Every finding on record at Monroe Springs Skilled Nursing and Rehab

This citation pertains to intake 3037808.Based on interview and record review the facility failed to provide adequate supervision from two staff members during a transfer with a mechanical lift for one (R507) of five residents reviewed for accident hazards/safety resulting in R507 falling off the lift during transfer, hitting their head, and requiring five staples for wound closure.Findings include:The State Agency (SA) received a complaint that R507 fell from a mechanical lift and sustained injuries.According to the Electronic Health Record (EHR) R507 admitted to the facility in 2019 with multiple diagnoses that included Multiple Sclerosis, severe malnutrition, and dementia. The Minimum Data Set (MDS) indicated R507 had intact cognition and was totally dependent on staff for bed mobility and transfers from surface-to-surface. A care plan for Activities of Daily Living (ADL) initiated on 3/29/26 and the Kardex (a reference guide that summarizes the resident's care plan and daily needs), indicated that R507 required the use of a mechanical lift and two staff persons for transfers. A progress note dated 5/29/26 at 3:30 PM indicated R507 fell out of the mechanical lift onto the floor and hit their head. The resident was transferred to the hospital for evaluation and returned at 8:00 PM with five staples to close the head wound.A review of the post fall assessment dated [DATE] completed by Licensed Practical Nurse (LPN) M documented that resident fell from the lift during transfer from only one staff member.R507 was not present in the facility during the time of the survey and therefore could not be interviewed.During an interview on 6/24/26 at 1:13 PM LPN M said that CNA E had transferred the resident using a mechanical lift by their self. The mechanical lift's sling slipped off one of the hooks and the resident (R507) slid off the sling onto the floor headfirst. LPN M said the resident had a small laceration on the top of their head and no other visible injuries. The resident's only pain was their head. The area was assessed and first aid was provided to the laceration on the top of the head. The resident returned to the facility a couple hours later with five staples to the area and no additional treatments were ordered. During an interview on 6/24/26 at 2:20 PM with Certified Nurse Assistant (CNA) E they said they performed the transfer for R507 with the mechanical lift by themselves without asking for assistance. CNA E acknowledged that they were aware R507 required two persons for transferring with a mechanical lift. CNA E reported that they were re-educated on the facility's policy and then observed afterwards. CNA E stated, They made sure I was doing it correctly. I'll never do that again. I'll definitely go and get someone else to help with transfers when using the lift.On 6/25/26 at 12:05 PM during an interview with the Nursing Home Administrator (NHA) they acknowledged R507 had been transferred with only one staff member and the facility's policy is to always use two staff members during transfers with a mechanical lift. The NHA said that re-education on proper mechanical lift transfers had been given to all nursing staff as of 6/5/26. Weekly audits had been conducted and will continue for one month to ensure compliance. At this time sign-in sheets for the re-educations were provided and reviewed. The sign-in sheets revealed all nursing staff had received the re-educations by 6/5/26. The NHA said safety with transfers was were included in the facility's Quality Assurance meetings. A review of the facility's investigation, subsequent actions, and Quality Assurance meetings on 5/29/26 and 6/5/26 were conducted. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included:-Mechanical lifts inspected 5/29/26 via maintenance and no issues noted.-Education was completed with all nursing staff regarding the policy and procedure for mechanical lifts. Completed on 6/5/26.-Resident reassessed to ensure appropriate sling size via nursing and rehab.-Random Audits/validation will be conducted on all shifts to ensure residents requiring the use of the mechanical lift are being transferred correctly. Audits will be conducted weekly for 4 weeks and extended for 1 month.-Audits of slings to ensure appropriate size as well as checking integrity of sling is on-going and will be extended for 1 month.-Nurse assistants will complete Clinical Competency training on mechanical lifts. -Nursing assistant involved with incident was provided immediate education, completed clinical competency validation (mechanical lift) and was suspended during investigation.-Nurse assistant involved with incident returned on 6/3/26.-Findings will be reported and tracked in QAPI for review, recommendations, and ensure continued compliance.The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to intake 3018035.Based on observation, interview, and record review, the facility failed to make an ophthalmology appointment as ordered by the physician for one (R505) of three residents reviewed for the coordination of outside physician appointments resulting in the delay of ophthalmology services for R505.Findings include:On 6/23/26 at 3:40 PM, R505 was observed lying in bed with the TV on. During interview R505 reported that the facility had not scheduled an appointment for their cataract extraction. R505 said, The doctor said I would be able to see better if I got my cataracts removed. I was all set up to go and then something happened. I never went to the eye doctor again. I keep asking about it and no one can tell me anything. I want to know why I haven't got my cataracts out yet.Review of R505's Electronic Health Record (EHR) revealed R505 re-admitted to the facility on [DATE] with multiple diagnosis that included peripheral vascular disease and legal blindness. An Optometry Order Form dated 12/9/25 read as follows: patient has been scheduled at [Named Eye Center] for bilateral cataract extraction. Please reschedule it when possible. There is no further documentation to support the appointment was made for R505 to have their cataracts extracted.On 6/23/26 at 3:55 PM during an interview with Social Worker (SW) N they said, We tried to set up an appointment, but we couldn't contact the family to assist with transport. I don't know what happened after that. We should have attempted to reschedule this appointment. I can't see we did that.On 6/24/26 at 1:00 PM the Director of Nursing (DON) reviewed R505's EHR and confirmed that R505 was ordered to have cataract extraction on 12/9/2025 and the appointment had not been made as of this time. The DON said, I'm not sure why we did not proceed with scheduling that. We will be scheduling that appointment as soon as possible.On 6/24/26 at 1:00 PM the Nursing Home Administrator (NHA) said R505 should have had the ophthalmology appointment made for cataract extraction and could not explain why it was not done. A request for the facility's policy for scheduling and transporting residents to an outside physician appointment was requested.According to the facility's policy for 'Resident Transport and Escort Services' last updated on 6/27/2024 read in part: It is the policy of this facility to establish a process to ensure that all employees are capable and able to participate in the care of residents during transport. To promote the safety of our residents/employees during escort to appointments in a facility or a contracted vehicle.

This citation pertains to intake 3037808. Based on interview and record review the facility failed to report an injury of unknown origin for one (R507) of four residents reviewed for abuse. Findings include:According to R507's the Electronic Health Record (EHR) R507 admitted to the facility in 2019 with multiple diagnoses that included Multiple Sclerosis, severe malnutrition, and dementia. The Minimum Data Set (MDS) indicated R507 had moderately impaired cognition and was totally dependent on staff for bed mobility and transfers from surface-to-surface. A progress note dated 6/18/26 at 8:39 AM indicated R507 complained of left knee pain. The physician was notified, pain medication was administered, and an X-ray ordered. The X-ray radiology report dated 6/18/26 indicated R507 had a slight comminuted fracture of the proximal left femur (comminuted fracture is when a bone splits or shatters into more than 3 pieces, usually caused by high impact trauma). R507 was transported to the emergency room for further evaluation and treatment. R507 was not present in the facility during the time of the on-site survey.On 6/24/26 at 12:05 PM the Nursing Home Administrator (NHA) was interviewed regarding R507's left leg fracture and stated, The resident had a fall from a mechanical lift on 5/29/26. The resident had never complained of leg pain until 6/18/26 which was about 3 weeks after the fall. We did not think that the fracture was caused by the fall. Since we didn't know what happened we started an investigation. I talked with the resident about how this could have happened. The resident denied that staff had hurt them or was abusive towards them. The NHA went on to say a full investigation was conducted and it could not be determined exactly when or how the resident sustained the left femur fracture. When asked if the injury of unknown origin was reported to the State Agency the NHA said, No, I didn't think it was abuse nor was there any allegation of abuse, so I didn't report it. I guess I should have. A request for the facility's abuse policy was requested.According to the facility's policy on Abuse and Neglect last updated on 6/28/2025 in part read;V. Investigation: Investigate all allegation of abuse, neglect, misappropriation of property and incident such as injuries of unknown source.VII. Reporting: All allegations and/or suspicions of abuse/neglect must be immediately reported to the facility Administration or designees in the absence of the administrator.Preliminary Investigation Report: The abuse coordinator must submit a preliminary investigation report to the appropriate State Agencies immediately once assurances for the resident's safety have been established. However, if the event that caused the allegation involved abuse or resulted in serious bodily injury, the allegation of abuse must be reported to appropriate state agencies immediately and not later than 2 hours after receiving the allegation of abuse or not later than 24 hours if the event that caused the allegation did not involve abuse and did not result in serious bodily injury.Final Investigation Report: The abuse coordinator must submit a final investigation report to the appropriate State Agency within five (5) working days of the allegation.

This citation pertains to intake 3018035. Based on interview and record review the facility failed to notify the physician of missing medications for one (R506) of four residents reviewed for medication administration resulting in the physician being unaware that R506 missed two consecutive medication doses for a respiratory inhaler and an antibiotic. Findings include: The State Agency received a complaint that R506 missed several doses of medications.According to the Electronic Health Record (EHR) R506 admitted to the facility on [DATE]. The admission orders dated 4/8/26 for medication included the following: 1) Advair Diskus Aerosol Powder Breath Activated 250-50 MCG/DOSE (respiratory inhaler)one (1) inhalation orally every 12 hours for copd (chromic obstructive pulmonary disease). 2) Cefadroxil Oral Capsule 500 MG (antibiotic) Give 1 capsule by mouth two times a day.A progress note on 4/8/26 at 6:40 PM indicated R506's Advair Diskus was not available.Review of R506's April 2026 Medication Administration Record (MAR) revealed R506's Advair Diskus and Cefadroxil were not administered on 4/8/26 at the 9:00 PM dose or on 4/9/26 at the 9:00 AM dose. There is no additional documentation to support the physician was notified.R506 did not reside in the facility during the time of the survey.During interview on 6/24/26 at 12:31 PM, Licensed Practical Nurse (LPN) C was asked about R505's missing medications and stated, I think there was a delay in the pharmacy delivering their medications. I can't really recall. But we are supposed to notify the doctor if two consecutive doses are missed.On 6/24/26 at 2:00 PM during an interview with the Director of Nursing (DON), R506's EHR was reviewed. The DON acknowledged that two consecutive doses of the Advair and Cefadroxil were not administered to R506 and there is no documentation to support the physician was notified. A request for the facility's Medication Administration policy was made.According to the facility's policy for Medication Administration updated on 12/19/2019 read in part: It is the policy of this facility that medications shall be administered as prescribed by the attending physician.2. Medications must be administered in accordance with the written orders of the ordering/prescribing physician.12. Should a drug be withheld, refused or given other than the scheduled time, the nurse must enter an explanatory note. NOTE: The Director of Nursing and the attending Physician must be notified when two (2) doses of a medication are refused or withheld.

Based on observation, interview, and record review, the facility failed to properly date-label stored food and remove expired food in resident refrigerators affecting all the residents who consumed food from the unit refrigerators resulting in unidentifiable resident food items, expired food items, and the potential for food-borne illness.Findings include:On 12/02/2025 at 10:30 AM unit refrigerators were observed with the Dietary Supervisor (DS) A. The following were noted:2nd floor unit fridge-Expired fruit, unlabeled.-A chocolate cake unlabeled.-A half loaf of expired bread.3rd Floor unit fridge-A container of unlabeled, undated spinach dip.-An expired cake unlabeled.-A container of a leftover meal undated, unlabeled.On 12/2/2025 at 10:40 AM DS A was interviewed and said dietary staff were responsible to maintain the unit refrigerators. DS A further said all staff were aware that resident food items need to be labelled and dated to decrease the risk for food borne illness.On 12/03/2025 at 11:14 AM the Director of Nursing (DON) was interviewed regarding the kitchenette refrigerators and said the expectation is for resident food to be labelled and dated and expired food to be thrown out to limit risk of foodborne illness.Review of the facility policy titled Food Brought by Family/Visitors reviewed 7/31/2023 revealed in part .Perishable foods must be stored in a re-sealable container with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item and the use by date. The nursing staff is responsible for discarding perishable foods on or before the use by date. The nursing and/or food service staff must discard any food prepared for the residents that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates).

