction/Prevention Program', policy dated [DATE], revealed that the residents have the right to be free from falls, or to sustain no or minimal injury from falls. Purpose: 'Safety of the residents will be maintained to the greatest extent possible in the facility. Residents will be assessed and periodically reassessed for fall risk and fall program will be implemented. Fall reduction care plan to address individual risk factors, appropriate interventions, and entered on the CNA care plan. Record review of resident #101's CNA's Care Plan dated [DATE] fall risk: yes, Alarm: Tab Alarm to bed and wheelchair and recliner. At the top of the form was noted a sticker for Bleeding Precautions. An interview on [DATE] at 11:30 AM with the south unit manager revealed that on [DATE] a personal/tab alarm was care planned and placed on resident #101. On [DATE] at the time of the fall, the resident #101 had a pressure sensor alarm to her chair. An interview on [DATE] at 2:10 PM with nurse #17 revealed: "...resident #101 was noncompliant with tab alarm. She would take the whole thing off, unclip from her clothes, sit at edge of chair, or attempt to stand, she wouldn't use the call light.....personal tab alarm/ metal clip to some where on her cloths, put it in the middle of her back, she would still reach it. The alarm box we would place out of reach, but she would find the cord, follow or pull the cord till she found the clip on her clothes or the box, she usually just unclipped it. Once in a while she would pull the tab cord to get the box to sound to get attention instead of using the call light. This went on for a couple of weeks, and then someone decided the tab alarm wouldn't work for her because she'd take it off. So a pressure pad/sensor pad alarm was put in place of the tab alarm. Pressure pad alarm, she would put blankets on the pressure pad to stop it from sounding or mute the alarm, or she would stuff the sound alarm box into the side of the chair between the chair and the cushion to mute the alarm. She would stuff it in the chair and pile blankets on top of it, it would mute so you (staff) couldn't hear it faintly, couldn't hear it unless right outside her door or in the room". An interview on [DATE] at 3:50 PM with the south unit manager revealed that alarm devices were audited and checked/monitored by CNA's each shift. Observations on [DATE] at 4:00 PM of the south unit by the state surveyor and south unit manager performed a safety device audit on 18 residents with alarm which revealed 6 out 18 residents had the wrong type of alarm device in place. The unit manager had no explanation for why the alarm audit did not match residents observed alarms. Further observation on [DATE] at 4:00 PM of extended sampled resident #201's room revealed that a bed sensor alarm to bed, with a tab/personal alarm, was found on top of her pillow. Extended sample resident #201 was found sitting in a chair with no alarm in place at the dining room entrance. Extended sample resident #202 was noted to have a tab alarm, but was not on the CNA every shift audit device form and had not been being checked. Resident #201: Care plan-Tab alarm in bed, Tab alarm in chair. Observed resident by south dining room with no alarm in place. Audited by CNA for sensor pad to bed, tab to chair. Resident #202: Care plan- Tab alarm to bed and chair. Observed with tab alarm. Not audited, the resident was not found on the daily safety device audit sheets. Resident #203: Care plan- Sensor pad to bed and chair. Observed tab alarm to bed. Audited by CNA for sensor to pad to bed and wheelchair. Reviewed orders dated [DATE] tab alarm discontinued, changed to senor pad alarm. Resident #204: Care plan-tab to bed and wheelchair. Observed senor pad to wheelchair. Physician orders: Tab alarm to chair and wheelchair, sensor pad to bed. Audited by CNA for tab alarm to bed and chair. Resident #205: Care plan- Tab alarm to bed and chair D/C'd (discontinued) [DATE]. Observed tab alarm to chair. Audited by CNA for sensor pad to bed, tab alarm to wheelchair. Resident #206: Care plan- Sensor pad to wheelchair, bed and bedside chair. Observed tab alarm to chair, no bed sensor pad. Audited by CNA for sensor pad to bed and chair. Resident #207: Care plan- No alarms indicated. Observed with tab alarm in place to chair. Audit sheets for the north unit could not be found by staff members. Observation on [DATE] at 4:45 PM on the north unit by the state surveyor and the north unit manager revealed there to extended sample resident #207 to be observed with a tab alarm in place, even though she was not care planned for an alarm. On [DATE] at 4:40 PM the north unit alarm audit, completed by the day shift CNA's during their shift, could not be found. The unit manager and director of