Every finding on record at Niles Care Center, LLC

Based on interview and record review the facility failed to ensure a safe transfer of a resident in 1 (Resident #103) of 3 residents reviewed for falls resulting in a fall by Resident #103.Findings include:Resident #103Review of an admission Record revealed Resident #103 was a male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: other abnormal involuntary movements, restless legs syndrome, other abnormalities of gait and mobility, and limitation of activities due to disability. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 2/16/26 revealed a Brief Interview for Mental Status (BIMS) score of 8, out of a total possible score of 15, which indicated Resident #103 was moderately cognitively impaired.Review of a Baseline Care Plan for Resident #103 revealed, .Effective Date 2/11/26.B. Functional Abilities and Goals - Mobility.2. Transfer: support provided.3. Two+ persons physical assist.Review of an Attended Fall Report for Resident #103 revealed, Date 2/26/2026 10:11.Incident Description: Nursing Description: It was reported to this nurse that resident was being transferred from his bed by staff for ADL (activities of daily living) care. While being transferred resident stated his legs were giving way and he was lowered to the floor by CNAs (certified nurse aides). Resident was able to assist standing with the help of both CNAs back to his wheelchair. ADLs were performed in the bathroom without further incident. Patient Description: Resident stated his legs gave out. Denies pain or discomfort at that time.Review of a Grievance and Satisfaction Form for Resident #103 dated 3/19/26 revealed, Received from Resident (Resident #103).Describe Grievance or Satisfaction On February 26th, 2026, (Resident #103) was lifted out of bed by only one person, whe (sic) (Resident #103) is a two-man assist. During lift (Resident #103) fell to the floor and hit his leg and his back on the bed and floor causing severe bruising and scratches on the back of his legs and back. The staff member that lifted (Resident #103) is named (CNA X).In an interview on 4/16/26 at 10:45 AM, CNA Z reported Resident #103 was a 2 person stand assist.In an interview on 4/16/26 at 2:01 PM, Resident #103 reported when the one lady (CNA X) tried to transfer him, she was starting to turn and he (Resident #103) tried to turn and when they started turning, he (Resident #103) started to slide, and he (Resident #103) let go of CNA X. Resident #103 reported he hit the floor hard and had two black and blue marks on his leg. Resident #103 reported (CNA X) was transferring him by herself but that he was supposed to have 2 people to transfer him.In an interview on 4/16/26 at 2:26 PM, CNA X reported she had been told that Resident #103 was an extensive assist of 1 person for transfers and that was the first time she had been taking care of him. CNA X reported she found out later that Resident #103 was an extensive assist of 2 for transfers and that she had basically tried to transfer him by herself.In an interview on 4/17/26 at 8:40 AM, Director of Nursing (DON) B reported that Resident #103 was a 2 person assist for transfers on 2/26/26 and that CNA X had transferred him by herself.

Based on interview and record review, the facility failed to ensure accurate medical records for 2 (Resident #100 and #101) of 3 residents reviewed for accurate medical records, resulting in an inaccurate reflection of the residents' medication administrations.Findings include:Resident #100Review of an admission Record revealed Resident #100 was a male, with pertinent diagnoses which included: morbid (severe) obesity due to excess calories. Review of an Order Summary Report with active orders as of 10/17/25 revealed, Wegovy Subcutaneous (under the skin) Solution Auto-injector 2.4 MG/0.75 ML (milligrams/milliliter) (Semaglutide (Weight Management) Inject 2.4 mg subcutaneously in the morning every Fri (Friday) for obesity.Order Date 10/14/2025.Start Date 10/17/2025Review of a Medication Administration Record (MAR) for October, 2025 revealed, Wegovy Subcutaneous Solution Auto-Injector 2.4 MG/0.75 ML (Semaglutide (Weight Management) Inject 2.4 mg subcutaneously in the morning every Fri for obesity was documented as being administered by Registered Nurse (RN) T on 10/17/25.In an interview on 4/14/26 at 3:04 PM, Pharmacist (P) CC reported the pharmacy had never sent Wegovy for Resident #100 because the insurance did not cover it. P CC reiterated he has never received Wegovy from our pharmacy.In an interview on 4/14/26 at 3:27 PM, RN T reported it was probably a mistake in clicking on the computer because I don't think it could have been given because it wasn't here. RN T reported he did not have a recollection if he gave it or not.In a follow-up interview on 4/16/26 at 1:50 PM, RN T reported he told Resident #100 that he did not recall giving the Wegovy shot and it was most likely an incorrect documentation. RN T reiterated he thought it was incorrect documentation and did not remember giving Resident #100 the Wegovy shot.In an interview on 4/17/26 at 9:49 AM, Director of Nursing (DON) B reported regarding Resident #100's MAR for October, 2025 documentation that Wegovy had been administered on 10/17/25, the facility believed it was a documentation error because there was nobody else in the building on that medication, the pharmacy had not sent the medication, and RN T had reported he did not remember giving the injection to Resident #100.Resident #101Review of an admission Record revealed Resident #101 was a male, with pertinent diagnoses which included: low back pain, unspecified and pain, unspecified. Review of an Order Summary Report with active orders as of 3/10/26 revealed Percocet Oral Tablet 7.5-325 MG (Oxycodone w/ (with) Acetaminophen) Give 1 tablet by mouth three times a day for PainReview of an Order Summary Report with active orders as of 3/10/26 revealed, Percocet Oral Tablet 7.5-325 MG (milligrams) (Oxycodone w/ Acetaminophen) *Give 1 tablet by mouth as needed for Breakthrough Pain Give ONCE DAILY for Severe Pain*Review of a Medication Administration Record (MAR) for March, 2026 revealed, Percocet Oral Tablet 7.5-325 MG (Oxycodone w/ Acetaminophen) Give 1 tablet by mouth three times a day for Pain was documented as being administered on 3/13/26 at 0800 (8:00 AM) by Registered Nurse (RN) EE, 1500 (3:00 PM) by Licensed Practical Nurse (LPN) R, and 2000 (8:00 PM) by LPN R. (Note that a total of 3 doses were documented as being administered.)Review of a MAR for March, 2026 revealed Percocet Oral Tablet 7.5-325 MG (Oxycodone w/ Acetaminophen) Give 1 tablet by mouth as needed for Breakthrough Pain *Give ONCE DAILY for Severe Pain* was documented as being administered on 3/13/26 at 952 (9:52 AM) by LPN EE and 1405 (2:05 PM) by LPN EE. (Note that a total of 2 doses were documented as being administered.)Review of a Controlled Drug Receipt document for OXYCOD/APAP (Percocet) for Resident #101 date received 3/10/26 revealed a total of 4 tablets were signed out on 3/13/26 (at 1100 (11:00 AM), 1410 (2:10 PM), 1450 (2:50 PM) and 2040 (8:40 PM).In an interview on 4/15/26 at 2:09 PM, LPN EE reported she remembered Resident #101 was in pain, so she gave him his routine Percocet and he was in more pain, so he was given a prn (as needed) Percocet. LPN EE reported whatever was documented on the Controlled Drug Receipt was what was given to the resident. LPN EE reported it was an error on the MAR, and she thought she documented incorrectly. LPN EE reported she counted the medications at the end of the shift and the count was correct. LPN EE stated, if anything, it must have just been an error documenting on the MAR. (referring to the second dose of prn Percocet that was documented as being administered)In an interview on 4/17/26 at 9:49 AM, DON B reported the MAR documentation indicating that Resident #101 received a total of 5 Percocet tablets instead of 4 had to be an error because the narcotic count was correct in showing that 4 Percocet tablets had been signed out.

Based on observation, interview, and record review, the facility failed to ensure the published menu was served as planned and residents were consistently informed in advance of any menu changes affecting all residents consuming food from the kitchen resulting in resident dissatisfaction with their meal experience and feelings of frustration related to meals. Findings include:During an interview on 1/21/2026 at 10:02 AM, Dietary Supervisor (DS) Q stated that they serve the main meal and there was an always available menu for the residents that didn't like the main meal served. Review of the always available menu revealed cheeseburger, hot dog, salad, tomato or chicken noodle soup, grilled cheese, peanut butter and jelly.During an observation on 1/22/2026 10:55 AM, the menu posted in the main dining room for lunch was onion sage chicken, au gratin potatoes, carrot medallions and spice cake. The week at a glance menu for 1/22/2026 was onion sage chicken, au gratin potatoes, carrots and upside-down spice cake.During an observation and interview on 1/22/2026 at 11:51 AM, the lunch on the tray line was observed to be au gratin potatoes and medallion carrots. When asked where the onion sage chicken was, Dietary [NAME] (DC) U stated that she was asked by DS Q to mix the chicken into the potatoes so she made it into a casserole. It was observed that there was hardly any chicken cut up and put into the potatoes and was approximately 1 ounce (oz) per serving instead of the recommended 3 oz protein serving size. When asked what the residents on mechanical soft diets would receive, DC U said that they would get the same carrots. When further queried since the carrots were hard on the steam table and they were getting ready for lunch service, DC U stated that they had to be cooked more so they could be softer for the mechanical soft diets and proceeded to take some out and cook it longer. DC U [NAME] said she usually made sure mechanical soft menu items were available but the carrots were hard to cook and she thought it was okay to serve. During an interview on 1/22/2026 at 12:05 PM, Registered Dietitian (RD) CC stated that the same meal was served to all residents except for some special tweaks such as for no added salt (NAS) diets, no salt packet was given, and for carbohydrate-controlled diets (for diabetics), instead of a dessert a fruit cup was given. At 1/22/2026 at 12:07 PM, it was noted that DS Q pulled out the menu spreadsheet for the day and went over what to serve mechanical soft diets, NAS diets and diabetic diets with the DC U and the dietary aide since they weren't sure what to serve. During an interview on 1/22/2026 at 12:07 PM, DM Q stated that the facility didn't have the correct amount of chicken so he told DC U to mix the au gratin potatoes with the chicken into a casserole. When asked about the menu board in the main dining room not being updated with this change, DS Q said he wasn't aware it had to be changed since the cook used the same food items and made it into a casserole. DS Q also stated that the cooks generally gave the same vegetables to mechanical soft residents as regular, they just cook the vegetables longer to where they are very soft. During a confidential Resident Council meeting on 1/23/2026 at 11:05 AM, 1 resident stated that the kitchen changed the menus quite a bit and sometimes they would let them know about the changes and sometimes they didn't. During another interview on 1/22/2026 at 1:05 PM, DS Q stated that the cook didn't cook enough chicken for the meal so he told her to make a casserole instead. DS Q said he was unaware that there wasn't enough protein for the lunch meal since they didn't cook enough chicken. When discussing the menu spreadsheets and whether they were being followed for quantities needed and for the therapeutic diets, DS Q reported that they don't follow the therapeutic diet if there was one and they usually alter consistencies with whatever is available or make the food soft. DS Q also stated that he changes the menus often from what the dining company RD makes since he knew what the residents prefer but he had to remember to change the menu board when he did that. During an interview on 1/22/2026 at 4:42 PM, Nursing Home Administrator (NHA) A stated that she wasn't aware of the menu not being followed in the kitchen, staff not knowing what to serve mechanically altered diets and diabetics, and the menu spreadsheets not being followed.

Based on interview and record review the facility failed to honor resident food choice preferences in 1 resident (Resident #37) of 3 residents reviewed for food preferences and didn't have enough food supply according to 2 residents (Resident #16, Resident #19) resulting in the increased likelihood for decreased food acceptance and frustration in not getting what they wanted to eat.Findings include:Resident #37 (R37)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R37 initially admitted to the facility on [DATE] and her Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R37 was cognitively intact.During an interview on 1/21/2026 at 11:14 AM, R37 stated that the food is horrible so she ordered the same thing for dinner every night-2 hamburger patties with no bun and dessert. R37 stated that she wanted English Muffins but had to buy her own because the kitchen wouldn't get it for her. R39 also said that she liked tomatoes on salad and more vegetables to be served. R37 stated that she talked to Dietary Supervisor (DS) Q about her preferences in the past but she was still unhappy.Resident #16(R16)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R16 admitted to the facility on [DATE] and his Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R16 was cognitively intact.During an interview on 1/21/2026 at 12:03 PM, R16 stated that the kitchen ran out of food a lot especially when the end of the month was near. R16 said that the kitchen ran out of brown sugar, butter, bananas and peach cups often. During another interview on 1/22/2026 at 9:56 AM, R16 stated that the kitchen had run out of hot dogs and hamburgers for a week before and it is supposed to be available since it's on the always available menu. R16 also said that the kitchen served food that no one liked and they didn't have condiments available. Resident #29 (R29)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R29 admitted to the facility on [DATE] and his Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R29 was cognitively intact.During an interview on 1/22/2026 at 1:06 PM, R29 stated that the kitchen ran out of hotdogs and hamburgers a lot. He said they also ran out of pudding and bananas, especially from the middle to the end of every month. Review of the always available menu revealed cheeseburger, hot dog, salad, tomato or chicken noodle soup, grilled cheese, peanut butter and jelly.During an interview on 1/21/2026 at 10:02 AM, Dietary Supervisor (DS) Q stated that he talked to the residents to get their food preferences. DS Q said they have the main meal and an always available menu for the residents that didn't like the main meal served. During an interview on 1/22/2026 at 12:07 PM, DS Q and RD CC stated that food orders came from 2 different food sources and they came on Thursdays and Fridays which was how it had always been and corporate wouldn't allow only 1 food company to deliver food. DS Q reported that he ordered the food for the week and then it went to the corporate level and they adjusted items from there to make sure they stayed in budget. When asked what DS Q does when they didn't have food in the kitchen, he stated that he went to the store and picked up any items he needed. DS Q stated that he didn't hear the residents talking about the kitchen running out of food and if they did it usually took 1-2 days to get the food in. RD CC stated that they have run out of brown sugar and haven't had it available since corporate took it off to stay in budget. During another interview on 1/22/2026 at 2:30, DS Q reported that they have run out of bananas before but they always had fruit cup, applesauce, and blueberries for an option. DS Q also said that he obtained food preferences from residents and he would talk to R37 again about her food preferences. During an interview on 1/22/2026 at 4:42 PM, Nursing Home Administrator (NHA) A stated that food orders were done by DS Q and then it went to a third party and they made changes as needed. NHA A stated she wasn't aware that residents said that food was running out by the middle to end of each month. Review of the Food Preference Policy with an adoption date of 7/11/2018 revealed .8. If the resident refuses or is unhappy with his or her diet, the staff will create a care plan that the resident is satisfied with.10. The Food Services Department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night.

Based on interview and record review, the facility failed to ensure that Quality Assessment and Process Improvement (QAPI) meetings had the Medical Director (MD) and the Infection Preventionist (IP) as mandatory attendees at least quarterly resulting in the potential for the MD and the IP to not be notified of quality deficiencies occurring in the facility.Findings include:Review of the QAPI Committee Adaptation and Attendance Record dated 1/28/2025, 4/25/2025 and 7/29/2025 revealed that the MD DD did not attend the meetings.Review of the QAPI Committee Adaptation and Attendance Record showed that there wasn't a meeting in September 2025 and November 2025 and the IP did not attend the meeting on 10/30/2025.During an interview on 1/23/2026 at 9:42 AM, MD DD stated that he tried to attend QAPI every month whether it was in person or by phone because he wanted to know what was going on in the facility in all the different areas. MD DD said he couldn't remember the dates that he wasn't at QAPI and stated that if he didn't sign the sheet then he didn't attend. During an interview on 1/23/2026 at 1:10 PM, Nursing Home Administrator A stated that they have QAPI meetings monthly to ensure that the required attendees such as the MD and IP attend quarterly. This surveyor reviewed the dates that the MD and IP were not at the QAPI meetings and NHA A nodded and said that there have been changes in management including her this past year. Review of the Quality Assessment and Assurance Program 9/18/2019 revealed .Required Members: Administrator serves as chairperson, Director of Nursing, Medical Director or other attending physician designated by the facility, at least three (3) other staff members, at least one must be the administrator, owner, a board member or other individual in a leadership roleInfection Control and Prevention Officer . Expectations of the Committee: QAPI is an ongoing process rather than a once a quarter event.The QAPI committee meets monthly. Committee members are required to attend regularly scheduled meetings. In the event that Committee members are unable to attend meetings, arrangements are made for a designee to present required work, data, reports and progress on issues.

Based on observation, interview, and record review, the facility failed to implement the necessary infection control measures for residents at risk based on physician orders and standards of infection control for 4 residents (Resident #63, #55, #15 and #13) of 7 residents reviewed for infection control practices, resulting in the potential for transmission of MDRO (multidrug-resistant organisms) and an increased risk of infections to a vulnerable population. Findings include:Resident #63 Review of an admission Record revealed Resident #63 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: obstructive uropathy (blockage in urine flow) and urogenital implant (indwelling foley catheter). Review of Resident #63's Physician Orders revealed, Maintain Foley catheter with 16 Fr 5cc balloon every shift.Start date 1/14/26 at 2:30 PM, Wound care for R (right) hallux (big toe) . Start date: 1/14/26, Enhanced Barrier Precautions (includes gown and gloves for high-contact resident care activities) for wound and foley catheter every shift for patient monitoring.Start date 1/14/26. During an observation on 01/21/2026 at 2:02 PM Resident #63's room was posted with signage indicating Enhanced Barrier Precautions (EBP) were in place and during transfers (direct care) that staff should wear a gown and gloves. Observed foley catheter tubing and a drainage bag attached to the bedframe and Resident #63's right foot observed wrapped with gauze. Certified Nursing Assistant (CNA) J and Registered Nurse (RN) P were preparing to transfer the resident from wheelchair to bed. Both staff were wearing gloves but did not have gowns on. RN P wrapped the gait belt around Resident #63's waist, then another facility staff entered the room and alerted RN P and CNA J to put gowns on. The staff both paused care to obtain gowns but there were no gowns in the resident's room or hanging on the door with the gloves. During an observation on 1/22/26 at 10:21 AM in Resident #63's room, Certified Occupational Therapy Assistant (COTA) BB was preparing to transfer the resident from bed to wheelchair and was wearing gloves but no gown. COTA BB wrapped the gait belt around Resident #63 and helped him to the edge of the bed. COTA BB stood in front of Resident #63 and wrapped her arms around him, holding onto the gait belt and assisted him to stand and pivot into the wheelchair. COTA BB then unhooked Resident #63's foley catheter bag from the bed frame and positioned it underneath the wheelchair. COTA BB discarded her gloves and wheeled Resident #63 out of the room. In an interview on 1/23/26 at 11:32 AM, Director of Nursing (DON) B reported that the facility holds a monthly all staff meeting that includes infection control and EBP reminders. DON B reported that staff are expected to wear gowns and gloves during every direct care activity, including transfers. DON B reported that staff should have both gowns and gloves available for use on the resident's door. DON B reported that staff are monitored by herself and other members of the management team. DON B reported that she could not confirm that COTA BB received the most recent infection control education. Review of the CDC (Centers for Medicare & Medicaid Services) Center for Clinical Standards and Quality/Quality, Safety & Oversight Group Memorandum (Ref: QSO-24-08-NH) with an effective Date of April 1, 2024 revealed, .The new guidance related to EBP is being incorporated into F-880 Infection Prevention and Control .GUIDANCE Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. EBP are indicated for residents with any of the following: .Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO .For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, .Wound care: any skin opening requiring a dressing . Resident #55 Review of an admission Record revealed Resident #55 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia, weakness, constipation, need for assistance with personal care. Review of Resident #55's Care Plan revealed, .FOCUS: (Resident #55) requires extensive assistance with bed mobility.total assistance with oral hygiene, personal hygiene, toileting hygiene, and showering/bathing.FOCUS: .at increased risk for alterations in skin integrity r/t incontinence of bowel and bladder, impaired mobility. Date initiated: 12/16/16.Interventions: .Precautions for prevention of pressure ulcers will be implemented, such as good peri-care and drying of (Resident #55's) skin, apply protective barrier cream.Date initiated: 9/8/18 .FOCUS: .incontinent of bowel and bladder. Date initiated: 10/12/16.Administer appropriate cleansing and peri-care after each incontinent episode. FOCUS: .at risk for UTIs (urinary tract infections) r/t incontinence of bowel and bladder, impaired mobility, and needs extensive total assistance with care. Date initiated: 9/10/24.FOCUS: .alteration in elimination due to bowel and bladder incontinence. Date initiated: 3/10/25. Interventions: .Provide incontinence care after incontinence episode PRN (as needed). Date initiated: 3/10/25 . During an observation on 01/22/2026 at 2:33 PM in Resident #55's room CNA J and CNA W were preparing to transfer the resident into bed and provide incontinence care. Observed incontinence care for Resident #55 by CNA J. Resident #55's incontinence brief was observed saturated and heavy with urine. CNA J performed the incontinence care using disposable wipes to clean the resident's front groin folds and then the buttocks; observed BM (bowel movement) between the buttocks and on the disposable wipes during incontinence care. Staff did not clean the resident's genital folds or between the resident's legs. CNA J did not change gloves or perform hand hygiene; with the same gloves CNA J opened the resident's nightstand drawer, used the bed controls and handed Resident #55 her call light. CNA J touched clean surfaces with contaminated gloves. In an interview on 1/22/26 at 2:50 PM, CNA J was unsure of the facility expectations regarding glove use and hand hygiene related to incontinence care. In an interview on 1/23/26 at 11:32 AM, Director of Nursing (DON) B reported that incontinence care should include thoroughly cleaning the folds of the female genitals, gloves should be changed after contact with BM, and barrier cream should be used with every incontinence episode. Review of the Centers for Disease Control website (https://www.cdc.gov/handhygiene/providers/index.html) last revised on June 25, 2018 revealed, When to Perform Hand Hygiene .After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings .After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient .If hands will be moving from a contaminated body site to a clean body site during patient care .Wearing gloves is not a substitute for hand hygiene. Dirty gloves can soil hands .Steps for Glove Use .Change gloves during patient care if the hands will move from a contaminated body-site (e.g., perineal area) to a clean body-site (e.g., face) .Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment) using proper technique to prevent hand contamination. Failure to remove gloves after caring for a patient may lead to the spread of potentially deadly germs from one patient to another. Resident #15 (R15) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R15 initially admitted to the facility on [DATE] with pertinent diagnoses including right knee with Methicillin Resistant Staphylococcus Aureus (MRSA) infection. Brief Interview for Mental Status (BIMS) reflected a score of 13 out of 15 which indicated R15 was cognitively intact. During an observation on 1/21/2026 at 11:03 AM, R15's door had a sign printed from the Centers for Disease Control (CDC) that revealed STOP: CONTACT PRECAUTIONS. Everyone must: clean their hands, including before entering and leaving room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. During an interview on 1/21/2026 at 12:06 PM, Licensed Practical Nurse (LPN) M reported to this surveyor as surveyor was donning (putting on) gown and gloves and getting ready to enter R15's room that R15 had a wound and it was unnecessary to wear PPE if someone was going to her room to talk to her. This surveyor asked LPN M if R15 had an active infection and she stated that she didn't know. Then, on 1/21/2026 at 12:15 PM, LPN came to the door of R15's room while surveyor was in there talking to R15 and stated that R15 had an active infection with MRSA and PPE was required. During an interview on 1/21/2026 at 12:10 PM, R15 stated that she had an infection in her knee and showed this surveyor her knee. R15 said that staff didn't always wear PPE when they were in her room and took care of her. During an observation and interview on 1/21/2026 at 12:39 PM, Dietary Supervisor (DS) Q took R15's lunch tray to R15 in her room without wearing any PPE. When asked about the sign on door, DS Q stated that he should have worn a gown and gloves when entering the room and apologized. Then, DS Q was observed telling all other staff on 400 Hall that were passing trays that any sign on the door meant they had to wear PPE when delivering meal trays. During an interview on 1/21/2026 at 1:01 PM, Certified Nursing Assistant (CNA) T stated for residents under contact precautions, PPE such as a gown and gloves weren't needed if you were just talking to the residents and passing water to them. CNA T said it was the same as Enhanced Barrier Precautions (EBP). During an interview on 1/22/2026 at 4:24 PM, Licensed Practical Nurse Manager (LPNM) K stated that R15 was under contact precautions due to an infected wound on her knee and that PPE such as gown and gloves were to be donned when entering the room unless you were just talking to her then there was no need for PPE. During an interview on 1/22/2026 at 4:27 PM, Wound Nurse (WN) D stated that R15 was under contact precautions due to an infected wound on her knee and that PPE such as gown and gloves were to be donned when taking care of her but if you weren't touching or going near her bed, PPE wasn't needed. WN D also said you can enter the room without PPE if you were taking care of R15's roommate. Review of R15's Care Plan revealed .Focus: I have an alteration in my skin integrity. I came to the facility after a left knee replacement surgery and my wound has delayed (sic) healing. I have a diagnosis of MRSA to my wound site. Date initiated 7/17/2016. Focus: I am on contact isolation due to MRSA in left knee. Date initiated 10/3/2024. Review of Physician orders revealed .Contact isolation related to MRSA in wound. Every shift. Active 3/23/2025. During an interview on 1/22/2026 at 4:37 PM, Director of Nursing (DON) B stated that anytime there was an active infection such as with MRSA, COVID and flu, a resident needed to be on contact precautions and PPE such as a gown and gloves needed to be donned. DON B said if you're not touching anything in resident area then you don't need any PPE. Review of the Contact Precaution Policy with an updated date of 2/22/20221 revealed . Procedure.2. Gloves and Hand Hygiene: A. Hand hygiene should be completed prior to donning gloves. B. Gloves should be worn when entering the room AND while providing care for the resident. 3. Gowns: A. A gown should be donned prior to entering the room .6. Contact Precautions May Be Considered for (Examples): A. Multi-drug resistant organisms (e.g., MRSA.) . Resident #13 Review of an admission Record revealed Resident #13 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: dysphagia (difficulty or inability to effectively swallow) and major depressive disorder (persistent depressed mood or loss of interest in activities causing significant impairment in daily life). Review of a Minimum Data Set (MDS) assessment for Resident #13 with a reference date of 1/2/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 00/15, which indicated the resident was severely cognitively impaired. Section K of the MDS revealed Resident #13 received all of her nutritional intake through a feeding tube. Review of a Care Plan for Resident #13 with a reference date of 6/4/25 revealed the following focus/goal/interventions: Focus: I have a history of dysphagia.deemed unsafe for any oral intake.Goal: I will remain NPO (nothing by mouth) to prevent choking. Interventions: Check patency (condition of being open) of g-tube (gastrostomy tube, feeding tube inserted through the abdomen directly into the stomach) prior to use. During an observation on 1/21/26 at 11:05am, a section of the wall approximately 4x5' in size, which Resident #13's bed was pushed against, was heavily soiled by dried drops of brown liquid. The dried liquid extended down the wall in streaks that were up to 2 feet long. Resident #13's linens rested against the soiled wall. Dried brown liquid was also noted on Resident #13's floor and feeding tube pole. During observations on 1/22/26 at 9:54am and 3:03pm, the soiled section of Resident #13's wall remained present with her bed pushed up against the wall. The feeding tube pole also remained soiled at the base with dried brown liquid. Resident #13's tube feeding formula was running and was noted to be a light brown color. During an observation on 1/23/26 at 9:31am, Resident #13's wall and feeding tube pole remained soiled as previously described.

Based on observation, interview, and record review, the facility failed to provide care and services to promote dignity for 1(Resident #13) of 1 resident reviewed for dignity resulting in a potential for feelings of decreased self-worth and embarrassment.Findings include:Resident #13Review of an admission Record revealed Resident #13 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: hemiplegia (severe or complete paralysis on one side of the body) and major depressive disorder (persistent depressed mood or loss of interest in activities causing significant impairment in daily life).Review of a Minimum Data Set (MDS) assessment for Resident #13 with a reference date of 1/2/26, revealed a Brief Interview for Mental Status (BIMS) assessment score of 00/15, which indicated the resident was severely cognitively impaired. Section GG revealed Resident #13 was dependent (helper does all the effort) for dressing her upper and lower body.Review of a Care Plan for Resident #13 with a reference date of 6/4/25 revealed the following focus/goal/interventions: Focus: I am dependent on staff for assistance with ADLs (activities of daily living), Goal: I will maintain my current level of functioning with assistance from staff. Interventions: (Resident #13) is dependent on staff for all dressing.During observations on 1/21/26 at 11:05am and 12:30pm, Resident #13 sat supported at a 45-degree angle in bed, awake, wearing a hospital gown that was gathered under her armpits, exposing her left breast and her incontinence brief. The resident's privacy curtain was not pulled around her bed, leaving her exposed to anyone who entered her room.During an observations on 1/22/26 at 9:54am and 3:03pm, Resident #13 sat supported in bed, awake with her hospital gown gathered under her armpits. The resident's abdomen, left breast, and incontinence brief were exposed. The resident's privacy curtain was not pulled around her.Review of a Dressing Task list revealed the only dressing assistance Resident #13 received on 1/22/26 took place at 9:03am. Resident #13 was observed wearing a hospital gown throughout that day.Review of a Behavior Documentation log revealed Resident #13 had no episodes of rejection of care in the last 14 days.In an interview on 1/22/26 at 9:40am, Family Member (FM) FF reported Resident #13 valued her modesty and would not want her torso exposed in view of others. FM FF also reported Resident #13 preferred to be dressed in her own clothes each day.In an interview on 1/23/26 at 9:31am, Registered Nurse (RN) E reported it was the expectation that staff assist Resident #13 with getting dressed in her own clothing each day because that was her preference.In an interview on 1/23/26 at 11:49am, Certified Nursing Assistant (CNA) X reported Resident #13 seemed to enjoy getting dressed each day and generally did not refuse assistance.In an interview on 1/23/26 at 10:51am, Director of Nursing (DON) B confirmed residents should be offered assistance with dressing in their own clothes each day and their dignity should be maintained by pulling privacy curtains around their beds if their private parts were exposed. DON B confirmed if a resident refused to get dressed, it should be documented on their dressing task list. Using the reasonable person concept, though Resident #13 could not verbalize feelings of embarrassment, it can be determined a reasonable person in the resident's position would have experienced embarrassment and a potential for feelings of decreased self-worth.

Based on observation, interview and record review, the facility failed to provide a transfer/discharge notice for 1 resident (Resident #49) of 2 residents reviewed for hospitalizations, resulting in the potential of residents and/or resident representatives being uninformed of the reason for transfer. Findings include: Resident #49 (R49)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R49 initially admitted to the facility on [DATE] with pertinent diagnoses including congestive heart failure (heart is too weak to pump blood to meet body's needs), heartburn and hypertension (high blood pressure). Brief Interview for Mental Status (BIMS) reflected a score of 14 out of 15 which indicated R49 was cognitively intact. R49 transferred to the hospital on 1/13/2026 after a fall with subdural hemorrhage (bleeding into the brain) and returned to the facility on 1/15/2026. During an observation on 1/21/2026 at 12:32 PM, R49 was resting in his room with his eyes closed in his wheelchair. He was too tired to speak with this surveyor.During an interview on 1/22/2026 at 4:13 PM, Registered Nurse (RN) P stated that he notified R49's guardian when he was transferred to the hospital. However, RN P couldn't remember filling out and sending a transfer/discharge notice with R49 or to his guardian when he went to the hospital. During another interview on 1/23/2026 at 9:20 AM, R49 stated that he remembered falling and being sent to the hospital. R15 couldn't remember RN P discussing the transfer/discharge notice.Review of R49's chart revealed that there was no transfer/discharge notice from 1/13/2026.During an interview on 1/23/2026 at 12:51 PM, Licensed Practical Nurse (LPN) N stated that he sends a transfer form with medications and other information when a resident is transferred to the hospital, but he hadn't heard of a transfer/discharge notice and hadn't been sending that with a resident transfer to the hospital. During an interview on 1/23/2026 at 11:41 AM, NHA A and Regional Clinical Nurse (RCN) stated that the facility had not been sending the transfer/discharge notice when a resident went to the hospital and they talked about implementing it. Review of the Discharge or Transfer Policy with an updated date of 1/28/2020 revealed .1. Transfer/discharge: Emergency.e. Provide Transfer Notice .to the resident and/or an immediate family member or legal representative. F. Document entire process in Nursing Progress Note.

Based on interview and record review, the facility failed to develop a baseline care plan that reflected the minimum healthcare information necessary to properly care for a resident based on admission orders and physician orders including, indwelling foley catheter (tube inserted into the bladder to drain urine) and cardiac pacemaker (mechanical device implanted under the skin that regulates heart rate) for 1 resident (Resident #63) of 1 resident reviewed for baseline care planning, resulting in the potential for unmet care needs and residents not maintaining their highest practicable physical, mental, and psychosocial well-being.Findings include:Review of an admission Record revealed Resident #63 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: chronic arial fibrillation (irregular and rapid heart rate), cardiac pacemaker, obstructive uropathy and urogenital implant (indwelling foley catheter). Review of Resident #63's Baseline Care Plan dated 1/14/26 @ 9:03 AM revealed, .C: Bowel and Bladder: Urinary Continence: Not Rated.Bowel and Bladder Appliances: None of the above (indwelling catheter was not selected). Catheter Care Planning: (No selections). There was no information related to cardiac pacemaker.Review of Resident #63's current Care Plan for indwelling foley catheter and cardiac pacemaker, revealed no information related to either appliance.Review of Resident #63's Physician Orders revealed, Maintain Foley catheter with 16 Fr 5cc balloon every shift.Start date 1/14/26 at 2:30 PM. There were 2 orders for Pacemaker that were queued on 1/14/26, but not active. Pacemaker (make) (model) (serial#) and Pacemaker check: to be completed via: (location/phone number).Review of Resident #63's Treatment Administration Record (TAR) revealed, Maintain Foley catheter with 16 Fr 5cc balloon every shift.Start date 1/14/26 at 2:30 PM. There were no treatment orders related to the cardiac pacemaker.Review of Resident #63's Nursing admission Assessment dated 1/14/26 indicated the resident had a diagnosis of chronic atrial fibrillation and his heart rate was irregular, but did not note that a pacemaker was in place. The assessment also indicated Resident #63 had a diagnosis of urinary obstruction and a foley catheter was in place.In an interview on 1/23/26 at 2:09 PM, Director of Nursing (DON) B reported that Resident #63 was admitted on [DATE] (9 days ago) with an indwelling foley catheter and had physician orders in place, but Resident #63's baseline care plan was incorrectly completed and indicated that the resident was incontinent and there was no catheter in place. DON B reported that the CNA (Certified Nursing Assistant) task's list included the foley catheter and therefore it showed up on the Kardex (CNA care guide) but did not pull through to the Care Plan. DON B reported that Resident #63 was admitted with a cardiac pacemaker but Resident #63's orders had not been activated because they were waiting to receive a model number for the pacemaker. DON B reported the facility received the model number via a copy of the pacemaker identification card but the copy was placed in a file to be scanned into the documents section in the resident record. DON B reported that Resident #63's baseline care plan did not indicate that he had a pacemaker and/or an irregular heart rate. DON B reported that it would be pertinent for staff to be aware of health condition and the pacemaker because Resident #63 should not get close to a microwave and to monitor heart rate to ensure pacemaker was functioning properly. DON B reported that going forward she would ensure that pacemaker orders were activated immediately upon admission.

Based on observation, interview, and record review, the facility failed to maintain professional standards of care and provide adequate incontinence care in 1 resident (Resident #55) of 1 resident, reviewed for bowel and bladder incontinence, resulting in an increased risk for UTI (urinary tract infection) and the potential for skin breakdown.Findings include:Resident #55Review of an admission Record revealed Resident #55 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: constipation and need for assistance with personal care.Review of Resident #55's Care Plan revealed, .FOCUS: (Resident #55) requires extensive assistance with bed mobility.total assistance with oral hygiene, personal hygiene, toileting hygiene, and showering/bathing.FOCUS: .at increased risk for alterations in skin integrity r/t (related to) incontinence of bowel and bladder, impaired mobility. Date initiated: 12/16/16.Interventions: .Precautions for prevention of pressure ulcers will be implemented, such as good peri-care (cleaning the genital and buttock areas) and drying of (Resident #55's) skin, apply protective barrier cream.Date initiated: 9/8/18 .FOCUS: .incontinent of bowel and bladder. Date initiated: 10/12/16.Administer appropriate cleansing and peri-care after each incontinent episode. FOCUS: .at risk for UTIs (urinary tract infections) r/t incontinence of bowel and bladder, impaired mobility, and needs extensive total assistance with care. Date initiated: 9/10/24.FOCUS: .alteration in elimination due to bowel and bladder incontinence. Date initiated: 3/10/25. Interventions: .Provide incontinence care after incontinence episode PRN (as needed). Date initiated: 3/10/25 .Review of Resident #55's Treatment Administration Order (TAR) revealed, Moisture Barrier Ointment: apply to peri-areas and buttocks topically every shift for skin protection. May keep at bedside. (CNA (certified nursing assistant) may apply). The record indicated that staff were applying the cream three times a day.During an observation on 01/21/2026 at 1:19 PM in Resident #55's room, CNA AA and CNA L prepared to transfer the resident into bed and perform incontinence care. CNA L reported that the resident had been up in her chair since before 7:00 AM (>6 hours). There was a strong urine smell when the resident was transferred into the bed, the chair was visibly wet where she had been seated, and her pants were visibly wet in the buttock area. Staff removed Resident #55's incontinence brief and it was observed saturated and heavy with dark yellow-brown urine. CNA AA performed incontinence care and CNA L helped with repositioning. CNA AA used disposable wipes to clean down the groin folds on the front of Resident #55 but did not clean the genital folds or attempt to clean between the resident's legs. CNA AA cleaned the resident's buttocks and there was BM noted between her buttocks and on the wipe. CNA AA changed her gloves but did not perform hand hygiene. The staff did not apply a barrier cream to Resident #55's peri-area following the incontinence episode.In an interview on 01/21/2026 at 1:36 PM, CNA L reported that it was normal for Resident #55's urine to smell strong and she did not remember having to collect a urine specimen for the resident recently. In an interview on 1/22/26 at 4:38 PM, CNA Y reported that she had Resident #55 on her assignment that day on first shift but had not tried to do care for Resident #55 because third shift staff had gotten Resident #55 up into her chair that morning and the resident's routine was to stay up all day. CNA Y reported that the resident would get mad if you tried to perform incontinence care between meals and only allowed incontinence care a couple times a day. CNA Y reported that Resident #55 needed very thorough incontinence care when it was done and thick barrier cream applied to keep her skin from breaking down due to her being in a wet brief all day. During an observation on 01/22/2026 at 2:33 PM in Resident #55's room CNA J and CNA W were preparing to transfer the resident into bed and provide incontinence care. Observed incontinence care for Resident #55 by CNA J. Resident #55's incontinence brief was observed saturated and heavy with urine. There was a strong urine odor when the resident was transferred into bed. CNA J performed the incontinence care using disposable wipes to clean the resident's front groin folds and then the buttocks; observed BM (bowel movement) between the buttocks and on the disposable wipes during incontinence care. Staff did not clean the resident's genital folds or between the resident's legs and did not apply barrier cream following incontinence care. CNA J did not change gloves or perform hand hygiene; with the same gloves CNA J opened the resident's nightstand drawer, used the bed controls and handed Resident #55 her call light. CNA J touched clean surfaces with contaminated gloves. In an interview on 1/22/26 at 2:50 PM, CNA J was unsure of the facility expectations regarding glove use and hand hygiene related to incontinence care. CNA J reported that he was not sure why Resident #55 was not laid down after meals that day, but that was the expectation for residents with incontinence. CNA J reported that Resident #55 does not have barrier cream and does not need it because she does not have any skin breakdown.In an interview on 01/23/2026 at 10:33 AM, CNA W reported that Resident #55 was a very heavy wetter and was usually out of bed before first shift starts.In an interview on 1/23/26 at 11:32 AM, Director of Nursing (DON) B reported that incontinence care should include thoroughly cleaning the folds of the female genitals, gloves should be changed after contact with BM, and barrier cream should be used with every incontinence episode.

Based on interview and record review, the facility failed to maintain accurate medical records for 1 resident (Resident #55) of 14 residents reviewed for complete and accurate medical record documentation, resulting in the potential for staff and providers mismanaging care for residents. Findings include:Resident #55Review of an admission Record revealed Resident #55 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: depression, anxiety and dementia.Review of Resident #55's Care Plan revealed, FOCUS: .history of anxiety and may exhibit signs or symptoms as evidenced by episodes of agitation, restlessness, tearfulness, and worried facial expressions. Date initiated: 3/3/25 FOCUS: history of depression and may exhibit signs and symptoms of depression as evidenced by episodes of crying, fearfulness negative statements, and/or having a sad, pained, or worried facial expression. Date initiated: 3/3/25 . Review of Resident #55's Physician Note dated 1/12/26 revealed, .Chief Complaint: Weight loss .Current Medications: .Lexapro (antidepressant) oral tablet 5 mg .Plan: .Ensure proper administration of prescribed medication .medications were reviewed and reconciled . Review of Resident #55's Physician Orders revealed, the orders did not include Lexapro. Review of Resident #55's Discontinued Physician Orders revealed, Lexapro oral tablet 5 mg .discontinued, end date: 8/19/2024 . In an interview on 01/22/2026 at 1:24 PM, Social Worker (SW) G reported that Resident #55 was not taking any medications for depression and that Lexapro had been discontinued through GDR (gradual dose reduction) in August of 2024. After reviewing the physician notes SW G agreed that the information related to Lexapro was not correct; the notes did not include documentation of the Lexapro GDR. Previous notes were reviewed back through August 2024 and all were found with the same inaccurate information related to Lexapro. SW G reported that Resident #55' GDR was a recommendation from the pharmacist in collaboration with facility interdisciplinary team members and Medical Director (MD) DD. SW G reported that Resident #55's GDR of Lexapro was successful and the resident was doing well since then. In an interview on 1/22/26 at 1:30 PM, Medical Director (MD) DD reported that he agreed that his physician notes did not accurately reflect Resident #55's current medications. MD DD reported that during all resident visits he reviewed the active medication list in the electronic health record, but he was not sure why that list was not accurately transcribed into the visit note. MD DD added that he did not normally include GDR information related to depression medications, as he expected the behavioral health providers to document their findings. Review of the most recent Psychiatry Progress Note dated 11/4/24 revealed, .ongoing management of psychotropic medications and neuropsychiatric conditions .Diagnosis, A/P (assessment and plan): Major depressive disorder, recurrent, moderate. Appears stable currently. 1. Continue Lexapro 5mg daily. 2. Continue to monitor and document any clinically significant changes in mood/behaviors. Generalized anxiety disorder: Moderately stable. 1. Continue Lexapro 5 mg daily . In an interview on 01/23/2026 at 12:42 PM, Medical Records (MR) S reported that she was not sure how MD DD's visit notes became part of the medical record, but that she did not scan them into the electronic health record and that she was not responsible for the accuracy of the notes. In an interview on 01/23/2026 at 2:09 PM, Director of Nursing (DON) B reported that MD DD's visit notes were uploaded to the electronic medical record by MD DD and the notes had not been reviewed for accuracy.