Based on observation, interview, and record review, the facility failed to prevent the misappropriation of one resident's (R22) property from four residents reviewed for abuse resulting in 26 tablets of R22's narcotic pain medication (oxycodone 10-325 milligram (mg)) missing and unaccounted for.Findings include:On 3/11/2025 the State Agency (SA) received a Facility Reported Incident (FRI)indicating R22 had missing narcotic pain medications.According to the facility's investigation report, 26 tablets of R22's Oxycodone 10-325 mg could not be accounted for during the 3/11/25 A.M. shift change narcotic count. It was determined that the discrepancy began on 3/10/25 with Registered Nurse (RN) E. The facility terminated RN E and reported their license to the State Licensing Board and local police. R22 was interviewed and reported receiving pain medications as requested. The facility replaced R22's missing medications.On 12/1/25 at 3:03 PM, R22 was interviewed regarding the FRI and said, I knew my meds were missing after they told me. I was still getting my pain meds so I really don't know what happened. R22 had no concerns at this time.According to R22's Electronic Health Record, the resident admitted to the facility on [DATE] with multiple diagnoses that included history of cellulitis and left leg above the knee amputation. R22 had intact cognition and was their own responsible party. A review of the resident's Mediation Administration Record revealed R22 was receiving her medications as prescribed by the physician.During the medication administration and storage tasks on 12/2/25 all narcotics were correctly reconciled and accounted for. No deficient practices were identified with regard to medications. On 12/3/25 at 2:15 PM during interview the Director of Nursing (DON) said, This was an isolated incident. We had no other medication discrepancy. We reviewed the policy and process for reconciling narcotics and did in-services for all licensed staff that passed meds. Audits for two months concluded we had no further issues.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included narcotic count with determination of no further discrepancy of narcotic medications, re-education of all licensed staff on narcotic reconciliation, and audits of the narcotic reconciliations for two months to ensure continued compliance. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview, and record review the facility failed to provide appropriate PEG tube care (a tube placed directly into the stomach through an abdominal wall incision for the administration of food, fluids, and medication) for one (R47) resident reviewed for tube feeding resulting in a compromised PEG tube with no cap, difficulty administering medications, and the potential for infection.Findings include: On 12/02/2025 at 9:33 AM, during observation of medication administration for R47, the resident's PEG tube was compromised and missing the attached cap. The PEG tube was clamped with a plastic clamp but not completely or securely capped off. The opening of the tube was covered with white tape. The white tape was soaked with beige colored liquid that was the same color and consistency of the resident's tube feeding formula. The tape easily slid off the port when LPN B touched it. The PEG tube was visibly worn with crushed medications observed inside the tube. Closer inspection revealed that the PEG tube port could not be securely connected to the feeding tube. The tube feeding connector port also had white tape on it that was covered with beige liquid.At this time Licensed Practical Nurse (LPN) B said, Oh, that's not supposed to be like that. The cap is broken off. That needs to be replaced. It's ill-fitting and not secure. We have new connectors in central supply. I will change it out. LPN B retrieved a 'Y' port connector and attempted to connect it to R47's PEG tube. The connector did not fit securely into the PEG tube. LPN B said, It's still not secure. I will notify the nurse practitioner. LPN B administered R47's medication through the PEG. The medication and water flush was very slow and took several minutes for administration. Some of the water flush leaked back out of the PEG tube, not through it. LPN B said, This whole tube needs to be replaced. You can see the medications stuck inside the PEG tube and it's difficult to give the meds through it. R47's Electronic Health Record (EHR) indicated the resident admitted to the facility with a PEG tube and diagnoses of Stroke and dysphagia (difficulty swallowing). A physician's order dated 5/29/25 reads as follows: cleanse peg tube site with Normal Saline pat dry and apply drain sponge. if there are any concerns with placement, notify medical provider immediately.A care plan for tube feeding initiated on 5/29/25 included the following intervention: provide care to feeding tube site as ordered and monitor for signs/symptoms of infection.A review of R47's progress notes from 11/1/2025 through 12/1/205 did not reveal any documentation regarding the resident's PEG tube. On 12/2/25 at 10:00 AM a progress note written by LPN B reads as follows: Writer in to administer medications this am and noted integrity of peg tube impaired and cap broken off and no longer present. (Named Guardian) contacted regarding this issue, family notified. Order obtained to send to [hospital] for peg tube replacement.On 12/3/25 at 11:30 AM the Director of Nursing (DON) said they were aware of R47's compromised PEG tube on 12/1/25. The DON said, There was a note written in the Nurse Practitioner (NP)/Doctor's log on 12/1/25 that the resident's (R47) PEG tube was compromised but there was no progress notes or documentation in the resident's chart. I don't know why there wasn't a follow-up. The resident was sent out to the hospital for the PEG tube replacement.

This citation pertains to intake MI00141226. Based on interview and record review the facility failed to properly secure a resident in a wheelchair before transportation for one resident (R901) out of three residents reviewed for safety, resulting in R901's wheelchair tipping backward and the potential for injury. Findings include: Record review of R901's face sheet revealed admission into the facility on [DATE] with a pertinent diagnosis of End Stage Renal Disease. According to the Minimum Data Set (MDS) dated [DATE], R901 had intact cognition and required assistance with Activities of Daily Living (ADLS). During an interview on 12/12/23 at 9:27 AM, R901 reported that on 11/19/23 when leaving the dialysis center and returning to the facility Transportation Aide A turned onto the road and the wheelchair then tipped backwards. During an interview on 12/12/23 at 10:05 AM with Transportation Aide (TA) A it was reported that on 11/19/23 she had picked up R901 at dialysis facility. When turning onto the road, R901 was heard yelling, I am falling. It was further verbalized that the bus was immediately driven into the parking lot of a restaurant. When asked how the resident's wheelchair was able to tip backwards, TA A said, I did not tighten down the hooks causing the wheelchair to fall backwards. At conclusion of the interview, TA A stated, I should have made sure the hooks were tightened down before we left. During an interview with the Nursing Home Administrator (NHA) on 12/12/23 at 12:30 PM, it was reported that it was the responsibility of TA A to make sure the resident was secured before operating the bus. Record review of policy Resident Transport and Escort Services dated 12/30/2019 documented the following: 2. Wheelchair Restraint Systems: Vehicle will have a system in place to secure the wheelchair prior to departure.

Based on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting 79 residents who receive meal services (1 nothing by mouth residents, or NPO) out of the facility's total census of 80 residents. Findings include: 1. On 11/14/23 at 3:04 PM, an accumulation of dust, ice, and food debris was observed on the floor of the walk-in freezer. At this time upon interview with the Dietary Manager, staff A, the surveyor inquired if the facility had any policies in place regarding cleaning related job duties for staff to follow to which they stated, Yes. We do a deep clean in here monthly. At this time the surveyor requested a copy of the walk-in-freezer's cleaning policy to review. On 11/15/23 at 9:14 AM, the exterior of the ovens, stove top, and its surrounding area were observed discolored with heavy staining in sections. At this time the surveyor inquired with staff A on if they thought these areas were being cleaned timely and sufficiently to which they replied, not to my liking. At this time the surveyor requested a copy of the kitchen's cleaning policy to review. On 11/15/23 at 10:19 AM, record review of a document titled, cleaning and sanitizing freezer stated, walk in freezers should be routinely cleaned for sanitization. However, no specific time frame requiring the unit to be cleaned and sanitized was observed on this document. On 11/16/23 at 11:10 AM, record review of a document titled, cleaning procedure for equipment and utensils revealed that facility has systems in place to ensure proper cleaning and sanitizing of equipment occurs. Review of 2017 U.S. Public Health Service Food Code, Chapter 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, directs that: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 2. On 11/14/23 at 2:44 PM, an air gap of at least 1 and twice the diameter of the receiving drain was not observed present on any of the three-compartment sink's drain lines. At this time upon interview with the Dietary Manager, staff A, the surveyor inquired if there had been any recent changes to the plumbing system since the last survey to which they replied, I know about a two months ago after we had the flood they needed to replace a lot of things we could start using our kitchen again. Review of 2017 U.S. Public Health Service Food Code, Chapter 5-203.14 Backflow Prevention Device, When Required directs that: A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT, including on a hose [NAME] if a hose is attached or on a hose [NAME] if a hose is not attached and backflow prevention is required by LAW, by: (A) Providing an air gap as specified under S 5-202.13 P

Based on observation, interview, and record review, the facility failed to: 1. Ensure the use of hair restraints of staff working in the kitchen; 2. Properly date-label opened food; 3. Ensure proper cooling of cooked, potentially hazardous (time-temperature for safety) food, baked penne, mashed potatoes, and meat cutlets; 4. Ensure ladles were stored properly to prevent contamination; 5. Consistently log the temperature of the high-temperature sanitizing dish washing machine; and 6. Removed expired, undated, unlabeled food from a resident refrigerator. These deficient practices had the potential to affect all the residents who consumed food from the kitchen, resulting in the increased potential for food borne illness. Findings include: On [DATE] beginning at 8:56 AM, the initial tour of the kitchen was conducted with Dietary Aide Q. Upon entering the kitchen, DA Q was observed near the tray serving line and steam tables and had not donned a hair net. During the tour, the following items observed in various refrigerators and were opened and undated: - 46 ounce container of thicken water - 46 ounce container of thicken apple juice - approximately 1 pound of sliced salami - five pound tub of sour cream - 16 ounce tube of whipped cream The following previously cooked and cooled food items were observed in the walk-in cooler: - ,d+[DATE] size pan of baked penne, dated [DATE] - ,d+[DATE] size pan of mashed potatoes, dated [DATE] - six to seven cutlets of Country Fried Steaks, undated When asked if there were cooling logs for the previously cooked food, DA Q stated, No. Four ladles of varying sizes were observed hanging from a metal bar, bowl side up. On [DATE] at approximately 9:30 AM, the morning cook, Cook S, was observed running meal trays through the high temperature dish machine. During interviews on [DATE] at 11:43 AM and [DATE] at 2:15 PM, Dietary Manager (DM) G was unable to provide a dish machine temperature log for [DATE]. DM G stated, We don't know if the machine was sanitizing correctly. In reference to the way the ladles were stored, DM G said particles of debris can fall in them. DM G said the shelf life of an opened container of thicken liquids was seven days. The opened containers of thicken liquids should have had an opened and expiration date. DM G stated, A cooling log was available, but it wasn't used (by the cooks). DM G said cooks are to use the cooling log to avoid the danger zone and to know how long you have to cool food properly. Finally, DM G stated, Food service is responsible for removing outdated foods and ensuring food is properly labeled in the kitchen and for refrigerators on the resident units. During an observation and interview on [DATE] at 1:22 PM with Licensed Practical Nurse (LPN) H, the following was noted in the resident refrigerator on the second floor. The top freezer section contained an opened and undated 20-ounce bag of pepperoni pizza snacks. All other items listed were observed in the lower refrigerator section: - a ham and cheese sandwich with two dates: [DATE] and [DATE]. LPN H stated, These should have been discarded [DATE]. - a slice of garlic toast in a clear plastic bag, undated. - a glass of apple juice, of pudding thickened consistency, with an undecipherable date. - an undated chicken or tuna salad sandwich, not labeled with a resident's name. - an undated container of spaghetti, not labeled with a resident's name. - pot pie, dated ,d+[DATE] - not labeled with a resident's name, LPN H said the kitchen staff was responsible for cleaning the refrigerator. A review of a facility document titled, Cleaning and Sanitizing Dishes, Utensils, Pots and Pans using Ware Washing Machines, undated but provided during the survey, revealed the following: Before running dishes through the dishwasher, warm up the dishwasher by running through an entire wash-rinse cycle and record the appropriate temperature. Record the wash and rinse temperature on the temperature log before washing dishes at each meal. According to the 2013 FDA Food Code: - Section ,d+[DATE], Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. - Section ,d+[DATE].11, Safe, Unadulterated, and Honestly Presented: Food shall be safe, unadulterated, and, as specified under S ,d+[DATE].12, honestly presented. - Section ,d+[DATE].14, Cooling: Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 135 F to 70 F; and (2) Within a total of 6 hours from 135 F to 41 F or less. - Section ,d+[DATE].11, Storing Equipment, Utensils, Linens, and Single-Service and Single-Use Articles: (B) Clean equipment and utensils shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted.

This citation pertains to intake MI00128788. Based on interview and record review, the facility failed to consistently ensure no more than 14 hours occurred between a substantial evening meal and breakfast the following day, except when a nourishing snack was served at bedtime, resulting in the potential for resident dissatisfaction and unmet care needs for all residents consuming food from the kitchen. Findings include: A concern was reported to the State Agency regarding timely meal service. On 1/22/2023 at approximately 11:07 AM, during a meeting with the Nursing Home Administrator (NHA), a CMS (Centers for Medicare & Medicaid Services) document titled, Entrance Conference Worksheet was reviewed which listed information requested from the facility. Item number 18 indicated a schedule of meal times for residents of the facility was needed. A document titled, Meal times, undated, was submitted during the survey by the NHA. A review of this document revealed the beginning breakfast and dinner mealtimes occurred at 7:45 AM and 4:45 PM respectively. During an interview on 1/24/2023 at 1:03 PM, Licensed Practical Nurse (LPN) H said a snack box comes up to the nursing unit from the kitchen after dinner. LPN H stated, Residents get one snack. If there are more left, they can have more. During an interview on 1/24/2023 at 1:49 PM Certified Nurse Aide (CNA) I said the kitchen provided a container of snacks and the CNAs take the snacks from room to room and offers them to the residents. CNA I stated unlabeled snacks (general snacks not specified for a particular resident) included cookies, peanut butter crackers, string cheese, (gelatin dessert), pudding, (fish-shaped crackers), apples, and fruit cups. During an interview and record review on 1/24/2023 at approximately 2:15 PM, Dietary Manager (DM) G provided a copy of a document titled, Meal and Dining room service, dated 1/22/2023. A review of this document revealed the beginning breakfast and dinner mealtimes occurred at 7:45 AM and 4:45 PM respectively. After this review, DM G agreed there was a 15-hour time span between dinner and breakfast the next day. DM G said the kitchen had no specific snack rotation. General evening snacks provided to residents in the facility included a variety of potato chips, pretzels, cheese puffs, pudding cups, applesauce, (gelatin dessert), and a variety of cookies. During an interview on 1/25/2023 at 10:11 AM, Registered Dietitian (RD) L stated the purpose of an evening snack was to give the resident some type of nourishment before they go to bed (and a substantial snack) was something that included a carbohydrate and a protein. RD L said that cookies, potato chips, pudding, and gelatin dessert would not be considered a substantial evening snack. During an interview on 1/25/2023 at 1:44 PM, the NHA said she knows about the mealtime span between dinner and breakfast the following day, and she now understands what a substantial snack is. The NHA was asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and no substantially new information was provided.