nursing were not able to locate the alarm audit check sheet, and the day shift CNA, came back to the facility to create new check sheet. On [DATE] the survey monitor placed a phone call to the facility notifying of an Immediate Jeopardy. On [DATE] at 10:40 AM, the state surveyor gave a typed letter of Immediate Jeopardy notification to the administrator that began on [DATE] at 2:15 AM, due to: 1) The facility's knowledge of resident #101's history of turning off her alarm and noncompliance with waiting for staff to assist with transfers and ambulation, and 2) failure to implement further interventions and monitoring to prevent falls, resulting in a fall for Resident #101 on [DATE] causing a head injury. Resident #101 subsequently died . This deficient practice places all additional residents, identified as requiring alarms for safety, at risk for serious harm, injury, and/or death. On [DATE], the surveyor confirmed that the facility implemented the following to remove the immediate jeopardy. 1. On [DATE], 24 residents with alarms were audited. 7 were found incorrect and were corrected. 2. On [DATE] and [DATE], re-audits were done to ensure that the care plan, ADL, and device in place were applied and functioning. 3. On [DATE] and again on [DATE], all alarms were checked in facility to assure that they were the same as the alarm listed in the care-plan, they were on the resident, and they were functioning properly. Interventions to check alarms each shift were implemented and unit managers began auditing alarms weekly. 4. By [DATE], a master alarm list had been created and will be reviewed by Director of Nursing and unit managers weekly. 5. In-services for clinical nursing staff were initiated by the Director of Nursing or designee on [DATE] regarding the use of alarms, reporting non-compliance with alarms, care plans, and documentation of alarms. From [DATE] through [DATE], 42 of 43 clinical staff has been in-serviced. The remaining staff member will receive the education prior to the start of the next scheduled shift. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope and severity of isolate with actual harm that is not immediate jeopardy due to all staffs had not yet received the in-service education and sustained compliance had not been verified by the state agency. #

This citation pertains to MI# 417 Based on observation, interview, and record review, the facility failed to review and revise care plans for falls in 2 of 11 sampled residents (#101, #207), resulting in: 1) Resident #101, who was care planned for a personal/tab alarm, had a known history of turning off her alarm, being non-compliant with required staff assistance for ambulation, and a history of falls, being found on the floor with a pressure sensor alarm placed in chair and not sounding, call light not sounding, where Resident #101 sustained a laceration to the back of her head, became unresponsive, and died , and 2) Resident #207 being observed with a personal/tab alarm in place, but not care planned for. Findings include: Record review of resident #101's accident/incident report dated [DATE] at 2:15 AM revealed that the resident was confused and fell in her room, un-witnessed. The accident/incident report revealed that: '(nurse) was called to room by certified nurse assistant (CNA), noted resident lying face down on floor in front of bathroom, call light off, alarm silenced by heavy blanket covering pad. After checking for injuries/obvious deformities, log rolled unresponsive resident onto back, noted face/head was purple/cyanotic in color and respirations were blowing type. Resident then log rolled onto side-lying position. Pressure applied to approximately 7 centimeter round lump with gash to back of head, with sterile gauze. 911 was called by CNA at 2:17 AM, ambulance/EMT personnel arrived at 2:26 AM and took over charge of scene. Resident never was responsive'. Record review of the facility 'Fall Reduction/Prevention Program', policy dated [DATE], revealed that the residents have the right to be free from falls, or to sustain no or minimal injury from falls. Purpose: 'Safety of the residents will be maintained to the greatest extent possible in the facility. Residents will be assessed and periodically reassessed for fall risk and fall program will be implemented. Fall reduction care plan to address individual risk factors, appropriate interventions, and entered on the CNA care plan. Record review of resident #101's CNA's Care Plan dated [DATE] fall risk: yes, Alarm: Tab Alarm to bed and wheelchair and recliner. At the top of the form was noted a sticker for Bleeding Precautions. Record review of resident #101's Care Plan for Potential for Injury related to History of Falls at Home dated [DATE], updated [DATE], #14 approach was hand