This citation pertains to Intake #2682078.Based on observation, interview, and record review, the facility failed to ensure that 1 resident (Resident #3) received physician ordered pain medication for effective pain management in 1 of 3 residents reviewed for medication management resulting in uncontrolled pain for 11 days and unmet needs.Findings include: Resident # 3 (R3) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R3 admitted to the facility on [DATE] with pertinent diagnoses including chronic pain, obesity, depression and osteoarthritis left hip (degenerative joint disease where joint cartilage breaks down causing bones to rub, leading to pain in the groin, buttocks and outer thigh, stiffness, swelling and reduced movement). Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R3 was cognitively intact (13 to 15 cognitively intact). During an observation and interview on 12/8/2025 at 10:33 AM, R3 was sitting in his wheelchair in his room and was very pleasant saying he was feeling better today. R3 stated that he went at least 9 days without his Norco pain medication that the physician ordered. R3 said the nurses were aware of his Norco not coming in and they kept telling him that the pharmacy had not shipped it yet. R3 stated that he received Ibuprofen and Tylenol, but he was still in a lot of pain, so the physician ordered Norco. R3 reported that his previous physician said that the pain R3 described was worse than a lady in labor and R3 rated his pain during the time without Norco as a 10/10. R3 said that he was finally able to get his Norco on 12/4/2025 after the Ombudsman came to the facility and talked to Nursing Home Administrator (NHA) A and Director of Nursing (DON) B. Review of R3's physician orders revealed Hydrocodone-Acetaminophen Tablet (Norco) 5-325 MG (milligrams), Give 1 tablet enterally (orally) two times a day for pain management. Start date 12/4/2025. This dose was different than the recommended Norco from the progress note completed by MD S on 12/4/2025 which indicated Norco 7.5/325 (mg) Bid (2 times a day) #60 (60 pills). Prior to the above order, R3's physician order was Hydrocodone-Acetaminophen Tablet 5-325 MG, Give 1 tablet enterally one time a day for pain management. Start date 11/22/2025, discontinued 12/4/2025. Review of R3's physician orders also revealed he received Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) every 8 hours as needed for pain and Ibuprofen Oral Tablet 600 MG (Ibuprofen), Give 1 tablet by mouth every 12 hours as needed for pain. Review of R3's hospital notes prior to admission on [DATE] revealed He (R3) has severe left hip osteoarthritis, diagnosed in April.He reports significant pain, stating 'I could barely move or walk due to pain.'. Review of R3's care plan revealed Resident has acute/chronic pain r/t (related to) hip needing to be replaced.date initiated 10/17/2025.Interventions: Administer analgesia per physician orders. Refer to physician orders and medication administration records for current meds. Date initiated 10/17/2025.Evaluate the effectiveness of pain interventions. Review for compliance, alleviating symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. If issues report to MD. Date initiated 10/17/2025.Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain. Date initiated 10/17/2025. Review of R3's progress note completed by Medical Director (MD) S on 12/4/2025 revealed . Medical Decision Summary: The patient was evaluated today for phalangeal (finger) joint pain without additional acute (condition starts suddenly) findings. He remains on prescribed medications and reports no systemic symptoms. His history includes.osteoarthritis. chronic pain.joint discomfort appears musculoskeletal (muscles, bones, tendons, ligaments, joints and cartilage) and may represent progression of osteoarthritis or overuse. Supportive care with pain control and monitoring was advised.Plan: Norco 7.5/325 (mg) Bid (2 times a day) #60 (60 pills). Review of R3's progress note completed by the Nurse Practitioner (NP) on 11/21/2025 revealed . Assessment: The patient is evaluated for severe hip pain, with no acute findings on exam. Pain appears consistent with known unilateral (1 side) hip osteoarthritis, compounded by morbid obesity, chronic weakness, and limited mobility (movement). maintaining adequate pain control is essential to preserve function and prevent further decline. Continued monitoring is recommended due to his complex medical history, including mobility impairment and multiple chronic conditions. Plan: Norco 5/325 mg daily. Ensure proper administration of prescribed medication. Review of R3's progress note dated 11/23/2025 revealed Hydrocodone-Acetaminophen Tablet 5-325 MG. Give 1 tablet enterally one time a day for pain management. Awaiting supply. Review of R3's progress note dated 11/24/2025 revealed Hydrocodone-Acetaminophen Tablet 5-325 MG. Give 1 tablet enterally one time a day for pain management. Awaiting order on supply. Review of R3's progress note dated 11/30/2025 revealed Hydrocodone-Acetaminophen Tablet 5-325 MG. Give 1 tablet enterally one time a day for pain management. Pharmacy states there is no script; Awaiting response. Review of R3's progress note dated 12/1/2025 revealed Hydrocodone-Acetaminophen Tablet 5-325 MG. Give 1 tablet enterally one time a day for pain management. On order awaiting supply. Review of R3's progress note dated 12/2/2025 revealed Hydrocodone-Acetaminophen Tablet 5-325 MG. Give 1 tablet enterally one time a day for pain management. Await (awaiting) pharmacy. This medication was not given to R3. Review of R3's November and December Medication Administration Record (MAR) revealed hydrocodone-acetaminophen (Norco) tablet 5-325 mg. Give 1 tablet enterally one time a day for pain management (started on 11/22/2025) with a d/c (stop) date of 12/4/2025. From 11/22/2025 through 12/2/2025, the pain level assessment was not completed, and Norco was not given per the codes on the MAR. R3 missed 11 doses of Norco in 11 days. During an interview on 12/9/2025 at 7:31 AM, Registered Nurse (RN) E stated that sometimes medications don't come in right away and it can take 3 or more days to get it at the facility. RN E said that it took a long time for R3 to get his Norco, but she wasn't sure why. RN E said she thought NHA A and DON B were aware of the medication issues. During an interview on 12/8/2025 at 3:45 PM, Licensed Practical Nurse (LPN) I stated that issues regarding getting resident's medications happens more than it should. LPN I said she thought NHA A and DON B were aware of these issues. During an interview on 12/10/2025 at 12:50 PM, LPN D stated that if pain medication was ordered for a resident and if it wasn't effective or if a script was needed, she would call the physician (MD S). LPN D said the nurses worked on getting R3's Norco script but wasn't sure if management was aware of this. During an interview on 12/10/2025 at 12:58 PM, LPN Z stated that if pain medication was ordered for a resident and if it wasn't effective or if a script was needed, he would call the physician. During an interview on 12/9/2025 at 3:30 PM, DON B and Regional Nurse Consultant (RNC) R stated that the facility has a backup system for most medications, and the pharmacy can open it remotely. DON B stated that she wasn't aware of R3 not getting his Norco for 11 days. When showing RNC R the Medication Administration Record (MAR) for November 2025 and December 2025, she nodded in agreement that R3 did not receive the ordered Norco from 11/22/2025 to 12/2/2025. DON B said she would look into what happened and get back to this surveyor. During an interview on 12/10/2025 at 9:25 AM, DON B stated that the pharmacy didn't get the script for Norco when the NP saw R3 on 11/21/2025 and ordered it. DON B said there was difficulty getting MD S into the facility to write the script due to the Thanksgiving holiday. DON B reported that the NP and MD S did not make it into the facility from 11/22/2025 until MD S saw the resident on 12/4/2025. DON B also said that there wasn't backup Norco in the Cubix at the time. During an interview on 12/10/2025 at 12:29 PM, MD S stated that he knew about R3's pain and didn't remember what happened with the script for Norco. He stated that he could send the script electronically if he wasn't in the building. MD S stated the NP saw R3 on 11/21/2025 and he saw R3 on 12/4/2025. MD S said on 12/4/2025 when he saw R3 he said he was in pain but R3 or staff didn't mention that they were unable to get the Norco that the NP ordered on 11/21/2025 so he increased the Norco. MD S reported that he looks at the MAR when a resident complains of pain from 1 visit to the next but on 12/4/2025 he didn't look at it. During an interview on 12/10/2025 at 1:02 PM, NHA A and DON B stated that they weren't aware that R3 wasn't getting his Norco until 12/4/2025 when the ombudsman came into the facility. DON B stated that the nurses call the physician when they need a script and MD S kept saying he was coming into the facility but he didn't come in until 12/4/2025. DON B said that the nurses should let her know when they have an issue with getting a script or getting medications from the pharmacy. Review of the Nursing Administration Policy with an adopted date of 7/11/2018 revealed . Policy: It is the policy of this facility to provide an environment and programs that assist each resident to attain or maintain the residence's highest practicable physical, mental and psychosocial well-being. Residents are provided and receive the care and services needed according to established practice guidelines.

This citation pertains to Intake #2682078.Based on observation, interview, and record review, the facility failed to follow professional standards of practice by following up on physician ordered medication that wasn't available in 1 resident (Resident #3) of 3 residents reviewed for medication management, resulting in physician ordered pain medication not being administered and resident having uncontrolled pain and unmet needs.Findings include: Resident # 3 (R3)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R3 admitted to the facility on [DATE] with pertinent diagnoses including chronic pain, obesity, depression and osteoarthritis left hip (degenerative joint disease where joint cartilage breaks down causing bones to rub, leading to pain in the groin, buttocks and outer thigh; stiffness, swelling and reduced movement). Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R3 was cognitively intact (13 to 15 cognitively intact).Review of the Fundamentals of Nursing revealed, The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe that the orders are in error, violate agency policy, or are harmful to the patient. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 20717-20719). Elsevier Health Sciences. Kindle Edition.During an observation and interview on 12/8/2025 at 10:33 AM, R3 was sitting in his wheelchair in his room and reported he was feeling better today. R3 stated that he went at least 9 days without his Norco pain medication that the physician ordered. R3 said the nurses were aware of his Norco not coming in and they kept telling him that the pharmacy had not shipped it yet. R3 reported that he received Ibuprofen and Tylenol but he was still in lots of pain, so the physician ordered Norco. R3 said that his previous physician said that the pain R3 described was worse than a lady in labor and R3 rated his pain during the time without Norco as a 10/10. R3 said that he was finally able to get his Norco on 12/4/2025 after the Ombudsman came to the facility and talked to Nursing Home Administrator (NHA) A and Director of Nursing (DON) B.Review of R3's physician orders revealed Hydrocodone-Acetaminophen Tablet (Norco) 5-325 MG (milligrams), Give 1 tablet enterally (orally) two times a day for pain management. Start date 12/4/2025. This dose was different than the recommended Norco from the progress note completed by MD S on 12/4/2025 which indicated Norco 7.5/325 (mg) Bid (2 times a day) #60 (60 pills).Prior to the above order, R3's physician order was Hydrocodone-Acetaminophen Tablet 5-325 MG, Give 1 tablet enterally one time a day for pain management. Start date 11/22/2025, discontinued 12/4/2025. Review of R3's progress note completed by Medical Director (MD) S on 12/4/2025 revealed . Medical Decision Summary: The patient was evaluated today for phalangeal (finger) joint pain without additional acute (condition starts suddenly) findings. He remains on prescribed medications and reports no systemic symptoms. His history includes.osteoarthritis. chronic pain.joint discomfort appears musculoskeletal (muscles, bones, tendons, ligaments, joints and cartilage) and may represent progression of osteoarthritis or overuse. Supportive care with pain control and monitoring was advised.Plan: Norco 7.5/325 (mg) Bid (2 times a day) #60 (60 pills). Review of R3's progress note completed by the Nurse Practitioner (NP) on 11/21/2025 revealed . Assessment: The patient is evaluated for severe hip pain, with no acute findings on exam. Pain appears consistent with known unilateral (1 side) hip osteoarthritis, compounded by morbid obesity, chronic weakness, and limited mobility (movement). maintaining adequate pain control is essential to preserve function and prevent further decline. Continued monitoring is recommended due to his complex medical history, including mobility impairment and multiple chronic conditions. Plan: Norco 5/325 mg daily. Ensure proper administration of prescribed medication.Review of R3's progress note dated 11/23/2025 revealed Hydrocodone-Acetaminophen Tablet 5-325 MG. Give 1 tablet enterally one time a day for pain management. Awaiting supply.Review of R3's progress note dated 11/24/2025 revealed Hydrocodone-Acetaminophen Tablet 5-325 MG. Give 1 tablet enterally one time a day for pain management. Awaiting order on supply.Review of R3's progress note dated 11/30/2025 revealed Hydrocodone-Acetaminophen Tablet 5-325 MG. Give 1 tablet enterally one time a day for pain management. Pharmacy states there is no script; Awaiting response.Review of R3's progress note dated 12/1/2025 revealed Hydrocodone-Acetaminophen Tablet 5-325 MG. Give 1 tablet enterally one time a day for pain management. On order awaiting supply.Review of R3's progress note dated 12/2/2025 revealed Hydrocodone-Acetaminophen Tablet 5-325 MG. Give 1 tablet enterally one time a day for pain management. Await (awaiting) pharmacy. This medication was not given. Review of R3's November and December Medication Administration Record (MAR) revealed hydrocodone-acetaminophen (Norco) tablet 5-325 mg. Give 1 tablet enterally one time a day for pain management (started on 11/22/2025) with a d/c (stop) date of 12/4/2025. From 11/22/2025 through 12/2/2025, the pain level assessment was not completed, and Norco was not given per the codes on the MAR. R3 missed 11 doses of Norco in 11 days. During an interview on 12/9/2025 at 7:31 AM, Registered Nurse (RN) E stated that sometimes medications don't come in right away and it can take 3 or more days to get it at the facility. RN E said that it took a long time for R3 to get his Norco, but she wasn't sure why. RN E said she thought NHA A and DON B were aware of the medication issues. During an interview on 12/8/2025 at 3:45 PM, Licensed Practical Nurse (LPN) I stated that issues regarding getting resident's medications happens more than it should. LPN I said she thought NHA A and DON B were aware of these issues. During an interview on 12/10/2025 at 12:50 PM, LPN D stated that if pain medication was ordered for a resident and if it wasn't effective or if a script was needed, she would call the physician (MD S). LPN D said the nurses worked on getting R3's Norco script but wasn't sure if management was aware of this. During an interview on 12/10/2025 at 12:58 PM, LPN Z stated that if pain medication was ordered for a resident and if it wasn't effective or if a script was needed, he would call the physician.During an interview on 12/9/2025 at 3:30 PM, DON B and Regional Nurse Consultant (RNC) R stated that the facility has a backup system for most medications, and the pharmacy can open it remotely. DON B stated that she wasn't aware of R3 not getting his Norco for 11 days. When showing RNC R the Medication Administration Record (MAR) for November 2025 and December 2025, she nodded in agreement that R3 did not receive the ordered Norco from 11/22/2025 to 12/2/2025. DON B said she would look into what happened and get back to this surveyor. During an interview on 12/10/2025 at 9:25 AM, DON B stated that the pharmacy didn't get the script for Norco when the NP saw R3 on 11/21/2025 and ordered it. DON B said there was difficulty getting MD S into the facility to write the script due to the Thanksgiving holiday. DON B reported that the NP and MD S did not make it into the facility from 11/22/2025 until MD S saw the resident on 12/4/2025. DON B also said that there wasn't backup Norco in the Cubix at the time. During an interview on 12/10/2025 at 12:29 PM, MD S stated that he knew about R3's pain and didn't remember what happened with the script for Norco. He stated that he could send the script electronically if he wasn't in the building. MD S stated the NP saw R3 on 11/21/2025 and he saw R3 on 12/4/2025. MD S said on 12/4/2025 when he saw R3 he said he was in pain but R3 or staff didn't mention that they were unable to get the Norco that the NP ordered on 11/21/2025 so he increased the Norco. MD S reported that he looks at the MAR when a resident complains of pain from 1 visit to the next but on 12/4/2025 he didn't look at it. During an interview on 12/10/2025 at 1:02 PM, NHA A and DON B stated that they weren't aware that R3 wasn't getting his Norco until 12/4/2025 when the ombudsman came into the facility. DON B stated that the nurses call the physician when they need a script and MD S kept saying he was coming into the facility, but he didn't come in until 12/4/2025. DON B said that the nurses should let her know when they have an issue with getting a script or getting medications from the pharmacy. Review of the Nursing Administration Policy with an adopted date of 7/11/2018 revealed . Policy: It is the policy of this facility to provide an environment and programs that assist each resident to attain or maintain the residence's highest practicable physical, mental and psychosocial well-being. Residents are provided and receive the care and services needed according to established practice guidelines.

This citation pertains to intake #2588471 and #2594155.Based on interview and record review, the facility failed to ensure residents received care in accordance with professional standards and advance directives were honored in 1 resident (Resident #101) of 4 residents reviewed for quality of care, resulting in an immediate jeopardy when, beginning on [DATE] at approximately 3:00 PM the resident had a serious acute change of condition (shortness of breath) and staff failed to assess, monitor and act promptly by notifying emergency services, resulting in death from cardiac arrest. This deficient practice placed all residents at risk for serious harm, injury and/or death.Findings include:The facility failed to assess, monitor and promptly notify emergency services for Resident #101, who was a full code and reported by Certified Nursing Assistant (CNA) J to be experiencing respiratory difficulties on [DATE] beginning at approximately 3:00 PM. Resident #104 was identified by Registered Nurse (RN) C at approximately 9:00 PM unresponsive and displaying agonal breathing (gasping for air that sound like snoring or gurgling). RN C contacted hospice services at 9:04 PM, who returned the call at 9:24 PM and instructed RN C to call 911 due to Resident #101's full code status. EMS arrived to transport Resident #101 to the hospital at 9:28 PM, and the resident was pronounced dead 1 hour later in the hospital.The Immediate Jeopardy began on [DATE] when the facility failed to assess, monitor and act promptly, by notifying emergency services when Resident #101 complained of respiratory difficulties and was found unresponsive approximately 6 hours later. The Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy on [DATE] at 12:15 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at a scope of isolated and severity of actual harm that is not immediate jeopardy due to sustained compliance has not been verified by the State Agency.Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: diabetes and heart failure. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #13 was cognitively intact. Review of the Functional Abilities revealed that Resident #13 was dependent on staff to transfer out of bed. Review of Resident #101's Advance Directive dated and signed on [DATE] by Resident #101 and a physician indicated Code Status: Full code.Treatment Options: Intubation, IV fluids, Antibiotics, Feeding tube, Hospitalization, Dialysis. All options were marked Yes. Review of Resident #101's Care Plan revealed, Advanced Directives.date initiated: [DATE] Interventions: Nursing will honor my code status by initiating CPR. Full Code. Intubation, antibiotics, hospitalization, IV fluids, Feeding tube, Dialysis.Review of Resident #101's Hospital Records dated [DATE] revealed, .At 9:47 PM: BIBA (brought in by ambulance) unresponsive, IGEL (artificial airway inserted through the mouth) in place with bag mask ventilation. No pulse per EMS (emergency medical services), pulse check completed, no pulse, CPR (cardiopulmonary resuscitation) initiated. Per EMS has been unresponsive for over 1 hour.Time of death: 10:25 PM.In an interview on [DATE] at 1:04 PM EMS Responder (MM) reported that they arrived to the facility on [DATE] at 9:28 PM and received report from a Registered Nurse (RN). EMS MM reported that the RN could not tell them anything except for Resident #101 had been unresponsive and demonstrated agonal breathing for 45-60 minutes, and there had not been any reports that he was having any issues earlier that day. EMS MM reported that the RN kept saying that she was not familiar with Resident #101 because she had not worked the day before, but that he was on hospice and a full code (wanted all necessary life-saving medical treatment). When EMS MM assessed Resident #101, he was completely unconscious, his skin was pale and cool, he had no response to stimuli or sternal rub, he had a weak pulse, and he was taking sporadic (infrequent, irregular) agonal breaths.In an interview on [DATE] at 1:01 PM, RN-Hospice (RN-H) O reported that she had received a message from her hospice on-call triage nurse on [DATE] at 9:17 PM to notify her that RN C had called hospice requesting a nurse visit due to Resident #101 being unresponsive and in respiratory distress. RN-H O reported that she returned the call to RN C at 9:24 PM and explained that she would be arriving in about an hour; RN C responded frantically and stated, (Resident #101) is a full code.he will be dead by then! RN-H O replied by instructing RN C to call 911 immediately. RN-H O reported that when a hospice resident has full code advance directives and is in acute respiratory distress, they would expect that the facility staff implement their own emergency polices and procedure prior to calling hospice.In an interview on [DATE] at 10:21 AM, RN C reported on [DATE] around 9:00 PM she went to administer medications to Resident #101 and noticed he was unresponsive, and his breathing sounded like he was snoring. RN C reported that she had not been in the room prior to 9:00 PM because Resident #101's room was at the end of the 400 hall and he was one of the last residents on her medication pass. RN C reported that she had not been notified of any concerns during report that day and/or from CNA's (Certified Nursing Assistant). RN C reported that she did not ask for assistance from other facility staff; RN C obtained vital signs and when they were abnormal, she gave Resident #101 oxygen and then called hospice to inform them of the resident's condition. RN C reported that Resident #101's blood pressure was very low and his blood oxygen level was 70%. RN C reported that she knew Resident #101 was full code, but thought she needed to contact hospice first for guidance with his care. RN C reported that she waited about 15 minutes for hospice to call back and then was instructed by the hospice nurse to call 911 due to Resident #101 being a full code. RN C reported that she had discussed the situation afterwards with other facility nurses and was told that she did the right thing by calling hospice first.In an interview on [DATE] at 1:25 PM, CNA J reported that Resident #101 put his call light on at the beginning of the shift around 3:00 PM on [DATE], he looked very tired, and complained of not feeling well and being short of breath; CNA J notified RN C and RN C said that she would give him a breathing treatment. CNA J reported that she had checked on him from the doorway several times before dinner; Resident #101 was snoring, and his chest was rising and falling. CNA J thought that the resident needed to rest, so she did not bother him. CNA J reported that Resident #101 would not wake up after dinner, and again CNA J reported that to RN C. CNA J reported that she was busy for the rest of the night and did not know anything until she saw Resident #101 leaving with EMS towards the end of the shift.In an interview on [DATE] at 10:48 AM, CNA AA reported that she remembered that Resident #101 was always putting his call light on and hollering to get up in his chair. CNA AA reported that Resident #101required the assistance of two people so she would turn the call light off and then tell his CNA. CNA AA reported that most of the time Resident #101 requested to get up during the busy meal time. CNA AA reported that call lights for Resident #101's hall could be heard but not seen from other halls.In an interview on [DATE] at 3:01 PM, Licensed Practical Nurse (LPN) F reported that RN C never asked for her help with Resident #101 on [DATE]. LPN F did not even know anything was wrong until the EMS arrived.Review of Resident #101's EMS report dated [DATE] revealed, .Call received at 9:24 PM.On scene: 9:28 PM.Chief Complaint: Unconscious. Duration: 1 hour. Arrived on scene, nurse met EMS at the door and let us in. Nurse advised that the patient was laying in his bed, unconscious but breathing. Nurse was not able to provide EMS with any medical history about the patient. Nurse stated that she was unsure of anything. Inside the patient room, patient was laying in bed. Patient was unconscious. Patient respiratory rate was 8-10 times a minute. Patient skin was pale, cool and cyanotic. Nurse stated that he has been in this state for 45-60 minutes now. Nurse also advised that his SpO2 (measurement of oxygen in the blood) level was reading very low, along with his blood pressure. When nurse was asked why the patient was on hospice, she replied with I'm not sure, but I'm sure it's on my other computer. Nurse was asked as to what his medical history was she again replied with I'm not sure, I didn't work yesterday. Nurse was also asked if there was any complaints from 1st shift or even 2nd shift and she stated I'm not too sure, not that I was told. Nurse stated that the patient was normally awake and talking to staff .When EMS asked the nurse any question, she would respond with many times with I'm not sure as I didn't work yesterday. Initial blood pressure was 68/30 - manually obtained. Nurse then left the room. Nurse was asked to come back and help move the patient from the facility bed to EMS cot.Patient did have a palpable carotid pulse at this time. Patient was agonal breathing with a rate of 6-8 breaths a minute.Arrived at (hospital).Patient still had a palpable carotid pulse but was getting weaker. Patient was sheet lifted from the cot and placed onto the hospital bed where he lost his pulse. They began CPR. Patient was full code per the nursing home.Review of Resident #101's Hospice report dated [DATE] revealed, .XXX[DATE] at 9:04 PM (RN C) Caller.requesting PRN (as needed) visit by (hospice nurse) at this time d/t (due to) change in pt (patient) condition; Caller states pt is unresponsive to stimuli, BP 87/43.O2 sat 60% on 4L (liters) (supplemental oxygen) via simple mask with noted terminal secretions; Caller denies any s/s (signs and symptoms) of acute respiratory distress or discomfort at this time;.offered support, reviewed comfort measures/medications.attempted to provide education on s/s to expect in EOL (end of life) and disease progression to the caller. (hospice triage nurse) inquired if the caller understood and was satisfied with the plan of care;.XXX[DATE] at 9:24 PM Call to (facility) by (RN-H O) Spoke with (RN C) regarding patients status and patient would probably pass soon and to inform her of ETA (estimated time of arrival), (RN C) stated But he's a full code. Instructed (RN C) to send patient to ER (emergency room) due to full code status and her concerns about patients declining vitals and being unresponsive. (RN C) voiced understanding and that she would call 911.Review of Resident #101's Progress Note dated [DATE] at 9:28 PM revealed, Found non-responsive, BP 87/43.oxygen in the 70s. Breath sounds adventitious. Placed on oxygen with mask. Hospice, 911 called.Picked up by EMS.The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy.Resident no longer resides at the facility.Nurse (RN C) was removed from the facility schedule on [DATE].On [DATE] 51 of 51 residents that reside in the facility had a head-to-toe assessment completed by a licensed nurse to ensure the residents had not experienced a change in condition. Any change in condition noted will be documented in the medical record and communicated to the attending physician. No change of condition with current residents were identified.On [DATE] the facility completed an audit of hospital transfers since [DATE]. Two other residents were transferred out and there were no concerns identified with the hospital transfers.A Facility Call List was placed at each nurse's station to ensure they know who to contact for emergencies in the facility, [DATE].On [DATE], education was initiated for Licensed Nurses, CENAs, Dietary and Housekeeping, Activities, Maintenance and Administrative staff members. Education will be completed by the DON or a designated nurse manager and included the following topics: Change of Condition, Life Threatening Change, Change of Condition- Monitoring, Change of Condition- Reporting, Alert Charting Process, Stop and Watch, Facility Call List, Rounding- beginning of shift and periodically throughout the shift, DNR/Advance Directives [DATE]. (As of [DATE] 6 out of 15 Licensed Nurses have been educated. Any staff member who has not received the education, will receive before the start of their next shift. They will not be allowed to work until education has been completed), EMS/Hospital Transfer (As of [DATE] at 430PM, 27 out of 71 staff members have received the education. Any staff member who has not received the education, will receive before the start of their next shift. They will not be allowed to work until education has been completed.)Medical Director was notified of these findings on [DATE].

This pertains to intake #2592743.Based on observation, interview and record review the facility failed to prevent an elopement and ensure safety in 1 resident (Resident #104) of 4 residents reviewed for safety/supervision, resulting in an Immediate Jeopardy when on 8/15/25 at approximately 7:00 P.M., Resident #104 (who was a known elopement risk) exited the facility unbeknownst to facility staff through an emergency exit door and was discovered outside by another resident and EMS (emergency medical services) who notified facility staff. Resident #104 was approximately 350 feet from the facility driveway walking alongside the main road, when he was first attended by facility staff at approximately 7:15 PM. This deficient practice placed 6 residents, identified as at risk for elopement, at risk for serious harm, injury, and/or death. Findings include:The facility failed to provide adequate supervision to prevent elopement for an exit seeking resident, Resident #104, who had been actively exit seeking for 2 days, and ensure that door alarms are functioning as intended for the wanderguard system (a device that triggers an alarm when near a restricted area). Resident #104 was found by another resident and EMS approximately 350 feet away from the facility driveway, walking on the side of a 30 MPH (miles per hour) road. The Immediate Jeopardy began on 8/15/25 when the facility failed to supervise Resident #104 and he eloped from the facility between 7:00 PM-7:15 PM. Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy on 8/19/25 at 9:00 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 8/20/25, but noncompliance remains at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance has not been verified by the State Agency.Review of an admission Record revealed Resident #104 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia. Review of Resident #104's Wandering Risk Scale Assessment dated 8/12/25 at 3:43 PM revealed a score of 14, indicating a high risk for wandering. Further details were that Resident #104 cannot follow instructions, is ambulatory, has a history of wandering, has a medical diagnosis of dementia/cognitive impairment; diagnosis impacting gait/mobility or strength. Review of Resident #104's Social Services Note dated 8/13/25 revealed, Resident admitted to facility on 8/12/25 for long term care placement. Resident has severe complications with comprehension and memory.Resident's cognition assessed scoring a 03 on the BIMS Brief Interview for Mental Status exam. Resident assessed for wandering and confirmed an elopement risk. Wander guard placed. A BIMS score of 3, out of a total possible score of 15, indicated Resident #104 was severely cognitively impaired. Review of Resident #104's Progress Note dated 8/13/25 at 9:08 PM revealed, .No exit-seeking this shift, however resident was wandering up to doors stating he needs to leave and find his dad.Alarms are not functioning even though bracelet is in good working order.Review of Resident #104's Progress Note dated 8/15/25 at 2:55 PM revealed, .Resident is agitated and wants to see his son.Review of Resident #104's Progress Note dated 8/15/25 at 4:59 PM revealed, Resident ambulates independently on unit. Resident very anxious on shift and repeats that he is getting tire (sic) of this he has things to do and he is walking out of here. Staff redirected resident and ensured that his family is returning tomorrow, for family visited resident earlier and stated that they will be back tomorrow. Resident attempted to be redirected with activities, which is short lived.Review of Resident #104's Event Note dated 7:30 PM revealed, Resident wandering the halls of the facility. Resident baseline is confused. Resident is ambulate without assistive device. Ambulance personal (sic) came back into the building and stated that one of the residents is outside that is not supposed to be outside. The writer of this note exited the building and ran into one of the alert residents out on loa (leave of absence) in the parking lot that stated that the resident went down that why (sic) pointing to the left of the facility. The writer of this note followed after the resident. The writer of this note followed behind the resident and redirected and assisted the resident back into the building. In an interview on 8/18/25 at 3:01 PM, Licensed Practical Nurse (LPN) F reported that Resident #104 had dementia and in the evening it got worse; he talked about going home and pushed on doors. LPN F reported that she had noticed a while back that the doors did not alarm when the wanderguard bracelets were near them, and she was told by other staff that the managers were already aware of the issue. In an interview and observation on 8/18/25 at 3:52 PM, Maintenance Director (MD) LL reported that he had not checked doors or alarms since 8/15/25 because there were no extra wanderguard bracelets to use to engage the alarms. MD LL reported that prior to 8/15/25 he checked every door, every day, and was not aware of any issues. Review of logs for the past 3 months revealed, new sheets of paper, perfectly dated and checked for every day; there were zero issues noted. An observation was then made, along with DON B; where a resident that was wearing a wanderguard bracelet was walked up to and through the main entrance and there was no alarm sound observed. DON B reported that it was supposed to sound when the resident was near the doorway. MD LL reported that he was not aware that the door was not alarming with the wanderguard bracelets. All other doors (4) were checked and none of them alarmed when the wanderguard was in the area.In an interview on 8/19/25 at 3:23 PM, Registered Nurse (RN) H reported that she was the nurse assigned to Resident #104 the night he left the building. RN H reported that the resident was wandering a lot, talking about his family and wondering when they were coming to get him. RN H reported that staff tried to redirect the resident and encouraged him to participate in an activity earlier in the evening, but that it did not work. RN H reported that she had last saw Resident #104 standing at the nurse's station when the EMS (emergency medical services) were leaving the building. RN H reported that she had gone to administer medication to another resident, and all other staff were down halls and/or in rooms when she left Resident #104 at the nurse's station. RN H reported that she did not hear any alarms but when she returned to the nurse's station a few minutes later, there was an EMT (emergency medical technician) from the EMS standing at the nurse's station. RN H reported that the EMT informed her of Resident #104 being outside of the building. RN H reported that she then exited the building and found Resident #104 walking on the side of the road. RN H reported that Resident #104's wanderguard bracelet did not alarm when he exited the building and that she was not aware of a device that was supposed to be used to check that the wanderguard was functioning properly. In an interview on 8/19/26 at 10:26 AM, EMT W reported that the EMS were in the building on 8/15/25 around 7:00 PM and when they went to leave the facility, they waited at the door to be let out. EMT W reported that a staff member outside of the door yelled the code so that they could open the door; the staff member came in and the EMT's went out. EMT W reported that while cleaning the ambulance and preparing for their next run, a man (Resident #104) came up to the door and started talking to them, then walked away and down the street. EMT W reported that shortly after that another man (Resident #106) told them the resident was not supposed to be outside, so they went back into the facility to inform staff.In an interview on 8/19/25 at 4:30 PM, EMT Y reported that when they left the building on 8/15/25 there was no staff around to let them out the door, and they waited at the nurse's station for a few minutes, until finally a facility staff member told them the code to the door. EMT Y reported that there were no residents nearby when they exited the facility, but then a few minutes later Resident #104 walked up to the back door of the ambulance and started conversing with them; EMT Y did not know he was a resident until she heard someone outside in a wheelchair start yelling, hey, he's not supposed to be out here! EMT Y went back into the facility to let staff know that there was a resident outside.In an interview on 8/19/25 at 10:15 AM, Resident #106 reported that he was outside on 8/15/25 when the EMS left the building. Resident #106 reported that he spotted Resident #104 outside after the EMS had walked out; he tried to alert the EMS and was about to go get Resident #104 himself had EMS not done something. Resident #106 reported that he wasn't sure if Resident #104 walked out with EMS or just afterwards.In an interview on 8/20/25 at 9:00 AM, Activities Aide (AA) II reported that she had tried to encouraged Resident #104 to participate in activities on 8/15/25 prior to the end of her shift (5:00 PM) but he was not interested and continued to wander around the facility. AA II reported that the facility does not offer activities after 5:30 PM.In an interview on 8/19/25 at 12:34 PM, DON B reported that she was not aware that the wanderguard alarms were not working properly until they were tested with this surveyor on 8/18/25. DON B reported that it was her understanding that EMS personnel must have known the door code and opened it themselves on 8/15/25 allowing Resident #104 to exit. DON B reported that all facility staff she interviewed had said they did not give EMS the door code, but she had not interviewed anyone from the EMS about the incident.In an interview on 8/20/25 at 9:11 AM, Human Resources staff (HR) P reported that the facility normally had 4 CNA's on second shift, but that there was a call in on 8/15/25 which left only 3 CNA's, a nurse and DON B who was filling in as a floor nurse. HR P reported that the activities staff clocked out at 5:00 PM, and there were no housekeepers working after 5:00 PM. In an interview and observation on 8/19/25 at 1:28 PM, Door Security Company (DSC) NN reported that the main entrance to the facility (the door that Resident #104 exited) did not have sufficient sensitivity to engage the alarm system when the wanderguard bracelets were near the door. DSC NN reported that he had suggested the facility replace the system 4 years ago due to the system frequently failing to work properly. Observed the wanderguard alarm now sound loudly when the wanderguard bracelet was within 2 feet of the main entrance door. DSC NN reported that the wanderguard bracelet will not make the other doors in the facility alarm, unless the bracelet goes through the doorway. Review of Resident #104's Baseline Care Plan revealed, RESOLVED: I am an elopement risk from the facility based upon the elopement risk assessment and secondary to confusion, disorientation, history of wandering, and an actual elopement on 8/15/25. Dated initiated: 8/12/25. Resolved Date: 8/15/25.Interventions: RESOLVED: Nursing to check wanderguard placement each shift. Date initiated: 8/12/25, Resolved Date: 8/15/25. Resident placed on 1:1 d/t (due to) elopement for 72 hours. Date initiated: 8/15/25. Resolved Date: 8/15/25. This plan of care had been deleted and was not active. Review of Resident #104's current Care Plan revealed, .is an elopement risk and/or exhibits wandering behavior r/t (related to) dementia, mental and behavioral disturbances. Date initiated: 8/16/25, Created on 8/15/25.Interventions: 8/15/25 Resident to be monitored by one-to-one staff member due to elopement risk increase/attempt. Date initiated: 8/16/25.Distract resident when increased wandering by offering pleasant diversions, structured activities, food, conversation, television, book, etc. per resident preferences. Date initiated: 8/15/25., May wander or attempt to leave facility unattended: triggers for wandering/eloping are watching visitors & family enter and leave building, wanting to go home. De-escalate by redirection, giving simple tasks to do . Date initiated: 8/15/25., Resolved: Wander alert: check for placement q (every) shift and function per policy. Date initiated: 8/15/25, Resolved Date: 8/16/25 (by DON B). This was Resident #104's active care plan.In an interview on 8/20/25 at 12:03, DON B reported that Resident #104 should have the wanderguard/wander alert bracelet as an active intervention on his care plan; DON B reported that it was not showing up. DON B then found the intervention resolved (removed) from the care plan and could not explain why. DON B reported that a resolved intervention is not available for staff to view.In a subsequent interview on 8/20/25 at 12:21 PM, DON B and Corporate Nurse Consultant (CNC) U reported that the wanderguard intervention was on Resident #104's current care plan and they did not see what the concern was. This surveyor reviewed a copy of Resident #104's care plan that revealed, DON B had created a new intervention on 8/20/25 that indicated, Check Wander guard for placement q shift and function per policy. CNC U acknowledged the discrepancy/error and reported that the intervention for Resident #104's wanderguard alert bracelet had accidentally been removed from his care plan on 8/16/25 and had been recreated on 8/20/25 to reflect the resident's current status. The Immediate Jeopardy that began on 8/15/25 was removed on 8/20/25 when the facility took the following actions to remove the immediacy.1. Resident #104:8/15/2025 Resident returned to the facility.8/15/2025 Skin assessment completed and no injuries noted.8/15/2025 Neuro check completed and resident remains at baseline.8/15/2025 Wander Risk Scale UDA completed.8/20/2025 Resident #104's Care plan reviewed and updated.8/15/2025 Physician notified of event and order for one on one supervision. 8/15/2025 D.O.N and Administrator were notified.8/15/2025 Attempted to notify emergency contact #1 and #2, message was left 8/15/2025 All doors/alarms were checked to ensure they are properly secured and functioning. It was determined all doors were properly secured and functioning at that time.8/16/2025 Facility has contacted Securitas to come out and service wanderguard system.8/18/2025 Facility will have a staff member at the nursing station monitoring the facility doors that go outside during non-business hours to ensure any resident at risk for wandering with a wanderguard in place do not exit the doors to the outside. During business hours the receptionist will monitor doors. This will be in place until the wanderguard system is serviced.8/19/2025 service was completed- it determined all doors were properly secured and were functioning and in working order. The front door needed the sensitivity increased, which was completed by the technician during his visit.8/16/2025 Signage was placed at door for family and visitors to stop at nursing station for assistance.2. On 8/15/2025 the facility completed a head count of residents to ensure no other residents were affected. 52 out of 52 residents were accounted for.3. 8/16/2025 All residents were reviewed to ensure a wander assessment was completed in the last 90 days and residents at risk for wander/elopement were reviewed to ensure resident safety and proper plan of care in place.4. On 8/15/2025, education was initiated for All Staff which includes Licensed Nurses, CENAs, Dietary, Housekeeping, Activities, Maintenance and Administrative staff members.a. Education will be completed by the DON or a designated nurse manager and included the following topics: 1. Elopement Policy and Procedures, Door Alarm and Wanderguard Alarm. 2. Verbal education provided on redirecting residents with exit seeking behaviors. 8/19/2025 facility added additional education on exit seeking behaviors- redirection includes offering snacks, walking with resident, calling family, seeing if personal needs are met (i.e. need to use bathroom, ensuring they are not too warm or cold, tired, looking for their room etc.), place on 15 minute supervision to keep in line of sight.b. As of 8/19/2025 at 1000AM, 47 out of 62 staff members have received the education.Any staff member who has not received the education, will receive before the start of their next shift. They will not be allowed to work until education has been completed.5. Medical Director was notified of these findings on 8/15/2025.6. 8/18/2025 QAA Committee has reviewed the plan and will continue to review the audits to ensure adherence to scope of practice, specifically elopement policy and procedures.7. On 8/20/2025 Errors were identified for resident 104, therefore, all residents at risk for elopement had care plans reviewed and updated.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food in the kitchen. Findings include: During the initial tour of the kitchen, at 9:40 AM on 12/3/24, observation of the walk-in cooler found a one-gallon container and a half gallon container both full of cooked roast beef. The roast beef was dated for 12/2 and was found covered with condensation and moisture on the inside tops of the containers. At this time, the surveyor took a temperature of the product with a Thermoworks Rapid Read thermometer and found the half gallon container was 40F and the gallon container was 43F. When asked what we should do to the product, Director of Housekeeping (DOH) F (Filling in for the Dietary Manager on Maternity leave) stated they should be discarded. When asked if there was a cooling log on the items, DOH F was unsure and was going to ask the cook after she was back from rounds. An interview with [NAME] GG, at 9:56 AM on 12/3/24, found that she didn't work last night and doesn't cool down or save food from meal service. [NAME] GG stated that they should have a log, but she's not sure where it is as its not in its usual spot. [NAME] GG stated that the cook who worked last night is new and has only been here a week or so. According to the 2017 FDA Food Code section 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less . According to the 2017 FDA Food Code section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; (2) Separating the FOOD into smaller or thinner portions; (3)Using rapid cooling EQUIPMENT; (4) Stirring the FOOD in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. (B) When placed in cooling or cold holding EQUIPMENT, FOOD containers in which FOOD is being cooled shall be: (1) Arranged in the EQUIPMENT to provide maximum heat transfer through the container walls; and (2) Loosely covered, or uncovered if protected from overhead contamination as specified under Subparagraph 3-305.11(A)(2), during the cooling period to facilitate heat transfer from the surface of the FOOD. Observation of the walk-in cooler, at 9:48 AM on 12/3/24, found the following items: sliced sausage dated 11/26, applesauce dated 11/25, orange slices dated 11/26, and a container of fruit cocktail with no date. Observation of the nourishment room, at 10:35 AM on 12/3/24, found a container of thanksgiving leftovers dated for 11/28 and another container of leftovers with no date. A sign on the front of the refrigeration unit states items are held for three days. According to the 2017 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . According to the 2017 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) . During a tour of the clean utensil drawers, at 10:00 AM on 12/3/24, it was observed that four mechanical scoops were found with dried stuck on food debris. During an observation of the drink station, at 10:02 AM on 12/3/24, it was observed that the underside of the coffee spout was heavily layered with an accumulation of coffee splash over time. Observation of the Microwave, at 10:10 AM on 12/3/24, found an accumulation of crusted debris on the top ceiling of the unit. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. During a tour of the kitchen at 10:05 AM on 12/3/24, it was observed that some of the ventilation filters on the cook line were found with excess grease accumulation. When asked if staff take these down and clean them, [NAME] GG stated they have a service that cleans them, but staff doesn't know how to take them down. During an observation of the three-compartment sink area, at 10:11 AM on 12/3/24, it was observed that the undershelf of the microwave table was found with heavy accumulation of yellow crusted debris. According to the 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean . During the initial tour of the kitchen, at 10:08 AM on 12/3/24, it was observed that the one compartment preparation sink, near the three-compartment sink, was found with no waste water line attached and set up in a manner that allowed water to dispense onto the floor. When asked about the sink, Dietary Aide HH stated that it's been that way for a while and staff just don't use it for now. During a tour of the chemical closet, at 10:29 AM on 12/3/24, it was observed that the sink was left on and connected to a pre-dispense chemical unit, allowing staff to just hit the button on the chemical unit for dispensing. This current set up of the mop sink faucet puts undue back pressure on the faucets internal vacuum breaker (VB) of which it is not rated to handle. During a revisit to the kitchen, at 12:10 PM on 12/3/24, it was observed that the water line to the garbage grinder would not shut off. When asked about the issue with [NAME] GG, she stated usually we just hit the stop button, but it doesn't seem to work. According to the 2017 FDA Food According to the 2017 FDA Food Code section 5-205.15 System Maintained in Good Repair. A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair. During a tour of the dish machine area, at 10:13 AM on 12/3/24, it was observed that Dietary Aide HH was doing dishes. When asked how the unit has been running, Dietary Aide HH stated good. Observation of the Dish Machine Log-Low Temp dated November 2024, found that the dish machine had been meeting the minimum requirements of 120F or higher for the wash and rinse temperatures and 50-100 parts per million of bleach as stated on the machines data plate. After running the machine three times, the water temperature never reached over 100F on the dish machines gauge or the surveyors thermometer. When asked if the dish gauge is the one that is used to record temperatures from, Dietary Aide HH stated Yes. According to the 2017 FDA Food Code section 4-501.15 Warewashing Machines, Manufacturers' Operating Instructions. (A) A WAREWASHING machine and its auxiliary components shall be operated in accordance with the machine's data plate and other manufacturer's instructions. During a tour of the dry storage room, at 10:27 AM on 12/3/24, it was observed that an open gallon of soy sauce was found on the dry storage shelf. A review of the manufacture's directions state Refrigerate After Opening. According to the 2017 FDA Food Code section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57C (135F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54C (130F) or above; or (2) At 5C (41F) or less. During an observation of tray line, at 12:32 PM on 12/3/24, it was observed that [NAME] GG touched multiple baked potatoes with her bare hands while placing and opening up baked potatoes for meal service. In the beginning of service [NAME] GG used utensils and gloved hands to help slice, open, and sometimes scrap the baked potato onto the plate. After roughly 2/3rds of the meals were plated, [NAME] GG started to get away from regularly using utensils and gloves to handle the ready to eat food and was osberved using her bare hands to plate numerous meals. According to the 2017 FDA Food Code section 3-301.11 Preventing Contamination from Hands. (A) FOOD EMPLOYEES shall wash their hands as specified under S 2-301.12. (B) Except when washing fruits and vegetables as specified under S3-302.15 or as specified in (D) and (E) of this section, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT .

Based on observation, interview, and record review, the facility failed to: 1. implement infection control practices during resident care for 5 (Resident #2, #4, #12, #11, and #299) of 12 residents reviewed for infection control, 2. maintain an ongoing infection control surveillance program, and 3. have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the increased risk of transmission of pathogenic organisms and cross contamination between residents. Findings include: Review of a facility policy titled Guidelines for Infection Prevention and Control revealed: .The INFECTION PREVNTION and CONTROL PROGRAM is designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This will be accomplished through preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, consultants, volunteers, visitors, and other individuals who provide services to residents in the facility . In an interview on 12/05/24 at 11:02am, Director of Nursing/ Infection Preventionist DON/IP B reported the facility relied on department managers to communicate to the Infection Preventionist when a staff member called in sick but often that information was not conveyed, and no tracking of employee illnesses had been completed. When further queried, DON/IP B reported the lack of tracking employee illnesses resulted in the potential for spread of illness for residents. In an interview on 12/05/24 at 11:02am, DON/IP B reported the facility had not completed ongoing hand hygiene or Personal Protective Equipment (PPE)audits to ensure staff were using proper techniques. DON/IP B reported no auditing had been completed since May 2024. When further queried, DON/IP B reported the lack of auditing created the potential for an increased likelihood of cross contamination between residents and/or staff to residents. 47955 Resident #2 Review of an Admission Record revealed Resident # had pertinent diagnoses which included: artificial left knee joint, and methicillin resistant staphylococcus aureus infection (MRSA). On 12/3/24 at 10:15 AM signage was noted on the door to Resident #2's room that indicated resident was in contact precautions and that anyone entering the room must clean their hands, including before entering and when leaving the room. Providers and staff must also put on gloves before entering the room, discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. use dedicated or disposable equipment. Clean and disinfect surfaces and equipment with a sporicidal agent. Review of Order Summary for Resident #2 revealed contact isolation related to MRSA in wound ordered on 11/28/2023. Review of Care Plan for Resident #2 revealed Goal : is on contact isolation due to MRSA in left knee . On 12/4/24 at 2:36 PM., Housekeeping Aide (HA) V was observed in Resident #2's room, removing trash from the bag in the trash can next to Resident #2's bed, picking up paper debris from the floor around Resident #2's bed, and exiting the room to dispose of gathered trash into the bag on her housekeeping cart in the hallway outside of Resident #2's room. HA 'V did not wear any PPE (personal protective equipment including gown and gloves) while in Resident #2's room. HA V was then observed applying gloves, HA V wore no other PPE, and gathering a rag, soaking the rag in a bucket of cleaning solution on her cart, and entering Resident #2's room and wiping off Resident #2's over the bed table with the rag. HA V then walked to Resident #2's roommates over the bed table and wiped the top of that table too. HA V then exited Resident #2's room, placed rag into the plastic bag on her housekeeping cart, removed, gloves. HA V did not perform hand hygiene before pushing her housekeeping cart down the hallway. In an interview on 12/4/24 at 2:42 PM., HA V reported she was a former certified nursing assistant, and the signage on Resident #2's door indicated Resident #2 was on contact precautions and PPE was to be worn by staff when Resident #2 received cares. HA V reported the signage did not apply to the housekeeping staff, only nursing. In an interview on 12/4/24 at 2:50 PM., Director of Nursing (DON) B reported Resident #2 was on contact isolation precautions and every staff member should wear PPE when encountering any item in her room. DON B reported contact precautions included housekeeping staff as well. In an interview on 12/4/24 at 2:59 PM., Director of Housekeeping (DH) F reported Resident #2 was the only resident on contact precautions. DH F reported contact precautions were for clinical staff only and did not apply to housekeeping staff. In an interview on 12/4/24 at 3:15 PM., Licensed Practical Nurse (LPN) L reported that Resident #2 was on enhanced barrier precautions (EBP) PPE was only required when providing direct care to Resident #2. In an interview on 12/4/24 at 3:20 PM., DON B Resident #2 was on contact precautions and her expectations was that all staff including housekeeping staff wear PPE when encountering anything in Resident #2's room. On 12/5/24 at 8:35 AM., Inservice Attendance dated 12/4/24 at 4:11 PM with a topic of EBP and contact precautions provided by the facility was reviewed and was noted to include signatures for 4 facility housekeeping staff members in attendance. Resident #4 Review of an Admission Record revealed Resident #4 had pertinent diagnoses which included: dysphagia (difficulty swallowing) following cerebral infarction (stroke) and gastrostomy status (feeding tube inserted directly into the stomach used to provide nutrients directly into the stomach). On 12/3/24 at 9:47 AM., Resident #4 was noted to have a G-tube present in her stomach and no signage was noted on the door to Resident #4's room to indicate she was in enhanced barrier precautions. Review of Order Summary for Resident #4 revealed pt (patient) receiving EBP (enhanced barrier precautions) due to Peg tube (g-tube) every shift, ordered on 5/29/2024. Review of Care Plan for Resident #4 revealed intervention of : Enhanced barrier precautions should be followed for all hands-on care with a revision date of 10/14/2024. On 12/4/24 at 4:10 PM no noted signage on Resident #4's room door to indicate the need for enhanced barrier precautions. Resident #12 Review of an Admission Record revealed Resident #12 had pertinent diagnoses which included: dysphagia (difficulty swallowing) following cerebral infarction (stroke) and gastrostomy status (feeding tube inserted directly into the stomach used to provide nutrients directly into the stomach). On 12/3/24 at 9:47 AM., Resident #12 was noted to have a G-tube present in her stomach and no signage was noted on the door to resident #12's room to indicate she was in enhanced barrier precautions. Review of Order Summary for Resident #12 revealed pt receiving EBP due to Peg tube (g-tube) every shift, ordered on 5/29/2024. Review of Care Plan for Resident #12 revealed intervention of : Enhanced barrier precautions while providing care to Resident #12 a revision date of 10/3/2024. On 12/4/24 at 4:10 PM no noted signage on Resident #12's room door to indicate the need for enhanced barrier precautions. In an interview on 12/4/24 at 2:17 PM., DON B reported EBP signage was to be posted on the door to the room for residents who were in enhanced barrier precautions. DON B reported nurses could access a resident's physician orders and see if there was an order for EBP, but certified nursing assistants would not know if a resident was in enhanced barrier precautions if there was no signage posted. DON B confirmed that Resident #4 and Resident #12 were both in enhanced barrier precautions but there was not signage posted on their doors to notify staff of enhanced barrier precautions. 48637 Resident #11 (R11) Review of the Admission Record and Minimum Data Set (MDS) dated [DATE] revealed R11 admitted to the facility on [DATE] with diagnoses including pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on skin), gastronomy tube (tube surgically inserted through the abdominal wall and into the stomach used for artificial nutrition, feeding tube), anxiety and depression. Brief Interview for Mental Status (BIMS) reflected a score of 14 out of 15 which indicated R11 was cognitively intact (13 to 15 cognitively intact). During an observation on 12/3/2024 at 10:30 AM, it was noted that R11's door had an Enhanced Barrier Precautions (EBP) sign on her door. The sign revealed Everyone must clean their hands, including before entering and when leaving their room. Providers and staff must also wear gloves and a gown for the following high contact resident care activities: dressing .device care or use: .urinary catheter, feeding tube .wound care: any skin opening requiring a dressing. Review of R11's physician orders revealed that R11 had an indwelling catheter, 2 pressure wounds-one on her right buttocks and 1 on her right trochanter (hip bone) and an enteral feeding (feeding tube). Review of R11's physician orders revealed that there wasn't an order for EBP. Review of R11's care plan revealed there wasn't a care plan for EBP. During an observation on 12/04/2024 at 8:41 AM, Assistant Director of Nursing (ADON) C and Certified Nursing Assistant (CNA) P went into R11's room with gloves on and no gown. ADON C stated to R11 that they were there to provide treatment to R11's wounds. R11's door was slightly ajar and surveyor observed wound treatment was performed. During an interview on 12/04/2024 at 8:55 AM, ADON stated that she was working with R11's wound and wasn't by her gastronomy feeding site on her body so she only wore gloves in R11's room. ADON stated that R11 was on EBP for her feeding tube and not for her wound. ADON reported that she is new to long term care and is still learning what needs to be done in relation to EBP. During an interview on 12/04/2024 at 9:11 AM, Director of Nursing (DON) B stated that any resident with a port of entry on their body such as a catheter, feeding tube and wounds should be under EBP. DON B said that staff should wear a gown and gloves when entering EBP rooms. During another interview on 12/04/2024 at 4:31 PM, DON B stated that physician orders and care plans should be put in the resident chart when they are under EBP. DON B reported that the admitting nurse or herself puts EBP physician orders in the chart and the Minimum Data Set (MDS) nurse puts the EBP care plan in. During an interview on 12/04/2024 at 4:31 PM, MDS nurse D verified that she did not see a physician order for EBP or a care plan for EBP in R11's chart. Resident #299 (R299) Review of the Admission Record and Minimum Data Set (MDS) dated [DATE] revealed R299 admitted to the facility on [DATE] with diagnoses including end stage renal disease and kidney transplant. Brief Interview for Mental Status (BIMS) reflected a score of 14 out of 15 which indicated R299 was cognitively intact. Review of R299's physician order revealed Enhanced barrier precautions d/t (due to) dialysis port in right chest. During observations on 12/03/2024 at 11:15 AM and 12/04/2024 at 11:46 AM, there wasn't EBP signage on R299's door. During an interview on 12/04/2024 at 2:04 PM, DON B reported that R299 should be under EBP with his chest port and she stated that she forgot to put the sign up. Review of the Guidelines for Enhanced Barrier Precautions (EBP) An Extension of Personal Protective Equipment (PPE) Policy with a revision date of December 2022 revealed Procedure: 2. Obtain a physician's order for the enhanced barrier precaution (EBP) and any additional precautions other than universal/standard precautions. 3. Ensure that proper signage is posted on the residence room door instructing those who plan to enter the room to check first at the nurses' station for education/instruction 6. Ensure that the resident's care plan is reflective of the resident's care regarding EBP or any additional precautions other than universal standard precautions as indicated. 38905 Observation of the facility, starting at 11:28 AM on 12/3/24 , found multiple stagnant lines, including a hopper, a wall mounted hopper spray, soiled utility room sink, the bathing tub, fixtures in the 500 hall bath (that's mainly used for just weights), the one compartment sink in kitchen with no waste water line, and a water line on the cook line of the kitchen that used to be used to fill equipment with water. During an interview with Maintenance (M) K and Director of Housekeeping (DOH) F, at 3:25 PM on 12/3/24, it was found that between the housekeeping and maintenance department, they do keep up on the flushing of water to resident fixtures as they clean and take water temperatures. When asked if there was a risk assessment or policy and procedure that had been done on the facility, M K and DOH F stated that they were both newer to the facility and would have to look on the computer to find that information. When asked how they knew to flush water lines on a regular basis, M K stated it came up on a weekly task list. When asked if there were other control measures and limits put in place, M K was unsure. During a review of the facility provided policy Water Systems - Legionella Risk Prevention, not dated, found that under the Procedure section it states Complete the worksheet titled Identifying Buildings at Increased Risk to determine if the entire buildings or parts of it are at increased risk for Legionella growth. No record review of the worksheet being completed was found. Following along on the procedure, the expectation is that the facility would create a building specific list of areas and equipment that should be monitored for as they are areas of risk associated with the growth of OPPP. The end of the policy gives directions on how to develop the water management plan: 1. Establish a Water Management Program Team 2. Describe the building water system using text and diagrams 3. Identify areas where Legionella could grow and spread. 4. Describe where control measures should be applied and how to monitor . No documentation was provided that showed that the plan was active and ongoing while fulfilling the requirements of the Water Management Plan.

Based on interview, and record review, the facility failed to maintain staff documentation of COVID-19 screening, education, offering and current COVID-19 vaccination status of one of one staff reviewed, resulting in increased risk for COVID-19 infections. This deficient practice has the potential to impact all residents within the facility. Findings include: Review of Infection Control Guidance: SARS-CoV-2 published 6/24/24 by the Centers For Disease Control, revealed: 1. Recommended routine infection prevention and control practices .Encourage everyone to remain up to date will all recommended COVID-19 vaccine doses .health care providers .should be offered resources and counseling about the importance of receiving the COVID-19 vaccine . Review of covid vaccination/education for Certified Nursing Assistant (CNA) DD revealed the staff member was last vaccinated for COVID 19 on 11/24/21. At the conclusion of the survey, the facility did not provide further documentation of annual offering of a covid vaccination or education related to the vaccination for this staff member. In an interview on 12/5/24 at 11:02am, the Director of Nursing (DON) who is also the Infection Preventionist (IP) B reported the facility had not offered staff members the COVID-19 vaccination for 2024 and had not tracked the immunization status or education of staff regarding COVID-19 vaccinations. DON B confirmed the facility was responsible to do so to reduce the risk of transmission to residents.

Based on observation and interview the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living, affecting all residents. Findings include: During a tour of the nourishment room, at 10:34 AM on 12/3/24, observation under the sink found a large hole in the wall exposing the back of the wall and leaving an opening for pests. Further review found old moisture damage and a black staining-like substance on the back wall inside of the hole. During a tour of the facility, at 11:29 AM on 12/3/24, observation of empty resident room [ROOM NUMBER] found a large brown splash stain in the far right corner of the room. The wall in this corner of the room was bubbling from the ceiling to the floor. During a tour of the 200 hall bath, at 11:35 AM on 12/3/24, it was observed that five towels and six washcloths were stored open and exposed between the sink and the shower. Items were stacked on top of a cabinet laying on the floor. Further review of the bath found a large green shower chair with dried brown splash staining a white support bar below the seat. During a tour of the 200 Hall Soiled Utility room, at 11:40 AM on 12/3/24, it was observed that brown tinted water came out of the hot and cold water lines of the hoppers mop sink faucet. Further observation found the sink had a slow leak when turned on. Observation in the cabinetry below the sink found dilapidated wood swollen with moisture with a sprawling black stain covering most of the wood. The odor of the cabinet was noticeably musty. During a tour of the 300 Hall Soiled Utility room, at 11:48 AM on 12/3/24, it was observed that the [NAME] valve, for flushing the hopper, would leak onto the floor when the unit was used. Further observation found the hopper was not able to completely flush with debris staying in the basin of the hopper. Further review found that the sink in the 300 hall Soiled Utility room was not operational, leaving a stagnant line that is not able to be flushed. Under the sink counter was found to have a disconnected wastewater line and a large hole on the back of the cabinet exposing the back wall. During a tour of the 200 hall Janitors closet, at 12:40 AM on 12/3/24, it was observed that a chemical pre dispense system was in place and that staff leave the faucet on and just use the pre dispense to run when needed. This set up puts undue back pressure on the faucets internal vacuum breaker (VB) of which will ruin the integrity of the mechanism. At 2:15 PM on 12/3/24, Observation of the boiler room with Maintenance (M) K found that one of the two water heaters was down and not operational. When asked about the issue, M K stated he has only been in the position a month but its something he would like to get fixed. When asked if they can keep up with current demand for hot water, M K stated yes. During a tour of the 500 hall bath, at 2:50 PM on 12/3/24, observation found an 8 inch by 12 inch piece of floor where the tile was smashed and missing. An interview with M K found that the floor was like that way when he started. M K went on to state that staff only use this bath to weigh residents on the scale. Further review of the two shower beds found excess debris and staining under the mats and an accumulation of hair caught on some of the structural tubing of the bed. A tub in the back of the room was found with two crayons along with dirt and debris. When asked if the tub is used or flushed, M K stated he didn't think it was used and wasn't something that was regularly flushed. 46999 During an observation on 12/4/24 at 4:24pm, the north wall of the facility's lobby area had 35 damaged areas in the dry wall. The damaged areas ranged from 1cm to 5 cm's in length, some exposed the brown underside of the drywall, and the damage extended across a 5ft wide section of the wall. 2 residents sat in the lobby area during this observation. During an observation on 12/5/24 at 1:49pm, bubbled up wallpaper that had been painted over was present on the east wall of the dining room, under the windows. Painted over wallpaper was bubbled up along the south wall of the dining room, near the ice machine, as well as along the north wall, under the 3rd window. The floor vent under the window on the east wall of the dining room was rusted across 75% of its surface, with the remaining 25% of the surface covered in chipped paint. During an obervation on 12/5/24 at 1:55pm, brown, built up debris was present around the door frames throughout the dining room and around much of the room.

Based on observation, interview, and record review the facility failed to maintain a medication error rate less than 5% (total error rate of 20%) in 4 residents (Resident #15, Resident #25, Resident #30, Resident #43) of 9 residents reviewed for medication administration resulting in improper injection location, late oral medication administration, missed dose of medication, and the potential for reduced medication effectiveness. Findings include: Resident #15 Review of an Admission Record revealed Resident #15 had pertinent diagnoses which included: diabetes mellitus (a disease that results in high blood sugar levels in the blood due to a body's decreased ability to produce insulin). Review of Order Summary for Resident #15 revealed insulin aspart injection solution 100 unit/ML (milliliter) (short acting insulin) inject as pre sliding scale : if 201-250 = 3 units; 251-300 = 5 units; 301-350 = 7 units; 351-400 = 9 units; 401-999 = 11 units, subcutaneously (administered just under the skin into the fatty areas of the abdomen, back of arms, or outer side of the thighs) three times a day related to diabetes, dated ordered 11/22/2024. Mounjaro subcutaneous solution auto-injector 7.5 mg/0.5ml (milligrams/milliliters) inject 7.5 mg subcutaneously in the afternoon every Wed (Wednesday) related to diabetes mellitus, date ordered 11/22/2024. On 12/4/2024 at 11:31 AM., Licensed Practical Nurse (LPN) L was observed administering a Mounjaro subcutaneous injection into the left arm deltoid (a thick triangular muscle that forms the rounded area of upper arm and the shoulder) area of Resident #15. On 12/4/2024 at 11:43 AM., LPN L was observed administering an insulin aspart injection into the right arm deltoid area of Resident #15. In an interview on 12/4/24 at 11:46 AM., when asked, LPN L reported that Resident #15's injections should be given subcutaneously. LPN L reported acceptable locations for subcutaneous injections were the deltoid muscle of the arm and the abdomen. In an interview on 12/4/24 at 4:11 PM., LPN M reported that insulin was a subcutaneous injection and could be administered in the arm, LPN M gestured to her own arm pointing to and touching the deltoid muscle as a demonstration of where a subcutaneous insulin injection should be given. In an interview on 12/5/24 at 12:32 PM., Director of Nursing (DON) B and Assistant Director of Nursing (ADON) C reported that subcutaneous injections should be given in the back of the arms, abdomen, and the outer side of the thighs into fatty areas. DON B reported it was not acceptable to give subcutaneous injections into the deltoid muscle of the arms. Resident #25 Review of an Admission Record revealed Resident #25 had pertinent diagnoses which included: nontraumatic intracerebral hemorrhage (stroke, not resulting from trauma). Review of Order Summary for Resident #25 revealed Baclofen 15mg give one tablet by mouth three times a day, ordered on 7/20/24. On 12/4/24 at 4:29 PM., LPN M was observed administering baclofen 15 mg tablet to Resident #25. Visualization of the computer Medication Administration Record (MAR) during the observation revealed an ordered time of administration of 15:00 (3:00 PM). When asked, LPN M reported that Resident #25's baclofen 15 mg tablet could be given an hour early (between 2:00 pm and 3:00 pm) or an hour later (between 3:00 pm and 4:00 pm) from the time it was ordered to be given. In an interview on 12/5/24 at 12:32 PM., DON B reported medication could be given an hour before and an hour after the ordered time. DON B confirmed a medication ordered at 3:00 pm and given at 4:28 pm was a late administration. Resident #30 Review of an Admission Record revealed Resident #30 had pertinent diagnoses which included: Type 2 diabetes with diabetic neuropathy (nerve pain). Review of Order Summary for Resident #30 revealed gabapentin capsule 100 mg give one capsule by mouth three times a day for neuropathy, ordered on 8/22/24. On 12/4/24 at 4:11 PM., LPN M was observed preparing medications for Resident #30. During medication preparations for Resident #30, LPN M reported Resident #30 did not have gabapentin 100 mg capsules available in the medications cart and Resident #30 would not get this dose. Resident #30 did not receive gabapentin 100 mg as ordered. In an interview on 12/4/24 at 4:18 PM., this surveyor asked LPN M if gabapentin 100 mg capsule was available from the facilities back up medication box, and LPN M reported she did not have time to deal with it right now. In an observation and interview on 12/5/24 at 10:15 AM., DON B accessed the facility's back up medication storage box and confirmed that gabapentin 100 mg was available for use if a resident's supply was gone, or a resident was waiting for a refill from the pharmacy. DON B reported her expectations were nurses pull a resident's missing medication from the backup medication box if available to ensure that residents did not miss a dose. Resident #43 Review of an Admission Record revealed Resident #43 had pertinent diagnoses which included: alcohol abuse. Review of Order Summary for Resident #43 revealed Acamprosate Calcium Oral Tablet Delayed Release 333 MG give 333 mg three times a day for reduce desire to drink alcohol, order started on 8/10/24. On 12/4/24 at 11:47 AM., LPN L was observed preparing acamprosate calcium oral tablet delayed release 333mg tablet for Resident #43. During the observation LPN L stated Resident #43 takes his medications crushed. LPN L was observed crushing acamprosate and mixing the crushed medication with vanilla pudding and providing the mixture to Resident #43 who ate the mixture of crushed medications and vanilla pudding. In an interview on 12/4/24 at 11:50 AM., LPN L reported that acamprosate could be crushed. Review of Medication Label on Resident #43's acamprosate prescription supply revealed Do Not Crush. In a telephone interview on 12/5/24 at 9:02 AM., Pharmacist (P) Y reported that acamprosate was a delayed release medication and should not be crushed, it should be swallowed whole. P Y reported when Acamprosate was crushed, the medication absorption by the body was altered. In an observation and interview on 12/5/24 at 12:41 PM., DON B reported delayed release medications should not be crushed. DON B reported Resident #43 takes his medication crushed in pudding or applesauce. DON B accompanied this surveyor to the medication cart and was observed removing Resident #43's prescription supply of acamprosate from the medication cart and confirming the pharmacy's prescription label did indicate do not crush.

This citation pertains to intake # MI00139483 Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance during cares for 1 (Resident #100) of 3 reviewed for falls, from a total sample of 5, resulting in Resident #100 sustaining a fall, fractured femur, decreased functional abilities, increased pain, and emotional distress. Findings include: Review of a Admission Record for Resident #100 dated 7/27/23 revealed the resident was admitted to the facility with the following pertinent diagnoses: Heart Failure ( a condition in which the heart does not pump blood as well as it should), Chronic Respiratory Failure(condition in which the lungs cannot get enough oxygen into the blood), Muscle Weakness, Major Depressive Disorder, Weakness, Unspecified Lack of Coordination, Morbid Obesity, and Blindness of One Eye. Review of a Minimum Data Set (MDS) assessment for Resident #100 dated 8/3/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated the resident was cognitively intact. Section GG of the MDS revealed Resident #100 required maximal assistance (helper does more than half the effort) for moving from a sitting to lying position and moving from lying to a sitting position. Resident #100 required moderate assistance (helper does less than half the effort but holds or supports limbs) to roll from lying on her back to resting on her side. Section J of the MDS revealed Resident #100 reported she occasionally experienced pain during the 5-day assessment period, had no difficulty sleeping due to pain and was not limited in her day-to-day activities due to pain. Section J also revealed Resident #100 had no falls between her admitted and 8/3/23. Review of a Minimum Data Set (MDS) assessment initiated on 9/1/23 due a significant change of status for Resident #100, revealed the resident required dependent (helper does all the effort) for moving from a sitting to lying position, moving from lying to sitting, and for rolling from her back to her side. Section J of the MDS revealed Resident #100 reported she frequently experienced pain during the 5-day assessment period, had difficulty sleeping and was limited with her day-to-day activities due to her pain level. Resident #100 rated her pain level a 9 on a zero to ten scale. Section J revealed Resident #100 had a fall since her admission and the fall resulted in a major injury (bone fracture). Review of a Care Plan for Resident #100 dated 11/13/17 revealed the following focus/goal/interventions: Focus: I am at risk for falls related to .requires ADL (activities of daily living) assist .loss of functional movement of joints .decreased strength .endurance .respiratory and heart diagnosis. Goal: I will have a safe environment. Interventions: enabler bars to help with turning .ensure proper positioning while in bed . Review of a Kardex (method for communicating important care information) for Resident #100 revealed instructions as follows: Communication: always have 2 staff members for all care at all times (sic). Bed Mobility: I require extensive assist of 1-2 for bed mobility Personal Hygiene: extensive assist x 2 staff. Review of an Emergency Medical Report hospital record dated 9/1/23 at 2:16am revealed Resident #100 was seen for a ground level fall and diagnosed with a right femur fracture. During her time in the emergency room , Resident #100 rated her pain level at a 10- unbearable. Review of form labeled Incident provided by the facility, dated 9/1/23 at 12:20am, revealed the following: Incident Summary: Staff (Certified Nursing Assistant (CENA) I) providing care for (Resident #100). Resident was on left side hand leaning on wall. Staff turned to reach for cleaning items . (Resident #100) rolled off the bed. Staff (CENA I)in-serviced in regards to (sic) (Resident #100) 2 -assist when providing care. In an interview on 10/2/23 at 10:41am, Resident #100 reported she fell from her bed while Certified Nursing Assistant (CENA)I provided personal care to her. Resident #100 reported she knew she was supposed to receive care from 2 staff members, but it was often difficult for staff members to find help. Resident #100 reported she tried to steady herself by placing her hand on the wall next to her, while laying on her left side, but when the CENA let go of her lower body to reach for more supplies, Resident #100 could not maintain the position of her body, rolled off the bed, and fell to the floor. Resident #100 reported after the fall she experienced increased pain that interferred with her sleep, worried frequently about falling again and was preoccupied about ensuring her body was in the middle of the bed. Resident #100 stated sometimes I would wake up in the middle of the night and was scared because I felt like I was falling again. In an interview on 10/2/23 at 11:02am, Certified Nursing Assistant (CENA) C reported Resident #100 required assistance of 2 staff for all care at the time of her fall. CENA C reported Resident #100 expressed more anxiety and pain following the fall. In a telephone interview on 10/2/23 at 1:20pm, Certified Nursing Assistant (CENA) I reported she proved cares alone to Resident #100 at approximately 2:00am on 9/1/23. CENA I reported all other staff were unavailable and that it was often difficult to find another staff member to assist with residents who required 2 staff members during cares. CENA I reported she thought Resident #100's care plan indicated the resident required assist of 2 staff for care. During cares on 9/1/23, CENA I assisted Resident into a side lay position on her left side. Resident #100 pressed her left hand against the wall. CENA I placed one hand on Resident #100's body to stabilize the resident and completed peri-care with the other hand. CENA I released her hand from Resident #100's body and turned around to gather more wipes. At that time, Resident #100 rolled off the bed and fell to the floor. In an interview on 10/3/23 at 10:50am, Director of Nursing (DON) B reported Resident #100 was supposed to receive care from 2 staff members at the time of her fall. DON reported Resident #100 required maximal assistance for cares which meant that 2 staff members were needed. In an interview on 10/3/234 at 11:13 am, Licensed Practical Nurse (LPN) G reported she was called to Resident #100's room on 9/1/23 at approximately 2 am. LPN G reported Resident #100 was lying face down on the floor between her bed and the wall. LPN G reported Resident #100 was sent to the hospital due to right leg pain and was diagnosed with a femur fracture. LPN G reported Resident #100 suffered from increased anxiety in the weeks following the fall. LPN G reported the resident experienced Night Terrors during which she awoke suddenly and was fearful that she was falling. Review of a Progress Note for Resident #100 dated 9/25/23 revealed the resident has moderate pain with turning and positioning .also has PTSD (post traumatic stress disorder) regarding her fall .states how close am i to the edge? Review of a an Order Summary Report revealed a physician added additional pain medication (Hydrocodone-Acetaminophen) to Resident #100's medication regimen. Review of Falls in Nursing Homes published by the Center for Disease Control, 2012 revealed Falls among nursing home residents occur frequently and repeatedly. About 1,800 older adults living in nursing homes die each year from fall-related injuries and those who survive falls frequently sustain hip fractures and head injuries that result in permanent disability and reduced quality of life. About 1,800 people living in nursing homes die each year from falls. About 10% to 20% of nursing home falls cause serious injuries; 2% to 6% cause fractures.

This citation pertains to intake: MI00134983, MI00138043 Based on interview, observation, and record review, the facility failed to ensure adequate staff to meet resident needs for 4 (Resident #100, Resident #102, Resident #101, Resident #103) of 5 residents reviewed for staffing, resulting in residents being transferred unsafely, residents receiving personal care unsafely, missed showers and lack of nail care. Findings include: Resident #100 Review of a Admission Record for Resident #100 dated 7/27/23 revealed the resident was admitted to the facility with the following pertinent diagnoses: Heart Failure ( a condition in which the heart does not pump blood as well as it should), Chronic Respiratory Failure(condition in which the lungs cannot get enough oxygen into the blood), Muscle Weakness, Major Depressive Disorder, Weakness, Unspecified Lack of Coordination, Morbid Obesity, and Blindness of One Eye. Review of a Minimum Data Set (MDS) assessment for Resident #100 dated 8/3/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated the resident was cognitively intact. Section GG of the MDS revealed Resident #100 required maximal assistance (helper does more than half the effort) for moving from a sitting to lying position and moving from lying to a sitting position. Resident #100 required moderate assistance (helper does less than half the effort but holds or supports limbs) to roll from lying on her back to resting on her side. Section J of the MDS revealed Resident #100 reported she occasionally experienced pain during the 5-day assessment period, had no difficulty sleeping due to pain and was not limited in her day-to-day activities due to pain. Section J also revealed Resident #100 had no falls between her admitted and 8/3/23. Review of a Kardex (method for communicating important care information) for Resident #100 revealed instructions as follows: Communication: always have 2 staff members for all care at all times (sic). Bed Mobility: I require extensive assist of 1-2 for bed mobility Personal Hygiene: extensive assist x 2 staff. In a telephone interview on 10/2/23 at 1:20pm, Certified Nursing Assistant (CENA) I reported she proved cares alone to Resident #100 at approximately 2:00am on 9/1/23. CENA I reported all other staff were unavailable and that it was often difficult to find another staff member to assist with residents who required 2 staff members during cares. CENA I reported she thought Resident #100's care plan indicated the resident required assist of 2 staff for care. During cares on 9/1/23, CENA I assisted Resident into a side lay position on her left side. Resident #100 pressed her left hand against the wall. CENA I placed one hand on Resident #100's body to stabilize the resident and completed peri-care with the other hand. CENA I released her hand from Resident #100's body and turned around to gather more wipes. At that time, Resident #100 rolled off the bed and fell to the floor. CENA I reported she regularly struggled to find another staff member who could assist her with caring for Resident #100. CENA I reported she cared for Resident #100 by herself so often that she had developed a system. Review of an Emergency Medical Report hospital record dated 9/1/23 at 2:16am revealed Resident #100 was seen for a ground level fall and diagnosed with a right femur fracture. During her time in the emergency room , Resident #100 rated her pain level at a 10- unbearable. In an interview on 10/4/23 at 10:24am, Confidential Informant (CI) M revealed she reported the need for additional staffing to corporate leadership and was told additional staff would not be provided. CI M reported the facility had many residents who required assistance of 2 staff members for care and the current staffing level was a safety concern. In an interview on 10/4/23 at 11:48am, Director of Nursing (DON) B the staff were doing the best they could, that she'd asked about increasing staffing and was told the current staffing level was what you have to work with. DON B reported she felt staff would not resort to doing 2-person assist with 1 person if more staff were available to help. Resident #102 Review of an Admission Record for Resident #102 dated 8/27/23 revealed the resident was admitted to the facility with the following pertinent diagnoses: Metabolic Encephalopathy (alteration in consciousness caused by brain dysfunction), Seizures, Depression, Cerebral Infarction (Stroke), Hemiplegia (paralysis on one side of the body), and Muscle Weakness. Review of a Minimum Data Set (MDS) assessment for Resident #102 dated 9/20/23 revealed the resident was dependent (helper does all the effort) for showering/bathing and required assistance of a staff member for personal hygiene. Review of a Kardex (method of communicating important care metinformation) revealed the following care instructions: resident to have 2 to 3 showers a week .transfer: hoyer (mechanical lift) with 2-person assist .keep fingernails short. During an observation on 10/3/23 at 2:11pm, the door to room [ROOM NUMBER] (Resident #102's room) was closed. Certified Nursing Assistant (CENA) K was inside the room, opened door, pushed a mechanical lift from the room to the hallway. No other staff members emerged from the room. In an interview on 10/3/23 at 2:16pm, Certified Nursing Assistant (CENA) K reported she transferred Resident #102 to bed, using a mechanical lift, did so alone. CENA K reported she resorted to transferring Resident #102 by herself because no other staff was available to assist with the transfer, the resident was extremely tired and had been waiting for a long time. CENA K confirmed managers had provided education regarding the need to complete mechanical lift transfers with 2 staff members present, but she felt this was unrealistic given current staffing ratios. CENA K reported sometimes the residents didn't receive showers or nail care because there was not enough staff to complete these tasks. In an interview on 10/3/23 at 1:00pm, a Confidential Informant (CI) L reported she spoke to several members of the leadership team, including one manager at the corporate level, regarding the need for more staffing due to the high number of residents who require assistance of 2 staff members. CI L reported she was told the facility was not going to add additional staff. CI L reported residents who required 2-person assist were frequently transferred and cared for by 1 staff member. CI L acknowledged that due to staffing levels, showers and nail care were often missed. During an observation on 10/4/23 at 1:45pm Resident #102 was awake, sitting supported in bed. Resident # 102's fingernails were noted to extend beyond her fingertip's, jagged edges were present on 2 fingernails. Dried dark brown material coated the underside of several nails. In an interview on 10/4/23 at 1:47pm Resident #102 was asked if she liked to keep her nails long, in response, Resident #102 stated My nails are awful. Review of Shower Sheets for Resident # 102 revealed 8 documented showers, 2 refusals for the twelve-week period of 7/23-9/23. In an interview on 10/4/23 at 11:48am, Director of Nursing (DON) B reported all shower sheets available for Resident #102 had been provided. DON B reported the staff should fill out a shower sheet each time and shower or bed bath was performed and that it was possible the Resident missed a shower if no shower sheet was completed. Resident #101 Review of an Admission Record dated 7/5/23 revealed Resident #101 was admitted to the facility with the following pertinent diagnoses: Huntington's Disease (inherited condition in which nerve and brain cells break down over time), Cerebral Infarction (Stroke), Encephalopathy (disturbance of the brain's functioning), Muscle Weakness, Repeated Falls, and Unspecified Lack of Coordination. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #101 scored 12 of 15 on a Brief Interview for Mental Status (BIMS) assessment, which indicated the resident was cognitively impaired. Section E of the MDS revealed Resident #101 did not refuse care. Section GG of the MDS revealed Resident #101 required maximal assistance (helper does more than half the effort) for bathing and personal hygiene. Review of a Care Plan for Resident #101 dated 8/19/21 revealed the following focus/goal/interventions: Focus: Late loss of ADLs .requires staff assist with ADL's due to debility, impaired balance, excessive movements .CVA. Goal: Will maintain current level of self-care ability .requires extensive assist of 1-2. Interventions: set up with personal hygiene every am and pm .encourage resident to complete as much as possible. During an observation on 10/2/23 at 10:15am, Resident #101 was awake, lying on a mattress on his floor, fingernails on both hands were noted to extend beyond his fingertips. The underside of several fingernails was coated with dried brown material. Review of Shower Sheets provided by the facility for Resident #101 revealed documentation of 11 showers/bed baths during a twelve-week period. In an interview on 10/4/23 at 11:48am, Director of Nursing (DON) B reported all shower sheets available for Resident #101 had been provided. DON B reported the staff should fill out a shower sheet each time and shower or bed bath was performed and that it was possible the Resident missed a shower if no shower sheet was completed. Resident #103 Review of a Minimum Data Set (MDS) assessment completed upon Resident #103's admission to the facility, dated 6/22/22 revealed the resident was admitted with the following pertinent diagnoses: Mood Disorder, Unsteadiness on Feet, Unspecified Abnormality of Gait and Mobility, Lack of Coordination, Weakness, and Osteoarthritis (degenerative joint disease). Review of a Minimum Data Set (MDS) assessment for Resident #103 dated 8/22/23, revealed the resident scored 15/15 on a Brief Interview for Mental Status (BIMS) assessment which indicated she was cognitively intact. Section GG of the MDS revealed Resident #100 was dependent (required assistance of 2 staff members) for showering/bathing and required extensive assistance for personal hygiene. Review of a Kardex (method of communicating important care information) a section titled Bathing/Dressing revealed Will have two showers with hair washed twice weekly. In a section titled Communication stated 2 staff members for all care at all times. A section titled Bathing stated Bathing-Schedule Preferred: Tuesday and Friday. In an interview on 10/4/23 at 9:51am, Resident #103 reported she was not sure she always got her showers and would like to have her nails taken care of. Resident #103's fingernails were chipped and jagged. Review of Shower Sheets provided by the facility revealed documentation that Resident #103 received 9 showers within a 12-week period. Based on the resident's preferred schedule for showering Tuesday and Friday, the resident should have been offered a shower 26 times. In an interview on 10/4/23 at 11:48am, Director of Nursing (DON) B reported all shower sheets available for Resident #103 had been provided. DON B reported the staff should fill out a shower sheet each time and shower or bed bath was performed and that it was possible the Resident missed a shower if no shower sheet was completed. In a telephone interview on 10/4/23 at 3:19pm, Nursing Home Administrator (NHA) A reported a staff member expressed to her that the floor staff were struggling to meet care needs due to the number of residents who required 2-person assistance for cares. In response, NHA A coordinated moving residents' rooms to attempt to make caring for the residents more convenient. In an interview on 10/4/23 at 2:46pm, Regional Director of Nursing Services (RDON) N referred to the facilities PPD staffing ratio (calculation of how many nurses need to be on a shift during a given day based on the number of residents) and stated, You can't find higher numbers than that. When asked if she was aware of the number of residents who required assistance of 2 staff members for care, Regional RDON N reported she was not aware of data until it was requested by the surveyor and shared with RDON N. Review of a facility provided list revealed 22 of 42 residents residing in the facility, required assistance of 2 staff members for cares. According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 50742-50744). Elsevier Health Sciences. Kindle Edition.Personal hygiene affects patients' comfort, safety, and well-being. Hygiene care includes cleaning and grooming activities that maintain personal body cleanliness and appearance. Personal hygiene activities such as taking a bath or shower and brushing and flossing the teeth also promote comfort and relaxation, foster a positive self-image, promote healthy skin, and help prevent infection and disease .

This citation pertains to intake MI00132852. Based on interview and record review, the facility failed to follow and implement their CPR (cardiopulmonary resuscitation) policy regarding AED use for 1 of 1 resident (Resident #143) reviewed for events surrounding death, resulting in an immediate jeopardy when beginning on [DATE] at approximately 9:20 AM, the facility failed to ensure that staff had access to a working AED (automated external defibrillator) per facility policy and Resident #143 was found unresponsive with no pulse or respirations and CPR was initiated. Resident #143 was pronounced dead at the hospital. This deficient practice placed all residents who were full code status (15 residents on [DATE]) at risk for serious harm, injury, and/or death. Findings include: Review of an Admission Record revealed Resident #143 admitted to the facility on [DATE] with pertinent diagnoses which included kidney disease, congestive heart failure, type II Diabetes, and cardiomyopathy. Review of a Minimum Data Set (MDS) assessment for Resident #143, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #143 was cognitively intact. Review of Resident #143's active orders on [DATE] at 3:21 PM revealed that Resident #143 was full code status. Review of a current Care Plan focus for Resident #143, initiated [DATE], revealed that Resident #143 had elected full code status. Review of Nursing Progress Note, dated [DATE] at 12:03 PM, revealed LPN (Licensed Practical Nurse) R was called to Resident #143's room at approximately 9:20 AM and assisted another nurse with CPR as resident was unresponsive with no pulse or respirations until EMT's (Emergency Medical Technicians) arrived. Resident #143 was then transferred to the local Emergency Department. In a telephone interview on [DATE] at 10:24 AM, CNA (Certified Nursing Assistant) X reported that she walked past Resident #143's room that morning and saw Resident #143 sitting up in bed facing the window. CNA X reported that she came back a minute or two later and Resident #143 was slumped onto her back with blue lips, not breathing. CNA X reported that Resident #143 was not eating at the time. CNA X reported that she called for help and two nurses responded and initiated CPR, performing chest compressions and giving her air. CNA X reported that the nurses looked for the AED (automated external defibrillator) and could not find it. In a telephone interview on [DATE] at 4:01 PM, LPN (Licensed Practical Nurse) R reported that she was called to the room of Resident #143 along with another nurse by CNA X because Resident #143 was not breathing. LPN R reported that she yelled to the desk to call 911. LPN R reported that the other nurse had already begun chest compressions when she arrived to Resident #143's room. LPN R reported that she grabbed the crash cart and continued CPR with the other nurse for about 5 minutes until EMT's (Emergency Medical Technicians) arrived. LPN R reported that there was no AED in the crash cart or able to be found. LPN R reported that EMT's worked on Resident #143 for approximately 15 minutes before leaving the facility to transport Resident #143 to the local hospital. In an interview on [DATE] at 4:44 PM, NHA (Nursing Home Administrator) A reported that the facility AED was locked in the Director of Nursing's office on [DATE] when CPR was being performed on Resident #143 and not available for responding staff. NHA reported that she did not know why the AED was locked in the Director of Nursing's office. Review of facility policy/procedure CPR Policy, effective [DATE], revealed .CPR sequence . Check patient for responsiveness . If unresponsive, call for help and activate EMS, or direct others to do so . Obtain AED and emergency equipment or direct others to do so . Check for breathing and pulse . if no pulse and not breathing, begin CPR cycle . Use AED as soon as it is available . On [DATE] at 9:48 AM, NHA (Nursing Home Administrator) A was notified of an Immediate Jeopardy that began on [DATE] and was identified on [DATE] when Resident #143 was found unresponsive without a pulse or respirations and staff were unable to fully implement the CPR Policy including use of an AED (automated external defibrillator). On [DATE], this surveyor verified the facility completed the following to remove the Immediate Jeopardy. 1- Resident #143 expired. 2- A facility wide audit was conducted to define which residents had the Advanced Directive of desiring to be a FULL CODE, as far as their documented wishes, orders and care plans. All residents with Full Code status were reviewed [DATE] by Social Service Director and DON. 3- On [DATE], the AED was assessed and all necessary supplies needed to perform a FULL CODE were available in the crash cart. 4- Beginning [DATE], the charge nurse on each shift will check for the accessibility of the AED. This will be ongoing. This will be documented. This will be done on a checklist and given to DON. 5- On [DATE], the CPR policy was reviewed by the Administrator, the DON, and the RNC. 6- Beginning [DATE], the DON/ADON/Nurse Manager will monitor 7 days weekly on various shifts to include some weekend shifts. This monitoring will go on for 4 weeks. After that the monitoring will be done 3 days weekly on various shifts, to include some weekend days for a period of not less than 6 months for ongoing compliance. After that, random checks will be conducted. Any concerns with any of the monitoring will be immediately addressed by the Administrator and DON. 7- Beginning [DATE], as additional oversight, the Regional Nurse Consultant will monitor the AED accessibility weekly. 8- Beginning [DATE], all nurses were in-serviced on the use of the AED and CPR/Advanced Directives. The in-servicing was conducted by the DON And MDS Coordinator with input from the Regional Nurse Consultant. Knowledge was measured by a POST TEST requiring 100% of the answers to be correct to pass. No staff will work after [DATE] until they have successfully completed and passed the test. This includes agency staff, prn staff, staff on any leave of any kind to include vacation or FMLA. The topics of the in-service include: 1- CPR/Advanced Directives, 2- What is an AED? Who can use it? When is it used? When should it be available? Where is it kept? Who keeps it ready to go?, 3- What is MY ROLE in my position, during a FULL CODE?, 4- What is a CRASH CART? When is it used? What is on it? Any staff who fail to comply with the points of the in-service will be further educated and/or progressively disciplined as indicated. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of actual harm that is not immediate jeopardy, and severity of isolated due to not all education had been completed and sustained compliance had not yet been verified by the State Agency.