This citation pertains to MI00128672. Based on observation, interview, and record review the facility failed to staff the third floor to meet the needs of 12 residents (R68, R27, R64, R56, R38, R67, R59, R8, R29, R41, R5, and R66) of 20 residents reviewed for staffing concerns resulting in untimely/incomplete incontinence care, no set-up assistance for personal care, limited assistance with activities of choice, inconsistent supervision, and concerns with safety with subsequent refusal of care. Findings include: On 1/22/23 during the initial tour at approximately 10:30 AM, of the 20 residents on the third floor, two residents (R67 and R68) were observed in the dining/day room area with the television on and unsupervised. R67 and R68 were not within view of where Nurse BB stood to pass medication at the nurses station. Three residents were observed awake, dressed, and up at the bedside in their room (R42, R57, and R25). The remaining 15 residents were observed in bed. There was no additional staff assisting residents on the floor at the time of observation. R68 Record review revealed R68 was readmitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus and Depression. According to the Minimum Data Set (MDS) dated [DATE], R68 had moderate cognitive impairment. On 01/22/23 at 10:58 AM Nurse BB was queried regarding the nursing staff available for patient care for the 20 residents on the 3rd floor. Nurse BB reported there was one nurse and one Certified Nursing Assistant (CNA) present on the floor. Nurse BB explained that one nurse and one CNA is how the 3rd floor is usually staffed and that sometimes a CNA is scheduled to work the floor around noon. R27 On 1/22/23 at 11:27 AM, R27 was observed in bed and was queried regarding nursing staff. R27 explained that most of the time there are not enough staff to assist the residents. When asked what would he do if there were more staff available he stated, I would like to have been up about an hour ago so I could be working on my puzzle in the day room. I keep asking for someone but they keep telling me they are going to come back (to assist). Record review revealed R27 was readmitted into the facility on [DATE] with diagnoses that included Congestive Heart Failure, Stroke, Hemiplegia (weakness to one side/part of the body), and End-Stage Renal Dialysis. Per the Minimum Data Set (MDS) dated [DATE], R27 had intact cognition. R64 On 1/22/23 at 2:00 PM R64 was observed in bed with a full beard. R64 was queried regarding any staffing concerns and explained that he requires some set-up help in order to complete his routine of self-care. R64 stated, I can get up. I would like to clean my beard up. I would shave it all off if I had someone to assist me. I have some weakness from my strokes. I laid here for months and got weak. During the interview, R64 repeatedly touched his facial hair while explaining that he wanted a clean shaven face again. Record review revealed R64 was admitted to the facility on [DATE] with diagnoses that included CVA/Stroke, Hemiparesis, and Hemiplegia. Per the MDS dated [DATE], R64 had intact cognition. R56 On 1/22/23 at approximately 2:30 PM, R56 was observed in bed and was queried regarding staffing. R56 explained that most of the time 'up here' (3rd floor) residents have to wait on a shower. R56 said that earlier on this shift she had to wait to be changed but R56 is alright now. R56 stated, They need more help. It is difficult for one person to care for the entire third floor. It is not fair to the CNAs. Record review revealed R56 was readmitted to the facility on [DATE] with diagnoses that included Stroke and paraplegia. Per the MDS dated [DATE], R56 had intact cognition. R38 On 1/22/23 at approximately 2:45 PM, R38 was observed in bed and was asked about any concerns with staffing. R38 stated, There is not enough staff. If they had enough staff, I would be getting up in the morning, I would recieve set up help to wash (self) and comb my hair. R38 explained there was a problem with having a dry brief and a wet pad on yesterday (Saturday, 1/21/23). R38 stated, I tried to keep my feet and legs out of the pad. I told the nurse and the nurse told the aid to assist the resident. R38 explained how she had to lay on a wet pad from roughly 6:10 PM to 9:30 PM and that R38 telephoned her family member regarding how she felt having to wait so long for assistance. R38 stated, There are not enough aids to take care of the residents. One aid (CNA) is not enough. I do not think two aids are enough. Record review revealed R38 was admitted in to the facility on [DATE] with diagnoses that included Hypertension, Lymphedema, Respiratory Failure, Cataract (Blind in right eye). According to the MDS dated [DATE], R56 had intact cognition. On 1/23/23 at approximately 9:30 AM Nurse AA and CNA Z were queried regarding staffing on the 3rd floor when there are 9 identified residents who require a hoyer lift for transfer. CNA Z regular 3rd floor staff explained that staff get R67 up first thing because, we have a midnight shift nurse and CNA available to assist with the hoyer transfer until 7 AM. Staff were then queried how a check and change is performed throughout the shift for the 3rd floor residents. CNA Z and Nurse AA explained that they plan to lay R67 back down after lunch. The plan of care for R67 was planned. However, the explaination for one resident (R67) did not explain how the care and needs of the remaining 19 residents were addressed when one nurse and one aid are providing care to R67. LPN AA and CNA Z acknowledged that it can be difficult to provide resident care at times. R67 Record review revealed R67 was admitted in to the facility on [DATE] with diagnoses that included Facial Fractures, Post Traumatic Stress Disorder (PTSD), and at Risk for Malnutrition. According to the MDS dated [DATE], R67 was severely cognitively impaired. R59 On 1/24/23 at approximately 1:45 PM R59 was observed up in the wheelchair at bedside. When queried regarding any staffing concerns, R59 explained that one CNA on the 3rd floor is not enough. R59 stated, I give up my showers because I don't feel safe when the staff come in and have to rush. I do not know how they do it with one person. They come on at 7 AM and have to change everyone and get people up for breakfast, then assist for breakfast. Record review revealed R59 was readmitted in to the facility on [DATE] with Chrohn's disease and Depression. R59 explained that she was a left above the knee amputee. Per the MDS dated [DATE], R59 had intact cognition. Review of the facility-provided list titled, 3rd Floor Hoyer Lift Transfer dated 1/24/23, included a total of 9 residents that required 2 staff to assist with the mechanical transfer of a Hoyer lift. The list included the following residents: R8 - According to the MDS dated [DATE], R8 required extensive 2-person assistance with all Activities of Daily Living (ADLs) and transfers. ADLs include getting dressed, toileting, hygiene, and bathing/showering. R29 - According to the MDS dated [DATE], R29 required 2- person, total assistance with ADLs and transfers. R41 - According to the MDS dated [DATE], R41 required the total assistance of 2 staff for ADL care and transfers. R56 - Accordidng to the MDS dated [DATE], R56 required 2 person assistance with transfers. R38 - According to the MDS dated [DATE], R38 required extensive to total 2-person assistance with transfers. R5 - According to the MDS dated [DATE], R5 required extensive to total 2-person assistance with transfers. R59 - According to the MDS dated [DATE], R59 required extensive to 2-person assistance with transfers. R67 - According to the Significant Change MDS dated [DATE], R-67 was an extensive to total 2-person assistance with ADL care and transfers. R66 According to the quarterly MDS dated [DATE], R66 required the extensive assistance of 2 persons with ADL care and transfers. Of note transfers did not occur during the assessment period of the most recent MDS. On 1/25/23 at approximately 2:00 PM, the Director of Nursing (DON) and the Administrator (NHA) were interviewed regarding 3rd floor staffing concerns. The DON and NHA acknowledged there were 9 residents who required two staff for transfers and that the 3rd floor was often staffed with one Nurse and one CNA. When queried regarding the acuity of care on the 3rd floor, the DON and NHA acknowledged the high acuity of care. When asked the expectation of care, the DON explained that there is an effort to get half-a-staff (staff to work part of shift) but there are many call-offs (staff not reporting to work.) The DON stated, I have lost a lot of staff. When asked what is the purpose for the half-a-staff the DON responded, I know it's hard. Just to get people up, you need two people. It is hard to staff three separate floors. I understand that we are short of staff.

This citation pertains to intake MI000128672. Based on observation, interview, and record review, the facility failed to consistently follow the facility-wide planned menu, resulting in resident dissatisfaction for five residents (#44, #58, #38, #57, and #59) of eight residents reviewed for meal acceptance and missed opportunities to serve expected meals to all residents consuming food from the kitchen. Findings include: A concern was reported to the State Agency regarding the lack of variety in the meals served to the residents. During a kitchen observation on 1/22/2023 at 11:43 AM, hot items included on the tray line for lunch meal service included fried chicken, mashed potatoes, mixed vegetables, green peas, green beans, and hot dogs. During an observation on 1/22/2023 at 1:57 PM, a menu posted in a resident's room documented the following hot foods were to be offered at lunch: fried chicken, mashed potatoes, and sliced carrots. The alternate meal offerings included: Italian sausage sandwich and green peas. During an interview on 1/24/2023 at 2:15 PM, a substitution log for lunch on 1/22/2023 was requested. Dietary Manager (DM) G stated, We haven't been doing a substitution log. DM G said the kitchen did not have carrots at lunch but served French [NAME] vegetables (a vegetable mix of green beans and carrots) instead. Italian sausage was not available, so they substituted hot dogs. DM G stated they are having to do a lot of substitutions. Sometimes it's (the food) not on the truck. A review of menus provided to residents was compared to food service documents titled, Daily Temperature Log. The daily temperature logs documented the food actually served to residents. This comparison revealed the following: On 1/9/2023 residents were to receive: Baked chicken breast with gravy, garlic mashed potatoes, Italian blend vegetables, chocolate brownie. Alternate entree was Italian Sausage with onions and peppers. Actual food served: Cheeseburger, tater tots, and brownie. On 1/10/2023 residents were to receive glazed ham, mashed sweet potatoes, green peas, and peach cobbler. Alternate choices included tuna salad sandwich and green beans. The actual food served included pork loin, stuffing, broccoli, tuna salad sandwich with chips, and cherry tart. On 1/11/2023 residents were to receive cream of broccoli soup with crackers, cheeseburger with lettuce, tomato & pickles, three bean salad, mandarin oranges. Alternate choices included Quiche Lorraine and carrots. The actual food served included chicken thighs, garlic mashed potatoes, peas & carrots, peas, mandarin oranges/peaches, and the alternate entree was supreme pizza. On 1/13/2023 residents were to receive devil's food cake for dessert but received chocolate chip cookies instead. On 1/14/2023 residents were to receive a veggie burger as an alternate entree. The actual alternate entree served was a cheeseburger on a bun. On 1/16/2023 residents were to receive a tuna melt as an alternate entree. The actual alternate entree served was a tuna salad sandwich. On 1/25/2023 at 10:11 AM during an interview, Registered Dietitian (RD) L stated the facility should follow the menu as posted so that patients can gauge what's coming and have something to look forward too, or if something is being served that they don't like, they can ask for a substitution. It's nice to have menus as a reminder of what's going to happen. RD L added that the kitchen notifies nursing about menu substitution and nursing notifies the residents. On 1/25/2023 beginning at 12:43 PM, three cognitively intact residents, Resident 23# (R23), Resident #44 (R44), and Resident #58 (R58), were individually and separately interviewed about menu substitutions. These interviews yielded the following comments: - R23 said they are not notified when the kitchen makes menu substitutions. - R44, stated, I wish they would serve what they are saying. They don't (tell us about menu substitutions). - R58 stated, (Expletive) no when queried if they were informed about menu substitutions. During an interview on 1/25/2023 at 12:35 PM, Registered Nurse W said they have not been notified of any menu changes this month. 28214 R38 On 1/22/23 at approximately 2:45 PM, R38 was observed in bed and was queried regarding any food concerns. R38 expressed dissatisfaction with the food served and stated, Flat out (a matter of fact) the menus are not being followed. Record review revealed R38 was admitted in to the facility on [DATE] with diagnoses that included Hypertension, Lymphedema, Respiratory Failure, Cataract (Blind in right eye). According to the MDS dated [DATE], R56 had intact cognition and was able to make her needs known. R57 On 1/22/23 at approximately 10:20 AM, R57 was observed up in a wheelchair at the bedside. R57 was queried regarding any food concerns and reported there is not enough salad and limited choices for the alternative meal. R57 explained that the facility lists the alternative, but when the alternative is ordered that is not what comes on the tray. R57 stated, The facility does follow the menu. Resident #57 was readmitted to the facility on [DATE] with diagnoses that included Osteoarthritis of hip, COPD, and Morbid Obesity. Per the MDS dated [DATE], R57 only required set-up for eating, had intact cognition, and was able to make his needs known. R59 On 1/24/23 at approximately 1:45 PM R59 was observed up in the wheelchair at bedside. R59 was asked about any food concerns and explained that she can not eat foods that cause a lot of gas because of her colostomy. Resident #59 reviewed the menu with the surveyor and identified brussel sprouts as the vegetable for dinner and carrots as the alternate vegetable for the night before and stated, I can not eat brussels sprouts. I asked for the alternate which was carrots. I received no alternate. They never send the alternate. They (CNA CC who called the kitchen ) told me they (the kitchen) just did not have it. I said, are they really gonna do this (not send any alternate) when the state is here?? Record review revealed R59 was readmitted in to the facility on [DATE] with Chrohn's disease and Depression. R59 explained that she had a colostomy. Per the MDS dated [DATE], R59 had intact cognition and was able to make her needs known.