written, "Personal (tab) alarm when resident up or in bed/chair". There were no interventions to address unassisted transfer and ambulation other than #14. Record review of resident #101's Care Plan for Noncompliance with healthcare related advice given by health care professionals. Documented resident is noncompliant with: Using call light, related to getting up without assistance, lying in bed at night, prefers to sleep in recliner. Documented approach #11 "Personal alarm [DATE]". The use of a tab alarm was indicated in the resident fall care plan. An interview on [DATE] at 11:30 AM the south unit manager revealed that on [DATE] a personal/tab alarm was care planned and placed on resident #101. On [DATE] at the time of the fall, the resident #101 had a pressure sensor alarm to her chair. The unit manager was not aware the type of alarm changed, when, or why it was changed, and why the care plan was not changed. According to an interview on [DATE] at 12:15 PM with staff #15 revealed that the tab alarm had be switched to a pressure sensor alarm. An interview on [DATE] at 2:10 PM with nurse #17 revealed: "...resident #101 was noncompliant with tab alarm. She would take the whole thing off, unclip from her clothes, sit at edge of chair, or attempt to stand, she wouldn't use the call light.....personal tab alarm/ metal clip to some where on her cloths, put it in the middle of her back, she would still reach it. The alarm box we would place out of reach, but she would find the cord, follow or pull the cord till she found the clip on her clothes or the box, she usually just unclipped it. Once in a while she would pull the tab cord to get the box to sound to get attention instead using the call light. This went on for a couple of weeks, and then someone decided the tab alarm wouldn't work for her because she'd take it off. So a pressure pad/sensor pad alarm was put in place of the tab alarm. Pressure pad alarm, she would put blankets on the pressure pad to stop it from sounding or mute the alarm, or she would stuff the sound alarm box into the side of the chair between the chair and the cushion to mute the alarm. She would stuff it in the chair and pile blankets on top of it, it would mute so you (staff) couldn't hear it faintly, you couldn't hear it unless you were right outside her door or in the room". Nursing staff were not able to explain why none of the care plan addressed the resident #101 removing the alarm and that she was muffling the alarm sound. An interview on [DATE] at 3:50 PM with the south unit manager revealed that alarm devices were audited and checked/monitored by CNA's each shift. Observations on [DATE] at 4:00 PM on the south unit by the state surveyor and south unit manager, performed a safety device audit on 18 residents with alarms which revealed 6 out 18 residents had the wrong type of alarm device in place. Observation of extended sampled resident #201's room revealed that a bed sensor alarm to bed, with a tab/personal alarm, was found on top of her pillow. Extended sample resident #201 was found sitting in a chair with no alarm in place at the dining room entrance. Extended sample resident #202 was noted to have a tab alarm, but was not on the CNA every shift audit device form and had not been being monitored and checked. Resident #201: Care plan-Tab alarm in bed, Tab alarm in chair. Observed resident by south dining room with no alarm on. Audited by CNA for sensor pad to bed, tab to chair. Resident #202: Care plan- Tab alarm to bed and chair. Observed with tab alarm. Not audited, the resident was not found on the daily safety device audit sheets. Resident #203: Care plan- Sensor pad to bed and chair. Observed tab alarm to bed. Audited by CNA for sensor to pad to bed and wheelchair. Reviewed orders dated [DATE] tab alarm discontinued, changed to senor pad alarm. Resident #204: Care plan-tab to bed and wheelchair. Observed senor pad to wheelchair. Physician orders: Tab alarm to chair and wheelchair, sensor pad to bed. Audited by CNA for tab alarm to bed and chair. Resident #205: Care plan- Tab alarm to bed and chair D/C'd (discontinued) [DATE]. Observed tab alarm to chair. Audited by CNA for sensor pad to bed, tab alarm to wheelchair. Resident #206: Care plan- Sensor pad to wheelchair, bed and bedside chair. Observed tab alarm to chair, no bed sensor pad. Audited by CNA for sensor pad to bed and chair. Resident #207: Care plan- No alarms indicated. Observed with tab alarm in place to chair. Audit sheets for the north unit could not be found by staff members. Observation and alarm audit on [DATE] at 4:45 PM by the state surveyor and the north unit manager revealed extended sample resident #207 to be observed with a tab alarm in place, even though she was not care planned for an alarm. #