This citation pertains to intake #: MI00130545, MI00130529, MI00130495 Based on interview and record review, the facility failed to 1.) allow a resident to return to the facility after an emergency room (ER) evaluation and 2.) notify the residents guardian in writing of their appeal rights for 1 of 5 residents (Resident #12) reviewed for facility initiated transfers, resulting in Resident #12 being denied return and entrance to the facility, the inability of Resident #12's guardian to appeal the involuntary discharge, and Resident #12 to have feelings of fear, betrayal and frustration. Findings include: Review of an Admission Record revealed Resident #12, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: left leg above the knee amputation. Review of a Minimum Data Set (MDS) assessment for Resident #12, with a reference date of 11/18/22 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #12 was cognitively intact. Review of Resident #12's Electronic Medical Record (EMR)-Progress Noted dated 8/16/22 revealed: 8/16/2022 at 3:54 Nursing Note Text: Assigned staff entered into resident's (Resident #12's) room to do care and note noticed that resident (Resident #12's) had parasites (maggots) on him at his left hand and side. Writer went into resident's (Resident #12's) room to assess resident and observed that there were parasites at resident (Resident #12's) left side of his body and at left hand Physician then gave the order to send resident out to hospital . In an interview on 12/20/22 at 9:47 AM., Hospital Social Worker/Case Manager (HSW) W reported Resident #12 arrived at the Emergency Department (ED) on 8/16/22. HSW W reported when he arrived he (Resident # 12) had maggots coming out of a wound. HSW W reported (Resident #12) was refusing treatment, and upset that the facility sent him out to the ED, (Resident #12) was refusing treatment at the facility, and once at the ED he refused treatment as well. HSW W reported attempts to reach (Resident #12's) guardian were attempted, but was unsuccessful. HSW W reported there was nothing we could do for him, as he (Resident #12) was refusing treatment in the ED and wanted to go back home (the facility). HSW W reported the ED decided until the guardian was involved they had to return him back to the facility until a court order or petition came through to sedate and treat his (Resident #12's) infected wound. HSW W reported the facility management (NHA A) was called numerous times, and (NHA A) refused to readmit him. HSW W reported (NHA A) told us (hospital staff-doctors) to send him out to psychiatric services and that she (NHA A) would not allow (Resident #12) back to the facility until he was treated for his wounds. HSW W reported many phone calls and communication from the hospital staff and social workers, including herself (HSW W) informed (NHA A) that they could not treat him, or send him to psychiatric services because he has the right to refuse treatment, and until his guardian was contacted he (Resident #12) would be sent back to the facility. HSW W reported (NHA A) informed her that she (NHA A) would lock the doors, and he would not be able to be readmitted . HSW W reported the facility felt it was okay to dump him (Resident #12) here and try for a psych evaluation. HSW W reported we (hospital staff) couldn't do a psych screen because the attending physician didn't see a reason, and he (Resident #12) would have to come back after the proper process and paperwork was completed by the guardian and courts. HSW W reported the second time she (HSW W) reached out to the facility she spoke with (NHA A) and then (NHA A) hung up on her (HSW W). HSW W reported when we (hospital staff) discharged him and sent him in the ambulance back to the facility they (facility staff) locked him (Resident #12) out of the building. HSW W reported the police were called by the ambulance drivers, because the facility locked the doors, and would not answer the door or phone. HSW W reported once the police arrived, the facility again refused to let him (Resident #12) back in, they (the police) decided they did not think it was safe for him due to the locked doors and situation itself, that (Resident #12) stay at the facility at that time. HSW W reported the hospital staff, and herself took (Resident #12) back in and admitted him for safety reasons. HSW W reported after 8/16/22 the guardian called and asked what was going on and then started the process of paperwork to sedate to treat the wound. HSW W reported we were able to get the court order and (Resident #12) was treated and released back to the facility a few days later. HSW W reported (Resident #12) was very upset, fearful he wouldn't have a home to go to, and worried about the situation the entire time he was in the hospital. HSW W reported the days (Resident #12) was in the hospital, there was a lot of push back and little communication collaborating with (NHA A). HSW W reported she had informed (NHA A) after speaking to (Resident #12's) guardian, that the facility wound have to take him back once discharged from the hospital because it was an improper facility initiated discharge. HSW W informed this surveyor she reached out to the local Ombudsman (Omb II) about the refusal to let (Resident #12) back into the building until things could be straightened out with his guardian once contact was made. Review of Resident #12's Hospital Social Worker (HSW) W notes to the (OmbII) dated 8/16/22 revealed: regarding a [AGE] year old patient, (Resident #12) He (Resident #12) was sent for wound care but is refusing treatment and when they (hospital ED staff) contacted the facility for a discharge plan they are refusing to take him back and said (NHA A) he (Resident #12) should to psych for treatment. He (Resident #12) was sent back by ambulance to (facility name) but they (facility) would not open the door. Police came and said he (Resident #12) has the right to return. He (Resident #12) was sent back to hospital for safety reasons and they (hospital ED staff) are trying to reach the guardian to get permission to sedate and treat the wound . During an interview on 12/20/22 at 12:43 PM.,Ombudsman (Omb) II reported on 8/16/22 she was contacted by (HSW W) about the facility failing to allow (Resident #12) to return back into the building. Omb II reported (Resident #12's) rights were violated and he (Resident #12) had every right to be able to re-enter the facility on 8/16/22. Omb II stated there was a much better way to handle this instead of locking him (Resident #12) out of the building, and involving the police. Omb II reported there is a system in place for facility initiated transfers/discharges that must be followed, and in this case that system/process was not followed. Omb II reported he (Resident #12) should not have been forced to go to the ED until contact had actually occurred with is guardian by the facility. Omb II reported no residents should be in fear of losing their home, and have to go through what (Resident #12) went through during those days. Omb II reported once (Resident #12's) guardian was reached, she (guardian) was 100% in favor of a court order to sedate and treat in the ED, and promptly got that information to the hospital. Omb II reported (Resident #12's) guardian was quick to respond, and worked with the hospital staff to get (Resident #12) treated and back to the facility. During an interview on 12/20/22 at 2:41 PM., Resident #12 report he went to the hospital a few months ago because he had maggots crawling out of a wound he hand on his arm. Resident #12 reported they (the facility) wound not let him back in that day, the police came and and he felt betrayed because its his home. Resident 12 reported he had to go back to the hospital for a few days. Resident 12 reported he was very upset, and frustrated with the entire ordeal. During an interview on 12/20/22 at 5:11 PM., Nursing Home Administrator (NHA) A reported (Resident #12) was sent out on 8/16/22 to the ED because he had maggots in a wound on his arm. NHA A reported when they brought him back to the facility, and he was not treated she (NHA A) would not allow (Resident #12) back into the building. NHA A reported initially his (Resident #12's) guardian was not available, when staff noted the maggots on his arm. NHA A reported the ambulance brought Resident #12 back to the facility, and re-entry was denied. NHA A the police came, and (Resident #12) was then escorted back to the hospital via ambulance for treatment. NHA A reported she had a conversation with (HSW W) and reiterated they (facility-NHA A) had no intention on allowing (Resident #12) to return to the facility without treatment. Review of Resident #12's Hospital Records dated 8/16/22-8/20/22 revealed the following communications for Resident #12 8/16/22 at 10:40 am- (HSW V) notified EMS (ambulance) attempted to take pt (patient-Resident #12) back to his former place of residency; (facility name omitted). However, when EMS brought pt. (Resident #12) to (Facility), (Facility) had all their building doors locked and refused to accept pt. (Resident #12) back into building. Per chart review, (Facility) is refusing to take pt (Resident #12) back d/t (due to) him (Resident #12) refusing treatment. Pt (Resident #12) is alert and 0x3 (alert and oriented x3-person, place, and time), which pt. (Resident #12) is able to make decisions for self (Facility name omitted) also did not provide any eviction notice to pt. (Resident #12) prior to coming to the ED. Due to (Facility) neglect of accepting pt. (Resident #12) back to their facility, an APS (Adult Protective Services) report will be filed .Electronically signed at 8/16/2022 10:42 AM .further review of R#12's Hospital Records dated 8/16/22 at 10:40 am revealed . (HSW V) spoke with pt.'s Guardian (Grd) FF regarding (Facility) not accepting pt. (Resident #12) back. Grd FF in agreement with (HSW V) that this is not acceptable as this is pt's (Resident #12) place of residency. (Grd FF) stated she will make attempts to contact the ombudsman and speak with (Facility name omitted) (Grd FF) will also follow up with (HSW V) .Further review of (Resident #12) hospital record revealed: At 11:47 (HSW V) informed (Grd FF) pt (Resident #12) was brought back to ED d/t police making the decision of not feeling comfortable leaving pt (Resident #12) in the (Facilities) care. (Grd FF) indicated she was writing a petition for the court, asking the judge to approve an order for pt (Resident #12) to be sedated in order for hospital to provide the proper wound care treatment for pt. (Resident #12). (Grd FF) will file petition today (8/16/22) for the judge to review. If order is given for sedation, (Grd FF) will fax order to hospital to proceed with care. Review of Resident #12's Hospital Records dated 8/16/22-8/20/22 revealed the following communications for Resident #12 (Previous facility Social Worker (SW-KK) Progress Notes Date of Service: 8/17/2022 1:48 PM Social Worker .Care Management .1348 - Call to pt's (Resident #12) (Grd FF) to update pt (Resident #12) has agreed to permit surgery today and not knowing if that means pt (Resident #12) will be agreeable to this tomorrow, knowing it likely will not be able to be scheduled yet today. She made note of this and reported they served the petition to the court yesterday at PM, requesting permission to consent to Tx (treatment)- for pt. (Resident #12) and have yet heard back .1530 Call from (Grd FF), stating they just received court orders permitting them to consent to pt's (Resident #12) medical treatment. She (Grd FF) will fax this to writer shortly. She (Grd FF) noted this does not include amputation 1550 pm- Received faxed order of the (Grd FF) consenting to Tx apply necessary soft restraints and/or sedation for the purpose of providing medical treatment to wounds while hospitalized . This legal document was placed in pt's (Resident #12) paper chart. Updated entire Tx team to receive of this document . During an interview on 12/20/22 at 5:38 PM., Resident #12's Guardian (Grd) FF reported she did not receive a notice of transfer when Resident #12 was discharged /transferred to the ED on 8/16/22. (Grd) FF reported she was made aware of a situation from the hospital about (Resident #12) being sent there from the facility due to maggots in his wound. Grd FF reported she could not understand why the facility was not allowing (Resident #12) back into the facility. Grd FF reported she responded the same day, and informed both the hospital staff (HSW V and HSW W) as well as (NHA A) that she was working on the petition to treat from the court, due to the fact (Resident #12) has the right to refuse. Grd FF reported she started the petition as soon as she possibly could, but in the meantime the facility cannot lock him (Resident #12) out of the building, that is his home. Grd FF reported she made it clear to (NHA A) that he had the right to return until she (Grd FF) could get the petition completed in the next day or so. Grd FF reported there is a process's for these types of discharges, and the correct process was not followed. Grd FF reported it was completely stressful, and unnecessary to do this to (Resident #12). Grd FF reported (Resident #12) was extremely upset about not being able to return to his home, and especially that he sat in the parking lot in an ambulance and the police had to come. Grd FF reported this incident was completely avoidable if the proper process and communication on the facilities behalf would have been done.

Based on observation, interview and record review the facility failed to provide treatment and services to prevent the worsening of a pressure ulcer and failed to adequately provide interventions to prevent pressure ulcers for 1 resident (Resident #107) of 3 residents reviewed for pressure ulcers, resulting in the potential for worsening of a Stage 2 pressure ulcer and a potential for the development of new avoidable pressure ulcers. Findings include: Review of the facility policy Preventive Skin Care dated XX/XXX, It is the intent of the facility that the facility provide preventive skin care through careful washing, rinsing, and drying to keep residents clean, comfortable, well-groomed and free from pressure ulcers. Equipment: .4. heels up or specialty ordered therapeutic boots. 5. appropriate wheelchair cushion. 6. pillows or positioning devices .Procedure: .3. A thin layer of barrier cream may be applied as a protective barrier .Medicated treatments ordered by the physician are to be applied by the licensed nurse .4. Residents identified as high risk for potential breakdown shall be turned and repositioned frequently .6. Positioning pillows and or specialty devices may be used between two surfaces or to slightly elevate bony prominences/pressure area off the mattress. 7. Heels up or specialty therapeutic boots may be used to protect heels .8. Pillows may be used to float heels to prevent potential pressure sores . Review of Fundamentals of Nursing (Potter and Perry) 9th edition revealed, Usually the time that a patient sits uninterrupted in a chair is limited to 1 hour. This interval is shortened in patients who are at very high risk for skin breakdown. Reposition patients frequently because uninterrupted pressure causes skin breakdown . Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition. Resident #107 Review of an Admission Record revealed Resident #107 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Minimum Data Set (MDS) assessment for Resident #107, with a reference date of 12/14/21 revealed a Brief Interview for Mental Status (BIMS) score of 4, out of a total possible score of 15, which indicated Resident #107 was cognitively severely impaired. Review of the Functional Status revealed that Resident #107 required extensive assistance of 2 people with mobility in bed. Review of Resident #107's Skin Care Plan revealed, I am at an increased risk for alteration in skin integrity and skin discoloration related to: incontinence of bladder and bowel, impaired mobility, dementia, incontinence Date Initiated: 04/23/2021 Revision on: 11/30/2021 .INTERVENTIONS: .Moon boots to be worn while in bed for pressure reduction Date Initiated: 12/17/2021 Revision on: 12/17/2021. Reposition frequently Date Initiated: 04/26/2021 .Precautions for prevention of pressure ulcers will be completed, such as: good pericare (cleaning of genital area) and drying of my skin, applying protective barrier cream, re-position me frequently when I am in my bed/chair/gerichair (wheelchair designed to assist with positioning) and/or broda (wheelchair designed to assist with positioning) chair, off load my heels .Date Initiated: 09/14/2018 . This care plan was updated on 12/17/21, following concerns identified on survey. Review of Resident #107's Pressure Ulcer Care Plan revealed, .has an alteration in skin integrity AEB (as evidence by): Other: Open area to coccyx. (Resident #107) is compliant with treatments .Date Initiated: 12/06/2021 Revision on: 12/12/2021 .INTERVENTIONS: .Reposition frequently while in chair and/or bed if applicable. Date Initiated: 12/06/2021. Pressure relieving mattress and/or chair cushion. Date Initiated: 12/06/2021 . Review of Resident #107's Braden Scale Assessment (predicts the risk for developing a pressure ulcer or injury) dated 10/12/21 revealed a score of 14, which indicated that the resident had a moderate risk. Review of Resident #107's Weekly Skin Alteration Record dated 12/14/21 at 17:23 (5:23 P.M.) revealed, .Site: Coccyx. Type of Wound: Pressure Ulcer .Size of Wound: 2.0 cm x 0.3 cm x 0.1 cm .Shear to coccyx .[MEDICATION(S)] (a topical gel used for wounds) applied and covered with bordered gauze .no new orders . During an observation on 12/16/21 at 10:22 A.M. Resident #107 was lying in his bed positioned on his right side with a pillow behind the left side of his upper body, with the HOB (head of bed) at approximately 30-45 degrees. Resident #107's legs were observed to be contracted (a deformity that prevents movement) and there was a blue cushion positioned under Resident #107's knees, which left his feet/heels pressed directly against the surface of the bed. Resident #107 was wearing a hospital gown and his hair was not groomed. Resident #107's wheelchair was observed with no pressure reducing cushion in place. During an observation on 12/16/21 at 12:01 P.M. Resident #107 was lying in his bed on his back with the HOB at 30-45 degrees with his feet/heels pressed directly against the surface of the bed. There was a pillow lying on the left side of the bed, not assisting with positioning. Resident #107 was still wearing a hospital gown and his hair was not groomed. During an observation and interview on 12/16/21 at 2:53 P.M. Resident #107 was observed in the same position, lying in his bed on his back with the HOB at 30-45 degrees with his feet/heels pressed directly against the surface of the bed. There was a pillow lying on the left side of the bed. Resident #107 stated, I need some help . Resident #107 was still wearing a hospital gown and his hair was not groomed. During an interview on 12/16/21 at 3:04 P.M., Certified Nursing Assistant (CNA) K reported that she had not taken care of Resident #107 yet today and stated, .it would have been first shift . (CNA L) had this hall . During an interview on 12/16/21 at 3:05 P.M., CNA L reported that Resident #107 had last been repositioned and taken care of on first shift. CNA L declined to provide any further details and walked away from this surveyor. During an interview on 12/16/21 at 3:06 P.M., Licensed Practical Nurse (LPN) M reported that Resident #107 did not have any wounds that she was aware of. During an observation on 12/16/21 at 3:10 P.M. Resident #107 was lying in his bed. LPN M and CNA K assisted the resident to reposition onto his right side and the incontinence brief was removed and revealed a quarter sized open wound on Resident #107's coccyx. The wound was not covered with a dressing. LPN M stated, .I will look into the orders .I don't know if it is supposed to be covered . During an interview on 12/16/21 at 3:23 P.M., Medical Director (MD) Y reported that the treatment in place for Resident #107's Stage 2 pressure wound was [MEDICATION(S)] (a moisture barrier ointment). MD Y reported that the wound could be effectively treated with [MEDICATION(S)] and stated, .along with lots of interventions .repositioning every 2 hours .off the wound .avoiding his back . MD Y reported that Resident #107 is at risk for pressure wounds on his feet also and stated, .the wedge cushion is not good for him with the condition of his legs .boots would be better . Review of Resident #107's Physician Orders revealed, Coccyx: Apply generous layer of [MEDICATION(S)]. Daily and PRN (as needed) every night shift for wound care -Start Date-12/16/2021 0000 (12:00 A.M.) -D/C (discontinue) Date-12/16/2021 1316 (1:16 P.M.) Review of [MEDICATION(S)] Package Insert revealed, For External Use Only .Uses: a moisture barrier that helps heal skin irritations from urine, diarrhea .wound drainage .Directions: apply thin layer of [MEDICATION(S)] ointment to reddened or irritated skin . Review of Resident #107's Nursing Progress Note dated 12/16/2021 at 20:06 (8:06 P.M.) revealed, .Writer (LPN M) informed by staff of open area on coccyx writer assisted staff with brief change writer informed physician of open area physician assessed writer informed by physician to continue with current order in place ([MEDICATION(S)]). Writer/staff cleaned area applied [MEDICATION(S)] as ordered . During an observation on 12/20/21 at 11:40 A.M. Resident #107 was observed in his gerichair sitting in the dining room. During an observation and interview on 12/20/21 at 12:16 P.M. CNA D was observed to be transferring Resident #107 into his bed and stated, .he has been up for a long time .we got him up early this morning before breakfast .and he just finished lunch .and he asked to go to bed . Resident #107's wheelchair was observed with no pressure reducing cushion in place. CNA D performed incontinence care for Resident #107. Resident #107's buttocks were observed red in comparison to the surrounding skin. CNA D obtained a tube of [MEDICATION(S)] ointment from her pocket and applied a layer to Resident #107's entire buttocks, and then an additional layer to the open wound on Resident #107's coccyx and stated, .it's the best butt cream ever . Resident #107 was observed positioned on his right side with a pillow behind his left upper body, wearing moon boots and the HOB at approximately 30 degrees. During an interview on 12/20/21 at 12:40 P.M. LPN M reported that the CNA's apply the wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A few moments later, LPN M reported that all wound treatments are to be provided by the nurse. Review of Resident #107's Physician Orders revealed, Coccyx: Apply generous layer of [MEDICATION(S)] every shift for wound care -Start Date- 12/16/2021 1430 (2:30 P.M.) -D/C Date- 12/20/2021 1256 (12:56 P.M.) Review of Resident #107's Physician Orders revealed, Coccyx: Apply generous layer of [MEDICATION(S)] Cover with border gauze dressing. every shift for wound care -Start Date- 12/20/2021 1430 (2:30 P.M.) During an observation on 12/20/21 at 2:43 P.M. Resident #107 was in the same position on his right side with the HOB at approximately 30 degrees, and wearing moon boots. Resident #107 had been in the same position for 2 1/2 hours. During an interview on 12/21/21 at 11:00 A.M., CNA D reported that Resident #107 does not have a pressure relieving cushion in his wheelchair and stated, .his roommate does, but not him .he never has .

This cite pertains to intake: MI 75 Based on observation, interview and record review the facility failed to develop and implement care plans for 6 of 16 residents (Resident #41, Resident #23, Resident #50, Resident #33, Resident #26, and Resident #158) reviewed for care plans, resulting in a fall from a lift with injury for Resident #41, the likelihood of additional falls for Resident #23 and Resident #50, and the potential for impaired psychosocial, mental and physical well being for residents. Findings include: Review of Fundamentals of Nursing (Potter and Perry) 8th edition revealed, An out of date or incorrect care plan compromises the quality of nursing care. Review and modification enable you to provide timely nursing interventions to best meet the patient's needs .It is necessary to revises related factors and the patient's goals, outcomes, and priories. Date any revisions. Revise specific interventions that correspond to the new nursing diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. (2014). Fundamentals of Nursing (8th ed.). St. Louis: Mosby. p. 257-258 Resident #41: Review of the Face Sheet revealed Resident #41 was a female admitted to the facility in 2017 and diagnosed with [CONDITION(S)] and muscle weakness. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #41 had a brief interview for mental status (BIMS) score of 04 to of 15 which indicate Resident #41 had impaired cognition. In an interview on 9/14/21 at 9:51 AM., Resident #41 reported she was dropped from a hoyer lift because there was only one staff transferring her. In an interview on 9/15/21 at 2:21 PM., Certified Nurse Aide (CNA) H reported she was trying to get (Resident #41) up and into bed from a shower chair. CNA H stated I was getting (Resident #41) into bed using a hoyer lift. CNA H reported she was placing the sling hooks onto the hoyer lift area. CNA H reported she thinks the sling fabric loops were not positioned correctly. CNA H reported when she pulled down on the fabric loops, they were on, but then the next thing she knew Resident #41 was falling. CNA H reported Resident #41 fell from approximately 3 feet, about the distance from the top of her (Resident #41's) bed which was raised up. CNA H reported Resident #41 went down sideways. CNA H stated I quickly grabbed her and lowered her (Resident #41) legs down, and her body to ground. CNA H reported Resident #41 told her she was ok. CNA H then went to get help. CNA H reported the nurse (which CNA H could not remember which staff nurse it was) came in the room to evaluate Resident #41. CNA H reported once the nurse did her vitals, and they (CNAH and the nurse) went to move Resident #41 from the ground into bed, Resident #41 reported her back and hip hurt. CNA H reported the nurse had Resident #41 sent to the Emergency Department (ED) and when she came back from the hospital, it was reported to her (CNA H) that Resident #41 had broken her hip. In an interview on 9/15/21 at 3:23 PM., Assistant Director of Nursing (ADON) C reported it is the facility practice to use 2 staff members for all hoyer lifts. ADON C reported Resident #41 was a 2 person transfer with a hoyer lift on her Care Plan. Review of Resident #41's Care Plan with a Date Initiated: 9/12/2017 revealed: Focus· I (Resident #41) am at risk for falls R/T Cognitive Impairments, debility, diuretic use with incontinence. Further review of Resident #41's care plan revealed the CNA care guide (Kardex) revealed: Transferring: * Transferring - I (Resident #41) use a Hoyer lift and assist of 2 staff with transfers.* two person assist with transfers using a hoyer type lift. Resident #23: Review of an Admission Record revealed Resident #23 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of falls Care Plan for Resident #23, revised on 4/27/2021, revealed the focus, .Resident is at risk for falls R/T Cognitive Impairments, Requires ADL assist for transfers and mobility related tasks, Decreased Strength and Endurance, DX: [CONDITION(S)] or [CONDITION(S)], DX: [CONDITION(S)] . with the intervention .Gather information on past falls and attempt to determine the root cause of the fall (s) .Anticipate and intervene to prevent recurrence .Anticipate and meet the individual needs of the resident .Ensure bed is in lowest position and fall matt in place to prevent injury Date initiated 8/26/21 .Resident to be placed in low air mattress with bolsters Date initiated 8/2/21 .Therapy screen r/t fall Date initiated 8/26/21 . Review of Progress Notes dated 8/26/21 at 23:52 PM, .Approximately 7:30 PM resident in room [ROOM NUMBER]-1 came in hallway and informed staff that his roommate was on the floor. Writer and other staff members entered the room and observed resident's upper body at right side on the floor and BLE (bilateral lower extremities) were in the bed under the covers. Resident stated, I fell out the bed Writer assessed resident and was able to move BLUE (bilateral lower and upper extremities) without any complaints. Resident's bed was moved in order to get resident in a position to be transferred, resident stated it hurts. Writer then asked, where does it hurts? Resident placed his hand on his right thigh and stated, Thigh. Writer and 2 other staff then transferred resident into bed. Vitals were taken and were WNL (within normal limits), neuro checks initiated, physician informed and new order for x-rays at right hip and thigh x2 views. Management informed . In an interview on 9/15/2021 at 1:19 PM, Licensed Pratical Nurse (LPN) EE revealed, .His roommate told myself that the resident had fallen .When I entered the room I approached his bed and he was facing the window on the right side of the bed .His legs were tangled in the covers .His legs were still in the bed .He leans to the one side a lot (to his right) and leaned so far and gravity pulled him out of the bed .I think it was gravity because he doesn't' try to get out of the bed .I contacted the doctor for the pain and they ordered an xray .Nothing was fractured . Review of Progress Notes dated 8/28/21 at 21:25 PM, revealed, .Resident does need to be repositioned frequently d/t (due to) he leans and has no upper trunk control. HOB (head of bed) to be down as much as tolerated . During an observation on 9/13/21 at 12:10 PM, Resident #23 was observed in bed and there was not a fall mat on either side of his bed, bed was not in the lowest position. Resident was observed with his head and upper body leaning towards the right side. Head of the bed was elevated approximately 35-40 degrees. During an observation on 9/14/21 at 11:21 AM, Resident #23 was observed laying in his bed on his back and there was not a fall mat on either side of his bed and his bed was not in the lowest position. Resident was observed with his head and upper body leaning towards the right side. Head of the bed was elevated approximately 35-40 degrees. During an observation on 9/14/21 at 1:08 PM, Resident #23 was observed laying in his bed on his back and there was not a fall mat on either side of his bed and his bed was not in the lowest postion. Resident was observed with his head and upper body leaning towards the right side. In an observation and interview on 9/14/21 at 1:32 PM, Certified Nursing Assistant K reported Resident #23 needed to be readjusted in the bed and assisted with repositioning him prior to assisting him with eating his lunch. CNA K' also raised the head of the bed for the resident. CNA K stated the resident leans to the side and his positioning needs to be adjusted for her to assist him with his meal. During an observation on 9/15/21 at 3:39 PM, Resident #23 was observed in bed and did not have a fall mat on either side of his bed, bed was not in the lowest position. Resident #50: Review of an Admission Record revealed Resident #50 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of MI-Fall Risk Review dated 6/22/21 at 04:46 AM, revealed, .History of Falls within last six months: 2. 1-2 Falls .2. Tries to stand, transfer, or walk alone unsafely: 1. Yes .Assess a resident's gait while standing in one spot, walking straight forward, and while making a turn: 1. Unable to independently come to a standing position 2. Exhibits loss of balance while standing 11. Decrease in muscle coordination .Equipment used of mobility: wheelchair .Based on the Fall Risk Review, the resident has been determined to be high risk for falls: 1. Yes .Current interventions used/List: See Fall care plan: New intervention: Offer toileting upon rising, before/after meals and before bedtime. Offer toilet assist at least q2h (every 2 hours) .Conclusion/Recommendations: Increase assist with toileting. Falls appear to occur when attempting to self transfer with toileting. Cognition significant decrease recently with new dx (diagnosis): Alzheimer's and poor safety awareness . Review of Incident Audit Report dated 7/18/21 at 20:50 PM, revealed, .Observed in a sitting position beside her w/c (wheelchair) in her bathroom slid off the w/c .Predisposing Situation Factors: Toileting Needs, Using Wheelchair . Review of Progress Notes dated 7/18/2021 at 22:09 PM, revealed, .Nursing Progress Note Note Text: Was observed in a sitting position by her w/c in her bathroom, said she was trying to go to the toilet, slid off the w/c, no visible injury, PROM full in all extremities, denied hitting head; son (Resident #50's DPOA), and MD were notified . Review of falls Care Plan for Resident #50, revised on 9/15/2021, revealed the focus, .(Resident #50) is at risk for falls r/t (related to) impaired mobility, occasional incontinence, hx (history) of falls. I have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Please assist me in getting up and out of bed early in AM as I will forget to seek assist and may experience fall if unassisted .Re-educate resident about having assistance when transferring .Sign to be placed on my bathroom door to remind me to call for help when toileting .Staff to offer toileting upon rising, before and after meals and before bedtime. Offer at least Q2H (every 2 hours) . Review of Electronic Medical Record CNA Activities of Daily Living care Documentation Survey Report for September 2021 for Resident #50 revealed: .September 1: Personal Hygiene, Toilet Use: 1 Assist was completed at 07:37 AM, 23:48 PM, and 01:40 AM; Sept. 2: Personal Hygiene, Toilet Use: 1 Assist was completed at 21:39 PM; Sept. 3: Personal Hygiene, Toilet Use: 1 Assist was completed at no time during this day; Sept. 4: Personal Hygiene, Toilet Use: 1 Assist was completed at no time during this day; Sept. 5: Personal Hygiene, Toilet Use: 1 Assist was completed at 22:29 PM, 02:50 AM; Sept. 6: Personal Hygiene, Toilet Use: 1 Assist was completed at 11:21 AM, 05:34 AM; Sept. 7: Personal Hygiene, Toilet Use: 1 Assist was completed at 14:27 PM, 20:22 PM, 23:52 PM; Sept. 8: Personal Hygiene, Toilet Use: 1 Assist was not completed at not time during this day; Sept. 9: Personal Hygiene, Toilet Use: 1 Assist was completed at 21:15 PM, 00:14 AM; Sept. 10: Personal Hygiene, Toilet Use: 1 Assist was completed at 08:11 AM, 22:29 PM, 02:15 AM; Sept. 11: Personal Hygiene, Toilet Use: 1 Assist was completed at 12:26 PM, 03:48 AM; Sept. 12: Personal Hygiene, Toilet Use: 1 Assist was completed at 12:13 PM, 23:10 PM, and 02:15 AM; Sept. 13: Personal Hygiene, Toilet Use: 1 Assist was completed at 14:29 PM; Sept. 14: Personal Hygiene, Toilet Use: 1 Assist was completed at 20:56 PM . Resident #33: Review of an Admission Record revealed Resident #33 was originally admitted to the facility on [DATE]. Review of current Care Plan revealed, Resident #33's care plan did not have a focus, goals, or interventions surrounded by person centered activities. Review of a Minimum Data Set (MDS) assessment for Resident #33, with a reference date of 4/14/21 revealed, .Interview for Activity Preferences: A. How important is it to you to have books, newspapers, and magazines to read? -Somewhat important; How important is it to you to do your favorite activities? - Somewhat important; How important is it to you to go outside to get fresh air when the weather is good?-Somewhat important . In an interview on 9/13/21 at 3:11 PM, Resident #33 stated, .The staff give me anything to do, they don't get me out of the bed, I just lay here and watch TV .This is a poor run establishment .They could give me something to do .I want to go outside .I have went outside since I have been here . In an interview on 9/15/21 at 11:02 AM with Activity Director F requested the Activity Care Plan for Resident #33 and none was provided with other requested items. Resident #26: Review of the Face Sheet revealed Resident #26 was a male admitted to the facility in 2021 and diagnosed with cor pulmonae (high blood pressure in the lungs). Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #26 had a brief interview for mental status (BIMS) score of 12 to of 15 which indicate he had moderately impaired cognition. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plans revealed no care plan for anticoagulation therapy or the intervention to elevate heel for Resident #26. During an interview on 09/15/21 at 12:01 PM, Assistant Director of Nursing (ADON) C reviewed the care plans for Resident #26 and stated, no Resident #26 was not care planned to float heels for pressure reduction to prevent breakdown on his heels or anticoagulation. Resident #158: Review of the Face Sheet revealed Resident #158 was a male admitted to the facility in 2021 and diagnosed with Alzheimer's dementia and anxiety. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #158 had severely impaired cognition. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plans revealed no documented care plan for Resident #158's antipsychotic medication. During an interview on 09/15/21 at 11:55 AM, ADON C reviewed Resident #158's care plans and stated, I don't see one (care plan) for the antipsychotic medication.