Based on interview and record review, the facility failed to demonstrate that one resident (R39) of five residents and/or their resident representative was made aware of the potential risk(s) or adverse consequences associated with a prescribed psychotropic medication (quetiapine) in a timely manner, resulting in the potential for diminished ability to make informed decisions regarding plan of care. Findings include: The clinical record for Resident #39 (R39) was reviewed and documented an initial admitted [DATE] and readmitted [DATE]. R39's diagnoses included anxiety disorder, psychotic disturbance, mood disturbance, and Alzheimer's disease. A Minimum Data Set (MDS) assessment dated [DATE] documented severe cognitive impairment and R39 received an antipsychotic medication all seven days of the MDS look back period. The clinical record also revealed an organization responsible for providing case management was granted full guardianship for R39. A review of a progress note dated 11/15/2022 documented in part the following: R39 was prescribed olanzapine as needed that was not effective. Patient was still anxious with increased blood pressure 171/132 and heart rate 102. Physician Y ordered olanzapine discontinued, to start R39 on quetiapine 25 mg nightly, and a psych consult. A review of physician's orders documented that 25 mg quetiapine once daily was initiated on 11/15/2022. During interviews on 1/25/2023 at 12:46 PM and again at 1:21 PM, the Director of Social Services, Social Worker (SW) J was queried about a consent for administering psychotropic medication, quetiapine, to R39. SW J said the nurse practitioner from the company that provided psychiatric services was responsible for calling the resident representative regarding medication changes and recommendations. A review of R39's clinical record, revealed that there was no indication that R39's resident representative was notified of the potential risk(s) or adverse consequences associated with quetiapine and/or gave permission to initiate quetiapine on 11/15/2022. SW J reviewed a progress note dated 12/7/2022 that indicated in part that R39 was evaluated by the psych nurse practitioner and recommendations were made to increase quetiapine 25 mg to twice daily. R39's physician and legal guardian were notified and agreed. During an interview on 1/25/2023 at 1:44 PM, Director of Nursing (DON) said the purpose of receiving consent prior to antipsychotic drug use was so the resident and/or resident representative understood the side effects. The DON was asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and no substantially new information was provided. A facility document titled, Behavior Management Guidelines, dated 3/2022, was reviewed and revealed the following: Patients, families/responsible parties are educated regarding the risk/benefits of psychoactive medications prior to the first dose being administered. If required by the specific state, signed consents are obtained and retained in the clinical record.

Based on observation, interview and record review, the facility failed to implement an effective in-service training program for nurse aides that supported and ensured consistency in procedure for perineal care with 2 out of 3 Certified Nurse's Aides (CNA), (D, E, F), resulting in the potential for unmet resident care needs. On 1/23/2023 at 1:20 PM, during observations, CNA D approached surveyor and said, recently the certified nurse assistants were trained to perform perineal care by turning and repositioning residents away from self (rolling away). CNA D said, in the past, training for perineal care was to turn and reposition residents towards self (rolling towards). CNA D said, changes in the procedure for perineal care was not explained and that no additional education was provided. CNA D said, she had concerns as to which procedure is correct for resident care. On 1/24/2024 at 4:30 PM during interview, UM B, with [AGE] years at facility, was queried on explaining the procedure for perineal care, she said, I would need to read the policy. On 01/25 at 8:45 AM, during interview and observation, CNA E, an agency staff, with one year at facility was queried on the procedure with positioning residents while providing perineal care. CNA E demonstrated, to roll from side to side and roll away to clean resident. Then CNA E changed her answer and stated, no, I mean to roll resident towards self (gestured .with arms raising inward towards self) then clean for perineal care, is that right? On 01/25 at 9:00 AM, during interview and observation, CNA/Scheduler F, with one to 5 years at facility, was also queried on positioning and turning while performing perineal care. CNA F said, the procedure for perineal care was to roll resident away from self. On 01/25/2023 at 9:15 AM, during interview, Infection Control, Staff Development (ICSD), RN C with start date in September 2022, was queried of the training provided to CNAs on perineal care. ICSD, RN C stated I have not done this in years, I need to review the policy. When asked to describe procedures she had used in the past, she stated, rolled away, place clean pad, wipe to front to back, then roll back and remove the dirty brief. Facility Policy titled, Perineal care on Female, date revised, May 20, 2022 .Turn the patient onto the side to the Sims (left side) position . to expose the anal area. Facility Policy titled, Perineal care on Male, date revised, May 20, 2022 . Help the patient into a supine position (lying on back; face up) . Turn the patient onto the side, if possible, to expose the anal area. Neither policy explained the procedure for positioning while performing perineal care.

Based on observation, interview, and record review the facility failed to provide a timely nutrition assessment for one resident (R29) of one reviewed for weight loss with a PEG tube (Percutaneous Endoscopic Gastrostomy, enteral feeding through a tube placed in the stomach) resulting in the potential for unmet nutritional needs. Findings include. On 1/23/23 at approximately 9:30 AM, Nurse AA was observed to perform care. Nurse AA was observed to discontinue R29's tube feeding and flush R29's gastrostomy tube (PEG). Nurse AA explained that R29 recently had to have the PEG tube replaced because R29 is known to pull and tug on the tube. Record review revealed R29 was readmitted to the facility on [DATE] with diagnoses that included Aphasia, Stroke, and at Risk for Malnutrition. According to the MDS dated [DATE] R29 had severely impaired cognition and had a PEG intact. Review of facility records revealed R29 had lost weight while receiving tube feeding. Review of the R29's clinical record revealed a Quarterly/Enteral Nutrition Review dated 8/8/22 that documented, Resident remains under hospice care. Current weight is 128.4# with a BMI of 22. Stable weight at 30x, 90x and 180x days. Resident is NPO with EN via PEG tube. Current orders for continuous feedings of Jevity 1.5 at 40 ml/hr until 600 mls have infused; flush with 120 ml q4 hours. Provides: 900 kcal / 38 gms protein / 456 ml free fluid / 720 ml flushes / 1176 ml total fluids. Tolerating current enteral feeding. Skin remains intact. No change in nutrition plan of care at this time, patient is nutritionally stable. However, further clinical record review revealed no monthly nutrional assessments for R29 during the months of September 2022, October 2022, November 2022, or December 2022. On 1/25/23 at approximately 10:15 AM, the Registered Dietician explained that resident (R29) is high risk and should have a monthly assessement to determine nutritional needs.

This Citation pertains to intake #MI00128412. Based on interview and record review, the facility failed to ensure one resident (R235) at risk for falls was assisted off the toilet out of four residents reviewed for accidents, resulting in the potential for a fall with injury(ies). Findings include: According to the facility reported incident (FRI) dated 4/24/22, R235 alleges that a nurse aide on afternoon shift on 4/24/22 was rough when providing care. Statement was taken from patient R235. Patient R235 stated, There was this Jamaican nurse aide on the afternoon shift who treated me like a ragdoll when I needed to go to the bathroom. She took me to the restroom and just set me next to the toilet and left me there and said she would be back. She did this twice .Statement was taken from nurse aide V who was identified to be the nurse aide working at the time of the alleged incident. Nurses' aide V stated she did not touch the patient. Nurses' aide V stated she brought in her dinner tray but when she came back in the patient hadn't touched it . Nurses' aide V stated when she came back in after that the patient had taken herself to the restroom and there was no call light on. Nurses' aide Then told the patient to notify her when she was done but she did not and when the nurse aide came in, R235 was lying in bed. She was at the edge of the bed but would not let the nurse aide move her to the middle . Nurses' aide V statement dated 4/24/22 revealed, .I gave her a dinner tray and she was sitting in the bed. I put the tray table in front of her and I asked if she wanted a sandwich instead and she said, 'maybe something'. When I came back in, she was lying in the bed like she was sleeping. I said mam are you going to eat the food and she said that is lunch and I said no, that's dinner. I just brought it in, and she said oh, that Is dinner and said it looks good, and she started eating it. I went back in the room, and she was no sitting in the bed, but she was in the bathroom. I checked on her and she was sitting on the toilet. I said, are you okay and I said please, please, just call when you are done. She did not say anything else, and she never called. When I came back in again, she was lying in bed. I never touched her. On 1/25/23 at 11:25 a.m., an unsuccessful attempt was made to contact Nurses 's aide V via telephone. Human Resource X confirmed Nurse's aide V was not a staff employee but was through the agency. According to the electronic medical record, R235 was admitted into the facility on [DATE] with diagnoses of multiple fractures of ribs, left side injuries of the head, anxiety disorder, epilepsy, major depressive disorder, panic disorder, psychotic disturbance, dementia, difficulties in walking, and hypertension. R235's admission Minimum data Set (MDS) with a reference date of 4/29/2022 indicated, R235 had moderate cognition impairment with a BIMS (brief interview for mental status) score of 10, required extensive assistance of one-person physical assistance with bed mobility, transfers, dressing, toileting, and hygiene. R235 required limited assistance of one person with ambulation. Section G0300 of the admission assessment documented, 'Balancing during transitions and walking as following: -A. Moving from seated to standing position; not steady, only stabilize with staff assistance. -C. Moving on and off toilet: not steady, only able to stabilize with staff assistance. -D. Surface to surface transfer (transfer between bed and chair or wheelchair); not steady, only able to stabilize with staff assistance. Section H0300: Urinary Continent (always continent). Section H0400: Bowel Continent (always continent). - Review of R235's care plans revision date 5/13/22 documented as following: - Activity daily living (ADL): ADL self-care deficit as evidenced by other lack of coordination related to multiple fractures of ribs left side with routine healing. Interventions: Use gait belt with one assist and two wheeled walker to facilitate safe transfers. -Falls: At risk for falls due to impaired balance/poor coordination, poor safety awareness, self-transfers, at times does not use call light. Interventions: provide assist to transfer and ambulate as needed. -Discharge: Resident is at risk for hospital readmission, most probable cause for readmission is safety. Review of the 'Falls' assessment dated [DATE] revealed, History of falls with a fall score of 13 indicative of a fall risk. During an interview with the Director of Nursing (DON) on 1/25/23 at 11:29 a.m., The DON was asked, should a resident that was a fall risk be left on the toilet alone? The DON stated, if they (CNAs) put them (risk for falls residents) there (On the toilet), they should be staying there. If the resident self-transfer themselves without assistance from the staff and the staff see the resident on the toilet, they should stand there with them, not leave them alone. According to the facility policy titled, Fall practice Guide issue date 12/2011, documented the following: -Purpose: The purpose of the falls practice guide is to describe the process steps for identification of patient fall risk factors and interventions and systems that may be used to manage falls. Fall management focuses on minimizing fall risk factors and fall related injuries while continuing to promote the patient's quality of life. The center utilizes the APIE framework as a systematic method to identify risk, select interventions to reduce the risk and monitor the effect on risk reduction.

This citation pertains to intake MI00128672. R43 Based on observation, interview, and record review, the facility failed to ensure timely incontinence care was provided for one resident (R43) of 11 residents reviewed for activities of daily living (ADLS), resulting in the resident being soiled and uncomfortable for a long period of time, verbalized frustration, and the potential for skin breakdown. Findings include: On 1/22/2023 at 12:50 p.m., during an initial tour of the facility, R43 was observed lying in bed. There was a strong odor of urine around R43's bed. R43 was observed wearing a soiled disposable brief with a urine-like odor and a soiled incontinent pad underneath with brown rings. When interviewed, R43 verified no one had been in the room during the shift to assist with ADL care. R43 stated, They came in the room today, but not to change me. I am wet and need changing. On 1/22/23 at 2:30 p.m., Certified Nursing Assistant (CNA) T was observed in and out of several resident's rooms including R43's. CNA T was not available for an interview. According to the electronic medical record, R43 was admitted into the facility on [DATE] with diagnoses of dementia, and hypertension. R43's admission Minimum Data Set (MDS) with a reference date of 12/30/22 indicated R43 was cognitively intact with a BIMS (brief interview for mental status) score of 13. Required extensive assistance of one person physically assistant with dressing and toileting. Required extensive assistance of two person for transfers, bed mobility, hygiene and bathing. MDS assessment indicated R43 was frequently Incontinent of bowel and bladder. Review of the ADLs care plan with a revision date of 1/13/2023 revealed, ADL self-care deficit as evidenced by physical limitations, decreased mobility, incontinence, spinal stenosis, Alzheimer's disease, dementia, chronic pain, anxiety, major depressive disorder. Goal as following: -Will receive assistance necessary to meet ADL needs daily. Interventions as following: -ADL assist of 1. -assist with daily hygiene, grooming, dressing as needed. On 1/25/23 at 11:32 a.m., the Director of Nursing (DON) was interviewed regarding the time frame incontinent residents are to be checked and changed. The DON said, Residents should be checked and changed every two hours. If a resident has a brown ring on the incontinent pad and soiled, that's a bit excessive. I wouldn't think that resident had been checked and changed. On 1/25/23 at 12:13 p.m., Licensed Practical Nurse (LPN) U stated during an interview, I did not see the CNA (CNA P) go into room [ROOM NUMBER] Sunday (#43) at all. My shift starts at 7:00 a.m., but I did see CNA T go into his room (#43) and change him when he got here. She (CNA P) is here from 7:00 a.m. to 11:00 a.m. then CNA T came in at 1100 a.m. We are struggling with not having enough CNAs. On 1/25/23 at 12:53 a.m., CNA P, R43's assigned CNA for 1/22/23 day shift was asked during an interview, was R43 changed during the shift? CNA P stated, I was here four hours on Sunday. CNA P was then asked, how often does she check and change the residents? CNA P stated, I try to do it every four hours, two times is the goal. Sunday, I went into room [ROOM NUMBER] around 8:30 a.m. when we were passing trays for breakfast. He was trying to get out of bed, so I fixed his legs by moving them over. I just covered him up, not change him then. Honestly, I didn't go back in his room to check and change him. But I told CNA T the rooms I didn't get to. I get here at 6:45 a.m. and I left Sunday around 11:00ish (11:00 a.m.).

This citation pertains to Intakes #MI 218 and MI 631. Based on interview and record review, the facility failed to prevent theft of residents-controlled substances in 3 of 4 residents (R#203, #204 and #205) reviewed for misappropriation of resident's medications, resulting in controlled substance diversion. Findings include: Resident #203 Review of R#203's Face Sheet on 5/18/2021 at 12:09 p.m. revealed the resident was initial admitted into the facility on [DATE] and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the significant sick change Minimum Data Set Assessment (MDS) dated [DATE], R#203 was cognitively intact, and required extensive assistance of one-person physical assistance with Activity Daily Living (ADLs) and extensive assistance of one-person physical assistance with transfers. Review of the physician Orders revealed R#203 was prescribed [MEDICATION(S)] Tablet 5 mg (Milligrams) one tablet by mouth two times a day for pain start date 8/5/2020 and end date of 9/16/2020, and [MEDICATION(S)] tablets 5-325 mg (Oxycodone Acetaminophen) one tablet by mouth every 8 hours for pain stating date 7/23/2020 and end date of 8/5/2020. Record review and interview on 5/18/2021 at 1:11 p.m., revealed, a facility provided investigation that was reported to the State Agency involving R#203, #204 and #205 was reviewed along with the facility's Administrator A. -The investigation documented that On 8/24/2020 at approximately 4:30 p.m., It was brought to the Administrator A's attention that during the month of August, Registered Nurse (RN) G had been signing out narcotics, wasting some that fell on the floor and discarded them without a witness. Administrator A started the investigation immediately on the narcotic count. Narcotic count was completed and found to be accurate. Times of Narcotics signed out by RN G were inconsistent with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN G was called in by this writer and questioned about discrepancy of medications and informed Human resource manager . RN G immediately suspended pending further investigation. Police called and report made .All interview able residents were interviewed regarding pain and discomfort and information obtained to ensure they were getting their medications. No negative outcomes. Immediately in services was started on proper destruction of narcotic medication, abuse reporting, misappropriation, and standards of business conduct. Investigation Summary/Action Taken: Immediately narcotic count on all medication carts in the building were counted with no discrepancies noted. Interview with RN G completed and admitted to taking [MEDICATION(S)] .Interviews completed by the Administrator, DON, and other nurses who have worked with RN G. Residents with a BIMS (Brief Interview for Mental Status Calculator) score of 13 and higher and who are alert and oriented were interviewed by Social Services regarding their current status of pain and if these residents were getting their pain medications that RN G had documented on. Pain assessment were completed no negative findings. Schedules pulled and verification dates completed where and with whom RN G had worked. Identification of Nurses completed, and interviews were completed with no negative findings. Discrepancies included [MEDICATION(S)] pill fell on floor and there was not a second wasting signature, and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The investigation from August 2020 back through January 2019, narcotic sheets were reviewed and continue to have discrepancies in destruction and wrong doses of narcotics taken. Several residents were affected .Education continues on Licensed Nurses regarding Corporate Compliance, Medication Destruction/Disposal, Abuse with misappropriation, Master control Substance Log, Narcotic and controlled Substance shift to shift count sheets and inventory of controlled Substances. The Administrator A reported license to the Board of Nursing on 8/27/2020 for drug diversion. This investigation does substantiate Diversion of Narcotics and investigation will continue. Residents that were affected will have payor source identified for reimbursement once completed. Review of the facility's Medications Pricing List documented; All medications involve in the Drug Diversion by RN G. as following: 1. [MEDICATION(S)] 5/325 mg, 2. Oxycodone 5/325 mg, 4. [MEDICATION(S)] 0.25 mg, 5. [MEDICATION(S)] 100 mg, 6. [MEDICATION(S)] 50 mg, 7. Lorazepam 0.5 mg, 8. [MEDICATION(S)] 0.5 mg, 9. [MEDICATION(S)] 100 mg, 10. [MEDICATION(S)] 100 mg, 11. [MEDICATION(S)] ER 30 mg, 12. [MEDICATION(S)] 5 mg . Reviewed RN G's Drug screen Results Letter dated 8/24/2020 at 15:15 documented, results Positive. Resident #204 Review of R#204's Face Sheet on 5/18/2021 at 12:40 p.m. revealed the resident was initial admitted into the facility on [DATE] and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician Orders revealed R#204 was prescribed [MEDICATION(S)] Tablet 800 mg one tablet by mouth daily started 2/8/2021, and [MEDICATION(S)] Tablet 7.5-325 mg ([MEDICATION(S)] Acetaminophen) one tablet by mouth every 8 hours started 9/17/2020. Resident #205 Review of R#204's Face Sheet on 5/18/2021 at 12:55 p.m. revealed the resident was initial admitted into the facility on [DATE] and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician Orders revealed R#205 was prescribed [MEDICATION(S)] Tablet 10-325 mg ([MEDICATION(S)] Acetaminophen) one tablet by mouth every 8 hours revision date of 5 12 2021, [MEDICATION(S)] Capsule 50 mg one capsule by mouth every 8 hours start date 2/23/2021. Administrator A was asked during an interview on 5/18/2021 at 12:49 p.m., how far back did she expand the search for narcotic discrepancies. Administrator A stated, We expand the search since she started to work here and that was in July of 2018 until she was terminated On September 3rd of 2020. Administrator A stated, Over the course of that time, 707 pills found taken from a total of 139 residents. Administrator A stated, She was given the residents their pain mediation, but she was taking one for herself too by signing them out with FOF (fell on Floor). Administrator said, at least she was being considerate of the residents by given them their pain medications first. Observed the Controlled Medications Shift Change Sign Out Sheet and the Investigation Log sheet with all the resident's RN G duplicated her signature singing out narcotics without a second nurse as a witness with the Administrator. The Administrator was asked, what were the proper procedure to waste narcotics? Administrator A stated, You get another nurse to see the narcotics are on the ground or whatever and both nurses will sign out on the Substance Controlled log. Administrator A validated that RN G did not waste the narcotics appropriately. The Administrator and the surveyor reviewed the Controlled Medications Sign Out Sheet indicating Where RN G signed out narcotics each time twice with FOF beside the narcotic count without a second nurse as a witness and signature. Administrator A Investigation log revealed dates ranging from 2018 through 2020 of duplicate signatures by RN G. Review of facility's Discontinuation and disposal of controlled Substances CII-V policy effective date 6/21/2017 documented, Procedure: 6. Follow State regulations regarding the timing of the destruction. The wasting of a dose of a controlled medication, due to resident refusal, mishandling, or other reason is witnessed by two nurses or individuals authorized to administer medications and documented in the corresponding location on the controlled drug receipt/record disposition form .

This citation pertains to intake MI 515. Based on interview and record review, the facility failed to operationalize the abuse policy and procedure for one resident (Resident #601) of five residents reviewed for abuse out of a total sample of five residents, resulting in allegations of abuse that were not reported to the Administrator timely, and not thoroughly investigated and the potential for further allegations of abuse to go unreported, and not thoroughly investigated. Findings include: Review of an Admission Record Report revealed, Resident #601 admitted to the facility on [DATE] with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Progress Note with a date of 4/24/21 at 12:57 p.m. revealed, Resident d/c (discharged ) home . In an interview via telephone on 4/28/21 at 10:06 a.m., Family Member Q reported Resident #601 alleged a rape by a male staff member a week prior to discharge. In an interview on 4/28/21 at 3:35 p.m., Certified Nursing Assistant (CNA) K reported if she heard about an allegation of abuse, she would report it to the charge nurse. In an interview on 4/28/21 at 3:40 p.m., CNA L reported any allegation of abuse is immediately reported to the nurse and the nurse will tell the Administrator. Review of a Patient Protection Abuse, Neglect, Exploitation, Mistreatment & Misappropriation Prevention policy with an issue date of 11/2016 revealed, . The purpose of the Guide is to outline the abuse prevention system using the seven (7) key components of: Screen Train Prevent Identify Investigate Protect Report/Respond . Employees are educated upon hire and annually on the abuse prevention program including the immediate reporting of ay suspicion of abuse .Any allegation of abuse must be immediately reported to the supervisor and abuse prevention coordinator . In an interview on 4/29/21 at 9:00 a.m., Licensed Practical Nurse (LPN) E reported when Resident #601 admitted to the facility she remembered staff saying that Resident #601 said He raped me. LPN E reported that she did not inform the DON or Administrator and was not sure if they were aware. In an interview on 4/29/21 at 9:16 a.m., CNA F reported during shift change a male CNA told her about Resident #601's rape allegation. In an interview on 4/29/21 at 10:21 a.m., DON B reported staff did not inform her of a rape allegation. In an interview on 4/29/21 at 11:18 a.m., CNA N reported Resident #601's rape allegation was a running joke. CNA N then reported the staff joked with him because Resident #601 said three black men from the kitchen committed the rape. CNA N reported abuse is reported to the charge nurse. In an interview on 4/29/21 at 11:51 a.m., CNA F reported all the nurses were aware of Resident #601's allegation of rape which CNA N mentioned during shift change. CNA F stated, They all were aware. In an interview on 4/29/21 at 12:24 p.m., CNA O reported she was present when Resident #601 said three black men from the kitchen raped her. CNA O reported she tried to calm Resident #601 down by saying nobody was in the room. CNA O reported she made LPN E aware of allegation. In an interview on 4/29/21 at 1:02 p.m., Administrator A and DON B reported they were not aware of a rape allegation for Resident #601. The Administrator reported if there is allegation of abuse it is immediately reported to the DON or Administrator.

This citation pertains to intake #MI . Based on observation, interview, and record review, the facility failed to assess and properly use a sit to stand lift (used for standing and raising the resident for short transfers) for one (R#400) out of a total sample of three Residents reviewed for activities of daily living (ADLs), resulting in a preventable injury while using the sit to stand lift, subsequently sustaining a fracture to the tenth rib which required hospitalization for further evaluation and treatment. Findings include: On 9/20/18 at 4:30 p.m., R#400 was observed resting in bed, alert and oriented to person only. R#400 denied any pain at that time and was unable to recall the incident. The Resident was observed independently turning side to side in bed while using bilateral grab bars (safety rails located on both sides of the bed). On 9/20/18 review of the clinical record revealed R#400 was initially admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], R#400 had moderate cognitive impairment, required extensive assistance of one person for ADLs, specifically with transfers. On 9/24/18, review of the facility's investigation report dated 8/30/18 revealed, R#400 was sent to the emergency roiagnom on the morning of 8/30/18. The nursing assessment also dated for 8/30/18, revealed R#400 complained of left arm pain and observed the left arm swollen with some discoloration. R#400 was returned to the facility on the same day with a [DIAGNOSES REDACTED]. The emergency department Physician notes dated 8/30/18, documented, The patient states she started developing pain over the past two days and noticed a significant amount of bruising. Patient is non-ambulatory and she denies falling or trauma to the area. However, she does use a sit to stand lift as part of the rehabilitation. The results of an x-ray completed to the left shoulder and left arm during the emergency room visit revealed, no acute fractures. Further record review of the emergency room report written by the attending Physician also revealed under the Number of [DIAGNOSES REDACTED]. On 9/24/18, the facility's investigation report also revealed, R#400 was sent to the hospital again on 9/3/18 due to increased [MEDICAL CONDITION] and no improvement to the left arm. The investigation report also revealed R#400 had not fallen, causing any injuries, and review of the medical chart showed the resident uses a sit to stand lift which will cause pressure to the rib area from the sling. Review of the admission [DIAGNOSES REDACTED]. Cat scan of the forearm and hand fails to show fracture. However, R#400 had a cat scan of the chest which showed new left-sided tenth rib fracture per the discharge summary report from the hospital. On 9/24/18 at 11:30 a.m., during an interview with the DON (Director of Nursing), was asked what the finding from the facility investigation were. The DON stated, I investigated it and I don't know what happened. I talked to multiple and no one witnessed her falling or anything. The Resident does not move enough to roll out of bed. She does not attempt to get out of the bed to walk. I reviewed her shower sheets for 8/29/18, and there was no discoloration or pain noted. The DON was then asked how the sit to stand is used. The DON offered to demonstrate the use of the sit to stand with a Velcro sling fitting around the waist. The DON stated, The vest was a size medium and is adjustable according to the size of the residents. During the demonstration, it was observed, the DON's vest became tighter around the waist during the lifting, and there was no space to apply two fingers under the sling. The DON was asked, did the vest feel tighter as it was lifting, the DON stated, Yes, it got tighter. On 9/24/18 at 2:00 p.m., CENA A was contacted for an interview via telephone. CENA A was asked what her memory of the incident was. CENA A stated, The Resident was given a shower around 11:00 a.m., there was someone else helping with that shower (another CENA). When me and the other CENA gave the shower, I didn't see any bruises or swelling during that time. I used the sit to stand. CENA A was then asked how she uses the sit to stand when caring for residents. CENA A stated, I put the girdle around the Resident's waist underneath the breast. The Resident was evaluated by physical therapy and stated it was ok to use the sit to stand. On 9/24/18 at 3:00 p.m., the DON was asked during an interview, for therapy notes and evaluations. The DON stated, The nurses always evaluate patients for sit to stands. I wouldn't have therapy notes because they don't evaluate for that. The DON was then asked to provide documentation on how nursing evaluated for the use of sit to stands. On 9/24/18 at 3:30 p.m., the DON presented a document titled Lift Assessment (Mercy) which indicated on 5/17/18, the Resident was assessed as being a Full Lift (Hoyer Lift). On 6/25/18, the Resident was reassessed and determined to be a sit to stand. On 8/30/18, the Resident was assessed on the day of hospitalization , which indicated a Hoyer Lift to be used. The DON was then asked how it was determined the appropriate lift the Resident needed. The DON stated, This is the criteria the Resident must meet for the appropriate lift (Hoyer, Sit to Stand, etc.) while referring to the Lift Assessment (Mercy). On 9/24/18, review of the resident's ADL self-care deficit care plan dated 5/17/18, with a revision date of 8/30/18 documented identified, At risk for impaired skin integrity and/ or actual impaired skin integrity related to fracture to T 10 through L1 decreased mobility and pain (initiated 5/17/18). Interventions which included: Tempo lift (Hoyer lift) (initiated 5/17/18, revision date 9/6/18). PT/OT/SP evaluate and treat as ordered (initiated 5/17/18). On 9/24/18, the manufactures instructions for the use of a sit to stand titled SARAH Plus was reviewed as followed: Standing Sling (sit to stand)- Encourage the patient to lean slightly forwards to enable the sling to be placed around the lower back of the patient (illustration indicated the caregiver placing the girdle on the lower back above the tail bone). Position the sling around the patient's back so that bottom of the sling lies horizontally approximately two inches above the patient's waist line, with the patient's arms outside the sling. Ensure the support strap is separated, brought loosely around the body, and is not twisted or trapped behind the patient's back.