This cite pertains to MI 575 This citation has two Deficiency Practice Statements. DPS #1: Based on observation, interview, and record review the facility failed to provide adequate supervision for 5 of 8 residents (Resident #41, #8, #23, #50, and #19) reviewed for accidents/hazards, resulting in a fall from a hoyer lift and [CONDITION(S)] for Resident #41, fall with [CONDITION(S)] for Resident #8 and the potential for injury for Residents Findings include: According to Potter and Perry, (2017) Patients with actual or potential risks to safety require a nursing care plan with interventions that prevent and minimize threats to their safety. Design your interventions to help a patient feel safe to move about and interact freely within the environment. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - Ninth Edition - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition. According to Potter and Perry, (2017) The patient's mobility problem is an obvious priority because of its influence on risk for falls and skin integrity. Plan individualized interventions on the basis of the severity of risk factors and the patient's developmental stage, level of health, lifestyle, and cultural needs (Box 27-7). Planning involves an understanding of the patient's need to maintain independence within physical and cognitive capabilities. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - Ninth Edition - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition. Resident #41: Review of the Face Sheet revealed Resident #41 was a female admitted to the facility in 2017 and diagnosed with [CONDITION(S)] and muscle weakness. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #41 had a brief interview for mental status (BIMS) score of 04 to of 15 which indicate Resident #41 had impaired cognition. In an interview on 9/14/21 at 9:51 AM., Resident #41 reported she was dropped from a hoyer lift because there was only one staff transferring her. In an interview on 9/15/21 at 2:21 PM., Certified Nurse Aide (CNA) H reported she was trying to get (Resident #41) up and into bed from a shower chair. CNA H stated I was getting (Resident #41) into bed using a hoyer lift. (CNA) H reported she (CNA H) was placing the sling hooks onto the hoyer lift area. CNA H reported she thinks the sling fabric loops were not positioned correctly. CNA H reported when she pulled down on the fabric loops, they were on, but then the next thing she (CNA H) knew she (Resident #41) was falling. CNA H reported she (Resident #41) fell from approximately 3 feet, about the distance from the top of her (Resident #41's) bed which was raised up. CNA H reported (Resident #41) went down sideways. CNA H stated I quickly grabbed her and lowered her (Resident #41) legs down, and her body to ground. CNA H reported (Resident #41) told her she (Resident #41) was ok. CNA H then went to get help. CNA H report the nurse (which CNA H could not remember which staff nurse it was) came in the room to evaluate (Resident #41). CNA H reported once the nurse did her vitals, and they (CNAH and the nurse) went to move (Resident #41) from the ground into bed, (Resident #41) reported her back and hip hurt. CNA H reported the nurse had her (Resident #41) sent to the Emergency Department (ED) and when she came back from the hospital, it was reported to her (CNA H) that (Resident #41) had broken her hip. CNA H reported she felt so bad, because there were not enough staff to initially help her when she was transferring (Resident #41). CNA H reported she was transferring her (Resident #41) because the facility was short staffed. CNA H reported this wouldn't have happened if there was another staff. In an interview on 9/15/21 at 3:23 PM., Assistant Director of Nursing (ADON) C reported the facility was short staffed the day of (Resident #41's) fall from the hoyer. ADON C reported it is the facility practice to use 2 staff members for all hoyer lifts. ADON C reported (Resident #41) was a 2 person transfer with a hoyer lift on her Care Plan. Review of Resident #41's Care Plan with a Date Initiated: 9/12/2017 revealed: Focus· I (Resident #41) am at risk for falls R/T Cognitive Impairments, debility, diuretic use with incontinence. Further review of Resident #41's care plan revealed the CNA care guide (Kardex) revealed: Transferring: * Transferring - I (Resident #41) use a Hoyer lift and assist of 2 staff with transfers.* two person assist with transfers using a hoyer type lift. Resident #8: Review of an Admission Record revealed Resident #8 was originally admitted to the facility on [DATE], with pertinent diagnoses which included weakness, abnormalities of gait and mobility, Dementia, adult failure to thrive, lack of coordination, unsteadiness on feet, seizures, fracture of right femur, and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #8, with a reference date of 6/8/21 revealed, Staff Assessment for Mental Status was completed indicating Resident #8 was unable to complete a Brief Interview for Mental Status. Review of falls Care Plan for Resident #8, revised on 9/15/2021, revealed the focus, .I am risk for falls R/T (related to) Cognitive impairments, [CONDITION(S)] .I have poor safety awareness, I also am very impulsive and will not wait for staff before standing . with the interventions .Observe for increase restlessness and assist with toileting, hunger, thirst, pain, etc needs .Provide 1:1 care/supervision as needed .Staff to maintain visual contact with resident when up in chair . Review of Progress Notes dated 8/20/2021 at 12:45 PM, revealed, .Nursing Progress Note Late Entry: Note Text: Late Entry - This nurse was called to the dining room by (Maintenance NN) Upon entering the dining room, resident was sitting upright, on the floor, on her buttocks, with her knees drawn up. Her w/c was approximately 2-3 tables over, where she had eaten her lunch. Upon assessing resident, she denied any pain, showed no s/s of distress. Resident did have on gripper socks, however they were noted to be wet, when this nurse went to get residents w/c, which was by the table were she ate. At her spot there was thickened, red juice spilled all over the fall, and on the wheels of her w/c. Assist x 2, up into the w/c without incident. No s/s of pain or distress with transfer. This nurse brought her out to the med cart, one of the psych service rep. meet with resident, and this nurse, asking questions, of the both of us. Resident showed this nurse how she waved as a beauty queen She was obviously tired, as she was up before 6am, self propelling in her w/c all over the different hallways, and had gotten up from w/c ambulating multiple times for lengthy distances. This nurse had CNA take resident to room to be changed and laid down . Review of Progress Notes dated 8/20/2021 at 12:52 PM, revealed, .Nursing Progress Note Late Entry: Note Text: Resident sitting on floor in front of her wheelchair. When asked if she sat down she smiled. Assisted with another staff member to get (Resident #8) up and back into wheelchair. Neuro checks WNL. Denies any pain or discomfort . Review of Progress Notes dated 8/20/2021 at 14:21 PM, revealed, .Nursing Progress Note Note Text: Resident presents in pain. Her normal behaviors include self propelling in the wheelchair and standing/walking with assist. During incontinent care, CNA reported to narrator that (Resident #8) looks like she is in a lot of pain, she keeps saying no and she will not stand. This resident is unable to verbalize her needs. Dr contacted. Orders received for bilateral hips to be x-ray'd. Diagnostic order sent in. Resident was given House standing order of tylenol 650mg by mouth . Review of Progress Notes dated 8/20/2021 at 18:46 PM, revealed, .Nursing Progress Note Note Text: Xray arrived and was escorted to patient room. Awaiting report . Review of Progress Notes dated 8/20/2021 at 21:49 PM, revealed, .Nursing Progress Note Note Text: Results ordered STAT. Result was fracture to R greater trochanter. EMS was called. DON and admin aware. Guardian called . Review of Progress Notes dated 8/20/2021 at 21:53 PM, revealed, .Nursing Progress Note Note Text: EMS arrived. Resident was transferred to stretcher x 3 assist. Vitals WNL obtained by EMS. Transported to (Hospital name) due to local hospitals being on bypass . Review of Clinical Summary dated 8/30/21, revealed, .Diagnoses: 1. [CONDITION(S)], 2. [CONDITION(S)], 3. [CONDITION(S)], 5. Dehydration . Review of Order dated 8/31/21, revealed, .Order Summary: Resident is NON-Weight bearing until further notice In an interview on 9/15/21 at 04:26 PM, Licensed Practical Nurse (LPN) OO reported, Resident #8 had a history of getting down and up out of her wheelchair and placing herself on the floor. It appeared she had spilled her juice as it was all around the bottom of her chair. LPN OO reported she was called to the dining room. A staff member was in the dining room waiting by Resident #8 to keep her safe. LPN OO stated, .She had crawled over to the other table .She was away from her wheelchair .She does walk but she had walked a lot that day and she was up early so she was exhausted .She had very wet socks and her pants were soaking wet and it was red from the juice she had spilled and crawled across .I am not sure if she tried to get up and spilled it .It was just my assumption as she had it all over herself and she was way too tired to stand up and get out of her wheelchair . LPN OO reported the resident was too heavy for her to get up by herself and she sought assistance from other staff while the staff member waited with the resident. LPN OO reported the resident was assisted to a standing position and sat in her wheelchair. LPN OO reported Resident #8 did not show signs or symptoms of pain when she was stood up. Resident #8's wheelchair was wheeled over to the medication cart. LPN OO reported the resident talked with the psychiatric doctor for approximately 30 minutes and the resident proceeded to wave as she was a beauty queen prior. LPN OO reported when Resident #8 was finished speaking with the psychiatric doctor, the CNA took her to change out of her clothes. LPN OO reported Resident #8 didn't report or complain to me about pain, leg shortening or rotation out or anything like that. In an interview on 9/15/2021 at 4:58 PM, Director of Nursing (DON) B reported there were two separate falls that day (8/20/21) that happened about 20 minutes apart. DON B reported Resident #8 stood up out of her wheelchair and fell to the floor. Resident #8 was assess and assisted back to her wheelchair. DON B reported Resident #8 took about 3-4 steps when she stood up out of her wheelchair and waved. The resident was assisted, with one person, back into her wheelchair. Resident #23: Review of an Admission Record revealed Resident #23 was originally admitted to the facility on [DATE], with pertinent diagnoses which included [CONDITION(S)], cognitive impairment, [CONDITION(S)], [CONDITION(S)], high blood pressure, seizures, high cholesterol, strike, weakness, need for assistance with personal care, pressure ulcer of right heel, stage 3, [CONDITION(S)] (life threatening complication of an infection), lack of coordination, pain, [CONDITION(S)], and dysphagia (difficulty swallowing foods and liquids). Review of a Minimum Data Set (MDS) assessment for Resident #23, with a reference date of 6/30/21 revealed a Brief Interview for Mental Status (BIMS) score of 8 out of a total possible score of 15, which indicated Resident #23 was moderately cognitively impaired. Review of falls Care Plan for Resident #23, revised on 4/27/2021, revealed the focus, .Resident is at risk for falls R/T Cognitive Impairments, Requires ADL assist for transfers and mobility related tasks, Decreased Strength and Endurance, DX: [CONDITION(S)] or [CONDITION(S)], DX: [CONDITION(S)] Disorder . with the intervention .Gather information on past falls and attempt to determine the root cause of the fall (s). Anticipate and intervene to prevent recurrence .Anticipate and meet the individual needs of the resident .Ensure bed is in lowest position and fall matt in place to prevent injury, Date initiated 8/26/21 .Resident to be placed in low air mattress with bolsters, Date initiated 8/2/21 .Therapy screen r/t fall, Date initiated 8/26/21 . Review of Care Plan for Resident #23, revised on 4/27/21, revealed the focus, .Resident requires staff assist with ADL's dt debility, impaired balance, poor activity endurance . with the intervention .2 person extensive assist with bed mobility . During an observation on 9/13/21 at 12:10 PM, Resident #23 was observed in bed and there was not a fall mat on either side of his bed, bed was not in the lowest position. Resident was observed with his head and upper body leaning towards the right side. Head of the bed was elevated approximately 35-40 degrees. During an observation on 9/14/21 at 11:21 AM, Resident #23 was observed laying in his bed on his back and there was not a fall mat on either side of his bed and his bed was not in the lowest position. Resident was observed with his head and upper body leaning towards the right side. Head of the bed was elevated approximately 35-40 degrees. During an observation on 9/14/21 at 1:08 PM, Resident #23 was observed laying in his bed on his back and there was not a fall mat on either side of his bed and his bed was not in the lowest postion. Resident was observed with his head and upper body leaning towards the right side. Review of Progress Notes dated 8/26/21 at 23:52 PM, .Approximately 7:30 PM resident in room 308-1 came in hallway and informed staff that his roommate was on the floor. Writer and other staff members entered the room and observed resident's upper body at right side on the floor and BLE (bilateral lower extremities) were in the bed under the covers. Resident stated, I fell out the bed Writer assessed resident and was able to move BLUE (bilateral lower and upper extremities) without any complaints. Resident's bed was moved in order to get resident in a position to be transferred, resident stated it hurts. Writer then asked, where does it hurts? Resident placed his hand on his right thigh and stated, Thigh. Writer and 2 other staff then transferred resident into bed. Vitals were taken and were WNL (within normal limits), neuro checks initiated, physician informed and new order for x-rays at right hip and thigh x2 views. Management informed . Review of Incident Audit Report dated 8/26/21, revealed, .Myself and other staff members entered the room and observed resident's upper body at right side on the floor and BLE (bilateral lower extremities) were in the bed under the covers .Resident stated I fell out the bed .Writer assessed resident and was able to move BLUE without any complaints .Resident's bed was moved in order to get resident in a position to be transferred, resident stated it hurts . asked, where does it hurts? .Resident placed his hand on his right thigh and stated, Thigh .Writer and 2 other staff then transferred resident into bed. Vitals were taken and were WNL, neuro checks Initiated, physician informed and new order for X-rays at right hip and thigh x2 views .management informed .Resident was able to move BLUE with no Complaints . Review of Progress Notes dated 8/28/21 at 21:25 PM, revealed, .Resident does need to be repositioned frequently d/t (due to) he leans and has no upper trunk control. HOB (head of bed) to be down as much as tolerated . In an interview on 9/15/2021 at 1:19 PM, Licensed Practical Nurse (LPN) EE, revealed, .His roommate told myself that the resident had fallen .When I entered the room I approached his bed and he was facing the window on the right side of the bed .His legs were tangled in the covers .His legs were still in the bed .He leans to the one side a lot (to his right) and leaned so far and gravity pulled him out of the bed .I think it was gravity because he doesn't' try to get out of the bed .I contacted the doctor for the pain and they ordered an x-ray .Nothing was fractured . Resident #50: Review of an Admission Record revealed Resident #50 was originally admitted to the facility on [DATE], with pertinent diagnoses which included fracture of right humerus (bone between shoulder and elbow), repeated falls, unsteadiness on feet, lack of coordination, weakness, Alzheimer's Disease, abnormalities of gait and mobility, overactive bladder, muscle weakness, fracture of right acetabulum (socket of hip bone). Review of a Minimum Data Set (MDS) assessment for Resident #50, with a reference date of 8/9/21 revealed a Brief Interview for Mental Status (BIMS) score of 7 out of a total possible score of 15, which indicated Resident #50 was moderately cognitively impaired. Review of falls Care Plan for Resident #50, revised on 9/15/2021, revealed the focus, .(Resident #50) is at risk for falls r/t (related to) impaired mobility, occasional incontinence, hx (history) of falls. I have a diagnosis of repeated falls . with the interventions .Please assist me in getting up and out of bed early in AM as I will forget to seek assist and may experience fall if unassisted .Re-educate resident about having assistance when transferring .Sign to be placed on my bathroom door to remind me to call for help when toileting .Staff to offer toileting upon rising, before and after meals and before bedtime. Offer at least Q2H (every 2 hours) . Review of Incident Audit Report dated 6/22/21, revealed, .Resident found sitting on the floor next to her bed. No evidence of hitting her head. Skin tear to right hand between first digit and thumb. First aid given to open area. Residents tolerated well. Bleeding ceased. Area covered with A&D ointment and LOTA. No s/s (signs and symptoms) of pain or discomfort. Resident assisted into bed. Brief changed. Resident pulled the blanket up to her chin and closed her eyes. Call light in reach .Predisposing Physiological Factors: Gait imbalance, Incontinent .Predisposing Situation Factors: Toileting Needs, Ambulating without Assist .Witnesses: No witnesses found . Review of MI-Fall Risk Review dated 6/22/21 at 04:46 AM, revealed, .History of Falls within last six months: 2. 1-2 Falls .2. Tries to stand, transfer, or walk alone unsafely: 1. Yes .Assess a resident's gait while standing in one spot, walking straight forward, and while making a turn: 1. Unable to independently come to a standing position 2. Exhibits loss of balance while standing 11. Decrease in muscle coordination .Equipment used of mobility: wheelchair .Based on the Fall Risk Review, the resident has been determined to be high risk for falls: 1. Yes .Current interventions used/List: See Fall care plan: New intervention: Offer toileting upon rising, before/after meals and before bedtime. Offer toilet assist at least q2h (every 2 hours) .Conclusion/Recommendations: Increase assist with toileting. Falls appear to occur when attempting to self transfer with toileting. Cognition significant decrease recently with new dx (diagnosis): Alzheimer's and poor safety awareness . Review of Incident Audit Report dated 7/4/21 at 05:55 AM, revealed, .Incident Details: The cna found the resident on the floor she stated she slid oob (out of bed) .Assessment done, resident denies injury, none noted at this time and she denies hitting her head. Assisted to restroom and btb (back to bed). Neuros and vs (vitals) done . Review of MI-Fall Risk Review dated 7/4/21 at 05:30 AM, .Predisposing Situation Factors: Incident during unassisted self transfer from bed and Improper footwear . Review of Progress Notes dated 7/4/21 at 05:30 AM, revealed, .Education done and reminders given to call for assist . Resident #50 has a BIMS of 7, reminding to use the call light is an ineffective action to prevent falls. Review of Progress Notes dated 7/4/21 at 17:05 PM, revealed, .IDT review of fall: dycem placed in WC r/t (related to) recent sliding out of chair. This intervention has been effective at this time, Care plans updated at time of fall . Review of Incident Audit Report dated 7/18/21 at 20:50 PM, revealed, .Observed in a sitting position beside her w/c(wheelchair) in her bathroom slid off the w/c .Predisposing Situation Factors: Toileting Needs, Using Wheelchair . Review of Progress Notes dated 7/18/2021 at 22:09 PM, revealed, .Nursing Progress Note Note Text: Was observed in a sitting position by her w/c in her bathroom, said she was trying to go to the toilet, slid off the w/c, no visible injury, PROM full in all extremities, denied hitting head; son (Resident #50's DPOA), and MD were notified . Review of Progress Notes dated 7/19/21 at 11:51 AM, .has an informal toilet schedule .place a sign on bathroom door to visually remind her to seek assistance with toileting needs . Review of Progress Notes dated 9/11/2021 at 12:34 PM, revealed, .Nursing Progress Note Note Text: Resident is alert and forgetful; she is able to verbalize needs. CNA notified to this writer that resident was on the floor. Resident was sitting on the floor, between W/C and her bed. Call light was within reach. This writer asked resident about the incident, resident smiling stated I don't remember. Assess: move all extremities without difficulty. Skin is clean no redness or skin issues noted at this moment, Resident observed without shoes, w/c locked and she was dry. Resident denies pain. BP 133/75, PULSE 71, TEMP 97.7, RESP 18, BIOX 97% at room air Transferred to her w/c with two staffs. MD, DON, administrator and POA notified . Review of MI-Fall Risk Review dated 9/11/2021 at 09:30 AM, revealed, .Conclusion/Recommendations: Will assist resident to get up early in the morning before breakfast . Review of Meal Times revealed, .Breakfast at 7:30 AM - 9AM . Review of Documentation Survey Report for July 2021 revealed no documentation to support Resident #50 was offered toileting every two hours and staff were offering toileting upon rising, before and after meals and before bedtime. Review of Documentation Survey Report for July 2021 revealed no documentation to support Resident #50 was offered toileting every two hours and staff were offering toileting upon rising, before and after meals and before bedtime. Review of Documentation Survey Report for July 2021 revealed no documentation to support Resident #50 was offered toileting every two hours and staff were offering toileting upon rising, before and after meals and before bedtime. In an interview on 09/14/21 at 12:26 PM, Resident Representative (RR) KK reported he was concerned with the number of falls that his mother has sustained since December of 2020 and has had meetings with the facility Director of Nursing to determine what they could do to prevent further falls for his mother. RR KK reported the facility and he discovered his mother had Alzheimer's Disease from a CT scan which was completed in May. Resident #19 Review of Hoyer Lift Transfer Usage policy, dated 3/22/11, revealed, .Policy: All residents determined to require a two-person transfer will be transferred with use of a Hoyer or Sit-to-Stand Lift . Review of an Admission Record revealed Resident #19 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #19, with a reference date of 6/24/21 revealed, Staff Assessment for Mental Status was completed indicating Resident #19 was unable to complete a Brief Interview for Mental Status. Review of Care Plan for Resident #19, revised on 6/20/2021, revealed the focus, .(Resident #19) requires an extensive to total assistance with ADLs due to [CONDITION(S)] (stroke), left sided [CONDITION(S)] (paralysis) following stroke, acute debility/weakness, and incontinent of bowel/bladder . with an intervention .Extensive 2 person assist with bed mobility .Extensive 2 person assist with transfers . Review of Care Plan for Resident #19, revised on 6/25/2021, revealed, .(Resident #19) is at risk for falls r/t (related to) cognitive impairments, communication impairment, decreased safety awareness, unable to use call light or request for assistance, Requires ADL assist for transfers and mobility related tasks, decreased strength and endurance .DX (diagnosis): [CONDITION(S)] with [CONDITION(S)] or [CONDITION(S)]. (Resident #19) moves self, flailing limbs as able to move off mattresses, bed, etc. This is exacerbated when s/s (signs and symptoms) of pain are present . with the intervention .Mattresses placed on the floor next to my bed with dycem under mattress to assist with placement .Gather information on past falls and attempt to determine the root cause of the fall(s). Anticipate and intervene to prevent recurrence .Staff to respond promptly to all request for assistance .Anticipate and meet individual needs of the resident . Review of Occupational Therapy (OT) Evaluation & Plan of Treatment dated 6/23/2021, revealed, .Functional Skills Assessment - Mobility During ADLs .Other Mobility: Hoyer x2 . During an observation on 9/13/21 at 11:21 AM , Resident #19 was observed in her room in her bed and she had slid down in the bed as the head of the bed was elevated approximately 40-45 degrees, she was yelling out. There was a bowel movement odor coming from the room. In an interview on 9/13/21 at 11:22 AM, Certified Nursing Assistant (CNA) D reported the resident does not like being dirty (soiled). During an observation on 9/13/21 at 11:21 AM , Resident #19 was observed in her room in her bed on her back and heard yelling out. During an observation on 9/14/21 at 1:19 PM, Resident #19 was observed out of her bed on to the mattress next to her bed. She is was yelling out for help. Resident #19 was attempting to grab an enabler bar on her bed and trying to move her torso closer towards the bed. Resident #19 asked this writer for assistance to get back into the bed. Registered Nurse (RN) I and Business Office Manager (BOM) JJ responded. During an observation on 9/14/21 at 1:20 PM, RN I observed seeking assistance (to move Resident #19 back into the bed form the mattress on the floor) in the hallway, observed no other staff present in the hallway, and headed to the business office. Received assistance from Business Office Manager (BOM) JJ. RN I walked across the mattress on the floor and got on her knees and positioned herself behind Resident #19. BOM JJ stated, .Do we use a hoyer? (to get her up off the mattress and into the bed) . RN I stated, .No . RN I assisted Resident #19 into the position to be parallel with her bed, no assistance provided by BOM JJ at that time .RN I was on her knees and positioned herself behind Resident #19. RN I placed her arms under the resident's armpits and BOM JJ crossed the resident's feet at the ankles, counted to 3, and both lifted the resident back into her bed. In an interview on 9/14/21 at 1:23 PM, RN I reported the resident had placed herself out of bed twice earlier today and she went to seek assistance, and no one was available to assist, and she placed Resident #19 back in her bed by herself this same way. In an interview on 9/15/21 at 10:04 AM, Rehab Program Manager HH reported Resident #19 was a Hoyer assist for transfers. Rehab Program Manager HH stated the resident had not been removed from requiring a Hoyer assist and she required extensive assistance because of her mobility. In an interview on 9/15/21 at 1:34 PM, Assistant Director of Nursing (ADON) C reported there are Hoyer in the building which do lower completely to the floor and if the resident required a Hoyer for transfer, they should be hoyered Deficient Practice Statement #2 Based on observation, interview, and record review, the facility failed to provide safe domestic hot water temperatures effecting 56 residents, resulting in the increased likelihood for resident discomfort, accidental skin [CONDITION(S)], and/or injury. Findings include: On 09/15/21 at 10:00 A.M., A common area environmental tour was conducted with Environmental Services CC. The following item was noted: Domestic hot water temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following restroom hand sink temperatures were recorded: Staff Break Room: 126.5 degrees Fahrenheit* Visitor/Staff Restroom: 135.2 degrees Fahrenheit* Men's Restroom: 135.2 degrees Fahrenheit* (*) The State Operations Manual Appendix PP section F689 states: Domestic Hot Water temperatures must be maintained between 105-120 degrees Fahrenheit to minimize accidental skin burn injuries. On 09/15/21 at 12:55 P.M., An environmental tour of resident rooms was conducted with Environmental Services CC. The following item was noted: Domestic hot water temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following resident restroom hand sink temperatures were recorded: 205: Restroom hand sink: 129.0 degrees Fahrenheit* 211: Restroom hand sink: 133.6 degrees Fahrenheit* 212: Restroom hand sink: 118.5 degrees Fahrenheit 216: Restroom hand sink: 132.6 degrees Fahrenheit* 301: Restroom hand sink: 132.8 degrees Fahrenheit* 303: Restroom hand sink: 129.1 degrees Fahrenheit* 304: Restroom hand sink: 125.2 degrees Fahrenheit* 305: Restroom hand sink: 124.5 degrees Fahrenheit* 314: Restroom hand sink: 124.2 degrees Fahrenheit* 315: Restroom hand sink: 127.7 degrees Fahrenheit* 401: Restroom hand sink: 126.8 degrees Fahrenheit* 403: Restroom hand sink: 121.7 degrees Fahrenheit* 501: Restroom hand sink: 127.5 degrees Fahrenheit* 511: Restroom hand sink: 126.2 degrees Fahrenheit* 514: Restroom hand sink: 118.2 degrees Fahrenheit (*) The State Operations Manual Appendix PP section F689 states: Domestic Hot Water temperatures must be maintained between 105-120 degrees Fahrenheit to minimize accidental skin burn injuries. On 09/15/21 at 04:15 P.M., Shower Room hand sink domestic hot water temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following hand sink temperatures were recorded: 200 Hall Shower Room: 130.6 degrees Fahrenheit* 300 Hall Shower Room: 131.0 degrees Fahrenheit* 400 Hall Shower Room: 124.7 degrees Fahrenheit* 500 Hall Shower Room: 123.1 degrees Fahrenheit* (*) The State Operations Manual Appendix PP section F689 states: Domestic Hot Water temperatures must be maintained between 105-120 degrees Fahrenheit to minimize accidental skin burn injuries. On 09/15/21 at 04:30 P.M., Record review of the Policy/Procedure entitled: Preventative Maintenance Program dated 3/4/20 revealed under Physical Plant - Daily Inspections: Domestic Water Temperatures: Take water temperature readings twice daily (once during morning rounds and once in the afternoon during the high usage times) from 1 area of each hot water system and document in the Domestic Water Temperature Log to be kept on file. Record review of the Policy/Procedure entitled: Preventative Maintenance Program dated 3/4/20 further revealed under Physical Plant - Semi-Annual Inspections: Water Tempering Valve Cartridges: Rotate and clean all mixing c [TRUNCATED]

This citation pertains to Intake #'s: MI 258, MI 694, MI 695 and MI 570, Based on observation, interview, and record review, the facility failed to ensure adequate nurse staffing to promote the physical, mental, and psychosocial well-being in 4 residents (#41, #50, #19, & #8) reviewed for staffing, resulting in a fall with injury for Resident #41 and Resident #8, and the potential for unmet care needs and the potential for physical and psychosocial harm. Findings include: Resident #41: Review of the Face Sheet revealed Resident #41 was a female admitted to the facility in 2017 and diagnosed with [CONDITION(S)] and muscle weakness. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #41 had a brief interview for mental status (BIMS) score of 04 to of 15 which indicate Resident #41 had impaired cognition. In an interview on 9/14/21 at 9:51 AM., Resident #41 reported she was dropped from a hoyer lift because there was only one staff transferring her. In an interview on 9/15/21 at 2:21 PM., Certified Nurse Aide (CNA) H reported she was trying to get (Resident #41) up and into bed from a shower chair. CNA H stated I was getting (Resident #41) into bed using a hoyer lift. (CNA) H reported she (CNA H) was placing the sling hooks onto the hoyer lift area. CNA H reported she thinks the sling fabric loops were not positioned correctly. CNA H reported when she pulled down on the fabric loops, they were on, but then the next thing she (CNA H) knew she (Resident #41) was falling. CNA H reported she (Resident #41) fell from approximately 3 feet, about the distance from the top of her (Resident #41's) bed which was raised up. CNA H reported (Resident #41) went down sideways. CNA H stated I quickly grabbed her and lowered her (Resident #41) legs down, and her body to ground. CNA H reported (Resident #41) told her she (Resident #41) was ok. CNA H then went to get help. CNA H report the nurse (which CNA H could not remember which staff nurse it was) came in the room to evaluate (Resident #41). CNA H reported once the nurse did her vitals, and they (CNAH and the nurse) went to move (Resident #41) from the ground into bed, (Resident #41) reported her back and hip hurt. CNA H reported the nurse had her (Resident #41) sent to the Emergency Department (ED) and when she came back from the hospital, it was reported to her (CNA H) that (Resident #41) had broken her hip. CNA H reported she felt so bad, because there were not enough staff to initially help her when she was transferring (Resident #41). CNA H reported she was transferring her (Resident #41) because the facility was short staffed. CNA H reported this wouldn't have happened if there was another staff. In an interview on 9/15/21 at 3:23 PM., Assistant Director of Nursing (ADON) C reported the facility was short staffed the day of (Resident #41's) fall from the hoyer. ADON C reported it is the facility practice to use 2 staff members for all hoyer lifts. ADON C reported (Resident #41) was a 2 person transfer with a hoyer lift on her Care Plan. ADON C reported it is common staff are late to their shifts especially the mornings and weekends. ADON C reported that is one of the reasons/problems with the staffing issue the facility is facing. Review of Fundamentals of Nursing (Potter and Perry) 8th edition revealed: Burnout is the condition that occurs when perceived demands outweigh perceived resources (Potter et al., 2013a). It is a state of physical and mental exhaustion that often affects health care providers because of the nature of their work environment. Over time, giving of oneself in often intense caring environments sometimes results in emotional exhaustion, leaving a nurse feeling irritable, restless, and unable to focus and engage with patients (Potter et al., 2013b) .Compassion fatigue impacts the health and wellness of nurses and the quality of care provided to patients .When a nurse experiences ongoing stressful patient relationships, he or she often disengages ([NAME] et al., 2011) .It is not uncommon for nurses who are experiencing compassion fatigue to become angry or cynical and have difficulty relating with patients and co-workers (Young et al., 2011). Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations 1671-1672). Elsevier Health Sciences. Kindle Edition. 1. Review of the Centers for Medicare and Medicaid (CMS) Form 672 (Resident Census and Conditions of Residents) submitted for review on 9/14/21 indicated a census of 56. The form revealed 55 residents were dependent on at least one+ staff to total dependence for bathing; 7 residents were dependent on at least one+ staff to total dependence for dressing; and 53 residents were dependent on at least one+ staff to total dependence for toilet use. .There is a positive correlation between direct patient care provided by an RN (Registered Nurse) and positive patient outcomes, reduced complication rates, and a more rapid return of the patient to an optimal functional status .Research also correlates poor staffing with missed nursing assessments and missed nursing care . Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing, Tenth Edition - E-Book (Kindle Location 1265 of ). Elsevier Health Sciences. Resident #50: Review of an Admission Record revealed Resident #50 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of falls Care Plan for Resident #50, revised on 9/15/2021, revealed the focus, .(Resident #50) is at risk for falls r/t (related to) impaired mobility, occasional incontinence, hx (history) of falls. I have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Please assist me in getting up and out of bed early in AM as I will forget to seek assist and may experience fall if unassisted .Re-educate resident about having assistance when transferring .Sign to be placed on my bathroom door to remind me to call for help when toileting .Staff to offer toileting upon rising, before and after meals and before bedtime. Offer at least Q2H (every 2 hours) . Review of Incident Audit Report dated 6/22/21, revealed, .Resident found sitting on the floor next to her bed. No evidence of kitting her head. Kin tear to right hand between first digit and thumb. First aid given to open area. Residents tolerated well. Bleeding ceased. Area covered with A&D ointment and LOTA. No s/s (signs and symptoms) of pain or discomfort. Resident assisted into bed. Brief changed. Resident pulled the blanket up to her chin and closed her eyes. Call light in reach .Predisposing Physiological Factors: Gait imbalance, Incontinent .Predisposing Situation Factors: Toileting Needs, Ambulating without Assist .Witnesses: No witnesses found . Review of MI-Fall Risk Review dated 6/22/21 at 04:46 AM, revealed, .History of Falls within last six months: 2. 1-2 Falls .2. Tries to stand, transfer, or walk alone unsafely: 1. Yes .Assess a resident's gait while standing in one spot, walking straight forward, and while making a turn: 1. Unable to independently come to a standing position 2. Exhibits loss of balance while standing 11. Decrease in muscle coordination .Equipment used of mobility: wheelchair .Based on the Fall Risk Review, the resident has been determined to be high risk for falls: 1. Yes .Current interventions used/List: See Fall care plan: New intervention: Offer toileting upon rising, before/after meals and before bedtime. Offer toilet assist at least q2h (every 2 hours) .Conclusion/Recommendations: Increase assist with toileting. Falls appear to occur when attempting to self transfer with toileting. Cognition significant decrease recently with new dx (diagnosis): Alzheimer's and poor safety awareness . Review of Incident Audit Report dated 7/4/21 at 05:55 AM, revealed, .Incident Details: The cna found the resident on the floor she stated she slid oob (out of bed) .Assessment done, resident denies injury, none noted at this time and she denies hitting her head. Assisted to restroom and btb (back to bed). Neuros and vs (vitals) done . Review of Incident Audit Report dated 7/18/21 at 20:50 PM, revealed, .Observed in a sitting position beside her w/c (wheelchair) in her bathroom slid off the w/c .Predisposing Situation Factors: Toileting Needs, Using Wheelchair . Review of Progress Notes dated 7/18/2021 at 22:09 PM, revealed, .Nursing Progress Note Note Text: Was observed in a sitting position by her w/c in her bathroom, said she was trying to go to the toilet, slid off the w/c, no visible injury, PROM full in all extremities, denied hitting head; son (Resident #50's DPOA), and MD were notified . Review of Progress Notes dated 7/19/21 at 11:51 AM, .has an informal toilet schedule .place a sign on bathroom door to visually remind her to seek assistance with toileting needs . Review of Progress Notes dated 9/11/2021 at 12:34 PM, revealed, .Nursing Progress Note Note Text: Resident is alert and forgetful; she is able to verbalize needs. CNA notified to this writer that resident was on the floor. Resident was sitting on the floor, between W/C and her bed. Call light was within reach. This writer asked resident about the incident, resident smiling stated I don't remember. Assess: move all extremities without difficulty. Skin is clean no redness or skin issues noted at this moment, Resident observed without shoes, w/c locked and she was dry. Resident denies pain. BP 133/75, PULSE 71, TEMP 97.7, RESP 18, BIOX 97% at room air Transferred to her w/c with two staffs. MD, DON, administrator and POA notified . Review of MI-Fall Risk Review dated 9/11/2021 at 09:30 AM, revealed, .Conclusion/Recommendations: Will assist resident to get up early in the morning before breakfast . Review of Meal Times revealed, .Breakfast at 7:30 AM - 9AM . Review of Documentation Survey Report for July 2021 revealed no documentation to support Resident #50 was offered toileting every two hours and staff were offering toileting upon rising, before and after meals and before bedtime. Review of Documentation Survey Report for July 2021 revealed no documentation to support Resident #50 was offered toileting every two hours and staff were offering toileting upon rising, before and after meals and before bedtime. Review of Documentation Survey Report for July 2021 revealed no documentation to support Resident #50 was offered toileting every two hours and staff were offering toileting upon rising, before and after meals and before bedtime. In an interview on 09/14/21 at 12:26 PM, Resident Representative (RR) KK reported he was concerned with the number of falls that his mother has sustained since December of 2020 and has had meetings with the facility Director of Nursing to determine what they could do to prevent further falls for his mother. RR KK reported the facility and he discovered his mother had Alzheimer's Disease from a CT scan which was completed in May. Review of a Minimum Data Set (MDS) assessment for Resident #50, with a reference date of 8/9/21, revealed, .Section G: Functional Status: B. Transfer - Limited Assistance, One person physical assist; G. Dressing - Limited assistance, One person physical assistance; I. Toilet Use - Limited Assistance, One person physical assistance; J. Personal hygiene- Supervision, One person physical assistance . Review of Documentation Survey Report for September 2021 for Resident #50 revealed, .September 1: Personal Hygiene, Toilet Use: 1 Assist was completed at 07:37 AM, 23:48 PM, and 01:40 AM; Sept. 2: Personal Hygiene, Toilet Use: 1 Assist was completed at 21:39 PM; Sept. 3: Personal Hygiene, Toilet Use: 1 Assist was completed at no time during this day; Sept. 4: Personal Hygiene, Toilet Use: 1 Assist was completed at no time during this day; Sept. 5: Personal Hygiene, Toilet Use: 1 Assist was completed at 22:29 PM, 02:50 AM; Sept. 6: Personal Hygiene, Toilet Use: 1 Assist was completed at 11:21 AM, 05:34 AM; Sept. 7: Personal Hygiene, Toilet Use: 1 Assist was completed at 14:27 PM, 20:22 PM, 23:52 PM; Sept. 8: Personal Hygiene, Toilet Use: 1 Assist was not completed at not time during this day; Sept. 9: Personal Hygiene, Toilet Use: 1 Assist was completed at 21:15 PM, 00:14 AM; Sept. 10: Personal Hygiene, Toilet Use: 1 Assist was completed at 08:11 AM, 22:29 PM, 02:15 AM; Sept. 11: Personal Hygiene, Toilet Use: 1 Assist was completed at 12:26 PM, 03:48 AM; Sept. 12: Personal Hygiene, Toilet Use: 1 Assist was completed at 12:13 PM, 23:10 PM, and 02:15 AM; Sept. 13: Personal Hygiene, Toilet Use: 1 Assist was completed at 14:29 PM; Sept. 14: Personal Hygiene, Toilet Use: 1 Assist was completed at 20:56 PM . Resident #19: Review of an Admission Record revealed Resident #19 was originally admitted to the facility on [DATE]. Review of Care Plan for Resident #19, revised on 6/20/2021, revealed the focus, .(Resident #19) requires an extensive to total assistance with ADLs due to [CONDITION(S)] (stroke), left sided [CONDITION(S)] (paralysis) following stroke, acute debility/weakness, and incontinent of bowel/bladder . with an intervention .Extensive 2 person assist with bed mobility .Extensive 2 person assist with transfers . Review of Care Plan for Resident #19, revised on 6/25/2021, revealed, .(Resident #19) is at risk for falls r/t (related to) cognitive impairments, communication impairment, decreased safety awareness, unable to use call light or request for assistance, Requires ADL assist for transfers and mobility related tasks, decreased strength and endurance .DX (diagnosis): [CONDITION(S)] with [CONDITION(S)] or [CONDITION(S)]. (Resident #19) moves self, flailing limbs as able to move off mattresses, bed, etc. This is exacerbated when s/s (signs and symptoms) of pain are present . with the intervention .Mattresses placed o the floor next to my bed with dycem under mattress to assist with placement .Gather information on past falls and attempt to determine the root cause of the fall(s). Anticipate and intervene to prevent recurrence .Staff to respond promptly to all request for assistance .Anticipate and meet individual needs of the resident . Review of Occupational Therapy (OT) Evaluation & Plan of Treatment dated 6/23/2021, revealed, .Functional Skills Assessment - Mobility During ADLs .Other Mobility: Hoyer x2 . During an observation on 9/13/21 at 11:21 AM , Resident #19 was observed in her room in her bed and she had slid down in the bed as the head of the bed was elevated approximately 40-45 degrees, she was yelling out. There was a bowel movement odor coming from the room. In an interview on 9/13/21 at 11:22 AM, Certified Nursing Assistant (CNA) D reported the resident does not like being dirty (soiled). During an observation on 9/13/21 at 11:21 AM , Resident #19 was observed in her room in her bed on her back and heard yelling out. During an observation on 9/14/21 at 1:19 PM, Resident #19 was observed out of her bed on to the mattress next to her bed. She WAS yelling out for help. Resident #19 was attempting to grab an enabler bar on her bed and trying to move her torso closer towards the bed. Resident #19 asked this writer for assistance to get back into the bed. RN I and Business Office Manager (BOM) JJ responded. During an observation on 9/14/21 at 1:20 PM, RN I observed seeking assistance (to move Resident #19 back into the bed form the mattress on the floor) in the hallway, observed no other staff present in the hallway, and headed to the business office. Received assistance from Business Office Manager (BOM) JJ. RN I walked across the mattress on the floor and got on her knees and positioned herself behind Resident #19. BOM JJ stated, .Do we use a hoyer? (to get her up off the mattress and into the bed) . RN I stated, .No . RN I assisted Resident #19 into the position to be parallel with her bed, no assistance provided by BOM J at that time. RN I was on her knees and positioned herself behind Resident #19. RN I placed her arms under the resident's armpits and BOM JJ crossed the resident's feet at the ankles, counted to 3, and both lifted the resident back into her bed. BOM JJ asked about placing Resident #19 in her broda chair and RN I told her she would have to have someone sitting by her the whole time and there was not enough staff to do this. In an interview on 9/14/21 at 1:23 PM, RN I reported the resident had placed herself out of bed twice earlier today and she went to seek assistance, and no one was available to assist, and she placed Resident #19 back in her bed by herself this same way. In an interview on 9/15/21 at 10:04 AM, Rehab Program Manager HH reported Resident #19 was a Hoyer assist for transfers. Rehab Program Manager HH stated the resident had not been removed from requiring a Hoyer assist and she required extensive assistance because of her mobility. In an interview on 9/15/21 at 1:34 PM, Assistant Director of Nursing (ADON) C reported there are Hoyer in the building which do lower completely to the floor and if the resident required a Hoyer for transfer, they should be hoyered. Resident #8: Review of an Admission Record revealed Resident #8 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #8, with a reference date of 6/8/21 revealed, Staff Assessment for Mental Status was completed indicating Resident #8 was unable to complete a Brief Interview for Mental Status. Review of falls Care Plan for Resident #8, revised on 9/15/2021, revealed the focus, .I am risk for falls R/T (related to) Cognitive impairments, [CONDITION(S)]. I often sit myself on the floor as I often exhibit childlike tendencies. Due to the nature of setting myself on the floor, and my ability to rise from a sitting position on the floor as I desire, these will not be considered a fall. I have poor safety awareness, I also am very impulsive and will not wait for staff before standing . with the interventions .Observe for increase restlessness and assist with toileting, hunger, thirst, pain, etc needs .Provide 1:1 care/supervision as needed .Staff to maintain visual contact with resident when up in chair . Review of Progress Notes dated 8/20/2021 at 12:45 PM, revealed, .Nursing Progress Note Late Entry: Note Text: Late Entry - This nurse was called to the dining room by (Maintenance NN) Upon entering the dining room, resident was sitting upright, on the floor, on her buttocks, with her knees drawn up. Her w/c was approximately 2-3 tables over, where she had eaten her lunch. Upon assessing resident, she denied any pain, showed no s/s of distress. Resident did have on gripper socks, however they were noted to be wet, when this nurse went to get residents w/c, which was by the table were she ate. At her spot there was thickened, red juice spilled all over the fall, and on the wheels of her w/c. Assist x 2, up into the w/c without incident. No s/s of pain or distress with transfer. This nurse brought her out to the med cart, one of the psych service rep. meet with resident, and this nurse, asking questions, of the both of us. Resident showed this nurse how she waved as a beauty queen She was obviously tired, as she was up before 6am, self propelling in her w/c all over the different hallways, and had gotten up from w/c ambulating multiple times for lengthy distances. This nurse had CNA take resident to room to be changed and laid down . Review of Progress Notes dated 8/20/2021 at 12:52 PM, revealed, .Nursing Progress Note Late Entry: Note Text: Resident sitting on floor in front of her wheelchair. When asked if she sat down she smiled. Assisted with another staff member to get (Resident #8) up and back into wheelchair. Neuro checks WNL. Denies any pain or discomfort . Review of Progress Notes dated 8/20/2021 at 14:21 PM, revealed, .Nursing Progress Note Note Text: Resident presents in pain. Her normal behaviors include self propelling in the wheelchair and standing/walking with assist. During incontinent care, CNA reported to narrator that (Resident #8) looks like she is in a lot of pain, she keeps saying no and she will not stand. This resident is unable to verbalize her needs. Dr contacted. Orders received for bilateral hips to be x-ray'd. Diagnostic order sent in. Resident was given House standing order of tylenol 650mg by mouth . Review of Progress Notes dated 8/20/2021 at 18:46 PM, revealed, .Nursing Progress Note Note Text: Xray arrived and was escorted to patient room. Awaiting report . Review of Progress Notes dated 8/20/2021 at 21:49 PM, revealed, .Nursing Progress Note Note Text: Results ordered STAT. Result was fracture to R greater trochanter. EMS was called. DON and admin aware. Guardian called . Review of Progress Notes dated 8/20/2021 at 21:53 PM, revealed, .Nursing Progress Note Note Text: EMS arrived. Resident was transferred to stretcher x 3 assist. Vitals WNL obtained by EMS. Transported to (Hospital in Indiana) due to local hospitals being on bypass . Review of Clinical Summary dated 8/30/21, revealed, .Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)], 3. [CONDITION(S)], 5. Dehydration . Review of Order dated 8/31/21, revealed, .Order Summary: Resident is NON-Weight bearing until further notice In an interview on 9/15/21 at 04:26 PM, Licensed Practical Nurse (LPN) OO reported, Resident #8 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . It appeared she had spilled her juice as it was all around the bottom of her chair. LPN OO reported she was called to the dining room. A staff member was in the dining room waiting by Resident #8 to keep her safe. LPN OO stated, .She had crawled over to the other table .She was away from her wheelchair .She does walk but she had walked a lot that day and she was up early so she was exhausted .She had very wet socks and her pants were soaking wet and it was red from the juice she had spilled and crawled across .I am not sure if she tried to get up and spilled it .It was just my assumption as she had it all over herself and she was way too tired to stand up and get out of her wheelchair . LPN OO reported the resident was too heavy for her to get up by herself and she sought assistance from other staff while the staff member waited with the resident. LPN OO reported the resident was assisted to a standing position and sat in her wheelchair. LPN OO reported Resident #8 did not show signs or symptoms of pain when she was stood up. Resident #8's wheelchair was wheeled over to the medication cart. LPN OO reported the resident talked with the psychiatric doctor for approximately 30 minutes and the resident proceeded to wave as she was a beauty queen prior. LPN OO reported when Resident #8 was finished speaking with the psychiatric doctor, the CNA took her to change out of her clothes. LPN OO reported Resident #8 didn't report or complain to me about pain, leg shortening or rotation out or anything like that. In an interview on 9/15/2021 at 4:58 PM, Director of Nursing (DON) B reported there were two separate falls that day (8/20/21) that happened about 20 minutes apart. DON B reported Resident #8 stood up out of her wheelchair and fell to the floor. Resident #8 was assess and assisted back to her wheelchair. DON B reported Resident #8 took about 3-4 steps when she stood up out of her wheelchair and waved. The resident was assisted, with one person, back into her wheelchair. DON B reported after she was placed in her chair she spoke with the psychiatric doctor for about 15 minutes and I went on my way. DON B stated, .I spoke with everyone who worked that day and non would say that they assisted her out of bed or assisted her back into bed .No one would cop to it .So I am not sure when it happened as she stood up and showed no indication of pain or shortening or anything . In an interview on 9/9/21 at 2:09 PM, Confidential Informant (CI) LL reported the facility has been working short on weekends utilizing only two aides for the whole facility. CI LL reported when staff come into work there are so many residents who have not been changed and they are soaked with urine and bowel movement .It is impossible to give them the care they need, their teeth or their hair isn't being brushed .They are tucked into the bed to try to keep them safe .The residents are not getting the treatment they deserve .There was a resident who was crying to me because he smelled really bad, his bandages hadn't been changed .He was saying that no one had touched him all day or changed him all day since 3rd shift the night before .That really upset me .People are quitting left and right .There is a new DON and she is already putting in her two weeks notice .The facility isn't looking out for the CNAs The lights will be going off and the nurses don't answer the call lights .Management doesn't answer the call lights .Residents are falling and hurting themselves .Breaking their hips .There are approximately 10 residents who need assistance with meals and it is difficult for them to get fed and the trays passed to the other residents on the unit .The nurses don't help pass the trays for the residents .The residents with wounds are not getting their dressings changed as ordered .Sometimes not for 4-5 days or even a week . In an interview on 9/14/21 at 4:40 PM, Certified Nursing Assistant (CNA) D stated, .I worked doubles last week Tuesday, Wednesday, Thursday, and Friday .Last weekend there was no one for second shift at all .They had to ask those from first shift if they would stay otherwise they wouldn't of had anyone for second shift .The staff member who had to move the resident with a hoyer and the resident fell .They couldn't get anyone to help move the resident .That never shouldn't have happened .The facility setting up them for failure .We don't get any help from the nurses .They will find us and tell us to do some thing or if we ask them for help we don't get help from them .The administrator used to be a CNA and he told us he could work circles around us but he has yet to come to the floor and do so .He doesn't help out either .None of the administration help out except for the Director of Nursing .She is really trying her best but she put in her two weeks notice and she's going to be leaving .She told us they are not using agency staff to help us because they said they don't have the money to use agency .My kids told me they haven't seen me in awhile .They said that I am never home anymore .I have a six-year-old and an eight-year-old .They're putting our licenses in jeopardy by not giving us the help that we need .We just get so tired because there's just only so much you can do just trying to keep people dry so their skin don't break down .Can't really do the other things they need done . Review of the Master Staffing Schedule provided to this writer by DON B revealed, .August 21, Evenings only two CNAs were scheduled, August 25, Evenings there was one CNA scheduled, August 26, Evenings there was no CNAs scheduled; August 30, Days 3 CNAs scheduled; August 31, Evenings there are two CNAs scheduled; September 3, Days 3 CNAs, Evenings 1 CAN scheduled; September 4, Evenings, 2 CNAs scheduled; September 5, Evenings 2 CNAs scheduled; September 8, Evenings, 1 CNA scheduled; September 9, Evenings no CNAs scheduled; September 14th, Evenings, 1 CNA scheduled . In an interview on 9/15/21 at 3:50 PM, Director of Nursing (DON) B reported she took over staffing when she started as she was responsible for ensuring there was staffing at the facility. DON B reported when the staff see that they have enough staff they call in sick, or they disappear and can't be found, or just leave. DON B reported the nursing staff have a master schedule and they work every other weekend .There is ever other weekend where there are only two CNAs scheduled for each shift .We offer bonuses to get staff to pick up shifts and it has been successful except for the fact they will pick up and call in for the part of the shift or all of the shift they pick up .We have so many holes it the schedule .Look at the evening of August 26th .There was no one scheduled after 10 and only one prior to .It is just too much for me .I have been working 16 hour days .Working on the floor as a nurse .I am the one who is on the hook when something happens .I am placing my license at risk every day I stay here .I have put in my two weeks notice and Friday (9/17/ 21) is my last day .We have had so many falls .The writing is on the wall .

This citation pertains to intake #: MI 817 Based on observation, interview and record review, the facility failed to provide preventative care, consistent with professional standards of practice for 2 out of 9 residents (Resident #101 and #102) reviewed for the risk for the development of pressure injuries, resulting in the development of an avoidable pressure ulcer and the potential for infection and overall deterioration in health status. Findings include: Review of the facility policy S.WA.T.---Skin Weight Assessment Team---Guidelines Pressure Ulcers .Procedure: PRESSURE ULCER ASSESSMENT 1) Pressure Ulcer Assessments will be performed on all pressure ulcers at least weekly .Procedure: SKIN ASSESSMENT: 1) A complete skin assessment is to be done weekly as part of the Skin Breakdown Prevention QAPI process. A licensed nurse will perform the skin assessment. The following will be observed: heels, sacrum, ischial tuberosities, spine, parts of the body affected by anti-embolic stockings, Femoral trochanters, and parts of the body where pressure and shear are exerted in the course of an individuals daily living activities. Parts of the body where there are external forces by equipment and clothing elbows, temporal region of skull, shoulders, back of head, toes and ears. Other areas should be examined as indicated. DURING PERFORMACE OF SKIN ASSESSMENTS THE FOLLOWING MUST BE CONSIDERED-Tissue Damage Threats .Non-blanching hyperemia .Purplish/bluish localized areas of the skin .NOTE: Any skin changes should be documented immediately and reported to appropriate parties with treatment put into place by physician order. Review of Potter and Perry: Fundamentals of Nursing revealed, For patients at risk for skin breakdown who are able to sit in a chair, limit the amount of time they sit to 2 hours or less at any given time. In the sitting position the pressure on the ischial tuberosities (V-shaped bone at the bottom of the pelvis that makes contact with a surface when a person is sitting down/sitting bones) is greater than in the supine position . Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book ([NAME] Locations - ). Elsevier Health Sciences. [NAME] Edition. Resident #101 Review of a Face Sheet revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 3/18/21 revealed a Brief Interview for Mental Status (BIMS) score of 2, out of a total possible score of 15, which indicated Resident #101 was severely cognitively impaired. Review of the Functional Status revealed that Resident #101 required extensive 2 person assist for bed mobility, transferring, dressing, toileting, and personal hygiene. Review of Resident #101's Care Plan revealed, I am at risk for skin breakdown R/T (related to) decreased mobility requiring assistance of staff with repositioning, I choose to stay in bed most days, and I am incontinent Date Initiated: 03/16/2016 .Assist me PRN (as needed) with turning and re-positioning throughout the shift as I will allow/tolerate . Conduct a skin inspection weekly with my shower schedule. Pay particular attention to bony prominences. My CNA (Certified Nursing Assistant) to observe my skin integrity with daily cares and report any changes to the charge nurse . Report any signs of skin breakdown (sore, tender, red, or broken skin areas) .Use wedges for positioning while I am in my bed and/or wheelchair . Resident has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #101's Braden Scale for Predicting Pressure Ulcers dated 2/21/21 revealed a score of 12 indicating Resident #101 was at high risk for pressure ulcer formation. Review of Resident #101's Physician Order dated 11/18/20 revealed, pad and protect coccyx area from skin breakdown as needed. Review of Resident #101's Weekly Skin Check dated 4/23/21 revealed that Resident #101 did not have any skin integrity concerns/breakdown. During an observation on 04/22/2021 at 7:52 A.M., Resident #101 was sitting in the dining room in a broda chair. There was a positioning wedge under her left arm. During an observation on 04/22/2021 at 9:44 A.M., Resident #101 was sitting in the dining room in a broda chair. There was a positioning wedge under her left arm. During an observation on 04/22/2021 at 10:33 A.M., Resident #101 was sitting in the dining room in a broda chair. There was a positioning wedge under her left arm. During an observation on 04/22/2021 at 11:42 A.M., Resident #101 was sitting in the dining room in a broda chair. There was a positioning wedge under her left arm. During an observation on 04/22/2021 at 12:42 P.M., Resident #101 was sitting by the nurses station in a broda chair. There was a positioning wedge under her left arm. During an observation on 04/22/2021 at 1:36 P.M., Resident #101 was sitting in her room in a broda chair. There was a positioning wedge under her left arm. During an observation on 04/22/2021 at 2:20 P.M., Resident #101 was sitting in the dining room in a broda chair. There was a positioning wedge under her left arm. During an observation and interview on 04/22/2021 at 2:36 P.M., CNA J and CNA N placed Resident #101 in bed. CNA J reported that she did not know the last time Resident #101's brief had been changed. Resident #101's brief was not saturated but had a strong odor of concentrated urine. Resident #101's left buttock had an open area (bright pink wound bed observed) approximately the size of a pea. CNA J and CNA N reported that that was a new open area for Resident #101. CNA N reported that all immobile residents should be repositioned at least every 2 hours. CNA N reported that because of being short staffed it was difficult to reposition and change residents as frequently as required. CNA N reported at times it is difficult to meet the needs of the residents. Review of Resident #101's Unit Nurse Skin Review dated 1/13/21 revealed all areas of documentation blank. Review of Resident #101's Unit Nurse Skin Review dated 4/7/21 revealed, .Weekly skin assessment completed, nothing noted at this time. Will continue to monitor. (No other skin assessments from 1/13/21 to 4/7/21). Review of Resident #101's Unit Nurse Skin Review dated 4/21/21 revealed, Weekly skin assessment completed, no new areas noted at this time. During an interview on 04/22/2021 at 2:25 P.M., CNA J reported that it is difficult to complete resident care without sufficient staff. CNA J reported that the 300 Hall (where Resident #101 and #102 reside) have multiple 2 person assist for transfer residents. CNA J reported that at times it would take extended periods of time to transfer residents to bed because of lack of staff. Resident #102 Review of a Face Sheet revealed Resident #102 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 3/26/21 revealed a Brief Interview for Mental Status (BIMS) score of 5, out of a total possible score of 15, which indicated Resident #102 was severely cognitively impaired. Review of the Functional Status revealed that Resident #102 required extensive 2 personal physical assistance for bed mobility, for personal hygiene activity only occurred once or twice two person physical assist, and for toileting, dressing, and eating activity only occurred once or twice one personal physical assist. Review of Resident #102's Care Plan revealed, I am at an increased risk for alteration in skin integrity related to: incontinence of bladder and bowel. Date Initiated: 10/28/2016 .Precautions for prevention of pressure ulcers will be completed, such as: good pericare and drying of my skin, applying protective barrier cream, re-position me frequently when I am in my bed/chair/gerichair and/or baroda (sic) chair (supportive chairs with a high back that can tilt), off load my heels PRN (as needed), CNA shower/skin observations to be reported to my nurse for any unusual findings/changes in my skin integrity . Review of Resident #102's Physician Orders dated 9/17/19 revealed, Weekly Skin Check .every Tue (Tuesday) for wound prevention. Review of Resident #102's Braden Scale for Predicting Pressure Ulcers dated 3/24/21 revealed a score of 13 indicating Resident #102 was at moderate risk for pressure ulcer formation. During an observation on 04/22/2021 at 7:52 A.M., Resident #102 was sitting in the dining room in a broda chair. During an observation on 04/22/2021 at 9:44 A.M., Resident #102 was sitting in the dining room in a broda chair. During an observation on 04/22/2021 at 10:33 A.M., Resident #102 was sitting in the dining room in a broda chair. During an observation on 04/22/2021 at 11:42 A.M., Resident #102 was sitting in the dining room in a broda chair. During an observation on 04/22/2021 at 12:42 P.M., Resident #102 was sitting in the dining room in a broda chair. During an observation on 04/22/2021 at 1:36 P.M., Resident #102 was sitting outside of his room in a broda chair. During an observation and interview on 04/22/2021 at 2:00 P.M., CNA P and CNA D placed Resident #102 into his bed to complete a brief change. Resident #102 had 2 briefs on. CNA P reported that he should not have 2 briefs on and that was not a standard practice in the facility. The entirety of Resident #102's buttocks was red with indentations noted from his brief. The underside of each buttock had a linear deep purple/red mark following the brief line, indicating that the double brief had been pressing into Resident #102's skin for an extended period of time. CNA P and CNA D reported that the reddened areas were new for Resident #102. CNA P reported that there are many 2 person assist residents on the 300 Hall (the hall that Resident #102 resided) which maked it difficult to meet the needs of the residents because of short staffing. Review of Resident #102's Progress Note dated 4/23/21 revealed, CNA notified nurse of a reddened area to residents sacrum. Nurse observed a scabbed abrasion to R (right) buttock where edge of brief touches. Nurse educated CNA to keep resident off of bottom as much as possible and change resident when wet. Wound charted and DON (Director of Nursing) aware. Review of Resident #102's Unit Nurse Skin Review dated 12/29/21 revealed, no new skin issues. Review of Resident #102's Weekly Skin Check dated 4/14/21 revealed, Does resident have loss of skin integrity? (No). Does resident have a new loss of skin integrity? (No). Review of Resident #102's Unit Nurse Skin Review dated 4/23/21 revealed, Right gluteal fold .Scabbed over abrasion 5cmX1cm .Sacrum dry abrasion on L (left) side of sacrum 1cm/1cm . (No other skin assessments from 12/29/20 to 4/14/21). Review of Resident #102's Weekly Skin Check dated 4/23/21 revealed, Does resident have loss of skin integrity? (No). Does resident have a new loss of skin integrity? (No). During an interview on 04/26/2021 at 2:40 P.M., CNA M reported that all immobile residents should be repositioned every 2 hours to offload pressure. During an interview on 04/26/2021 at 10:38 A.M., Licensed Practical Nurse (LPN) U reported that Weekly Skin Assessments should be completed on all facility residents by a licensed nurse. LPN U reported that all Weekly Skin Assessments are completed in the Electronic Health Record (EHR). During an interview on 04/26/2021 at 11:55 A.M., Nursing Home Administrator (NHA) A reported that licensed nurses reference Shower Sheets and sign off on the documents. NHA A reported that Weekly Skin Assessments should be completed weekly by licensed nursing staff and are separate documents from the Shower Sheets. During an interview on 04/26/2021 at 2:32 P.M., Registered Nurse (RN) C reported that Weekly Skin Assessments should be completed weekly on all residents in the facility. RN C reported that Weekly Skin Assessments are ordered by the physician in the EHR and therefore should be followed. RN C reported that the licensed nurses sign off on the newly identified skin integrity issue (or the lack thereof) on the Shower Sheet and do not complete a full head to toe skin assessment at that time which is why the Weekly Skin Assessment is ordered for the licensed nurses to complete. The facility staff were not able to provide additional Weekly Skin Assessments for Resident #101 or #102 prior to survey exit.

This citation pertains to Intake #: MI 620 Based on interview and record review, the facility failed to conduct and complete and accurate assessment of resident pain after pain was noted following a fall in 1 of 3 residents (Resident #101) reviewed for quality of care, resulting in delay in identification of and treatment for [REDACTED]. Findings include: Review of the facility policy Incidents/Accidents/Falls revealed, Procedure: 1. If a resident is involved in an incident/accident an immediate assessment of the resident will be completed by a nurse .2. In the case of a fall, the resident will have a head to toe assessment to include a pain assessment and assessment as to any change in their ROM (range of motion) ability/function. Further, residents who have an unwitnessed fall must have neuro checks started and continued per policy. Neuro checks will be initiated even if the residents states they did not hit their head in an unwitnessed fall . Review of facility document, What to do for FALLS revealed, . Documentation: .If you did not complete a progress note within the Risk Management tab (referring to the Incident Report), then you need to enter one in the Resident Progress Notes . Review of a facility policy Management of Pain revealed, The assessment will cover the following areas: intensity, location, onset, type and frequency, description, change, treatment, effect, and what makes it better or worse .9. Pain Monitoring - Document on the back of the MAR (medication administration record)/pain flow sheet the effectiveness of pain medication. Effectiveness should be measured 1-2 hours after administration . Review of a facility Neurological Flow Sheet revealed, Vital Signs and Neuro Checks: q (every) 15 mins. X (1) hour, q 30 mins. X (1) hour, q 1 hour x (4) hours, q 4 hours x (24 hours) with the following items listed to check/document at each check Date, Time, Level of Consciousness, Movement, Hand Grasps, Pupil Size Rt. (right), Pupil Size Lt. (left), Pupil Reaction Rt., Pupil Reaction Lt., Speech, B/P (blood pressure), Pulse, Respiration, Temperature . Review of the Fundamentals of Nursing revealed, The health assessment and physical examination are important steps toward providing safe and competent nursing care .By performing health assessments and physical examinations, you identify health patterns and evaluate each patient's response to treatments and therapies .You identify additional objective data through a head-to-toe body system review during the physical examination. Your clinical judgments are made on the basis of all of the gathered data to create a plan of care for each situation. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition. Review of a Face Sheet revealed Resident #101 was an [AGE] year-old female, originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] following hospitalization for a fracture following a fall, with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 07/14/20 revealed a Brief Interview for Mental Status (BIMS) score of 03, out of a total possible score of 15, which indicated Resident #101 was severely cognitively impaired. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 07/14/20 revealed, .G0400. Functional Limitation in Range of Motion . with a 1 entered for A. Upper extremity, which indicated impairment on one side of upper body (in this case, the left side); with a 2 entered for B. Lower extremity, which indicated impairment on both sides of lower body. Review of a Fall Incident Report for Resident #101 dated 07/24/20 8:00 revealed, Incident Description, Nursing Description: resident slid out of her bed along with the wedge onto the floor feet were still on the mattress; Resident Description: unable to describe what happened; Immediate Action Taken Description: bed bolsters, to bed for added safety; Resident Taken to Hospital? N (indicating no); Injuries Observed at Time of Incident .No Injuries observed at time of incident; Level of Pain 0 (indicating none) .Injuries Report Post Incident Injury Type No Injuries Observed Post Incident; Level of Pain (not documented) .Other Info (no entry) .7/24/20 9:08. In an interview on 9/25/20 at 2:46 P.M., Licensed Practical Nurse (LPN) Q indicated being the nurse on duty on the COVID unit where (Resident #101) resided when she fell on [DATE]. LPN Q reported (Resident #101) was found during rounds with left shoulder on the floor and the rest of her body suspended (cocooned) in the blanket; she appeared to have slid off the bed. LPN Q reported did not have copies of the Neuro Check sheet (the form the facility uses to check resident vitals following a fall) in the COVID unit, so wrote on a piece of paper and gave it to ADON (Assistant Director of Nursing F). LPN Q reported Resident #101 was assessed for ROM (range of motion) after the fall and recorded on said piece of paper (not in the clinical record). In an interview on 09/30/20 at 8:52 A.M., Assistant Director of Nursing (ADON) F explained that (Resident #101) had been on the COVID unit at the time of the fall due to testing positive for COVID-19 and there was no copy of the Neuro Check sheet on the unit so the nurse (LPN Q) hand wrote vital signs on a sheet of paper. Review of a handwritten document provided to this surveyor by ADON F on 09/30/20 at 8:52 A.M. revealed, Fall (Resident #101) 7/24, Time 0800 fall from bed, Vitals 987-74-20-144/76, Pox (amount of oxygen in blood) 95% R/A (room air), Pupils equal reactive, Orient (orientation) 4ES, Speech slurred per her normal, Pain Response no pain active passive ROM (range of motion) WNL (within normal limits) L (left) shoulder area has ROM per her normal. ROM All extremities were assessed both actively and passively. No pain expressed either verbally or facially. Resident was then via mechanical lift placed back into her bed via a mechanical lift. Note - document was not found within Resident #101's permanent medical record. ADON F indicated the document had been in their office. In an interview on 9/25/20 at 3:30 P.M., Certified Nursing Assistant (CENA) P reported they took care of (Resident #101) while on COVID unit. CENA P indicated as part of routine care, had to rotate (reposition) (Resident #101) every 2 hours for pressure relief because resident could not move herself. CENA P indicated that after (Resident #101's) fall on 7/24/20, she would pinch, scratch, or moan every time she was changed or repositioned. CENA P indicated sometimes (Resident #101) would even reach out and try to push away (indications of possible pain), which was unlike her. CENA P indicated they reported to LPN Q and ADON F but does not know what they did about it. Review of a document COVID 19 Symptom Screener for Positive Residents for Resident #101, dated 7/25/20 08:10 am, revealed, .Daily Skilled Progress Note .resident appears painful with repositioning tylenol given . Review of Resident #101's Order Summary Report reveals no evidence of a physician order for [REDACTED]. Review of a Nursing Progress Note for Resident #101 dated 07/25/20 at 10:22 am revealed, Late Entry: Note Text: IDT (Interdisciplinary Team): Met to review res (resident) fall f/u (follow up) res alert able to answer yes and no questions, res during rounds noted to roll out of bed, res has a dx (diagnosis) of Cerebral Infarction (stroke) and [MEDICAL CONDITION] and [MEDICAL CONDITION] .no discolorationor (sic) c/o (complaints of) pain . There was no indication regarding communication from CENA P on Resident #101's possible pain symptoms. Review of a document COVID 19 Symptom Screener for Positive Residents for Resident #101, dated 7/27/20 08:39 am, revealed, .Daily Skilled Progress Note .resident appears painful with repositioning tylenol given . Review of Resident #101's Order Summary Report reveals no evidence of a physician order for [REDACTED]. Review of Resident #101's MAR/TAR (Medication Administration Record/Treatment Administration Record) for July, 2020 revealed, *Monitor and Record Pain Scale* .New pain or intensity pain change = Call MD every shift for pain monitoring, -Start Date- 01/17/2019 2230 with documented pain assessed at a level of 4 (indicating moderate pain) on 7/26/20 at evening shift, documented pain assessed at a level of 4 on 7/26/20 during overnight shift, documented pain assessed at a level of 3 (indicating mild pain) at evening shift on 07/28/20, and documented pain assessed at a level of 3 on 7/28/20 during overnight shift. All documented pain assessments for the period 7/1/20-7/23/20 were assessed at a level of 0, indicating that Resident #101 did not have pain prior to the 07/24/20 fall but did have pain after 07/24/20 fall. No evidence on MAR/TAR of MD being contacted for documented pain per order and no assessment noted for possible source of pain. Review of a Nursing Progress Note for Resident #101 dated 07/30/20 at 06:21 am revealed, Note Text: This morning while the aid was changing the resident, the aide noted to this writer about the resident c/o (complaints of) of pain on knee. I assess the resident and notice slightly swollen on the L/knee; this nurse passed it to the next nurse to call the Dr. for further evaluation. Review of a Nursing Progress Note for Resident #101 dated 07/30/20 at 14:00 revealed, Note Text: Left knee noted to be swollen, warm, and very tender to touch. Res (resident) wincing and yelling out when touched. (Name omitted) NP (Nurse Practitioner) informed and x-ray ordered. Dtr (daughter) called and notified. Medical diagnostic called and will be in today. Oncoming nurse informed. Will cont (continue) to monitor. Note that this is 6 days after Resident #101 fell on [DATE]. Review of a Nursing Progress Note for Resident #101 dated 07/30/20 at 21:54 revealed, Note Text: STAT Xray result received. Supracondylar fx of the distal left femur (thigh bone (femur) broken at the knee). NP notified. New order received to send to (hospital name omitted) for eval and tx (evaluation and treatment) .EMT (emergency medical technician) notified at 9pm . Review of Resident #101's hospital records dated 07/30/20 11:37 P.M. revealed, Patient is an [AGE] year-old female with a history of prior stroke with chronic left-sided deficits who is nonverbal at baseline presents to the emergency department today from a nursing home for left knee pain. EMS (emergency medical services) reports patient had a ground-level fall at the nursing home facility on 07/24/20 . an x-ray was reportedly done which showed a [MEDICAL CONDITION] knee and patient was sent to the emergency room for further evaluation.

This citation pertains to Intake #: MI 620 Based on interview and record review, the facility failed to provide care per professional standards of practice to prevent the development of an avoidable unstageable pressure ulcer for 1 of 1 sampled residents (Resident #101) reviewed for alterations in skin integrity, resulting in the development of an unstageable pressure ulcer and the potential for delaying wound healing, infection, and overall deterioration in health status. Findings include: Review of a facility policy, SKIN OBSERVATION/ASSESSMENT revealed, Policy: It is the policy of the facility to ensure that each resident is provided with showers and or baths to maintain proper hygiene as well as comfort. During the shower/bath, the care giver will observe the resident's skin. Conditions that will be observed for include but are not limited to what appear to the care giver to be bruises, red areas, open areas, scratches, abrasions, blisters, discoloration, dry flaky skin, pressure ulcers, scars as well as any other conditions of the skin. Note: Only licensed nurses can assess the skin. If the care giver is not a nurse and they observe a change in the resident's skin, the care giver will notify the nurse immediately .Procedure: .4.) Other times that the resident will have a skin assessment will be upon admission, readmission, after a fall or an injury, upon discovery (by a care giver) of a skin change, prior to discharge or as indicated with a condition change . Review of a Face Sheet revealed Resident #101 was an [AGE] year-old female, originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] following hospitalization for a fracture following a fall, with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 07/14/20 revealed a Brief Interview for Mental Status (BIMS) score of 03, out of a total possible score of 15, which indicated Resident #101 was severely cognitively impaired. Review of an Order Summary for Resident #101 revealed, Per Dr. (name omitted) - resident to wear immobilizer to left lower extremity at all times except during skin care, non weight bearing to left lower extremity. every shift for fracture - comfort .Active 08/06/2020. Review of a MAR/TAR (Medication Administration Record/Treatment Administration Record) for the period 08/20 and 09/20 revealed the following: Physician order [REDACTED]. and notify md immediately every shift for skin integrity -Start Date- 08/10/2020 1430 -D/C Date- 09/24/2020 1416 with no observations documented *EVE shift on 8/11, 8/13, 8/18, 8/19, 8/21, 8/24, 8/25, 8/26, 8/28, 9/3, 9/8, 9/9, 9/10, 9/22, 9/23. Review of a Nursing Progress Note for Resident #101 dated 9/18/20 04:17 revealed, Note Text: Called to residents room by CNAs (Certified Nursing Assistant) due to foul odor coming from resident LLE (left lower extremity - lower leg). Removed brace (immobilizer) to visually inspect skin. Noted open area to LLE malleolus (the bony prominence on the side of the ankle). Bright red blood with brown thick fluid draining. NP (nurse practitioner) notified as well as wound nurse . In an interview on 9/25/20 at 9:58 A.M., Assistant Director of Nursing (ADON) F reported that an immobilizer (a device worn to prevent movement) was placed on Resident #101's left leg by the (hospital) orthopedic doctor due to a femur fracture discovered on 07/30/20. ADON F indicated the immobilizer was ordered to remain in place until (Resident #101) was seen for a follow-up appointment with the orthopedic doctor originally scheduled for 8/28/20. ADON F reported that Resident #101 missed the appointment due to a transportation service error. ADON F reported the appointment was rescheduled for 9/25/20. ADON F indicated the ankle wound was discovered on 09/18/20 when a nurse noted an odor, checked Resident #101's skin underneath the immobilizer, and noted a blister that had popped on the ankle. ADON reported the wound doctor came to assess the wound on 9/21/20. Review of a Visit Report for 9/21/20 for Resident #101 revealed, Chief Complaint .This patient was seen today as a consultation for evaluation of the patient's wounds .Previously had orthopedic surgery with knee immobilizer in place. Developed unstageable pressure ulcer due to immobilizer .Wound Assessment(s) Wound #1 Left, Lateral Ankle is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 6cm length x 3cm width x 0.1 cm depth, with an area of 18 sq cm and a volume of 1.8 cubic cm. There is a moderate amount of serous drainage noted which has no odor .Additional Information Wound #: 1 - Wound goals: Healing, Granulation % 20, Slough % 80 .Procedures Wound #1 . (Pressure Ulcer) is located on the left, lateral ankle. A skin/subcutaneous tissue level surgical debridement with a total area debrided of 14.4 sq cm was performed by (physician name omitted) . In an interview on 9/30/20 at 2:45 P.M., Certified Nursing Assistant (CENA) P indicated that the aides (referring to CENAs) were not allowed to remove the immobilizer from Resident #101s leg; they told us we could not take it off whatsoever. CENA P recalled an episode of a loose, watery bowel movement (diarrhea) (could not recall date) that ran down (Resident #101)'s leg underneath the brace (immobilizer). CENA P stated all we could do was try to take a washcloth and wipe in between it because we didn't have an extra one (brace/immobilizer) to change it and they told us we could not take it off. CENA P reported staff had noticed an odor in Resident #101s room that smelled like wet flesh for a couple weeks. In an interview on 9/30/20 at 3:24 P.M., Licensed Practical Nurse (LPN) W reported there were conflicting orders originally entered in the computer regarding skin care for Resident #101 related to the immobilizer. LPN W indicated one order said the immobilizer was not to be removed even with care and another order said to remove the immobilizer and check for circulation but the same order also said the immobilizer was never to be removed. LPN W reported nurses were never supposed to remove the immobilizer. LPN W reported found the wound because did rounds with the Certified Nursing Assistants (CENAs), went to check on Resident #101 and she was moaning in pain. LPN W indicated the bottom part of the immobilizer where the Velcro attaches was way too tight, I couldn't put my 2 fingers under it, and it wreaked (stunk really bad). LPN W reported contacted DON (Director of Nursing) for permission to remove the immobilizer to treat the skin and the DON said okay. In an interview on 10/01/20 3:43 P.M., LPN T was asked to describe how checked Resident #101's skin under the immobilizer. LPN T indicated did not take the immobilizer off - had to check around it - there was an order not to take the immobilizer off. LPN T reported it there was an because Resident #101 had a fracture so had to check to see if the immobilizer is okay and make sure it was in place. LPN T stated, You cannot take it off because she had the fracture - it is to protect the leg. You look around the immobilizer. In an interview on 10/1/20 beginning at 2:02 P.M., ADON F was asked what interventions were in place for pressure relief of the immobilizer. ADON F indicated there was an order in the computer as far as checking it every shift. This surveyor noted multiple dates on the 08/20 and 09/20 MAR/TAR (Medication Administration Record/Treatment Administration Record) with no documented observation of skin under immobilizer per physician order. ADON F agreed there were missed skin observations. ADON F was then asked how many times the immobilizer was actually removed before the wound was found. ADON F did not answer the question.

Based on observation, interview, and record review, the facility failed to treat residents with dignity and respect and failed to provide an environment that promoted and enhanced resident quality of life for 1 of 12 residents (Resident #19) reviewed for dignity, resulting in the potential for feelings of frustration, depression, and loss of self-worth and an overall deterioration of psychosocial well-being. Findings include: Review of facility policy, DIGNITY no date, revealed, As an extension of appropriate interactions between staff and residents, the following will be practices of the facility: NOTE: Depending on scope and severity; what appears to be a dignity issue often can be interpreted and even meet the criteria for abuse. Conversations . 2. Staff will not speak in a manner that could be interpreted as even minimally condescending . as this can be interpreted as meeting criteria for abuse .5. Staff will ask the resident directly to answer questions pertaining to the resident whenever possible and not talk over the resident as this can diminish the resident's feeling of self-worth . General appearance/CIothing/Apparel . 6. Female residents who desire not to wear supporting undergarments such as a bra, will have this care planned. These garments should always be worn unless otherwise dictated by resident choice .Care 1. Staff will maintain resident privacy during all personal care .3. Should a resident have an episode of incontinence, staff will change them upon discovery of the episode . Note: Residents are to have all aspects of their dignity maintained by staff regardless of the resident's cognitive level or ability to realize or understand what is being said or done by others. Review of a Face Sheet revealed Resident #19 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #19, with a reference date of 6/24/2020, revealed a Brief Interview for Mental Status (BIMS) score of 2 , out of a total possible score of 15, which indicated Resident #19 was severely cognitively impaired. Further review of the MDS revealed Resident #19 required extensive for toileting and transfers by 2-person physical assist. Review of Resident #19's Care Plans revealed, Focus .I have a [DIAGNOSES REDACTED].Emphasize person-centered care strategies such as: Promotion of respect, dignity, & overall well-being. Date Initiated: 04/16/2019 Revision on: 04/16/2019 . Review of Resident #19's Care Plans revealed, Focus . I am incontinent of: Bladder and Bowel rt (related to) impaired cognition and impaired mobility . Revision on: 10/11/2018 .Goals . I will be clean, dry & odor free through the next review .Revision on: 02/27/2020 Target Date: 6/11/2020 .Interventions .Administer appropriate cleansing & peri-care after each incontinent episode. Date Initiated: 10/11/2018 . I have a self care deficit and I require staff assistance (extensive to total) with ADL's to maintain the highest possible level of functioning R/t my impaired cognitive status and Dx of [MEDICAL CONDITION] .Revision on: 05/17/2019 .Goal . I will maintain my current level of ADL functioning without a significant decline unless the disease process causes unavoidable deterioration thru next review .Revision on: 02/27/2020 Target Date: 06/11/2020 .Interventions . I am a two person assist with all transfers. Date Initiated: 08/01/2019 Provide assistance with all ADL's as required per the residents need dependence: Eating, Transferring, Bed Mobility, Bathing, Dressing, Personal Hygiene, Ambulation and Personal Hygiene. Date Initiated: 10/11/2018 .Ensure proper positioning while in the bed and/or chair. Date Initiated: 10/11/2018 .Focus .I am at an increased risk for alteration in skin integrity related to increased uncontrolled constant movement r/t [MEDICAL CONDITION]'s Chorea. I have multiple discolorations on my arms, legs, torso, and head, including a discoloration to my left eye (August 2020) r/t my involuntary movements from my chronic disease process. Date Initiated: 01/03/2019 .Goals . I will not develop any skin integrity issues thru next review, unless the disease process causes unavoidable deterioration .Revision on: 02/27/2020 Target Date: 06/11/2020 .Interventions . I have padded foam to my wall, headboard, footboard, and bed frame. I also have foam between my mattress on the floor and my bed frame for safety. Date Initiated: 12/23/2019 Revision on: 08/24/2020 I like to be on a matt or mattress next to my bed. Please place a mattress next to my bed and a fall matt on the floor along the edge of the mattress when I am in bed. . Revision on: 08/24/2020 .Focus I require long term care r/t a [DIAGNOSES REDACTED]. Goals . I will be content and my needs met with collaboration of facility staff and family thru next review Date Initiated: 01/09/2019 Revision on: 02/27/2020 Target Date: 06/11/2020 .Interventions .Assist me as needed with ADLS and personal care q (each) shift to keep me clean and comfortable Date Initiated: 01/09/2019 . According to https://ghr.nlm.nih.gov/condition/[MEDICAL CONDITION]-disease , [MEDICAL CONDITION] is a progressive brain disorder that causes uncontrolled movements, emotional problems, and loss of thinking ability (cognition). Review of Resident #19's Kardex (a guide for resident care) admitted : 9/26/2018, revealed, Safety . I like to be on a matt or mattress next to my bed. Please place a mattress next to my bed and a fall matt on the floor along the edge of the mattress when am in bed .Toileting . Toilet Use - I am totally dependent on staff for toileting needs .Dressing . Dressing - I am extensive assist with dressing .Bladder and Bowel Bladder Continence - I am incontinent. Bowel Continence - I am incontinent .Mobility I am a two person assist with all transfers . During an observation and interview on 8/23/2020 at 1:00PM, Resident #19 was seen from hall through open door, lying on her left side on floor mattress next to bed. Wearing a tank top shirt, no female supporting undergarment, plain socks, and a brief. The resident's forehead and face were pushed into the bolster that was between the floor mattress and the bed frame. The resident was flailing her arms, legs, and body. As the flailing increased, she became more wedged under the bed with her right leg on top of the bed and left leg completely under the bed. No fall mat was next to the floor mattress. Brief was soiled with soft, oozing bowel movement running out of top, and leg holes of brief. Resident had fecal matter on her back from side to side, and down both legs to mid-thighs. The floor mattress sheet had a wet brown substance resembling fecal matter and yellow liquid, resembling urine, approximately the width and half the length of the resident. This was the area of the sheet the resident was lying on. The sheet had come off the other length-half of the mattress the resident was not lying on. There, the mattress also had the wet brown substance and yellow liquid. A long spongy tube, resembling a pool noodle was attached to the frame with black narrow tape, resembling electrical tape. Part of the noodle was worn away exposing the metal frame. On the noodle was the same brown substance as what was on the resident, sheet, and mattress. Both the head board and foot board edges were covered with a noodle with wide silver tape, resembling duct tape, and black narrow tape. Parts of these noodles were also worn away exposing the boards. A sheet of black foam padding had been placed between the bed frame and floor mattress by the resident's head. Certified Nursing Assistant (CNA) P entered the room behind the surveyor and stated, I am not her aide and stood next to the surveyor looking down at the resident. CNA E entered room, performed hand hygiene and donned gloves. CNA P stated while looking at resident and donning gloves, Whoever feeds her needs to clean her up because she will poop right after she eats. CNA E stepped on resident's floor mattress to remove the soiled sheets and place a clean set on without cleaning or sanitizing the mattress. Both, CNA P and CNA E tried to get Resident #19 to roll over onto her back. They attempted to bribe resident with milk. CNA P took the resident's right foot by the sock and tried to turn her onto her back by pulling on her leg and foot. Resident #19 continued to flail from side to side with increased intensity. CNA P stepped onto the floor mattress repeatedly telling the resident to turn onto her back. With Resident #19 still face-down and now on her left side, CNA P started to remove the resident's brief. Resident #19 turned onto her right side with now apparent fecal matter oozing out of her brief and onto the mattress and bed frame and noodle. CNA P pulled the brief off resident spilling more fecal matter on mattress and bed frame. CNA P again stepped onto the mattress with both feet. Resident #19 rolled onto her stomach. CNA P attempted to clean resident with resident lying on her stomach. CNA P stated, I can't see to clean her. Then stated to Resident #19, You are getting stuff on the bed frame and continued to try and clean fecal matter from resident's genital area by reaching under her. While reaching under Resident #19 to clean her, CNA P stated, That's nasty. With soiled sheet under resident, and resident still lying face down on her stomach, CNA P attempted to put a clean brief on the resident. CNA P then noticed resident had wedged herself under the bed between the mattress and bed frame. CNA P was the only staff at this time in the room with Resident #19 and surveyor. CNA P pleaded multiple times with resident to roll over onto her back. Director of Nursing (DON) B and CNA E entered the room and donned gloves. At resident's head, DON B kneeled on the soiled mattress. CNA P removed the soiled sheet from the mattress. Resident #19 had now flailed enough to have her right side, face-down, between the mattress and under the bed. DON B pleaded with resident to help move herself from under the bed. DON B, CNA P, and CNA E pulled resident from under the bed and onto the soiled mattress. CNA P put the clean brief under the resident and asked her multiple times to roll onto her back. DON B held resident's shoulders with CNA P kneeled on the soiled mattress and placed the brief on Resident #19 without cleaning resident's front peri area. CNA E stepped on the mattress and tried to put pants on Resident #19. CNA T stated, She (referring to Resident #19) needs a clean shirt on because it has pee on it. Observed Resident #19's socks speckled with fecal matter. Resident kept placing her right leg and on bed mattress with clean sheet. CNA E stated, We should put a sheet on the floor mattress; we got the main stuff off her. Without cleaning and sanitizing the mattress, CNA P placed a clean sheet over the soiled floor mattress. CNA E left the room and DON B and CNA P kneeled onto floor mattress next to Resident #19. DON B was concerned with the black foam padding and stated, It looks like it gets shredded. CNA P asked Resident #19 to Do a big roll-over and then we will let you sleep and have some chocolate milk. DON B asked Resident #19 if she needed help to roll onto her back. Resident #19 moved her right leg with jerking motions onto the bed mattress while lying on her stomach and her left leg got wedged under the bed. At this time, CNA Q entered the room and assisted DON B with putting a fitted sheet on floor mattress without cleaning or sanitizing it. DON B then removed Resident #19's tank top with some struggling. CNA Q placed a hospital gown on Resident #19 before noticing it did not have strings on it. CNA Q left the room to get another gown. CNA P entered room with clean gown, and DON B and CNA Q got it on Resident #19. Resident #19 was now flailing and rolling back and forth with increased intensity. DON B and all CNAs exited the room, leaving Resident #19 sitting on floor mattress alone. Resident #19 rolled onto her left side. Her gown began to come off from around her neck. Observed on 08/24/20 at 12:16 PM Resident # 19 was seen from hall through open door, on knees leaning on bed wearing only a short-sleeved cotton shirt and a brief. The brief was saturated with urine and fecal matter, drooping low enough to see from left to right through the leg holes. CNA D was assisting to feed resident. CNA D stated, (Resident # 19) usually has a bowel movement right after she eats and that is when she will get cleaned up. The staff that feeds her will clean her up after feeding her. I knew I'd have to clean her up after I fed her, so I waited to change her. During an interview on 8/25/2020 at 10:56 AM, CNA P stated, Peri-care with (Resident #19) you can usually roll her on her back and clean front to back. Because you are to clean from front to back. After I clean the front, I go clean her back (bottom). The CNAs are responsible for cleaning up the mats, mattresses, and walls. The urine and fecal matter should be cleaned up right away and by the aides. I put the sheet on the floor mattress because I don't want her lying on that dirty mattress that people step on. She prefers to lay on that mattress and people step and walk on it and she should not have to lay on that. A floor mat should be placed on the floor next to the mattress because (Resident #19) moves around a lot. During an interview on 8/25/2020 at 11:25 AM, DON B stated, Peri-care should not be done with the resident lying on their stomach. One reason is you cannot see if everything is clean and to do skin an evaluation. When fecal matter or urine is on the mattress it should be cleaned at that time and the aides are supposed to clean it. Then they notify housekeeping to come sanitize. The pool noodles and black foam should be cleaned at the time right when it is soiled and then staff should contact housekeeping to sanitize it. When you (referring to surveyor) were observing yesterday, I was hoping CNA P and CNA E knew what they were doing, and they did not. It was a disaster during the care. Dignity and peri-care were all done wrong. Review of the Psychosocial Outcomes Guide revealed that it is appropriate for the use the reasonable person concept to determine a resident's psychosocial outcome, which may not be readily determined when a resident may not be able to express their feelings, there is no discernable response, or when circumstances may not permit the direct evaluation of the resident's psychosocial outcome. Such circumstances may include, but are not limited to .cognitive impairments, or insufficient documentation by the facility; or when a resident's reaction to a deficient practice is markedly incongruent (or different) with the level of reaction a reasonable person would have to the deficient practice. Using the reasonable person concept, Resident #19 would not have wanted to be partially dressed, exposed, and with fecal matter on her and her mattress, and provided incontinence care in a manner that was dehumanizing and did not follow a person-centered care plan. Resident #19 was unable to voice evidence of harm, but it is reasonable to assume that Resident #19 would experience embarrassment, anxiety and avoidance due to the possibility of being vigorously cleaned while lying on her stomach on a mattress placed on the floor with staff walking on it, causing embarrassment and humiliation when cares were performed; potentially diminishing her level of participation in activities of daily living (ADL) which could increase the potential for skin breakdown. Resident #19 would likely have ongoing feelings of dehumanization if she had not been cognitively impaired.

This citation pertains to intake number MI 860 Based on interview and record review, the facility failed to have two staff members assist during a transfer for 1 of 8 (Resident #106) residents reviewed for falls, resulting in Resident #106 sustaining a fracture. Findings include: Review of a Face Sheet revealed Resident #106 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #106, with a reference date of 3/21/2019 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #106 was severely cognitively impaired. Resident #106 needs extensive assistance while transferring, toileting, and activities of daily living (ADL's). Review of Resident # 106's care plan revealed, Focus, I have a self-care deficit and require assistance with ADL's to maintain the highest level of functioning as evidenced by the following limitations and potential contributing factors: Impaired cognitive status . Date Initiated: 09/12/2017 Revision on: 01/02/2019 Goal, I will maintain my current level of ADL functioning without a significant decline unless the disease process causes unavoidable deterioration. Date Initiated: 09/12/2017 Revision on: 01/02/2019 Target Date: 03/20/2019. Interventions, Two person assist with transfers using a hoyer lift. Date Initiated: 09/12/2019 Revision on: 03/31/2019. Review of Resident #106's Kardex revealed, Transferring, .I use a sit to stand lift and an assist of 2 staff members with transfers. Two-person assist with transfers using a sit to stand lift. Toileting, Toilet use- I require extensive assist for toileting, 2 staff members. An interview on 6/27/2019 at 9:45 AM, certified nursing assistant (CNA) O indicated on the morning of 2/21/2019, he was in Resident #106's room by himself and transferred her from the bed to her wheelchair with ease. CNA O indicated when he went to transfer Resident #106 from her wheelchair to the toilet is when he noticed one of Resident #106's legs were weak. It was at this point CNA O indicated he had to use most of his strength to assist Resident #106 and decided to get help to transfer Resident #106 onto the toilet safely. CNA O indicated he was let go from his position at the facility because he failed to follow protocol during a transfer that resulted in a fracture of Resident #106's leg. Review of the facility investigation revealed, Investigations summary: Resident was transferred by one CNA when care guide stated two CNA's. Resident did not fall to ground but was lowered to toilet. Unaware of resident foot was twisted or turned improperly upon transfer to toilet when lowered until help could be retrieved for assistance. Due to facility policy of failing to follow the care guide when transferring resident CNA O was terminated for employment. Staff has been in serviced on knowing and following residents care guide. An interview on 6/27/2019 at 11:09 AM, nursing home administrator (NHA) indicated the fracture of Resident #106's leg likely occurred when CNA O transferred Resident #106 from the wheelchair to the toilet. Review of progress notes dated 2/21/2019 at 7:28 PM written by LPN F revealed, At roughly 1900 cna found resident ankle/foot/lower right leg bruised and swollen. tender to touch. decrease ROM (range of motion). MD (medical doctor) and DON (director of nursing) notified. Her (resident #106) mother is aware as she is her roommate. Stat (immediate) x-ray ordered and just took x-rays. now waiting for results. Resident given tylenol 325mg 2 tabs per MD order. Will continue to observe for signs of pain/discomfort. Review of radiology report dated 2/22/2019 revealed, Findings: Diffuse osteopenia. Undisplaced bimalleolar (ankle) fracture. Ankle mortise appears intact. Soft tissue swelling. Calcaneal spurring. Calcification in the Achilles tendon. Review of document, In-Service Attendance Record: Signature Sheet, dated 4/31/2019, revealed the following topics were covered: . correct transfers. The form was signed by 1 RN, 3 LPN's and 12 CNA's. Only 16 of the 34 nursing staff had received education regarding correctly transfering a resident.