Based on observation, interview and record review the facility failed to prevent pressure ulcer affecting Resident # 503 resulting in Two new avoidable pressure ulcers. Resident # 503 (R#503) On 5/17/17 record review of R#503's electronic medical record reveals he was admitted to the facility on [DATE] and then readmitted on [DATE]. Admission [DIAGNOSES REDACTED]. According to the initial Admission Minimum Data Set (MDS) assessment , Resident # 503 had no cognitive impairment and required extensive assistance with most activities of daily living (ADLs). On 05/17/17 at 9:00 a.m., observation of wound care by Assistant Director of Nursing. Resident presented with a right gluteal fold Stage IV (full thickness skin loss with extensive destruction , tissue necrosis( dead tissue) or supporting tissue) pressure sore. Wound one measures 1.5cm x 1.3cm x 6.5cm . Wound two pressure ulcer , left gluteal fold( bottom of buttocks and crease of thigh meet) stage IV measuring 1.3cm x 1.4cm x 4.7cm. On 5/17/17 at 8:50 a.m., interview Assistant Director of Nursing( ADON), when asked if resided was admitted to facility with any pressure sores, ADON states No. On 5/17/17 at 11a.m, Interview with Resident # 503, when asked how he acquired the two pressure ulcers, R#503 states When I first got here, they (facility staff) would leave me up in chair for long time, several hours. I cannot feel from my waist down , I didn't know I would get these. On 5/18/17, record review of Skin Assessment dated 2/3/17 reveals no documentation of any pressure ulcers. Braden Scale score of 12. A score of 12 means resident is at risk for skin breakdown. Review of MMNC- Standards of Practice for Ulcer Care reflects, To minimize pressure and manage tissue loads: Schedule regular and frequent turning and repositioning for bed and chair bound residents(at least q(every) 2 hours when in bed: q 1 hour when up in chair for those who are incapable of performing chair positions themselves) .

This citation retains to intake #MI 255. Based on interview and record review the facility failed to consistently monitor blood glucose (amount of sugar in the blood) levels for one sampled resident (#501) out of three residents reviewed for glucose monitoring from a total sample of three resulting in low blood glucose levels going undetected. Findings include: On 7//6/16 at 4:30 PM during a phone interview with Resent #501's sister she stated she visited the resident on 3/31/16 and the resident was very sleepy and lethargic. She said that did not believe that the facility staff was monitoring her brothers blood sugar levels and that the resident was hospitalized later that day for [DIAGNOSES REDACTED] (low blood sugar levels). On 7/7/16 at 8:55 am record review revealed that resident #501 was admitted into the facility on [DATE] and dischargee on 3/31/16. The admission [DIAGNOSES REDACTED]. Per the Social Service initial assessment, Resident #501 was alert to person, place and time with occasional confusion. Review of the admission physician orders [REDACTED]. The blood sugar results and times from 3/24/16 through 3/28/16 were as follows (standard range between 70-150): 3/24-16:19=593 3/25-16:50=358 3/26-6:32=33 3/26-11:42=328 3/26-16:34=292 3/27-4:30=59 3/27-5:00=70 3/27-5:30=44 3/27-7:02=82 3/27-11:01=179 3/27-16:55=75 3/28-5:44=167 3/28-11:30=253 There were no blood sugar results recorded for 3/29/16 or 3/30/16. On 7/7/16 at 10:30 am Staff Nurse A was interviewed and stated she was familiar with Resident #501 and was assigned to care for the resident on 3/31/16. Nurse A said that she remembers the resident sleeping through out the shift but would respond when spoken to. The remembers administering Resident #501's morning dose of insulin that morning. She stated,I thought he was very sound asleep because I had administered to him a dose of antianxiety medication. I remember he fell asleep while his breakfast tray was in his room and he fell asleep putting his head on the bedside table that his breakfast tray was on causing it to crash to the floor. He did wake up when the tray fell . Nurse A was asked if this was normal behavior for Resident #501 to which she responded sometimes he would be sleepy. Review of the nursing progress notes with Nurse A did not reveal any documented evidence that the antianxiety medication made Resident #501 very sound asleep or sleepy. Nurse A was queried as to why Resident #501's blood sugars had not been check since 3/28/16. The nurse responded that the physician had ordered for the blood sugars to be checked from 3/24/16 to 3/28/16 and I faxed over the blood sugar results to him on 3/29/16. Nurse A was asked what further instructions did the attending physician give after reviewing the 5 day blood sugar monitoring and said she does not remember, but it was odd not to be checking a resident's blood sugar when they were receiving insulin. Nurse A was asked why she did not check Resident #501's blood sugar levels that morning when she saw how very sound asleep the resident was to which she responded I thought it was his medicine (antianxiety) that was making him so sleepy. On 7/7/16 at 11:30 am, along with the Director of Nursing (DON) the food acceptance records (FAR) dated 3/31/16 for Resident #501 was reviewed. The FAR indicated that Resident #501 ate 25% of his breakfast foods and refused his lunch foods. On 7/7/16 at 12:30 further record review revealed progress notes documenting the following: 3/31/16 16:20 (4:20 PM)- .At approximately 15:30 (3:30 PM) therapy (staff) attempted to get patient up for therapy but he was unresponsive. Writer (Nurse A) went in to assess patient and he was not responding not even with sternal rub accu check (blood sugar check) =29. Oxygen applied and IM (intramuscular) [MEDICATION NAME] (concentrated sugar) given as per standing orders .Rechecked blood sugar and at that time read low. At approximately 15:35 called Emergency Medical Technician (EMT) to transport patient to emergency department (ED) for treatment. EMT arrived at approximately 15:44 patient still non-responsive. They rechecked blood sugar and it was in the 30's At approximately 16:40 patient was being transported to ED by the EMT unable to get an (Intravenous line) started on patient stated they would give (resident #501) more [MEDICATION NAME] in the ambulance. 3/31/16 18:14 (6:14 PM)- Call placed to Emergency Department (ED) to check status of patient (Resident #501) .(ED staff) stated patient would be admitted that he was vented (a machine that helps a patient breathe) and moving to Intensive Care Unit (ICU) . On 7/7/16 at 12:50 PM, along with the DON a phone interview was conducted with Resident #501's Attending Physician. The Physician stated that when a patients blood sugar levels are fluctuating, the resident is not eating and is receiving insulin the blood sugar levels should be monitored at least once or twice every day. At 1:00 PM the DON confirmed that Resident #501 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. On 7/7/16 at 1:15 PM review of the facility's Acute Change of Condition Documentation on the 24 hour Report Board policy dated 11/04, updated 10/11 documented, #3. The 24 hour Report Board may be used for residents experiencing a change of condition that is not life threatening, however, warrants more timely intervention, follow up or clarification. Examples include changes in level of consciousness/mental status and unanticipated changes in clinical conditions (i.e., weight loss, poor oral intake, shortness of breath, uncontrolled pain, worsening of symptoms related to infections, etc.). A licensed nurse should document the resident's condition and appropriate nursing assessment on the form and contact the physician via telephone. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION DURING TOILETING BASED ON THE RESIDENT'S ASSESSED NEEDS, FOR ONE (#513) OF TWO SAMPLED RESIDENTS REVIEWED FOR ACCIDENTS FROM A TOTAL OF 15, RESULTING IN A FALL WITH FRACTURED FINGERS. FINDINGS INCLUDE: ON 8/15/13 AT 9:40 A.M., RESIDENT #513 WAS OBSERVED IN THE DINING AREA PARTICIPATING IN AN ACTIVITY BEING CONDUCTED, WITH ANTI-TIPPING DEVICES AND AN ALARM APPLIED TO THE RESIDENT'S WHEELCHAIR. ON 8/15/13 AT 10:50 A.M., THE ACTIVE CLINICAL RECORD FOR RESIDENT #513 WAS REVIEWED. THE RESIDENT WAS readmitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MD'S) DATED 4/10/13 (BEFORE THE FALL) INDICATED THE RESIDENT WAS SEVERELY COGNITIVELY IMPAIRED AND REQUIRED EXTENSIVE ASSISTANCE WITH TOILETING AND TRANSFERRING FROM BED TO WHEELCHAIR. THE FALL RISK assessment dated [DATE] FOR RESIDENT #513, REVEALED THE FOLLOWING: "PREVIOUS FALL HISTORY, 12/2012. PREVENTION PLAN (SPECIFIC MEASURES): "IDENTIFY AND TREAT CAUSE, ALARM AND LOW BED." THE FOLLOWING WAS DOCUMENTED ON THE FALL CARE PLAN DATED 4/01/13, PROBLEM: "RISK FOR FALLS RELATED TO (R/DT) NEEDS, ASSIST WITH ALL ADL (ACTIVITIES OF DAILY LIVING), HYGIENE..." GOALS: RESIDENT WILL BE MONITORED THROUGHOUT THIS OBSERVATION PERIOD." A THERAPY PROGRESS NOTE WITH A START DATE OF 5/17/13 REVEALED: "PRECAUTIONS: FALL RISK, DEMENTIA AND ANXIETY, HAS HISTORY OF GETTING UP UNASSISTED...." ON 8/15/13 AT 11:00 A.M., NURSES NOTES WERE REVIEWED. ACCORDING TO THE NOTES DATED 5/20/13, "LATE ENTRY ON 5/19/13, "PATIENT (RESIDENT #513) fell IN BATHROOM. (NURSE) AIDE ("I") PUT PATIENT ON TOILET, LEFT ROOM, ANOTHER AIDE CHECKED ON PATIENT 2 MINUTES LATER. TWO MINUTES AFTER THAT ORIGINAL AIDE ("I") CAME BACK TO ROOM AND FOUND PATIENT ON LEFT (L) SIDE ON BATHROOM FLOOR....SKIN TEAR ON LEFT MIDDLE KNUCKLE." PER NURSES NOTES DATED 5/21/13: "X-RAY OF LEFT HAND STAT (RIGHT AWAY), DUE TO EDEMA AND BRUISING TO HAND AND FINGERS. TENDER TO TOUCH." ON 8/15/13 AT 11:10 AM, A REVIEW OF A HOSPITAL "CONSULTATION SHEET" DATED 5/23/13 FOR RESIDENT #513 REVEALED: "FALL-NON-DISPLACED FRACTURES-PROXIMAL....RING FINGER AND LITTLE FINGER, LEFT HAND....LEFT RING AND SMALL DIGITS PROXIMAL PHALANX FRACTURES (OPEN)...." ON 8/15/13 AT 12:30 PM, AIDE "I" WAS INTERVIEWED. AIDE "I" WAS ASKED HOW SHE WOULD DETERMINE WHETHER OR NOT A RESIDENT WAS TO BE LEFT ALONE IN THE BATHROOM AND WHETHER RESIDENT #513 SHOULD HAVE BEEN LEFT ALONE ON THE TOILET. CNA "I" STATED, "A MONTH AGO WE WERE USING THE SIT TO STAND (MECHANICAL LIFT) ON (RESIDENT #513). SHE SHOULD NOT BE LEFT ALONE. WE DON'T LEAVE ANY RESIDENTS ALONE IN THE BATHROOM IF THEY ARE FALL RISK OR IF THEY HAVE AN ALARM." AIDE "I" DID NOT RESPOND WHY SHE HAD LEFT THE RESIDENT UNATTENDED IN THE BATHROOM WHEN THE FALL OCCURRED. ON 8/15/13 AT 1:00 PM. THE ASSISTANT DIRECTOR OF NURSING (ADON) WAS QUERIED CONCERNING THE INCIDENT INVOLVING RESIDENT #513. THE ADON STATED " SHE WAS ONE OF THE RESIDENTS WHOSE ALARM WE REMOVED (BEFORE THE FRACTURES OCCURRED), BUT WE REALIZED THAT THE ALARM WAS HOW THE CNA'S KNEW NOT TO LEAVE THE RESIDENT ALONE. THE ALARM WAS A TRIGGER FOR THEM." THE ADON DID NOT RESPOND WHY THE RESIDENT WAS LEFT ALONE ON THE TOILET. THE ADON STATED " WE DISCIPLINED THE CNA AND SHE WAS INSTRUCTED THAT RESIDENTS WHO ARE AT HIGH RISK FOR FALLS SHOULD NOT BE LEFT ALONE IN THE BATHROOM." ON 8/15/13 AT 1:30 PM, PER REVIEW OF RESIDENT #513'S "FALL" CARE PLAN DATED 4/1/13, THERE WAS NO DOCUMENTED INTERVENTION INSTRUCTING STAFF NOT TO LEAVE THE RESIDENT UNATTENDED IN THE BATHROOM, UNTIL 5/20/13, AFTER THE FALL AND FRACTURES HAD OCCURRED. ON 8/15/13 AT 3 PM, THE FACILITY'S "FALL POLICY, "REVISED 4/2013, WAS REVIEWED THAT NOTED: -"ALL RESIDENTS WILL BE ASSESSED FOR FALLS WITH A CARE PLAN DEVELOPED WITH SPECIFIC INTERVENTIONS TO MEET THE NEEDS OF THE RESIDENT." THE POLICY DID NOT SPECIFICALLY ADDRESS THE ISSUE OF LEAVING DEPENDENT RESIDENTS UNATTENDED IN BATHROOMS. ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO MONITOR FOOD ACCEPTANCE, RESPOND TO LOW [MEDICATION NAME] LEVELS AND PERFORM CONSISTENT SKIN ASSESSMENTS FOR THE PREVENTION OF PRESSURE ULCERS FOR ONE (#701) OF THREE RESIDENTS REVIEWED FOR PRESSURE ULCER, OUT OF A TOTAL OF 15 SAMPLED RESIDENTS, RESULTING IN A FACILITY ACQUIRED PRESSURE ULCERS. FINDINGS INCLUDE: ON 9/28/11 AT 2:35 P.M., RESIDENT #701 WAS OBSERVED ASLEEP IN BED LYING ON HIS LEFT SIDE. A FOLEY CATHETER WAS NOTED DRAINING DARK YELLOW URINE. ON 9/28/11 AT 2:45 P.M., REVIEW OF RESIDENT #701 FACE SHEET REVEALED AN ORIGINAL admitted INto the facility on [DATE] AND WAS A RE-ADMISSION ON 6/7/11 WITH [DIAGNOSES REDACTED]. THE FACE SHEET ALSO REVEALED A hospitalization FOR THE TIME PERIOD OF 5/31/11 - 6/7/11. THE RESIDENT'S SIGNIFICANT CHANGE MINIMUM DATA SET (MDS), dated [DATE], INDICATED A SEVERELY IMPAIRED COGNITION, AND WAS DEPENDENT UPON THE STAFF FOR ALL ACTIVITIES OF DAILY LIVING (ADL'S). THE MDS IDENTIFIED RESIDENT #701 AT RISK FOR DEVELOPING PRESSURE ULCERS. REVIEW OF THE HOSPICE RECORDS, REVEALED AN ADMISSION INTO HOSPICE ON 6/25/11. RESIDENT #701'S ADMISSION SKIN ASSESSMENT, UPON RE-ADMISSION INTO THE FACILITY, DATED 6/7/11, INDICATED ONE PEA SIZE STAGE I PRESSURE ULCER WAS NOTED TO RESIDENT #701'S SCROTUM. THE SURROUNDING AREAS WAS NOTED TO BE RED. THERE WAS NO AREAS OF PRESSURE ULCERS DOCUMENTED. ON 9/28/11 AT 2:45 P.M., THE TREATMENT NURSE WAS QUERIED WHETHER RESIDENT #701 HAD PRESSURE ULCERS. NURSE "C" STATED, "HE HAS TWO PRESSURE ULCERS. THERE IS ONE ON HIS COCCYX THAT DEVELOPED 6/20/11. THE OTHER ONE ON HIS LEFT ISCHIAL THAT DEVELOPED 8/5/11." BOTH OF THE PRESSURE ULCERS HAD DEVELOPED AFTER RESIDENT #701'S RE-ADMISSION INTO THE FACILITY. ON 9/28/11 AT 2:50 P.M., THE FACILITY'S INTERVENTIONS FOR THE PREVENTION OF PRESSURE ULCERS WERE REVIEWED AND REVEALED THE FOLLOWING: REVIEW OF THE "RISK FOR INFECTION" CARE PLAN, DATED 6/7/11, INDICATED THE RESIDENT HAD AN OPEN WOUND ON HIS SCROTUM. THE ONLY INTERVENTION DOCUMENTED WAS "MONITOR FOR CHANGES IN SCROTUM. REPOSITION EVERY TWO HOURS." REVIEW OF THE "PREVENTATIVE SKIN" CARE PLAN, DATED 6/7/11, INDICATED A BRADEN SCALE SCORE OF 7 (INDICATIVE OF A SEVERE RISK FOR THE DEVELOPMENT OF PRESSURE ULCERS). THE ONLY INTERVENTION DOCUMENTED ON THE CARE PLAN WAS "SKIN ASSESSMENT WITH BATH." A "POTENTIAL FOR IMPAIRED SKIN INTEGRITY RELATED TO DECREASED MOBILITY," DATED 6/20/11 WAS NOTED WITH INTERVENTIONS THAT INCLUDED: 1. [MEDICATION NAME] TO COCCYX EVERY SHIFT AND AS NECESSARY, DATED 6/20/11 (ONSET OF FIRST PRESSURE ULCER), 2. MONITOR FOR REDNESS/[MEDICAL CONDITION] AND SIGNS OF INTEGRITY CHANGES. REVIEW OF THE TREATMENT ASSESSMENT RECORD (TAR) INDICATED ONE SKIN ASSESSMENT FOR THE MONTH OF JUNE 2011. THE ONE ASSESSMENT WAS COMPLETED ON 6/28/11 AND IT INDICATED NO SKIN ALTERATIONS. REVIEW OF THE "NUTRITION AND HYDRATION" CARE PLAN, DATED 6/7/11, INCLUDED INTERVENTIONS TO "FEED RESIDENT, RECORD INTAKE AT EVERY MEAL, BRADEN SCALE ASSESSMENTS EVERY WEEKS FOR FOUR WEEKS AND AS NECESSARY, AND SKIN ASSESSMENTS WEEKLY." REVIEW OF THE NUTRITION CARE PLAN DATED 7/7/11, REVEALED THE FOLLOWING INTERVENTIONS: "MONITOR LABS AND SKIN, MONITOR INTAKE AND WEIGHT, HONOR FOOD PREFERENCE, AND SEND SUPPLEMENT AS ORDERED." THERE WAS NO UPDATED NOTED TO THE CARE PLAN AFTER THE RESIDENT BEGAN TO LOSE WEIGHT AND AFTER THE RESIDENT DEVELOPED PRESSURE ULCERS. REVIEW OF THE NUTRITION CARE PROGRESS NOTE, DATE 7/7/11, REVEALED DOCUMENTATION THAT READ, "SKIN WAS INTACT AND WILL CONTINUE TO MONITOR LABS." THE ONSET OF THE FIRST PRESSURE ULCER (PER THE TREATMENT NURSE) WAS ON 6/20/11. THE NOTES DATED 9/2/11 AND 9/12/11 DID NOT NOTE THE [MEDICATION NAME] LEVEL OF 2.0 (LOW LEVEL WHICH PUTS THE RESIDENT AT EVEN A HIGHER RISK FOR PRESSURE ULCERS) FROM A LAB RESULT ON 7/14/11. THE DIETICIAN DID NOT ADDRESS PREVENTATIVE SKIN CARE MEASURES OR INTERVENTIONS FOR WOUND HEALING EITHER. THERE WAS NO RE-ASSESSMENT OF ESTIMATED NUTRIENT NEEDS SINCE THE INITIAL NUTRITION RISK ASSESSMENT ON 4/14/11 (ORIGINAL ADMISSION). THE RESIDENT'S PRESSURE ULCERS WERE NOT ADDRESSED UNTIL 9/12/11 IN A NUTRITION PROGRESS NOTE. BY THAT TIME A SECOND PRESSURE ULCER HAD DEVELOPED (8/5/11). THERE WAS NO OTHER RISK ASSESSMENT AFTER THE DEVELOPMENT OF THE PRESSURE ULCER AND THE SIGNIFICANT CHANGE MDS. A SIGNIFICANT CHANGE MDS WAS COMPLETED ON 7/11/11, BUT YET THERE WAS NO DOCUMENTATION OF THE PRESSURE ULCER NOR NUTRITION PLAN OF CARE. THERE WERE NO PREVENTATIVE MEASURES UNTIL 9/12/11. THE FOOD ACCEPTANCE RECORDS (FARS) WERE REQUESTED. ONLY THREE DAYS OF FARS WERE NOTED (6/9, 6/10 AND 6/11/11). THE FARS INDICATED 50 - 100%. THERE WAS NO OTHER DOCUMENTATION OF THE RESIDENT'S FOOD AND FLUID INTAKE. REVIEW OF THE FACILITY'S POLICY ENTITLED, "FOOD ACCEPTANCE RECORDS," (LAST REVISION 6/09), REVEALED DOCUMENTATION THAT READ, 'FOOD ACCEPTANCE RECORDS WILL BE INITIATED AND MAINTAINED AS FOLLOWS: NEW AND RE-ADMISSIONS. FARS WILL BE COMPLETED ON ALL NEW AND RE-ADMISSIONS FOR AT LEAST FIVE DAYS TO ASSIST IN ESTABLISHING THE RESIDENT'S CURRENT EATING PATTERN. THE REGISTERED DIETICIAN WILL REVIEW FARS AFTER THE FIFTH DAY TO DETERMINE THE NEED FOR CONTINUED MONITORING. THE REGISTERED DIETICIAN AND NURSING MANAGEMENT WILL BE RESPONSIBLE FOR MONITORING FARS ON A REGULAR BASIS...ISSUE WITH DISCREPANCIES OR INCOMPLETE RECORDS WILL BE ADDRESSED..' REVIEW OF RESIDENT #701'S WEIGHTS REVEALED 29 POUND WEIGHT LOSS FROM THE TIME OF ADMISSION TO 9/9/11. THE RESIDENT'S ADMISSION WEIGHT ON 6/7/11 WAS DOCUMENTED AS 177 POUNDS. THE WEIGHT ON 9/9/11 WAS DOCUMENTED AS 148.0 POUNDS. ON 9/28/11 AT 2:55 P.M., THE DIETICIAN (EMPLOYEE "E") WAS QUERIED REGARDING THE INTERVENTION FOR COMPLETING FOOD ACCEPTANCE RECORDS LISTED ON THE NUTRITION CARE PLAN AND WHY THERE WAS ONLY THREE DAYS WORTH OF RECORDS AND WHY SHE DID NOT ADDRESS THE CONCERN OF PRESSURE ULCERS UNTIL 9/12/11. THERE WAS NO EXPLANATION PROVIDED. ON 9/29/11 AT 9:15 A.M., RESIDENT #701'S SHOWER SHEETS WERE REQUESTED. THE SHOWER SHEETS WERE REVIEWED AND THE FOLLOWING REVEALED: THE SHOWER SHEET DATED 6/7/11 INDICATED "ONE SORE ON SCROTUM." THERE WAS NO OTHER SKIN ALTERATIONS NOTED ON THE SHOWER SHEET. THE SHOWER SHEET DATED 6/15/11, AN "OLD BRUISE"TO RESIDENT #701'S RIGHT ARM. THERE WAS NO OTHER SKIN ALTERATIONS. THE SHOWER SHEET DATED 6/22/11, INDICATED AN OPEN AREA TO THE RESIDENT'S COCCYX. THE SHOWER SHEET DATED, 6/29/11, AGAIN, INDICATED AN OPEN AREA TO THE RESIDENT'S COCCYX AREA. ON 9/29/11 AT 9:55 A.M., THE DON WAS QUERIED AS TO WHERE THE REST OF THE SHOWER SHEETS WERE. THE DON WAS UNABLE TO PROVIDE AN EXPLANATION. ON 9/29/11 AT 9:40 A.M., AN OBSERVATION OF THE RESIDENT'S WOUND WERE MADE WITH THE HOSPICE NURSE. THE HOSPICE NURSE REMOVED THE DRESSING AND PACKING FROM THE LEFT HIP. MODERATE AMOUNTS OF SEROSANGUINOUS DRAINAGE WAS NOTED. THE MAJORITY OF THE WOUND WAS NECROTIC WITH A A SMALL PINK TISSUE PERIMETER. THE WOUND DESCRIBED AS UNSTAGEABLE. IT MEASURED 8.7 CENTIMETERS (CM) X 8.0 CM WITH 3.1 DEPTH. THE WOUND WAS CLEANSED WITH NORMAL SALINE AND PACKED WITH A SATURATED [MEDICATION NAME] DRESSING . THE DRESSING WAS REMOVED FROM THE COCCYX. THE COCCYX HAD A SMALL AMOUNT OF SLOUGH IN THE CENTER. THE WOUND BED WAS MOSTLY RED. THE WOUND DESCRIBED AS UNSTAGEABLE AND MEASURED 4.0 CM X 2.5 CM WITH 2.8 DEPTH. THE WOUND WAS PACKED WITH A SATURATED [MEDICATION NAME] DRESSING. THE HOSPICE NURSE WAS QUERIED REGARDING WHEN THE RESIDENT RECEIVED THE SPECIALTY MATTRESS ("MICRO AIR," SETTING SET ON 3). THE HOSPICE NURSE STATED, "WE GAVE HIM THE MATTRESS AFTER THE DEVELOPMENT OF THE PRESSURE ULCER." ON 9/29/11 AT 10:50 A.M., THE DIRECTOR OF NURSES (DON) WAS QUERIED WHETHER THERE WERE MORE SHOWER SHEETS. THE DON REPORTED THOSE WERE ALL OF THE SHOWER SHEETS SHE WAS ABLE TO FIND. THE DON PROVIDED NO EXPLANATION FOR THE MISSING SKIN ASSESSMENTS IN JUNE 2011, (PRIOR TO THE DEVELOPMENT OF THE PRESSURE ULCERS) NOR THE MISSING SHOWER SHEETS THAT INDICATED SKIN ASSESSMENTS. ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW THE FACILITY FAILED TO ENSURE THAT 1 OF 4 SAMPLED RESIDENTS (#501) WAS PROVIDED BOTH PROPER AND SAFE TRANSFER WITH A "TEMPO" MECHANICAL LIFT WHEN THE RESIDENT'S WHEELCHAIR TIPPED BACKWARD AND HE SUSTAINED A HEAD INJURY THAT REQUIRED 4 STAPLES. FINDINGS INCLUDE: REVIEW OF THE CLINICAL RECORD FOR RESIDENT #501 REVEALED THAT HE HAD [DIAGNOSES REDACTED]. THE COMPREHENSIVE assessment dated [DATE], INDICATED THAT THE RESIDENT WAS DEPENDENT ON STAFF AND REQUIRED EXTENSIVE ASSISTANCE WITH TRANSFERS. THE COMPREHENSIVE CARE PLAN DATED 12/28/10, INDICATED THAT THE RESIDENT REQUIRED A "TEMPO" MECHANICAL LIFT FOR TRANSFERS. DURING A TOUR OF THE FACILITY ON 6/14/11, AT 10:00 A.M., RESIDENT #501 WAS OBSERVED IN HIS WHEELCHAIR IN THE CORRIDOR OUTSIDE OF HIS ROOM LOCATED ON THE SECOND FLOOR. REVIEW OF THE NURSE'S NOTES DATED 5/25/11, INDICATED THAT THE RESIDENT HAD A FALL INCIDENT AND SUSTAINED A LACERATION TO THE BACK OF HIS HEAD. THE NURSE'S NOTES INDICATED THAT RESIDENT #501 WAS TRANSFERRED TO AN AREA HOSPITAL FOR EMERGENCY TREATMENT. REVIEW OF THE HOSPITAL RECORD INDICATED THAT "4 STAPLES" HAD BEEN APPLIED TO THE LACERATION AND THE RESIDENT WAS KEPT OVERNIGHT IN THE HOSPITAL FOR OBSERVATION AND RETURNED THE FOLLOWING DAY TO THE NURSING HOME. REVIEW OF AN INCIDENT REPORT DATED 5/25/11, INDICATED THAT RESIDENT #501 HAD A FALL WHEN HE WAS BEING TRANSFERRED WITH A "TEMPO" MECHANICAL LIFT BY EMPLOYEES "A" AND "B". THE INCIDENT OCCURRED IN THE RESIDENT'S ROOM AT APPROXIMATELY 8:40 A.M., ON 5/25/11. THE REPORT INDICATED THAT WHEN EMPLOYEE'S "A" AND "B" WERE UNHOOKING THE STRAPS TO "TEMPO" MECHANICAL LIFT THE RESIDENT'S WHEELCHAIR TIPPED BACK RESULTING IN THE RESIDENT FALLING BACKWARD STRIKING THE BACK OF HIS HEAD ON THE FLOOR. ON 6/14/11, AT 12:00 P.M., INTERVIEW WITH EMPLOYEE "A" REVEALED THAT AT APPROXIMATELY 8:30 A.M., ON 5/25/11, SHE AND EMPLOYEE "B" WERE USING A "TEMPO" MECHANICAL LIFT TO TRANSFER RESIDENT #501 OUT OF HIS BED AND INTO HIS WHEELCHAIR. EMPLOYEE "A" STATED EMPLOYEE "B" WAS OPERATING THE "TEMPO" LIFT WHILE SHE (EMPLOYEE "A") GUIDED RESIDENT #501 INTO THE WHEELCHAIR FROM THE LIFT SLING. EMPLOYEE "A" STATED THAT SHE LOCKED THE BRAKES TO THE RESIDENT'S WHEELCHAIR BEFORE THE TRANSFER WAS INITIATED. EMPLOYEE "A" STATED THAT WHEN THE TWO AIDES (EMPLOYEES "A" AND "B") UNHOOKED THE STRAPS OF THE "TEMPO" LIFT, THE RESIDENT'S WHEELCHAIR TIPPED BACKWARD. EMPLOYEE "A" STATED THAT RESIDENT STRUCK THE BACK OF HIS HEAD ON THE FLOOR. ON 6/15/11, AT 11:05 A.M., INTERVIEW WITH EMPLOYEE "B" REVEALED THAT SHE WAS OPERATING THE "TEMPO" MECHANICAL LIFT WHILE EMPLOYEE "A" GUIDED RESIDENT #501 FROM THE LIFT SLING DOWN INTO THE WHEELCHAIR. EMPLOYEE "B" STATED THAT SHE LOCKED THE BRAKES TO THE LIFT BEFORE SHE AND EMPLOYEE "A" UNHOOKED THE SLING STRAPS. EMPLOYEE "B" STATED THAT AFTER THE LIFT STRAPS WERE UNHOOKED, THE WHEELCHAIR TIPPED BACKWARD AND RESIDENT #501 STRUCK THE BACK OF HIS HEAD ON THE FLOOR. EMPLOYEE "B" STATED THAT THE "TEMPO" LIFT BRAKES WERE IN THE LOCKED POSITION WHEN THE ACCIDENT OCCURRED. ON 6/15/11, AT 11:00 A.M., INTERVIEW WITH THE ASSISTANT DIRECTOR OF NURSES (ADON) REVEALED THAT SHE (THE ADON) HAD RESPONDED TO THE ROOM WHEN SHE HEARD A LOUD SOUND. THE ADON STATED THAT THE BRAKES TO THE TEMPO LIFT WERE IN A LOCKED POSITION AT THE TIME OF THE INCIDENT. THE ADON STATED THAT THE LOCKED "TEMPO" LIFT BRAKES WERE A CONTRIBUTING FACTOR IN THE RESIDENT'S WHEELCHAIR TIPPING BACKWARD. REVIEW OF THE "TEMPO- MECHANICAL LIFT OPERATING AND PRODUCT CARE INSTRUCTIONS MANUAL" INDICATED THE THE FOLLOWING RECOMMENDATION: ? REMEMBER TO RELEASE THE BRAKES IF THEY HAVE BEEN APPLIED BEFORE TRANSPORTING THE RESIDENT. THE ADON FURTHER REPORTED THAT SUBSEQUENT TO THE INCIDENT, ALL NURSING STAFF HAD BEEN RE-INSERVICED ON USE OF THE "TEMPO" MECHANICAL LIFT AND TO ENSURE THAT THE BRAKES BE RELEASED WHEN TRANSPORTING A RESIDENT. FURTHERMORE, THE ASSISTANT DIRECTOR OF NURSING STATED THAT THE FACILITY'S WRITTEN POLICY ON USE OF THE "TEMPO" LIFT HAD BEEN MODIFIED TO ALERT STAFF TO RELEASE THE BRAKES WHEN TRANSPORTING A RESIDENT AS RECOMMENDED IN THE "TEMPO" MANUAL. ( )