This citation has 2 deficiency practice statements, A and B Deficiency Practice Statement A Based on observation, interview, and record review the facility failed to perform surveillance, identify, investigate and implement measures to prevent a gastro-intestinal illness outbreak among staff and from 5 of 20 sampled residents (Resident #17, Resident #54, Resident #5, Resident #46, and Resident #30) reviewed for infection control, resulting in an Immediate Jeopardy placing all residents with the potential for gastro-intestinal illness. Findings include: Review of the Policy Infection Surveillance dated 11/18/16 revealed the policy was A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. The policy further revealed monthly time periods will be used for capturing and reporting data. Data to show comparisons over time periods will be monitored for trends and Employee, volunteer, and contract employee infections will be tracked, as appropriate such as influenza or gastrointestinal infection outbreaks. Review of the Policy Infection Reporting dated 11/18/16 revealed It is the policy of htis facility to timely report possible incidents of communicable disease or infections to appropriate personnel or authorities and Any staff member, resident, family member, or visitor may report changes in a resident's condition to the resident's nurse or physician when a possible infection is suspected. Review of the Policy Surveillance of Work Related Illness un-dated revealed Surveillance is a systemic method of collecting, consolidating and analyzing data concerning the increased risk of transmission of and/or acquiring a work related illness and Information is gathered, monitored and tracked throughout the month .information is reviewed by the infection control coordinator for trend identification that may require out break investigation. In an interview on 03/22/18 at 12:05 PM, Director of Nursing (DON) B was asked by the surveyor if she had any increased surveillance or identified any trends in the facility at this time. DON B stated, I have not identified any trend right now (indicated no surveillance, monitoring or tracking at this time). DON B was asked what trends would be identified for a potential outbreak in the facility. DON B stated, she would be looking for anything on the same unit, trends, for example a diarrhea on the same unit and to map all infections. Review of the Employee Call Off/Reported Illness Form revealed, on 3/17/18 at 8:00 P.M., Dietary Aide HH called in for his shift for complained of stomach pains and vomiting. In an interview on 03/23/18 at 02:46 PM, Director of Nursing (DON) B was asked about the staff call in on 3/17/18. DON B stated Dietary Aide (DA) HH had called in for diarrhea and vomiting. DON B was asked by the surveyor if one staff or resident with gastrointestinal illness could be considered an outbreak. DON B stated, no, one case is not considered an outbreak. DON B was asked by the surveyor when she became aware of the staff illness. DON B stated, 2 days later because that (3/17/18) was a Saturday, it was discussed on Monday (3/19/18) morning. DON B was asked by the surveyor if any increased surveillance or isolation was performed by herself or facility staff to monitor gastrointestinal illness of staff or residents on 3/17/18. DON B stated, no, none of the residents were ill. Review of the Health Care Worker Absence Tracking Log revealed, on 3/18/18 Certified Nursing Assistant II called in for her shift for vomiting. In an interview on 03/23/18 10:42 AM, DON B was asked about staff Certified Nurse Aide (CNA) II call in on 3/18/18. DON B stated CNA II called in for vomiting. DON B was asked by the surveyor if any increased surveillance or isolation was implemented for any residents. DON B stated, No, we didn't have anything, no residents that displayed any signs or symptoms (indicated no surveillance of staff). Resident #17: Review of the Face Sheet revealed Resident #17 was a [AGE] year old male admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the MDS dated [DATE] revealed a BIMS score of 15 out of 15 which indicated he was cognitively intact. In an interview on 3/22/18 at 02:10 P.M., LPN O reported that Resident #17 was exhibiting symptoms of a gastrointestinal illness earlier that week. Review of the Nurses Notes dated 3/23/18 at 10:19 PM revealed Resident #17 came down the hall in his w/c and stated, well, I just threw up again. In an interview on 03/23/18 10:42 AM, (DON) B stated, (Resident #17) had diarrhea and vomiting on 3/19/18. DON B was asked why no isolation precautions or increased surveillance was performed. DON B stated, why not? There were not (any precautions, isolation or surveillance), I can't answer that .I was not aware of this on the 19th and Of course I would want to know about that, because I would want to set up precautions for him, contact precautions (contact isolation to prevent the spread of potential gastrointestinal outbreak). DON B was not aware of the emesis and diarrhea by Resident #54 on 3/19/18. Review of the Nurses Notes, physician's orders [REDACTED].#17. Resident #54: Review of the Face Sheet revealed Resident #54 was a [AGE] year old male admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #54 had a brief interview for mental status (BIMS) score of 13 out of 15 which indicated he was cognitively intact. Review of the Nurses Notes dated 3/19/18 at 03:12 PM revealed during lunch, he vomited when almost finished with lunch. Back in his room he had diarrhea (2X). Review of the Nurses Notes, physician's orders [REDACTED].#54. Review of the Employee Call Off/Reported Illness Form revealed, on 3/22/18 at 3:00 A.M., Certified Nursing Assistant Q called in for her shift for coughing and emesis (vomiting). Review of the Employee Call Off/Reported Illness Form revealed, on 3/22/18 at 3:30 P.M., Dietary Aide BBB called in for her shift for Vomited on the Bus. Review of the Employee Call Off/Reported Illness Form revealed, on 3/22/18 at 5:15 (no A.M. or P.M. indicated), Certified Nursing Assistant ZZ called in for her shift for Diarrhea and emesis. In an interview on 3/22/18 at 11:54 Dietary Manager (DM) D reported that the night shift cook was complaining of abdominal pain as he ended his shift the morning of 3/22/18. In an interview on 3/22/18 at 12:05 P.M., Certified Nursing Assistant (CAN) T (also responsible for scheduling) reported that CNA ZZ and CNA Q called in sick with complaints of diarrhea and vomiting. In an interview on 03/22/18 at 01:54 PM, DON B , I have 2 staff with vomiting, and one previous to the weekend. DON B was asked by the surveyor if any increased surveillance or contact isolation was performed to further prevent a gastrointestinal outbreak. DON B stated, It does not meet the criteria, (Resident #18) had one diarrhea and (Resident #5) she had one vomiting and one diarrhea and I had one person over the weekend (Resident #54) who had one vomiting and one diarrhea but he's not on the same hall as the other 2 residents. In an interview on 03/23/18 10:42 AM, (DON) B was asked by the surveyor about staff call in on 3/19/18. DON B stated, .(CNA T) went home that day, she was nauseated, she was off the next day. DON B was asked by the surveyor if any isolation precautions, increased surveillance or monitoring of staff and residents for gastrointestinal outbreak was done. DON B stated, No, there were not. In an interview on 03/23/18 at 08:30 A.M., DON B reported that she had not started the Employee Illness Tracking Tool to identify which staff members were ill and what units they worked. DON B reported that she did not place Dietary Aide HH on the tracking tool because he wasn't symptomatic. He wasn't throwing up and he didn't have any symptoms that could be contagious. DON B reported that she was tracking vomiting and diarrhea and not abdominal pain. In an interview on 3/23/18 at 9:41 A.M., Administrator A reported that the health department identified the Gastrointestinal Illness as a cluster with no pattern. Administrator A reported it is difficult to determine which staff member spread the illness because the CNA's work all the units in order to assist each other with resident care. Administrator A provided a list of Residents exhibiting symptoms and the date the symptoms began. (Resident #162 symptoms began 3/23, Resident #5 symptoms began 3/22, Resident #43 symptoms began 3/22, Resident #18 symptoms began 3/22, Resident #17 symptoms began 3/19, and Resident #54 symptoms began 3/18). In an interview on 3/23/18 at 10:42 AM, DON B was asked by the surveyor regarding staff call ins for 3/22/18. DON B stated, we had 3 staff call in diarrhea and vomiting and I had 2 early morning and 2 in the afternoon that had diarrhea and diarrhea and vomiting (Resident #5, Resident #43 and Resident #18). DON B stated, contact precautions have been placed. DON B was asked by the surveyor why contact precautions were not placed before this afternoon. DON B stated, It didn't get reported to me, it was in the afternoon (indicated a delay in report gastrointestinal outbreak). Resident #5: Review of the Face Sheet revealed Resident #5 was [AGE] year old female admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the MDS dated [DATE] revealed Resident #5 had a BIMS score of 11 out of 15 which indicated she had moderately impaired cognition. Review of the Nurses Notes dated 3/22/18 at 07:35 AM revealed Resident #5 .vomited moderate amount of undigested sour food, also had loose stool x 1 . During an interview on 03/22/18 at 11:38 AM Housekeeper (Hsk) G indicted the 200 & 300 had a resident over the last weekend with vomiting and diarrhea, this resident vomited in the dining room after breakfast. During an interview on 03/22/18 at 11:57 AM Hsk H indicated another housekeeper called in sick with vomiting and diarrhea last weekend. During an interview on 03/23/18 at 10:32 AM DON B indicated she was unaware if Health Care Worker Absence Tracking Logs were completed prior to (MONTH) (YEAR), DON B stated I just started in March, I am not sure who was responsible for tracking staff absences. Review of the facility infection control tracking book, no Health Care Worker Absence Tracking Logs were noted in the book. During an interview on 03/23/18 at 10:41 AM Activity Director (AD) I indicated she keeps track of her activity staff sick/call ins by using an individual form. AD I indicted the Interdisciplinary Team (IDT) meet every morning and each department discusses the call offs, but not always are symptoms discussed. During an interview on 03/23/18 at 2:08 PM DON B indicated she was a consultant for the facility prior to (MONTH) (YEAR), since (MONTH) (YEAR). DON 'B indicated she took DON role as of (MONTH) (YEAR). DON B indicated she was in charge of the infection control program since (MONTH) (YEAR). DON B indicated morning meetings management discuss staff call in's. DON B indicated she does not record if staff call in for car breaking down or day care issues, the form is strictly for health concerns. Prior to (MONTH) 1st (YEAR) DON B indicated she was not doing the staff call in aspect of Infection Control. During an observation on 03/28/18 at 09:37 AM Activity Director (AD) I exited her office, walking toward the dining room touching her face, near her mouth. AD I proceeding into dining room, touched her face under her nose, and then began to move items from a dining table, set up a table cloth. AD I then walked out of dining room, down to get a cart , bringing the cart back into the dining room. AD I did not wash her hands, nor did she use hand sanitizer during this time. During an interview on 03/28/18 at 09:39 AM with AD I indicated she was unaware of her touching her face. ADI indicated she was trained along with all staff about hand washing last week due to [MEDICAL CONDITION] in the facility. During an observation 03/29/18 at 08:48 AM Medical Director (MD) CC was seated at the nurses station, while documenting, and signing orders in resident charts, MD CC touched his face numerous times, scratching his mustache. Once MD CC finished documentation, he proceeded to place the documents on the counter of the nurse station. MD CC dropped a paperclip onto the floor, picked it up, placed it on the nurses station desk. MD CC did not use hand sanitizer or wash hands after touching the floor. MD CC took left hand scratching his nose, then proceeded to grab his nose between his 2 left hand fingers and squeeze the tip, and rub his nose with bare hands. MD CC did not use hand sanitizer, or wash his hands any time during this observation. MD CCcontinued to document and sign paperwork at the nurses station. During an observation on 03/29/18 at 09:50 AM observed MD CC exit the bathroom, walk over to hang the key up, remove hand sanitizer from his pocket and apply to both hands. MD CC then immediately touched his nose, sat down at the nurses desk, scratching his neck area, and under his nose on his mustache. During an interview on 03/29/18 at 09:59 AM MD CC indicated he did not follow policy and procedure with proper hang hygiene, MD CC indicated proper hand hygiene should have been used after each time he touched his face, as well as picking up the paperclip from the floor. During an observation on 03/29/18 at 02:07 PM room [ROOM NUMBER]-1 observed room to be isolation room. Bed-1 call light handle with button visibly soiled with a scant amount of a reddish dried substance, the remote control for the bed was soiled with a reddish substance, appeared to be a small about of emesis from the resident in bed 1. room [ROOM NUMBER] bed -1 bedside table was visibly soiled with dried stuck on foods. During an observation on 03/30/18 at 10:02 AM from unit 200 hallway, Resident # 46 was approaching the hall from inside her bedroom. Resident #46 projectile vomited across the entryway of her room. Resident #46 stated they just took me out of isolation. Resident #46 In an observation on 3/30/18 at 10:05 A.M., Resident #46 vomited in her room. The area of vomit was in the entryway of her room. A staff member covered the vomit with a blanket and pushed it into Resident #46's bathroom. There were streaks of vomit left in the entryway of Resident #46's room. At that time a staff member reported that she was just moved back from isolation that morning. The staff member reported that she would be brought back down to the 500 Hall to be placed back in isolation. Resident #30 Review of a Face Sheet revealed Resident #30 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #30,with a reference date of 1/17/18 revealed a Brief Interview for Mental Status (BIMS) score of 99, out of a total possible score of 15, which indicated Resident #30 was severely cognitively impaired. Review of the MDS Function Status revealed that Resident #30 required total assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. In an observation on 03/28/18 at 10:04 A.M., Resident #30 was in bed. Certified Nursing Assistants (CNA) ZZ and J were performing incontinence care. Resident #30 had strong smelling liquid stool in her brief. Resident #30 stated, I might be hungry because my stomach is cramping. In an interview on 3/28/18 at 10:51 A.M., Licensed Practical Nurse (LPN) O reported that CNA's ZZ and J did not report to LPN O that Resident #30 had loose stool. In an interview on 3/28/18 at 10:52 A.M., MDS Coordinator C reported that the resident normally has loose stool and did not feel that this was a part of the outbreak in the facility. In an interview on 03/28/18 at 11:50 A.M. CNA J reported that Resident #30 has loose stool after each meal. In an observation on 03/28/18 at 11:53 A.M., Resident #30 was crying and reported stomach pains/cramps. Resident #30 was guarding her stomach (indicating pain). At this time Resident #30 had another episode of strong smelling liquid stool. This surveyor asked Resident #30 where her stomach hurt and she pointed across her whole abdomen. In an interview on 03/28/18 at 12:02 P.M., LPN O entered room to apply lotion to Resident #30's buttocks. CNAs ZZ and J did not report to LPN O that Resident #30 had abdominal pain or another episode of liquid stool. LPN O applied the lotion to Resident #30's buttocks, removed her gloves, exited the room without using sanitizer or washing hands, and went to the 300 Unit Medication Cart. LPN O then continued to the Dining Room area without performing any hand hygiene. In an observation on 03/28/18 at 12:02 P.M., Resident #30's brief was changed and she was transferred from her bed to the GeriChair and brought down to the dining room at 12:13 P.M. In an observation on 3/28/18 at 01:07 P.M., Resident #30 was up in GeriChair in the dining room. In an interview on 03/28/18 at 02:09 P.M., Director of Nursing (DON) B reported that Resident #30 has a [DIAGNOSES REDACTED]. DON B was shown Resident #30's [DIAGNOSES REDACTED]. DON B reported this was a false diagnosis. DON B reported that Resident #30 is experiencing abdominal pain due to her [DIAGNOSES REDACTED].#30's Care Plan for Chronic Abdominal Pain and Chronic Loose Stools. The Care Plans for Chronic Abdominal Pain and Chronic Loose Stools were not received by the end of survey on 3/30/18. DON B reported that she will place Resident #30 in Isolation. Review of Resident #30's Care Plans revealed no Care Plan for Chronic Abdominal Pain and Chronic Loose Stools In an observation on 03/28/18 at 03:07 P.M., Resident #30 was in isolation and was moved to room [ROOM NUMBER]-2. In an observation and interview on 3/28/18 at 5:23 P.M., Resident #30 was observed loudly yelling out and crying. LPN VV stated that Resident #30 only cries out like that when she is in pain. Resident #30 was observed holding her abdomen and crying. On 03/23/18 at 03:40PM, NHA A was notified of the immediate jeopardy that began on 3/17/18 and was identified on 3/22/18 as a result of the facilities failure to identify, monitor and provide surveillance for a gastrointestinal outbreak. On 3/29/18, the following was verified to remove the immediate jeopardy. 1. As of 03/23/18 through assessment and monitoring the Director of Nursing/design has identified 9 residents out of 53 that were placed in contact precautions and treated symptomatically. All residents that have been symptomatic with Gastroenteritis have been placed in contact precautions. 2. As of 0f 03/24/2018 through assessment and monitoring the Director of Nursing/design has identified 10 residents out of 56 that were in contact precautions and treated symptomatically. All residents that have been symptomatic with Gastroenteritis have been placed in contact precautions. 3. As of 03/25/2018 through assessment and monitoring the Director of Nursing/design has identified 11 residents out of 56 that were in contact precautions and treated symptomatically. All residents that have been symptomatic with Gastroenteritis have been placed in contact precautions 4. As of 03/26/2018 through assessment and monitoring the Director of Nursing/design has identified 13 residents out of 57 that were in contact precautions and treated symptomatically. All residents that have been symtomatic with Gastroenteritis have been placed on contact precautions. 5. All residents that have been symptomatic with Gastroenteritis have been placed in contact precautions. MDs and families have been notified and orders for symptom relief have been instituted as of 03/23/2018 at 2PM by the Director of Nursing. 6. County Health Department has been notified on 03/23/2018 and information for education of the staff and cleaning have been received on 03/24/2018. Director of Nursing spoke with (Health Department Worker) from County Health Department. Recommendations have been made by Epidemiologist to test stool of 6 residents for Norovirus starting 03/24/2018. Previous residents that are asymptomatic can be tested even if no diarrhea is currently present. Collection will be made from the facility on 03/27/2018 through the Director of Nursing 7. Director of Nursing completed follow up call with (Health Department Worker) at County Health Department with information of additional sick residents and staff on 03/26/2018 8. Director of Nursing completed follow up call with (Health Department Worker) at County Health Department with information of additional sick residents and staff on 03/27/2018 9. Cleaning recommendations have been made from County Health Department for the housekeeping department to the Administrator and Director of Nursing effective 03/23/2018. Cleaning of high touch areas such as facets, railings, doorknobs, and toilets/skin basin were started on 03/22/2017 by the housekeeping department. Ongoing cleaning by housekeeping department for all high touch areas two times per day is being completed 10. The Facility policy and procedure was reviewed and updated according to County Health Department and CDC recommendations on 03/24/2017 by the Director of Nursing and updated 11. All staff are being inserviced on the identification of a Gastroenteritis including identification, treatment, communication of s/s of Gastroenteritis and Hand washing from the Director of Nursing/designee and putting contact precautions in place starting 03/23/2018 12. Any staff currently in orientation is being educated on Gastroenteritis, transmission- based precautions, and hand hygiene by Director of Nursing/ designee during their orientation starting the first orientation class after 03/24/2018 13. All staff are being re-inserviced on Handwashing and Hand Hygeine Procedures and transmission-based precautions starting 4PM on Friday by the Director of Nursing /designee. Return demonstrations are being implemented 3/24/2018 by the Director of Nursing/Designee. 14. CDC has been contacted for recommendations on Gastroenteritis by (Administrator) at 4PM on 03/24/2018. Director of Nursing planned with CDC procedures for containment and prevention of transmission with CDC on 03/24/2018 at 8PM. CDC did not recommend testing of water on 03/24/2018 to the Director of Nursing 15. Administrator Consulted with APIC on 4PM on 03/24/2017 and received recommendation for consultant to review develop and implement infection control program with the facility. 16. On 03/24/2018, an infection control nurse was hired by the Director of Nursing and Administrator at 6PM, to provide education and training of staff regarding infection control procedure. New Gastroenteritis Policy was reviewed with the infection control nurse including hand washing procedure and transmission -based precautions. 17. Restructuring employee call off report for facility call offs to include surveillance of illness by the facility Administrator on 03/27/2018. Any infection surveillance will be reported by the HR director to the Infection Control Nurse to ensure appropriate tracking. 18. Implement Stand Up meetings to ensure that information is communicated from shift to shift and floor staff to nursing administration starting 03/27/2018 by the Director of Nursing 19. Director of Nursing is monitoring 24- hour report daily to ensure that any resident with signs and symptoms of Gastroenteritis is being placed in transmission -based precautions at the onset of the illness starting 03/23/2018. 20. Director of Nursing is monitoring residents on transmission- based precautions for signs and symptoms of Gastroenteritis until residents are 72 hours symptom free from illness starting 03/24/2018 21. On 03/26/2018 at 5 PM, Director of Nursing spoke with (Health Department Worker) at the County Health Department and provided update from the week end of the Status of Gastroenteritis within the facility. No new recommendations were made from the Health Department 22. On 03/27/2018 at 2PM, Director of Nursing spoke with (Health Department Worker) at the County Health department and provided update from the previous day of the Status of Gastroenteritis within the facility. No new recommendations were made. Stool samples were picked up. 23. On 03/28/2018 at 1PM, Director of Nursing spoke with the Epidemiologist from Berrien County Health Department and created Noro-Like Illness Outbreak Report providing update on resident and staff illness. No results for the 6 stool samples have been received. 24. On 03/28/2018 at 3pm, MD was notified of loose stools for R30. New orders were received for Contact Precautions. Resident was put into Contact Precautions by the Director of Nursing. 25. On 03/28/2018 at 6PM, all interviewable residents were interviewed related to experiencing any signs or symptoms of Gastroenteritis by Director of Nursing/Designee. Nursing staff were interviewed related to any residents having signs or symtoms of Gastroenteritis. Any residents with signs or symptoms of diarrhea, vomiting or nausea has been placed into contact precautions by Director of Nursing/Designee 26. On 03/28/2018 at 7PM, all facility staff were re-inserviced related to reporting signs and symptoms of Gastroenteritis and Hand Hygiene and the updated Infection Control Policy by the Director of Nursing Designee. In servicing is ongoing every shift through completion. No staff will be allowed to work without receiving the education. 27. On 03/28/2018, at 10PM Administrator and Director of Nursing discussed with the (Health Department Worker), Epidemiologist at the Health Department, the new residents that have been placed in contact precautions. 28. On 03/29/2018 at 10 AM, Director of Nursing and Administrator followed up with Health Department and (Health Department Worker) Epidemiologist for the region of the State of Michigan. Per both epidemiologists' recommendations, the facility is to continue Contact Precautions for ill residents which will continue for 72 hours after last symptom, hand washing when contact with ill residents, continued cleaning of high touch areas (such as rails, doorknobs, faucets, sinks), and staff members to remain off work until 48 hours after symptoms resolve. No results have been received from the 6 stool specimens that were submitted to the Health Department. 29. On 03/28/2018 at 6PM Director of Nursing and Department Managers randomly monitored hand hygiene and use personal protective equipment. Monitoring is on going to ensure that all staff are washing hands and using personal protective equipment appropriately. 30. On 03/29/2018, Director of Nursing Spoke with the (Health Department Worker) from the Health Department related to an update on Line List. Recommendations were given to continue same course of action and to look at using Styrofoam and plastic dinner ware for all meals. As of 03/29/2018, Administrator and Food Service Supervisor initiated the use of Styrofoam and plastic dinner ware for all meals. 31. On 3/30/18, Resident #46 was placed back into isolation. Although the immediate jeopardy was removed on 3/30/18, the facility remained out of compliance at a scope of widespread and severity of no actual harm with the potential for more than minimal harm due to not all staff had received education and the State Agency had not verified sustained compliance. Deficiency Practice Statement B Based on observation, interview, and record review the facility failed to maintain follow the standards for infection control during a dressing change for 1 of 1 sampled residents (#58), reviewed for wound care, from a total sample of 20 residents, resulting in the potential for cross contamination, increased damage to skin, pain and harm. Findings include: Review of a Face Sheet revealed Resident # 58 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #58, with a reference date of 1/151/18, revealed a Brief Interview for Mental Status (BIMS) score of 10, out of a total possible score of 15, which indicated Resident #58 cognition was moderately impaired. Review of the MDS Function Status reflected Resident # 58 required extensive assistance of one staff member for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of the Physician order [REDACTED]. During an interview and observation on 03/29/18 at 1:31 PM, Licensed Practical Nurse (LPN) PP and CNA YY cleaned hands and gloved, Resident #58 asked CNA YY to be careful when moving brief between her legs it was sore, the over the bed table was noted to have brown smears on the table top, LPN PP covered the spills with paper towels, and placed his supplies. CNA YY assisted to roll Resident #58 on her left side, loosen her clean brief, LPN PP used normal saline to wet a 4 x 4 gauze pad and wiped from approximately 4-6 inches around the outside wiping toward the wound center to clean area with a 4 x 4 normal saline then patted dry. LPN PP cleaned his hands, put on clean gloves, then put triad on the skin by the mid buttock which appeared a irregular quarter size area involving the underlying tissue. LPN PP reported that he had not worked with Resident #58 in a few weeks and did not know if there were any other areas of concern. At the time of exit a Policy and Procedure for Wound Care was not presented to survey team. Review of Potter and Perry Fundamental of Nursing 9th edition reflected, Repositioning reduces the duration and magnitude of pressure over vulnerable areas of the body and contributes to comfort, hygiene, dignity and functional ability The presence of skin damage from moisture increases the risk of pressure ulceration. Rubbing or massaging areas of nonblanching [DIAGNOSES REDACTED] causes further tissue damage .After applying a solution to sterile gauze, clean away from the wound. Never use the same piece of gauze to clean across an incision or wound twice.

Based on observation, interview and record review, the facility failed to provide care per professional standards of practice to prevent the development of an avoidable pressure ulcer for 2 of 15 sampled residents (Resident #30 and #58) reviewed for alterations in skin integrity, from a total sample of 20 Residents, resulting in the development of an avoidable pressure ulcer and the potential for delaying wound healing, infection, and overall deterioration in health status. Findings include: Review of the Facility Policy and Procedure, Policy and Procedure for the Treatment and Prevention of Skin Breakdown last revised on 11/17 revealed, It is the policy to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for ulcers according to industry standards of care .keep local areas of skin clean, dry and free of body wastes, perspiration, and wound drainage. Establish an individualized turning and repositioning schedule if the resident is immobile. While in bed not to exceed 2 hours and while in sitting position and/or HOB (head of bed) is greater than 30 degrees not to exceed 1 hour .keep HOB at or below 30 degrees (unless medically contraindicated) .Lift do not slide resident ie; use of lift sheet. Use assistive devices to reduce friction and facilitate resident movement ) ie; turning sheets, trapeze, grab bars, patient lift, etc.) .assess and treat incontinence. Apply protective ointments/products to the skin to counteract effects of excessive moisture on the skin. Review of the Facility Policy and Procedure, Repositioning Guidelines last revised on 4/10/10 revealed, The facility developed specific guidelines for turning and repositioning residents based on individuality identified needs. Guidelines for positioning may include, but are not limited to, the following: Choose a turn schedule, odd or even numbers. Instruct chair bound residents to shift body weight evey one to two hours depending on resident needs if capable. Post individual turn and reposition schedule on the resident's kardex. Validate turn schedules are followed as clinically indicated. Review of Fundamentals of Nursing (Potter and Perry) 8th edition revealed, Positioning interventions reduce pressure and shearing force to the skin. Elevating the head of the bed to 30 degrees or less decreases the chance of pressure ulcer development from shearing forces .patient's need repositioning on a schedule of at least every 2 hours .Some patients are able to sit in a chair. Make sure to limit the total amount of time they sit to 2 hours or less. Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. (2014). Fundamentals of Nursing (8th ed.). St. Louis: Mosby. p. 1196-1197 Resident #30 Review of a Face Sheet revealed Resident #30 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #30,with a reference date of 1/17/18 revealed a Brief Interview for Mental Status (BIMS) score of 99, out of a total possible score of 15, which indicated Resident #30 was severely cognitively impaired. Review of the MDS Function Status revealed that Resident #30 required total assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. In an observation on 03/22/18 at 02:12 P.M., Resident #30 was transferred from her GeriChair (geriatric chair/medical recliner) to her bed using a hoyer lift (used for transfers when a person requires extensive assistance with transfers). When Resident #30 was transferred to bed her GeriChair was visibly saturated with strong smelling urine. Resident #10's sweatpants were saturated with strong smelling urine. The urine on her sweatpants covered the entirety of her buttocks to just above her posterior knee area. The two CNA's assisting the resident changed her brief that was heavily saturated with strong smelling urine. At that time it was observed that Resident #30 had skin breakdown/pressure ulcer. Resident #30's entire buttocks was a deep red in color. Resident #30's right buttock near the intergluteal cleft, approximately half way between the sacrum and perineum had an open area approximately the size of two pencil erasers next to each other horizontally. It presented as a shallow open ulcer with a red/pink wound bed without slough (partial thickness loss of dermis). The depth of the wound appeared to be the thickness of a dime. Review of Resident #30's Kardex (quick summary of an individual Resident's needs) revealed, Skin Integrity- 12/20/17 Foam wedge to offload from coccyx (tailbone) while in bed. 3/14/18: Cleanse and apply cream provided by Hospice to Right buttock area BID and PRN. Offload buttock, lay resident down after lunch per hospice request. Resident #30 did not have a turn and reposition schedule on the Kardex. Review of Resident #30's Skin Assessment Progress Note revealed that on 3/21/17 at 3:16 P.M., MDS Coordinator C documented, area to buttocks still reddened Spoke to (Hospice RN) on 3/20/18, she was to complete skin assessment, no changes to orders for care. Continue to monitor. there was no notation of an open area. Review of Resident #30's Skin Assessment Progress Notes revealed that on 3/21/18 at 7:26 P.M. new open area on R Buttock reported by (CNA) for Hospice during bed bath. Area measured. Hospice notified, use previous skin prevention cream supplied by hospice for this area. Offload from R side while in bed, lay down in afternoons so resident is not up in chair for long periods of time. Continue to monitor. In an observation on 03/28/18 at 08:11 A.M., Resident #30 was in sitting up in her GeriChair in the dining room. In an observation on 03/28/18 08:54 at A.M., Resident #30 was in bed lying on her back. There was a repositioning wedge underneath her right side and left side and a pillow under her knees. In an observation on 03/28/18 09:15 at A.M., Resident #30 was in bed lying on her back. There was a repositioning wedge underneath her right side and left side and a pillow under her knees. In an observation on 03/28/18 09:52 at A.M., Resident #30 was in bed lying on her back. There was a repositioning wedge underneath her right side and left side and a pillow under her knees. In an observation on 03/28/18 10:04 at A.M., Resident #30 was in bed lying on her back. There was a repositioning wedge underneath her right side and left side and a pillow under her knees. Requested to observe next wound assessment. MDS Coordinator C reported she was available to complete a wound assessment at this time. After the assessment Resident #30 was positioned on her back with the repositioning wedge underneath her right side and left side and a pillow under her knees In an observation on 03/28/18 10:47 at A.M., Resident #30 was in bed lying on her back. There was a repositioning wedge underneath her right side and left side and a pillow under her knees In a interview on 03/28/18 at 11:50 A.M., Licensed Practical Nurse (LPN) GG reported that repositioning wedges should be used to reposition resident from one side to another. LPN GG reported that the wedges should not be used under each side at the same time. In an observation on 03/28/18 at 11:49 A.M., Resident #30 was in bed lying on her back. There was a repositioning wedge underneath her right side and left side and a pillow under her knees In an observation on 03/28/18 at 12:02 P.M., Resident #30's brief was changed and she was transferred from her bed to the GeriChair. In an observation on 3/28/18 at 01:07 P.M., Resident #30 was up in GeriChair (Sitting higher than 30 degrees) in the dining room. In an observation on 3/28/18 at 02:08 P.M., Resident #30 was up in GeriChair (Sitting higher than 30 degrees) in the dining room. CNA J reported that Resident #30 has been up in the GeriChair since she was transferred to it at 12:02 P.M. In an interview on 03/28/18 at 02:09 P.M. Director of Nursing (DON) B reported that repositioning wedges are used to keep residents from getting a pressure sore. DON B reported that a resident does need to be repositioned from left side to right side to their back at least every 2 hours. In an observation on 3/28/18 at 03:07 P.M., Resident #30 was up in her GeriChair in her room. In an observation on 3/28/18 at 5:23 P.M. Resident #30 was up in her GeriChair in her room. Resident had not been placed back in her bed after lunch Resident #58 Review of a Face Sheet revealed Resident # 58 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #58, with a reference date of 1/151/18, revealed a Brief Interview for Mental Status (BIMS) score of 10, out of a total possible score of 15, which indicated Resident #58 cognition was moderately impaired. Review of the MDS Function Status reflected Resident # 58 required extensive assistance of one staff member for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of the Care Plans during the on-site investigation 3/20/18-3/30/18, did not reflect a care plan for pressure ulcer/injury or shearing for Resident #58. Review of the Nursing Skin/Wound Note dated 3/13/18 at 1:51 PM, reflected Alerted by Certified Nursing Assistant (CNA) for open area. Skin assessment completed. Resident has 1.5 x 0.5 open area to L (left) buttock, r/t (related) friction and shear. Cleansed and applied Triad. New orders for Triad BID and PRN to this area, as well as offload from L side frequently. Educated resident, MD notified, Nurse on duty to call family (name of family member) and to notify oncoming nurse. Review of the Nursing Skin. Wound Note dated 3/29/2018 at 8:12 AM, reflected Skin assessment completed with (name of physician) the facility Medical Director. It is in his clinical opinion that this surface area on R (right) buttock is a friction and shear area and not a staged pressure ulcer. (Name of the physician) wants the Triad order for this area to continue as written BID and PRN. CNA assigned to hall educated to re position after doing peri care for resident. Educated resident also about allowing staff to get her up into chair as (name of the physician) educated that laying in bed will slow down the healing process. Continue to monitor. Retrieved from the State Operations Manual, Friction is the mechanical force exerted on skin that is dragged across any surface . Shearing occurs when layers of skin rub against each other or when the skin remains stationary and the underlying tissue moves and stretches and angulates or tears the underlying capillaries and blood vessels causing tissue damage. During an interview and observation on 3/21/18 at 9:10 AM, Resident #58 was up in her wheelchair in the dining room she had no complaints about care stated they come when I ask. During an observation on 03/21/18 at 10:40 AM, Resident #58 up in her wheelchair in an activity in the dining room, moved directly over from breakfast. During an observation and interview on 03/21/18 at 11:03 AM, Resident #58 was moved to a table for lunch, she asked staff to take her to her room to lie down, the staff ask if she wanted to wait till after lunch, Resident #58 said ok. During an observation and interview on 3/21/18 at 1:30 PM, Resident #58 was sitting in her wheelchair at the nursing station she reported that her legs were sore and she was waiting to go lie down and have her brief changed. During an interview and observation on 03/21/18 at 4:00 PM, Resident # 58 laying in bed reported she had been changed not to long ago when she was laid down. During an interview and observation on 03/22/18 at 9:25 AM, Certified Nursing Assistant (CNA) JJ reported that she had completed care for Resident #58 when she came shift this morning, and would need to get her up for PT before lunch. During an interview and observation at 2:00 PM CNA JJ stated she just changed her when she requested 20 minutes prior. CNA SS assisted CNA JJ to turn Resident #58 on her right side, CNA JJ stated the cream that was on Resident #58's bottom was provided by the nurse to put on after perineal care. CNA JJ pointed out the wound to left top buttock, it appeared to be the size of a dime with a dip the size of a size two pencil eraser, that was clean and well defined, there were other scattered areas of discolored skin at the top of her buttock near the right. Resident #58 did not complain about pain. During an observation on 3/27/18 at 12:00 PM, Resident #58 was up in her wheelchair in the dining room. During an observation and interview on 3/27/18 at 4:31 PM, Resident #58 was sitting in her wheelchair at the end of the bed facing the television away from the head of the bed, she reported that someone brought her to the room, but they were not with the right department and could not help her into bed so they just parked her. Resident #58 looking out the door for staff to be coming down the hall and called to anyone passing the door, her call light was clipped on the bed by the pillow at the head of the bed. Resident #58 reported that she was not able to reach it and no staff was noted in the hall and why would this surveyor not help her and push the call light for her after waiting 10 minutes to see if staff would come in the hall. Admissions W came to the room, turned off the light stated she could not help her, but would get someone, the portable oxygen tank was noted to be in the red (empty) Resident #58 uses 2 liters by nasal cannula. (2) Certified Nursing Assistants (CNA) AA and CNA AB entered the room, Resident #58 stated my leg hurts when you move them 6/10. CNA AA asked if she had enjoyed sitting in dining room and visiting with family. CNA AA checked the oxygen tank found it was empty and transferred Resident #58 to the oxygen concentrator. During on observation on 3/27/18 at 4:50 PM, CNA AA placed the mechanical lift in front of the wheelchair with the legs spread apart, CNA AB was behind Resident #58's wheelchair to place the hoyer sling pad (seat) straps in the hoyer hook, the legs of the hoyer pad were noted to have rips on both leg section of the hoyer pads by the fabric holding the strap (the left leg strap measuring at least 2 -3 one inch long, the right leg strap by the fabric holding the leg strap had a tear from center near the top of leg strap going around the sewing and extending an additional 3 inches past the strap going through padding). CNA AA and CNA AB reported that they inspected the sling prior to use and were ready to start and began lifting Resident #58 from her wheelchair, the surveyor ask them to stop, stating it was unsafe due to the tears in the sling. CNA AA reported what are we suppose to do, she did not lower Resident #58 back to her wheelchair when she complained of leg pain, she stated Resident #58 was in pain we are going to continue to transfer her, she wants to go to bed. CNA AA used the mechanical lift to transfer Resident #58 from the chair and dangle her over the floor approximately 3 feet and push the mechanical lift over her bed and position her in place. CNA AA and CNA AB washed their hands, put on gloves, brought supplies to the bedside, explained the procedure, removed Resident #58 pants and a strong urine odor was noted, the brief was moved aside and a soapy wash cloth was used to clean down the left and right side of Resident #58's thighs towards the anus followed by a wet wash cloth to rinse the soap and a dry cloth to dry the area, (CNA AA did not have Resident #58 drop her legs so she could clean the labia nor did she attempt to separate the leg to clean between the labia). CNA AA with the assist of CNA AB rolled Resident #58 on her right side and rolled a very saturated brief tinged brown with urine, and used a soapy wash cloth to cleaned left buttock and anal area, rinsed and dried the area with a clean wash cloths, and assisted to turn Resident #58 so CNA AB could remove the saturated brief and clean the right buttock and put a clean brief on her. A wound was noted on buttock (Left side) was not covered was clean and approximately the size of a pencil eraser, scattered areas of disturbed skin were noted on the upper right side. No cream was placed on her bottom or vaginal area. Resident #58 was positioned for comfort and CNA's washed their hands after cleaning the area. The sling was left on the chair in the room. During an interview on 03/28/18 at 4:10 PM, Wound Nurse (WN) C reported that she had just looked at the wounds on Resident #58 and they were from friction and shear, she had observed the one that had the depth of a pencil eraser and will have the physician look at it tomorrow, she had not considered it a pressure ulcer. During an interview and observation on 03/29/18 at 1:31 PM, Licensed Practical Nurse (LPN) PP and CNA YY cleaned hands and gloved, Resident #58 asked CNA YY to be careful when moving brief between her legs it was sore, the over the bed table was noted to have brown smears on the table top, LPN PP covered the spills with paper towels, and placed his supplies. CNA YY assisted to roll Resident #58 on her left side, loosen her clean brief, LPN PP used normal saline to wet a 4 x 4 gauze pad and wiped from approximately 4-6 inches around the outside wiping toward the wound center to clean area with 4 x 4 normal saline then patted dry. LPN PP cleaned his hands, put on clean gloves, then put triad on the skin by the mid buttock which appeared a irregular quarter size area involving the underlying tissue. LPN PP reported that he had not worked with Resident #58 in a few weeks and did not know if there were any other areas of concern. Review of the MI-Admission/Readmission Screener dated 2/21/18, reflected C. Skin Integrity 10. Integrity- Does the resident have impaired skn integrity upon admission Yes 11. Comments- New Left pacemaker placement, dressing intact A bandaid to the right scapula for Throacentesis. Review of the Braden Scale (a skin risk assessment) dated 2/21/18, reflected Resident #58 was a moderate risk for skin breakdown with a score of 13. Review of the Visual/Bedside Kardex Report (Certified Nursing Assistant tool) print date 3/22/18, reflected Resident #58 Toileting *Toilet Use, Bed Modility *Turn and Reposition, Resident Care * Make sure my call light is in reach, Skin Integrity- 3/14/18 Cleanse and apply Triad to R buttock area BID and PRN. Educate resident to offload from sacral area while in bed.

Based on observation, interview, and record review the facility failed to consistently perform and document skin assessments, follow Physician Orders, and provide prompt treatment to prevent the development of pressure ulcers for 1 (Resident #6) of 14 residents reviewed for pressure ulcers/wounds, from a total sample of 14 residents, resulting in the development of an avoidable facility acquired pressure ulcer and the potential for pain and infection. Findings include: Review of the Policy and Procedure Showers/Skin Assessments dated 5/20/10, Purpose .to ensure that all residents have a complete evaluation of the skin on a regular basis to promote good hygiene and identify any significant changes in the skin for appropriate treatment. Areas that will be identified include but are not limited to .discolorations .pressure ulcers, and other ulcerations of the skin .The licensed nurse will verify skin assessments that are completed during showers and bathing. Review of a Face Sheet revealed Resident #6 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #6, with a reference date of 7/24/17 revealed Resident #6 was an extensive assist with 2 staff for transfers, dressing, hygiene and bathing. A Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, revealed Resident #6 had severe cognitive impairment. During the initial tour on 10/16/17 at 11:15 A.M. Licensed Practical Nurse W reported that Resident #6 had a Stage II Facility Acquired Pressure Ulcer. Review of Facility Nursing Progress Notes Nurse Skin Review revealed that on 8/5/17 Resident #6 had no observed skin problems. On 9/25/17 Resident #6 had a small abrasion noted on left buttock measuring 0.4 X 0.4 X <0.1 (centimeters (cm) implied). On 10/9/17 Resident #6 had an open area on right buttock measuring 0.8 cm X 0.5 cm X 0.1 cm (depth). Per Hospice order Triad, leave open to air. Review of Resident #6's Physician order [REDACTED]. Review of Resident #6's Treatment Administration Record (TAR) on 10/16/17 revealed the order, Triad to open area & buttocks for 2 weeks then evaluate had not been transcribed. In an interview on 10/17/17 at 8:20 A.M., MDS Coordinator C reported that the Physician order [REDACTED].#6's TAR on 10/9/17. In an interview on 10/18/17 at 8:48 A.M., Director of Nursing (DON) B reported that the expectation for the implementation of Physician ordered treatments is to begin treatments the day they are ordered. In an interview on 10/18/17 at 9:10 A.M., DON B stated, I looked through (Resident #6's) orders and found the order for Triad from Hospice. I looked at the TAR and it was not transcribed. In an interview on 10/17/17 at 3:00 P.M., LPN FF reported that she did not have access to Triad for Resident #6's treatment. LPN FF reported that no staff members in the building, at that time, had a key to the treatment cart or a key for the cabinet in the clean utility room which stored Triad. Review of the Care Plan Risk for alteration in skin integrity for Resident #6 revealed, Precautions and prevention of pressure ulcers will be completed .reposition resident frequently when in bed/chair/Geri chair and/or wheelchair. In an observation on 10/17/17 at 10:10 A.M., Resident #6 was up in a Geri chair with head elevated at a 45 degree angle and both feet elevated. In an observation on 10/17/17 at 10:37 A.M., Resident #6 was up in a Geri chair with head elevated at a 45 degree angle and both feet elevated in a common area during an activity. In an interview on 10/17/17 at 10:40 A.M., Licensed Practical Nurse (LPN) FF reported that Resident #6 has been in the Geri chair since approximately 8:00 A.M. In an observation on 10/17/17 at 11:42 A.M., Resident #6 was up in a Geri chair with head elevated at a 45 degree angle and both feet elevated in the dining room for an activity. In an observation on 10/17/17 at 12:17 P.M., Resident #6 was up in a Geri chair with head elevated at a 45 degree angle and both feet elevated in the dining room. In an observation on 10/17/17 at 12:43 P.M., Resident #6 was up in a Geri chair with head elevated at a 45 degree angle and both feet elevated in the dining room. In an observation on 10/17/17 at 1:00 P.M., Resident #6 was up in a Geri chair with head elevated at a 60 degree angle and both feet elevated in the dining room to eat lunch. In an interview on 10/17/17 at 12:28 P.M., DON B reported that the expectation for staff, for residents at risk for alteration in skin integrity, is to follow the Resident's care plan and/or reposition every 2 hours. In an observation on 10/17/17 at 3:10 P.M., Resident #6's entire buttocks were reddened and purple in color. The pressure ulcer was circular in shape and was approximately 1.4 centimeters in diameter. The depth of the wound and the possible tunneling/undermining (wounds that extend from the initial injury deeper into the surrounding tissues which include skin layers and muscle) was not observed. There was no Triad noted on Resident #6's wound or buttocks. In an interview on 10/17/17 at 3:10 P.M., Resident #6 was unable to communicate current pain level due to severe cognitive impairment. Review of the Treatment Record revealed an order for [REDACTED]. Review of the September Treatment Record revealed, Resident #6 had shower/skin assessments scheduled on 9/4/17, 9/17/17, and 9/26/17. Absence of nursing staff initials indicated that the shower/skin assessment was not completed on 9/4/17. No progress notes were available regarding the completed shower/skin assessments on 9/17/17 and 9/26/17. Review of the October Treatment Record (reviewed on 10/18/17) revealed, Resident #6 had shower/skin assessments scheduled on 10/3/17, 10/10/17, and 10/17/17. Absence of nursing staff initials indicated that the shower/skin assessment was not completed on 10/10/17 or 10/17/17. No progress notes were available regarding the completed shower/skin assessment on 10/3/17. In an interview on 10/17/17 at 8:20 A.M., MDS Coordinator C reviewed Resident #6's Treatment Orders and reported that the skin checks were ordered for twice a week. MDS Coordinator C reported that the completion of a treatment is indicated by the initials of a nurse, If it's empty then it wasn't done. If the resident refused then it would have been documented.