THIS CITATION PERTAINS TO INTAKE: MI 647 BASED ON INTERVIEWS AND RECORDS REVIEW THE FACILITY FAILED TO PROPERLY UTILIZE SAFETY EQUIPMENT (PERSONAL ALARM) TO PREVENT FALLS IN 1 OF 4 RESIDENTS ( # 101) , RESULTING IN RESIDENT # 101 FALLING AND SUSTAINING A LACERATION TO HER FOREHEAD AND A RIGHT PROXIMAL RADIAL NECK FRACTURE (ELBOW). FINDINGS INCLUDE: ACCORDING TO THE FACILITY INCIDENT REPORT DATED 2/28/11, ON 2/27/11 AT APPROXIMATELY 10:30 A.M., RESIDENT #101 WAS HEARD YELLING FOR HELP. FACILITY STAFF FOUND RESIDENT # 101 LAYING ON THE FLOOR IN FRONT OF HER BATHROOM WITH A LACERATION TO THE THE RIGHT SIDE OF HER FOREHEAD AND A FRACTURED ELBOW. THE RESIDENT'S PERSONAL ALARM WAS NOT SOUNDING. THE HOSPITAL'S X-RAY REPORT DATED 2/27/11, IDENTIFIED RESIDENT #101 AS HAVING A TRANSVERSE PROXIMAL FRACTURE OF THE RIGHT RADIUS. THE HOSPITAL'S CAT SCAN REPORT DATED 2/27/11 INDICATED RESIDENT # 101 WAS NEGATIVE FOR A CRANIAL BLEED OR SKULL FRACTURE. ACCORDING TO RESIDENT # 101'S FACE SHEET DATED 2/15/11, RESIDENT # 101 WAS A [AGE] year OLD FEMALE WHO admitted to the facility on [DATE] WITH MULTIPLE [DIAGNOSES REDACTED]. ON 2/16/11, THE PHYSICIAN PRESCRIBED: ALARMS TO BED AND WHEELCHAIR TO ALERT THE STAFF OF RESIDENT'S UNASSISTED ATTEMPTS TO SELF-TRANSFER A REVIEW OF THE CARE ASSESSMENTS AND FALL RISK ASSESSMENTS FROM 12/23/10 - 3/7/11 IDENTIFIED RESIDENT #101 AS BEING AT RISK FOR FALLS. A CARE PLAN FOR 'FALLS' DATED 2/14/11 HAD LISTED THE FOLLOWING INTERVENTIONS; PERSONAL ALARM WHILE IN BED AND WHEELCHAIR. ON 3/23/11 AT 11:45 A.M., CNA #5 SAID THAT SHE HAD ASSISTED RESIDENT # 101 TO THE BATHROOM AT APPROXIMATELY 9:30 A.M., AND THEN REPLACED RESIDENT # 101'S PERSONAL ALARM ONTO THE BACK PART OF THE RESIDENT'S SHIRT. CNA # 5 SAID SHE WAS NOT ASSIGNED TO RESIDENT # 101 AT THAT TIME, BUT HAD ASSISTED IN TAKING HER TO THE BATHROOM. ON 3/23/11 AT 11:30 A.M., LICENSED PRACTICAL NURSE (LPN) # 4 SAID THAT ON 2/27/11 AT APPROXIMATELY 10:30 A.M., SHE HEARD A LOUD NOISE FROM RESIDENT # 101'S ROOM AND THEN HEARD THE RESIDENT YELLING FOR HELP. LPN # 4 SAID THAT RESIDENT # 101 WAS LAYING ON THE FLOOR, NEAR THE BATHROOM DOOR, WITH A LACERATION OVER HER RIGHT EYEBROW. RESIDENT # 101'S ALARM WAS NOT SOUNDING AND NOT CONNECTED TO THE RESIDENT. THE ALARM WAS SITTING ON THE BACK OF RESIDENT #101'S WHEELCHAIR WITH THE CLIP ATTACHED TO THE ALARM BOX. THE WHEELCHAIR WAS NEAR THE RESIDENT'S BED AND THE RESIDENT WAS HALF WAY ACROSS THE ROOM, NEAR THE BATHROOM DOOR. LPN # 4 SAID THE RESIDENT HAD BEEN RECENTLY EXAMINED BY THE PHYSICIAN AND HAD BEEN TOILETED BY THE CERTIFIED NURSE ASSISTANT (CNA) IMMEDIATELY BEFORE THE PHYSICIAN CAME INTO THE ROOM. LPN # 4 WAS UANBLE TO EXPLAIN WHY THE PERSONAL ALARM WAS NOT IN USE. ON 3/23/11 AT 12:00, THE PHYSICIAN SAID THAT ON 2/27/11 AT APPROXIMATELY 10:00 A.M., HE HAD EXAMINED RESIDENT # 101'S EYES, WHILE SHE WAS SEATED IN HER WHEELCHAIR, NEXT TO THE BED, IN HER ROOM. THE PHYSICIAN SAID HE DID NOT TOUCH THE RESIDENT'S ALARM, OR NOTICE IF IT WAS PROPERLY ATTACHED TO THE RESIDENT'S SHIRT. ( )