Based on observation, interview and record review, the facility failed to implement facitility policy and nutrition interventions to maintain nutritional status in 2 of 2 sampled residents (Resident #3 and Resident #9) reviewed for weight loss, out of a total sample of 14 residents, resulting in significant weight loss for Resident #3 and Resident #9. Findings include: Review of an Admission Record for Resident #9 revealed he was a [AGE] year old man originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment completed on 9/8/17 revealed a Brief Interview for Mental Status (BIMS) revealed a score of 01/15 indicated Resident #9 was severely cognitively impaired. Review of a care plan revised 9/9/17 revealed, Focus: I exhibit memory loss and impaired decision making skills related to stroke. This is confounded by my communication impairment also related to stroke. Goal: I will make a choice when presented with 2 concrete options. Interventions: Present me with visual, concrete option that I can say yes or no or point to. Speak to me using simple words that I can understand. Ask me questions that I can respond to with yes/no. Review of a care plan revised 9/6/17 revealed, Focus: The resident may be at risk for weight loss related to reduced ability to feed self, swallowing problems, poor ability to communicate, inadequate intake. Family has had feeding tube removed and does not want replaced. Goal: The resident will be offered foods and fluids consistent with diet order per regular schedule and as needed for comfort. Interventions: Soft puree diet. Prepare/serve the resident's nutritional diet as ordered. Record percent intake. Weigh the resident monthly or per facility protocol. Review of a Nutritional Risk Review for Resident #9 dated 9/6/17 revealed, Weight = 180.0 lbs . Oral intake of food: Intake meets 26-75% of estimated needs . Consumes less than 1,000 cc/day of fluids . Resident is not on a fluid restriction .Coughing or choking during meals .Nutritional requirements: calorie requirements = 2045 calories/day. Protein requirements = 82 grams/day. Fluid requirements = 2460 ml/day. Narrative progress note: [AGE] year old male with hospice referral, previously on feeding tube, however this was removed and family wants only comfort. Per occupational therapy, resident does not appear hungry, but is vomiting up solids and liquids, not able to get food down. Resident is not able to communicate with this writer. Concern for inadequate intake, will need documentation that family is aware Resident #9 can not consume adequate nutrition and hydration by mouth at this time . Care plan updated . Family did sign that they want Resident #9 to eat whatever he wants, but this is a nutritional issue now more than a swallow issue as he is not getting adequate nutrients. This surveyor requested from facility all dietary assessments, progress notes, and documentation regarding nutritional status and care for Resident #9 on 10/18/17 at 11:00 a.m. Review of Resident #9's Weight Summary revealed: 9/1/17 180.0 lbs 9/1/17 180.0 lbs 9/12/17 178.0 lbs 10/8/17 176.0 lbs Review of a Shower Schedule dated 10/11/17 revealed: Resident #9 Weight: 167.0 A weight loss 180.0 lbs to 167.0 lbs represents a 7.22% weight loss in less than 2 months. In an interview on 10/17/17 at 11:32 a.m., Family Member EE stated, I know (Resident #9) has lost weight. He used to have more of a belly, his clothes are looser too. He doesn't like his pureed diet. Most of the time he doesn't eat it. And I always have to ask for beverages. I bring him food from home when I come in the evenings just so I know he is eating something. In an observation on 10/18/17 at 9:10 a.m., Resident #9 was in the back dining room with his breakfast in front of him. No cup or beverage carton observed. Review of a meal tray ticket observed on the table next to Resident #9's breakfast meal revealed, Beverage: orange juice, 4 oz In an interview on 10/1817 at 9:10 a.m., this surveyor asked Resident #9, Did you get orange juice? Resident number 9 shook his head, no. In an observation on 10/18/17 at 9:14 a.m., Resident #9 appeared to have eaten approximately 75% of his cream of wheat. Some white, runny food was dripping from his mouth. Three other food items on his plate were untouched. No other foods or fluids were offered by staff during the meal. In a telephone interview on 10/18/17 at 11:28 a.m., Registered Dietitian (RD) H reported that for someone with a high risk of weight loss she would start with interventions that included food first. She would look at the resident's estimated needs and implement food interventions first, and then move toward supplements. RD H stated, Sometimes nurses will start supplements. RD H stated, I would put someone at high risk for weight loss on weekly weight for closer monitoring. For someone like Resident #9, I would verify his food preferences, meal/beverage intake, and make him or family aware of alternate menus options. The dietary manager should be taking food preferences upon admission and on going as needed. The facility gave me a list of people to work on. Resident #9 was not on that list. Review of the current (10/2017) physician orders [REDACTED]. In an interview on 10/18/17 at 11:45 a.m., Dietary Manager G reported he wasn't sure if the nurse aides recorded meal acceptance. Dietary Manager G stated, I assume they are, but I'm not sure where. I'll have to check .I take the food preferences upon admission, but I don't keep a record of the conversation. I didn't see a need to. I just enter dislikes on their tray tickets. In an interview on 10/18/17 at 12:20 p.m., Family member ''EE stated, Yes, Resident #9 likes orange juice. But he loves milk. He would drink it at every meal, and more if they would give it to him. I always have to ask for it when I'm there. Family Member EE reported no one has come to me to talk about food preferences, and stated, I don't even know who the Dietary Manager is. In an observation on 10/18/17 at 12:52 p.m., Resident #9 was in the back dining room at a table with one other resident. His lunch tray was delivered to him by Certified Nurse Aide (CNA) Q. CNA Q walked away. Resident #9 raised both hands while he looked at a nearby staff member. After a few moments a CNA approached Resident #9 and asked, Milk? Resident #9 nodded his head, yes. Review of Resident #9's lunch tray ticket revealed, beverage: 8 oz apple juice. In an interview on 10/18/17 at 12:55 p.m., this surveyor asked CNA Q how she knew Resident #9 might want milk. CNA Q stated, I know he likes milk. Plus his ticket just says apple juice. CNA Q went to the kitchen door and obtained milk for Resident #9. In an observation on 10/18/17 at 1:25 p.m., Resident #9 was at his table in the dining room. He had consumed 100% of his milk and a 4% chocolate ice cream. The other lunch items and the apple juice were untouched. No other foods or fluids were offered. Review of the facility's policy and procedure, Weights, revised 1/10/10, revealed Residents that are identified to be nutritionally at risk will be weighed weekly and discussed at the Nutrition at Risk Meeting. Resident #3 Review of a facility Admissions Record revealed Resident #3 was an [AGE] year old female originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment completed on 7/17/17 revealed Resident #3 was and an extensive assist with 2 staff for transfers, dressing, hygiene, and ambulation. A Brief Interview for Mental Status (BIMS) score revealed Resident #3 was severely cognitively impaired. Review of Resident #3's Dietary Care Plan, revised 10/1/17, revealed care plan focus to be I continue to be at Nutritional/Hydration risk R/T (related to) Alzheimer's Dementia progress and edentulous, care planned goal to be I will not experience significant weight loss, will have adequate intake ., and care planned intervention to be Weigh me every month and/or prn (as the circumstances arises) and notify MD (physician), Guardian, and RD (registered dietician) of any significant wt. (weight) loss, Assist me with meals as needed ., .document intake. Review of monthly weights in the facilities Electronic Medical Record (EMR) for Resident#3, revealed last weight taken was 8/7/17 and Resident #3 weighted 140 lbs. Review of the hand written Shower Schedule, Wednesday 1st Shift, 10/11/17, revealed Resident #3 weighted 128 lbs. Review of Resident #3's MI-Nutritional Risk Review, effective day 10/11/17, completed by Registered Dietician (RD) H, revealed RD Assessment Summary: weight is without significant change of +5% 90 days and +6% 180 days. usual weight range is ~132-136#. awaiting October weight. diet consistency per edentulous state and history of pocketing food (see NN). intake ranges from 50-100% of meals. use of ice cream at 3 meals is likely not indicated per weights. Heme (blood work) indices wnl (within normal limits). hydration adequate per labs and [MEDICATION NAME] wnl. Recommend d/c (discontinue) ice cream with meals. provide for preferences and ice cream as desired by resident. proceed to care plan. During an observation on 10/17/17, at 9:10 a.m., Resident #3 was slumped low, in a sitting position in bed, with breakfast on the over bed table in front of Resident #3. Resident #3's gown and bed was covered with food. Resident #3 attempted multiple times to scooped food with a spoon and bring it to the mouth, often missed the plate, and scooped the air. Resident #3 missed mouth multiple times, spilling food on the bed and gown. During an observation on 10/17/17 at 12:50 p.m., Resident #3 was in the dining room seated in wheelchair eating lunch. Resident #3 used hands to self-feed, missed mouth many times and spilled food on wheelchair and clothing. In an interview on 10/17/17 at 9:20 a.m., Certified Nursing Assistance (CNA) CC indicated Resident #3 normally can self-feed, but today Resident #3 is not doing too well (self-feeding). In an interview on 10/17/17 at 1:10 p.m., CNA Z indicted the CNA's check the hall specific clipboards at the nurse's station to see which residents need to be weighted. CNA Z indicated the nurses highlight the resident's that need to be weighted on each hall. Each CNA should write down the resident's weight on the clipboard and put the weight in the computer as soon as possible. CNA Z does not know why Resident #3's 10/11/17 weight was not put in the computer, it should have been done that day. CNA Z indicated could not find Resident #3's 9/17 weight on the clipboard or on the computer. In an interview on 10/18/17 at 9:30 a.m., Director of Nursing (DON) B indicated LPN W should have the missing weights. DON B indicated will find Resident #3's 9/17 weight. DON B indicated would be concerned with a resident with a 12 lb. loss in 3 months. In an interview on 10/18/17 at 10:30 a.m., Dietary Manager (DM) G indicated reviews weights on each resident from the EMR every 3rd Wednesday of the month. DM G brings weight loss or gain trends to Quality Assurance meeting to initiate new interventions and notify all parties involved in the resident's care. DM G indicated only checks weights in the computer and relies on the nursing staff to weight the resident as often as needed. In an interview on 10/18/17 at 11:05 a.m., RD H indicated based Resident #3's 10/11/17 nutritional assessment on the 8/9/17 weight of 140 lbs. RD H indicated could not find a more recent weight in the EMR. RD H indicated Resident #3's weight loss of 12 lbs. in 3 months, a significant weight loss and should have been notified by the facility. RD H indicated will follow policy and procedure and add Resident #3 to high risk list and assess Resident #3 within 72 hours. In an interview on 10/18/17 at 2:30 p.m., DON B indicated could not find 9/17 weight for Resident #3.

Based on observation, interview and record review, the facility failed to provide adequate care and services to prevent pressure ulcers in 2 of 10 sampled residents (Resident #5, Resident #8) reviewed for pressure ulcers, in a total sample of 15 residents, resulting in the worsening of the coccyx ulcer, pain and the potential for systemic infection for Resident #8 and the potential for poor wound healing and worsening resident condition for Resident #5. Findings include: Resident #8 Review of the Admission Record and Minimum Data Sheet ((MDS) dated [DATE], reflected Resident #8 was an [AGE] year old male re-admitted to the facility on [DATE]. The MDS and Admission Record reflected Resident #8's [DIAGNOSES REDACTED]. The MDS reflected that Resident #8's ability to make daily decisions was severely impaired and he currently required the assistance of one to two staff member for transfer, bed mobility, toileting, hygiene, and bathing. Review of the Licensed Nurse Weekly Assessment Form dated 12/29/15, reflected previous area noted to right ischium healed. Barrier cream applied. Review of the Physician order [REDACTED]. Review of the Licensed Nurse Weekly Assessment Form dated 1/5/16, reflected new open area, abrasion to right ischium noted, treatment ordered. Review of the Formal Wound assessment dated [DATE], reflected Resident #8 had a ischial wound that measured 2.9 cm x 1.7 cm with yellow/green wound bed, moderate drainage. Review of the Formal Wound assessment dated [DATE], reflected Resident #8 had a ischial wound that measured 2.5 cm x 2 cm with yellow/green and necrotic (black) wound bed, moderate drainage. Review of the Treatment Administration Record (TAR) dated March 2016, reflected Resident #8 treatment Right ischium - Cleanse with NS/wound cleanser, pack with curasalt (type of saline) guaze, cover with gauze and then ABD, change every day and as needed. Review of the TAR reflected of the 31 opportunities to apply the prescribed treatment 8 were not documented as completed. In Legal and Ethical Issues in Nursing by G. Guido (2001), it documents that Documentation must show continuity of care, interventions that were used, and patient responses to the therapies implemented. Nurse ' s notes are to be concise, clear, timely, and complete. (pg. 171) It states that A jury can infer that no observation of the patient was conducted if there is no mention of a change in condition of the patient. (pg. 171) According to Legal and Ethical Issues in Nursing, 4th Edition, (Guido, G, 2006), A major responsibility of all health care providers is that they keep accurate and complete medical records. From a nursing perspective, the most important purpose of documentation is communication. The standards for record keeping attempt to ensure, patient identification, medical support for the selected diagnoses, justification of the medical therapies used, accurate documentation of that which has transpired, and preservation of the record for a reasonable time period. Documentation must show continuity of care, interventions used, and patient responses. Nurses' notes are to be concise, clear, timely, and complete. Review of the Physician Phone Order dated 3/10/16 revealed referral to wound clinic ASAP (as soon as possible) for evaluation right ischium wound odorous with drainage. Review of the Formal Wound assessment dated [DATE], reflected Resident #8 had a wound that measured 3 cm x 2.4 cm with yellow/green, necrotic (black) wound bed, moderate drainage. Review of the Formal Wound assessment dated [DATE], reflected Resident #8 had a wound that measured 3.4 cm x 3.2 cm x 4.3 cm with granulating (red), necrotic (black) wound bed, low drainage and increasing odor. Review of the TAR dated April 2016, reflected Resident #8 treatment Right ischium - Cleanse with NS/wound cleanser, pack with curasalt guaze, cover with gauze and then ABD, change every day and as needed. Review of the TAR reflected of the 26 opportunities to apply the prescribed treatment 15 were not documented as completed. Review of the Operative/Procedure Record dated 4/18/16, reflected that Resident #8 had a right ischial ulcer that was debrided quite aggressively .Findings: Necrotic subcutaneous tissue and fascia extending down to bone in the proximal aspect of the right ischial ulcer. We had 7 x 2 x 6 cm wound after debridement with 3 cm of undermining at 12 o'clock, 2 x 3 cm area of exposed bone. Review of the TAR dated April 2016, reflected Resident #8 treatment Left ischium - apply triad BID (twice a day) and as needed . Review of the TAR reflected no start date, of the 52 opportunities to apply the prescribed treatment 38 were not documented as completed. Review of the TAR dated May 2016, reflected Resident #8 treatment Left ischium - apply triad BID (twice a day) and as needed . Review of the TAR reflected no start date, of the 62 opportunities to apply the prescribed treatment 39 were not documented as completed. Review of the TAR dated June 2016, reflected Resident #8 treatment Right ischium - Cleanse with NS/wound cleanser, pack with curasalt guaze, cover with gauze and then ABD, change every day and as needed. Review of the TAR reflected of the 21 opportunities to apply the prescribed treatment 5 were not documented as completed. Review of the TAR dated June 2016, reflected Resident #8 treatment Left ischium - apply triad BID (twice a day) and as needed, perineal area. Review of the TAR reflected no start date, of the 42 opportunities to apply the prescribed treatment 21 were not documented as completed. Review of the Certified Nursing Assistant (CNA) Care Sheet obtained on 6/21/16, reflected that Resident #8's required a cushion in the wheelchair, use moisture barrier after incontinence, air mattress, lay down after meals, turn and position every two hours from side to side float heels, while in bed open area to ischium (back lower portion of the hip bone). Review of the skin Check/Shower Worksheet dated 6/22/16, reflected Resident #8 had a dressing to his right ischium, scratches on his loser legs and heels soft. During an observations on 6/21/16 at at 2:00 p.m., 3:50 p.m., 4:50 p.m., and 6/22/16 at 7:30 a.m., 8:20 a.m., 8:44 a.m., 9:00 a.m., 9:25 a.m., 10:25 a.m., 12:00 p.m., 2:10 p.m., Resident #8 was noted to be laying on his back in bed with his heels on the bed, no pillow or wedge was seen between his knees or near his legs for elevation. In interview on 6/22/16 at 10:30 a.m., Certified Nursing Assistant (CNA) Z reported that Resident #8's dressing was wet after his shower that was done at approximately 10:00 a.m. and that she would let the nurse know that his dressing was wet. In interview at 2:10 p.m., CNA J reported that she had not checked or changed Resident #8 since he had returned from the shower and did not know if the wound care nurse had been informed of the wet dressing left from the shower. In an observation and interview on 6/22/16 at 3:50 p.m., Registered Nurse (RN) E removed the old soaked dressing that had serosanguinous fluid stain noted to the outside of the dressing. The wound was well granulated and appeared a little larger that a quarter and approximately 3/4 inches deep to without probing. A sour odor was noted when the dressing was removed. RN E stated that the dressing was wet, she was informed that Resident #8 had a shower at approximately 10:00 a.m., RN E reported that she had not been informed that Resident #8 had a shower and the dressing was wet. # Resident #5: Review of the Face Sheet revealed Resident #5 was a [AGE] year old female admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #5 had severely impaired cognition. Review of the Assessment Chart for Wound Management dated 3/9/16 revealed Resident #5 had a pressure ulcer to left heel which measured 4 centimeters by 3 centimeter. Review of the Assessment Chart for Wound Management dated 3/28/16 revealed Resident #5 had a pressure ulcer to left heel which measured 6.3 centimeters by 4.1 centimeters and was 0.3 centimeters in depth. Review of the Assessment Chart for Wound Management dated 5/11/16 revealed Resident #5 had a pressure ulcer to left heel which measured 6.8 centimeters by 4 centimeters (indicated wound was larger than previous). Review of the Hospital Discharge Summary dated 5/26/16 revealed Resident #5 had a skin ulcer to left heel which had a foul odor and had been seen by Surgery and they have performed bedside debridement (a surgical procedure to remove wound tissue) of the pressure ulcer. Review of the Certified Nurse Aide (CNA) Care Sheet dated 6/22/16 revealed Resident #5 had wound to left heel .sage boots (pressure relieving boots placed on the lower extremities) on at all times. Review of the Treatment Record dated 5/2016 revealed Sage boots on at all times ordered 3/25/16. In an observation on 6/22/16 at 8:50 am, Resident #5 was noted to be in bed. Observed in the empty roommate's bed were the sage boots. Sage boots were not observed to have been on Resident #5's legs. In an observation on 6/22/16 at 10:00 am, Resident #5 was noted to be in bed. Observed in the empty roommate's bed were the sage boots. Sage boots were not observed to have been on Resident #5's legs. In an observation on 6/22/16 at 11:15 am, Resident #5 was noted to be in her bed. Observed in the empty roommate's bed were the sage boots. Sage boots were not observed to have been on Resident #5's legs. In an interview on 6/22/16 at 11:22 am, Certified Nurse Aide (CNA) D was asked if Resident #5 needed her sage boots on while she was laying in bed. CNA D stated the sage boots were to be on Resident #5's legs when she's (Resident #5) up in her chair (wheelchair). In an interview on 6/22/16 at 5:10 pm, Wound Nurse (WN) E stated Resident #5 had an ulcer on left heel and the hospital debrided it (left heel ulcer), now it looks great (indicated wound improvement after surgical debridement). In an interview on 6/22/16 at 11:26 am, Director of Nursing (DON) B stated, yes the CNA's were to follow the CNA Care Sheet. DON B stated the CNA care sheet was updated every morning. Director of Nursing (DON) B further stated sage boots were a protective boot for the heel. DON B stated according to the CNA Care Sheet sage boots were to be worn at all times to promote pressure ulcer healing for Resident #5. ( )

This portion of the citation (Resident #4) pertains to intake number MI 075. Based on observation, interview and record review the facility failed to consistently assess, monitor and implement measures to prevent the development of new pressure ulcers in 2 of 21 sampled residents (Resident #4 and Resident #6) reviewed for skin issues/pressure ulcers, from a total sample of 21 residents, resulting in the the development of avoidable pressure ulcers. Findings include: According to the Pressure Ulcer Treatment, Quick Reference Guide, 2009, under Common Definition of Pressure Ulcers, a pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure with combination of shear. According to the National Pressure Ulcer Advisory Panel (NPUAP) defines a Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. Unstageable: Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) in the wound bed. According to Stedman's Medical Directory - 28th Edition, pg. 1781, (2000) Lippincott Williams & Wilkins Company, slough is defined as: Necrotic tissue separated from the living structure said of dead or necrotic part. Resident #4 According to the Face Sheet Resident #4 had a medical history which included Stage 3 kidney disease, [MEDICAL CONDITION] (weak heart), [MEDICAL CONDITION] (irregular heartbeat), [MEDICAL CONDITION], pacemaker, and fall history. Review of the Medical Record revealed Resident #4 was admitted to the facility on [DATE], sent to the hospital from 6/30 to 7/6/15, was again hospitalized from [DATE]- 8/22/15, had an emergency room visit on 9/7/15 (was not admitted ), and hospitalized again on 9/13/15. Review of the Minimum Data Set (MDS) dated ,[DATE] revealed Resident #4 was moderately impaired for daily decision making skills, displayed no verbal or physical behaviors, required extensive one person assistance with bed mobility, transfers, ambulating in room and hall, dressing, toileting and personal hygiene, totally dependent on one person assistance with bathing, frequently incontinent of urine and continent of bowel. Review of the Nursing Care Plan dated 7/16/15 titled Pressure Ulcer revealed the interventions of: systematic skin inspection weekly. Pay particular attention to bony prominences. CNA to observe skin integrity with daily care. Encourage oral intake to promote good nutrition for skin integrity. Float heels in bed. Check and change if incontinent at least every two hours, keep bony prominences from direct contact with one another with pillows/blankets/foam wedges. Keep linens, clean dry and wrinkle free. Report any signs of skin breakdown sore, tender, red, broken skin areas. No briefs in bed allow skin to breathe. Review of the Nurses Notes dated 6/24/15 titled Section B: Admission Evaluation and Interim Care Plan revealed section titled Skin: Dry, Warm, Bruising was checked. Section E: Skin Conditions Braden Scale = 18 (assessment to evaluate factors predicting pressure ulcer risk) indicating At Risk. No Nurses Notes were present in the medical record from 6/25/15 to 6/29/15. Nursing Notes dated 6/30 revealed the check-box nursing note format in section titled skin: Dry and Warm were checked only. Review of the Shower and Skin Check Monitoring Form revealed no documentation present for June 2015. Review of the Admission Evaluation and Interim Care Plan dated 7/6/15 (readmission from hospital) Section B: Skin Feet warm, dry, intact no skin issues. Braden Scale=19. Handwritten Nursing Notes dated 7/6/15 documented bruises to bilateral arms, old scabs on bilateral lower legs. Review of the Medical Daily Nurses Notes (a check box format) sporadically charted from 7/7/15 to 7/31/15 revealed intact in the section titled Skin. Review of the physician progress notes [REDACTED]. No acknowledgement regarding any skin issues were present. Review of the Medical Daily Nurses Notes dated 8/1/15 to 8/15 revealed 3 documented areas addressing skin as intact. On 8/4 and 8/8/15 only one shift documented information regarding Resident #4. On 8/9 one shift completed documentation. Handwritten Nursing Notes dated 8/3/15 to 8/14/15 revealed no information related to skin assessment/documentation for Resident #4. Review of the Progress Note dated 8/4/15 and 8/10/15 revealed documentation written by NP VV Scrotal Redness & Pain with [MEDICATION NAME] ordered (for fungal infections). physician progress notes [REDACTED]. Review of the Hospital records for Resident #4 dated 8/16/15 revealed on 8/16 at 11:22 AM arrived in ED (emergency department). 8/16/15 3 PM admitted . The hospital nursing admission records dated 8/16/15 at 6:47 PM revealed, Pressure Ulcer Right Ankle Outer/Lateral, Mid Black, unblanchable, open wound Pre-Existing Yes, Wound Bed Black Red, Wound Length X Width; 2.2 X 2.5 cm. Pressure Ulcer Right Foot Outer/Lateral Posterior Deep Tissue Injury Pre-Existing Yes Length X Width 2.2 X 2.5 cm. Pressure Ulcer Left Foot Outer/Lateral Upper/Superior Unopened, black wound, deep tissue injury. Wound bed Black-Red Length X Width 0.5 X 1 cm. Pressure Ulcer Left Foot Mid;Outer/lateral Unopened black pressure ulcer. Black Red, [DIAGNOSES REDACTED] (red) Wound length X Width 2.5 X 2.5 Pressure Ulcer Left Foot; Outer/lateral lower/inferior Unopened black pressure ulcer. Black Red Wound Length X Width 1.2 X 2. Pressure Ulcer Coccyx Mid;Anterior Unstageable, purple and blister no open wound Pre-Existing Yes. First Assessed 8/16/15 4:06 PM Wound bed: Red open formerly blister formation, Length 7 cm X Width 10 cm. Review of the Hospital Record titled Wound Nurse Consult dated 8/17/15 revealed documentation related to Right Foot: heel 3.5 X 3 cm purple, lateral ankle 2 X 2 cm purple, mid lateral foot 2 X 3 cm purple 5 th metatarsal head 1.5 x 2.5 cm. purple, 1st metatarsal head white non-blanchable area 2 x 2 cm. Left foot: lateral heel 3 x 3 cm purple, lateral ankle 1 x 1 cm, mid lateral foot 2 x 2 cm purple, 5 th metatarsal head 1 x 1 cm purple. Coccyx open area seemed to have been a blister that is now open 3 x 3 x 0.1 cm 90% red with a purple center. There are scattered purple areas and a few fluid filled purple blisters over the sacrum coccyx bilateral gluteal area measuring 13 x 15 cm. Assessment: Right foot and left foot scattered areas of purple that are not open all suspected deep tissue injuries, placed feet in Sage boots. Coccyx: unstageable pressure ulcer cover area with [MEDICATION NAME] turn side-side. Review of the Nursing Care Plan revealed no updated interventions related to skin care/pressure ulcer status upon re-admission from the hospital on [DATE] or 8/22/15. Resident #4 was observed on 9/8/15 at 1:20 PM, in bed, in his room. Resident #4 was noted to be sitting with the head of the bed at a 90 degree angle. Resident #4 stated I need to get up and put my feet over the edge of the bed they hurt. After Resident #4 moved the top sheet, noted present on both feet, were blue foam Velcro strapped boots. One pillow was present under the resident's head none under his feet. At 1:22 PM, Certified Nurse Aide (CNA) M entered the room and stated, Oh, he has sores on his feet. He has boots on to help not get others then left the room. CNA M re-entered the room accompanied by CNA FF Noted present on Resident 4's legs were multiple black scabs on both legs and heels. CNA M and CNA FF began providing care. Upon turning Resident #4 was noted to have deep creases, wrinkles embedded on his back and buttocks. CNA M reported, He has been dry all day. I didn't notice he had open areas when I checked him at 6:30 AM. Noted on both sides of the buttocks were two open reddish-pink area approximately the size of 25 cent piece each. No dressing was present. CNA M exited the room and returned with Licensed Practical Nurse (LPN) J. LPN J reported that Resident #4 had been sent on 9/7/15 to the emergency room and that the dressing must have been removed in the ER. He returned on 2nd shift on 9/7/15, so the dressing must have been off. Third shift should have checked on that. I was just told he hasn't had a dressing on today. During personal care this surveyor observed 4 areas referred here as Area 1: Right heel and 2nd toe; Dressing was dated for 9/6/15. Area 2: Left foot and heel along the outside of left foot; dressing was dated 9/6 and soiled with moderate amount of drainage. Area 3: Above the bend of the left elbow, a dry gauze was present with small amount of dark red drainage. No date was written on the dressing. Area 4: both the left and right buttocks. No dressing was present. LPN J exited the room and returned with supplies for a dressing change. LPN J washed her hands, put on gloves, removed scissors from her uniform pocket, cut the dressings, applied the dressing to the coccyx area, stating it took me awhile to come back I had to call the doctor to substitute mediplex that is on the supply truck to get here Wednesday 9/9 the dressing was due to be changed Wednesday, so calcium alginate was substituted. Upon completing the dressing change LPN J went to the bathroom sink and washed the scissors with soap and water and replaced them in her uniform pocket. During an interview on 9/9/15 at 5:15 PM, Family Member BB reported, The bed sore, he got here. When he first got here, he was able to get up and move and she had done the bathing for Resident #4. Family Member BB produced a calendar diary with the following information: 6/21/15 fell at home to hospital 6/24/15 admitted to facility 6/30/15 sent to ER in hospital until 7/6/16 7/26/15 bathed no skin issues 7/29/15 bathed him again no skin issues 7/31/15 had a fall 8/5/15 to 8/13 verbal report during visits he was out of it 8/13/15 totally out of it won't wake up for me 8/14/15 started IV's, dry mouth caked full of food cleaned out 8/16/15 sent to ER, told he had sores on his butt. 8/22/15 back to that place 9/6/15 another fall 9/7/15 to ER swollen penis Family member BB reported that the first few days after [MEDICATION NAME] was started on 8/1/15, he was OK. He then began not being able to talk or open his eyes, eat or drink, was more sedated, and began becoming incontinent of urine and stool. On 9/19/15 at 10:20 AM, Resident #4 was observed sitting in the dining room in a wheelchair. Noted under the resident was the lift sling (transfer device) and Resident #4 was squirming in the seat of the wheelchair and stated, I hurt all over, my butt included. In an interview on 9/10/15 at 3 PM, Family Member CC reported, He (Resident #4) was always in bed on his back with only one pillow under his head, not even anything under his feet. I know you should turn people and move them around. I even noticed he had the same clothes on a couple of times from the last visit. In August, I asked how his pressure ulcer was on his butt, the nurse here told me they were healed. Another family member was the one who found them and told me. The wound nurse at the hospital spoke to us and told us he was admitted with them. Review of the Wound/Skin Record dated 8/24/15 related to wounds located on Site A: left outer ankle Site B: Sacral Site C: Side of left foot near 5 th toe was located in the Medical Record. ( ) Resident #6 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected Resident #6 was a [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS reflected Resident #6 had a BIMS (assessment tool) score of 5 which indicated her ability to make daily decisions was severely impaired, and she required one person physical assist with locomotion on unit and personal hygiene and two person physical assist with transfers, bed mobility, dressing, toileting and bathing. In an observation and interview during the initial facility tour on 9/8/15 at 10:15 a.m. Resident #6 was observed in her room, in bed laying on her back with the bed elevated at about a 110 degree angle. Resident #6 asked this surveyor for assistance. This surveyor asked Resident #6 how she would get help from staff if I were not present. Resident #6 reported she uses a call light that she taps with her head but was not able to reach it. Observed Resident #6 attempting to reach the call light on the far right of the bed that was out of reach. Registered Nurse (RN) Unit Manager Y and Licensed Practical Nurse (LPN) Z entered Resident #6 room and reported Resident #6 requires total care and attended to care needs. In an observation on 9/8/15 at 3:40 p.m. Resident #6 was in bed with the head of the bed elevated at about a 110 degree angle. Review of the facility Pressure Ulcer Care Plan dated 9/15/14 revealed Resident #6 was at risk for skin breakdown related to a [DIAGNOSES REDACTED]. Intervention included, conduct a systematic skin inspection weekly. Pay particular attention to bony prominences. CNA (Certified Nurse Aid) to observe skin integrity with daily cares .Encourage and assist PRN (as needed) with turning and repositioning q (every) 2 hrs .Explain risk of not turning and repositioning .Keep resident off bony prominences .Maintain the head of the bed at the lowest degree of elevation possible .Supplements as ordered .Toilet upon rising, before and after meals, at HS (bed time) and PRN .Use moisture barrier product to perineal area Review of the facility ADL Care Plan dated 9/15/14 and last updated 9/4/15 revealed Resident #6 was dependent on staff for completion of all ADL's related to the [DIAGNOSES REDACTED].Do not rush the resident. Allow them time to perform and compete ADL's as able . Review of the CNA Care Sheet dated 9/8/15 reflected Resident #6 was to receive encouragement and assistance to turn and position every 2 hours and as needed. Skin needs reflected wounds to right and left ischium, coccyx, and right ankle. Resident #6 was marked for fall risk on care sheet. No documentation noted for bed in low position, alarms, keep resident off bony prominences, head of bed at lowest degree of elevation as possible, or use of moisture barrier products. In an observation on 9/9/15 at 8:30 a.m. Resident #6 was in bed on her back with head of bed elevated in sitting position and foot of bed slightly elevated. In an interview on 9/9/15 at 10:50 a.m. LPN HH reported she was almost ready to perform dressing changes for Resident #6 and she would locate this surveyor prior to performing dressing changes. In an observation on 9/9/15 at 11:15 a.m. LPN HH exited Resident #6's room with bagged items and placed them in the dirty utility room. In an observation and interview on 9/9/15 at 11:30 a.m. through 12:00 p.m. LPN HH entered Resident #6's room and reported she had planned to perform wound care for Resident #6. LPN HH reported she had gathered the supplies and removed the old dressings prior to notifying this surveyor. The bed side table had a towel covering the surface and the supplies placed on the top. A CNA assisted to roll Resident #6 to right side after the bed was lowered. Resident #6 complained of pain when turned. LPN HH reported she had already removed the old dressings prior to performing dressing change because of the old dressing odors. The left ischium wound appeared to be about baseball size including length, width and depth with moderate amount serosanguinous drainage noted to pad on the bed. The wound had necrotic tissue at 6 o'clock. LPN HH cleaned the wound with normal saline and a 4x4 gauze and gloves changed prior to packing with [MEDICATION NAME]. LPN HH removed soiled gloves and used hand sanitizer and donned clean gloves and covered left ischium wound with two 4x4's and an ABD pad and placed skin barrier around the ABD pad. LPN HH placed dated tape on the top, bottom and lateral side of the ABD pad after about 30 seconds. LPN HH removed soiled gloves, washed hands with hand sanitizer. LPN HH and CNA rolled Resident #6 to left side and LPN HH performed dressings to right ischium and coccyx. Resident #6 asked several times to set the head of the bed up, I am hurting. LPN HH set the head of the bed up between each dressing. After performing the dressing to Resident #6's right ischium and coccyx area LPN HH informed Resident #6 she would return later to perform the dressing change to her right ankle to allow her time to rest between dressing changes. LPN HH and CNA left Resident #6's room after cleaning up and Resident #6 was in bed with the head of the bed elevated to about 110 degrees and positioned on her back. LPH HH reported she would reposition her after she performed the dressing change to Resident #6's ankle. No teaching with Resident #6 noted related to healing and positioning prior to leaving Resident #6's room. Review of the facility Wound/Skin Records dated 10/3/14 through 6/3/15 revealed no documentation noted indicating Resident #6 had any skin breakdown to the left gluteal fold/left ischium area. Review of the facility Wound/Skin Record dated 6/8/15 revealed Resident #6 developed a new wound on 6/4/15 to the left posterior upper thigh at left gluteal fold. On 6/8/15 the skin record reflected measured 1cm x 1.7cm with 0 depth and was a stage I with no odor and black and blue wound bed and irregular wound edges. Review of the facility Wound/Skin Record dated 6/10/15 and 6/16/15 revealed Resident #6 wound to the left posterior upper thigh at left gluteal fold had healed. Review of the facility Wound/Skin Record dated 6/24/15 revealed Resident #6 had a wound that was noted with date of onset at 6/4/15. Skin record indicated wound to the left posterior upper thigh at left gluteal fold was noted as a stage II and had improved respose to treatment and measured 1.2cm x 0.6cm with less than 0.1cm depth and wound bed noted as, granulation/pink Review of the facility Wound/Skin Record dated 7/1/15 revealed Resident #6 wound to the left posterior upper thigh at left gluteal fold had healed. Review of the facility Wound/Skin Records dated 7/8/15 and 7/15/15 revealed no documentation noted indicating Resident #6 had any skin breakdown to the left gluteal fold/left ischium area. Assessment signed by the Director of Nursing (DON) B. Review of the facility Wound/Skin Record dated 7/29/15 revealed Resident #6 had a new unstagable left ischium wound that was noted with the date of onset as 7/29/15. The skin record indicated the new wound to the left ischium measured 4.7cm x 5cm with a 7cm depth and wound bed was noted as purple with documentation of, mod serosang noted in the exudate type/amount section. The Skin Record reflected the surrounding skin color to be red. Assessment signed by the DON B. Review of the facility Wound/Skin Record dated 8/5/15 revealed Resident #6 had an unstagable left ischium wound that was noted with the date of onset as 7/29/15 with no changes. The skin record indicated the wound to the left ischium measured 4.7cm x 5cm with a 7cm depth and wound bed was noted as deep red with documentation of, mod serosang noted in the exudate type/amount section. The Skin Record reflected the surrounding skin color to be pink. Assessment signed by the DON B. Review of the facility Wound/Skin Record dated 8/12/15 revealed Resident #6 had a unchanged left ischium unstageable wound that was noted with the date of onset as 7/29/15. The skin record indicated the wound to the left ischium measured 4.7cm x 5cm with a 7cm depth and wound bed was noted as red with documentation of, mod serosang noted in the exudate type/amount section. The Skin Record reflected the surrounding skin color to be pink. Assessment signed by the DON B. Review of the facility Wound/Skin Record dated 8/19/15 revealed Resident #6 had a improved left ischium unstageable wound that was noted with the date of onset as 7/29/15. The skin record indicated the wound to the left ischium measured 5cm x 5.3cm with a 6.5cm depth and wound bed was noted as red with documentation of, mod serosang noted in the exudate type/amount section. The Skin Record reflected the surrounding skin color to be pink. Assessment signed by the DON B. Review of the facility Wound/Skin Record dated 8/25/15 revealed Resident #6 had a deteriorated left ischium unstageable wound that was noted with the date of onset as 7/29/15. The skin record indicated the wound to the left ischium measured 5cm x 5.3cm with a 6.5cm depth and wound bed was noted as, purplish with documentation of, mod serosang noted in the exudate type/amount section. The Skin Record reflected the surrounding skin color to be pink. Assessment signed by the DON B. Review of the facility Wound/Skin Record dated 9/2/15 revealed Resident #6 had a deteriorated left ischium unstageable wound that was noted with the date of onset as 7/29/15. The skin record indicated the wound to the left ischium measured 8.5cm x 6.5cm with a 5.5cm depth and wound bed was noted as, purplish with documentation of, mod serosang noted in the exudate type/amount section. The Skin Record reflected the surrounding skin color to be pink. Assessment signed by the DON B. In an observation on 9/9/15 at 1:30 p.m. Resident #6 was in bed, laying on her back with the head of the bed elevated to about 110 degrees. In an observation on 9/9/15 at 3:45 p.m. Resident #6 was in bed, laying on her back with the head of the bed elevated to about 110 degrees. In an interview on 9/9/15 at 4:10 p.m. LPN HH reported that she had just changed Resident #6 ankle dressing. This surveyor asked LPN HH what position Resident #6 was on prior to the dressing change and she reported her back. This surveyor asked LPN HH what position Resident #6 was in now, after the ankle dressing change and she reported, on her back. LPN HH reported, we should document each time we turn her. LPN HH reported she had planned to perform ankle dressing change much sooner than 4:00 p.m. but was busy. LPN HH was observed asking two CNA's working in the 200 Hall if Resident #6 had been repositioned and they reported they had not repositioned her today and reported their shift started at 2:30 p.m. In an observation on 9/10/15 at 8:35 a.m. Resident #6 was in bed on her back with the head of the bed elevated to about 110 degrees. Resident #6 reported she is planning to take a shower soon. In an observation on 9/10/15 at 10:40 a.m. to 11:30 a.m. Resident #6 was observed returning to her room on a bath bed. Two hospice aids transferred Resident #6 from the shower bed to her bed in the room. LPN Z entered Resident #6's room and performed the dressing changes to the right and left ischium and coccyx area with assistance with rolling from the hospice nurse. Resident #6 stated several times, sit me up. LPN Z reported Resident #6's last pain medication was given at 8:00 a.m. and her next dose is due at 12:00 p.m. Resident #6 was positioned on her back with head of the bed elevated to about 110 degrees after dressing change was complete. No teaching with Resident #6 noted related to wound healing and positioning. In an observation on 9/11/15 at 9:30 a.m. Resident #6 was in bed on her back with the head of the bed elevated to about 110 degrees with her eyes closed. In an interview on 9/14/15 at 12:30 p.m. Director of Nursing (DON) B reported that Resident #6 frequently refuses to be repositioned. DON B reports that those behaviors are care planned but staff know that she refuses to change positions a lot and she believes staff forgets to document or offer position changes or remind resident of consequences if she refuses. DON B reported that the MDS employee who created the Care Plans for Resident #6 is no longer employed with the facility. DON B reported that she was aware there were issues with resident specific interventions and that the facility is currently working to correct that with a new employee in that position. ( )

This Citation pertains to MI 494, MI 839, and MI 155 Based on observation, interview and record review the facility failed to provide adequate supervision, implement interventions to prevent falls, and ensure that personal pressure alarms were in working order for 4 of 15 sampled residents (#1, #3, #4, and #16) reviewed for falls, from a total sample of 21 residents, resulting in the potential for injury and actual injuries. Findings include: Resident #1 Resident #1 was admitted to the facility in 10/13 with a medical history, according to the Face Sheet, which included dementia, delusions, [DIAGNOSES REDACTED], muscle weakness, anxiety, lack of coordination, heart disease, osteoarthritis and urinary incontinence. Review of the MDS (mininum data set an assessment tool) dated 7/14/15 revealed Resident #1 was severely cognitively impaired with daily decision making skills, displayed behaviors related to delirium short attention span, disorganized thinking, required extensive one person assistance with transfers, dressing, personal hygiene and two person assistance with bathing, and was frequently incontinent of both bowel and bladder. Review for balance on the MDS revealed that Resident #1 was not steady and only able to stabilize with staff assistance with surface-surface (moving between chair-bed, on and off toilet), rising from seated to standing position. Review of the Incident/Accident reports dated from 1/15 -8/14/15 revealed Resident #1 had 8 falls during that time frame. Falls Review: Review of the Incident/Accident report revealed, Resident #1 on 1/12/15 at 11 AM had an unwitnessed fall in her room, the bed alarm was found on the bedside dresser not sounding, Resident #1 was sent to the ER for an injury for a head laceration. Review of the Cause Determination Worksheet revealed Roommate's husband said resident was on floor. Bed alarm found on dresser not sounding, changed bed alarm. Did Resident require supervision 'yes'. Recommended steps to prevent recurrence: every time resident is put in bed, make sure bed alarm in under the fitted sheet, Instruct Certified Nurse Aides (CNA's). Review of the CNA Care Guide (instructions on how to provide care) and Nursing Care Plans in place at the time of the fall revealed neither had information about where to place the sensor alarm box only the notation 1/13/15 bed alarm replaced. Review of the Incident/Accident report dated 3/1/15 revealed Resident #1 had a fall at 2:15 AM and was transferred to the ER with head laceration. The alarm was sounding, room furniture was rearranged and the mattress was replaced with a wing-mattress. Toileting every 2 hours was documented as an intervention implemented. Upon return from the hospital the Neurological Assessment Flow Sheet dated 3/1/15 revealed the facility only completed every four hour checks to assess Resident #1's level of consciousness, movement, hand grasp, pupil size, speech, blood pressure, respirations, temperature beginning at 5:30 AM on 3/1/15. Review of the Neurological Flow Sheet provided the guide for every 15 min X 1 hour, every 30 min X 1 hour, every 1 hour X 4 hours then every 4 hours X 24 hours. (Total 16 checks) Review of the Neurological Assessment procedure revealed, Purpose: provide guidelines for assessment 1) upon physician order, 2) following unwitnessed fall 3) subsequent to a fall with a suspected head injury. Per the Falls/Fall Risk Process Guidelines (MDCH, 2001) residents who have fallen are at risk for delayed consequences which may occur within several days after the fall; occasionally they can occur several weeks later. Acute subdural hematomas develop within 48 hours of injury and have an organized clot. Subacute subdural hematomas develop within 3 days to 2 weeks after a head injury. The chronic subdural hematoma can produce symptoms from about 3 weeks to several months after the injury. The damaged area is filled with fluid rather than an organized clot. (Phipps, W. J., Monahan, F. D., Sands, J. K., Marek, J. F., & Neighbors, M. (2003) Medical-Surgical Nursing Health and Illness Perspectives (7 th Ed.). St. Louis: Mosby.) Resident #1 had an unwitnessed fall on 6/6/15 at 8:30 AM , staff responded to an alarm sounding and found Resident #1 sitting on the bathroom floor. Intervention: Nurse or aide will offer toileting prior to medication administration. Resident #1 had last been checked at 7 AM in bed in sleep position eyes shut, did the resident require supervision yes. Both nursing and CNA care plans were updated for every 2 hour toileting. Resident #1 received an abrasion to the left elbow. Review of the Incident/Accident report revealed Resident #1 had an unwitnessed fall on 6/13/15 at 2:25 PM in her room, sitting on the floor holding the right side of her head bleeding from a laceration and was sent to the ER. Resident #1 returned with staples in her head. Resident attempted to get drink of water fell . Intervention: ensure frequently used items are in reach. Neurological Flow Sheet was started hourly (and not per policy) at 6:30 PM until the every 4 hour checks which started at 4:30 AM on 6/14/15. Review of the Incident/Accident report revealed Resident #1 had an unwitnessed fall on 6/29/15 at 10:30 AM in the Main Dining Room. A CNA found the resident lying on her back in the dining room. An alarm was sounding. No apparent injury was sustained. Intervention: Do not leave resident unattended while up in wheelchair. Review of the Incident/Accident revealed Resident #1 had an unwitnessed fall on 7/10/15 at 4:30 PM in the Activities Room. The Incident/Accident Report documented nurse at nurses station when dining room aid called for help. Resident sitting on dining room floor on buttocks in front of her wheelchair. No injuries, Resident's tab alarm was unhooked from resident. Documented was: Did the resident require supervision?; Response, No. (Per previous incident on 6/29/15, Resident #1 was not to be alone in wheelchair). Interventions included: Place tab alarm out of the reach of resident, every 30 minute checks, every two hour toileting. Neurological checks were completed 14 of 16 checks per facility flow sheet. Review of the Incident/Accident revealed Resident #1 had an unwitnessed fall on 7/19/15 at 4:45 PM in her room. Incident/Accident Report documented heard resident talking to someone in hallway went in to see who she was talking to observed on floor next to bed. No one in room, Sensor pad not working replaced. Intervention: ensure bed alarm is working. Review of the Medication Administration Record dated 7/2015 revealed sensor alarm on bed check placement and function every shift was documented on 7/18/15 and 7/19/15 as checked and functional for 11-7 a, 7-3 and 3-11 shift. ( ) Resident #3 Resident #3 was admitted to the facility 11/13 and readmitted on ,[DATE] with a medical history, according to the Face Sheet, which included diabetes, debility, chronic kidney disease, congestive heart failure (weak heart), psychosis, falls, alzheimer's, osteoarthritis, bipolar disease, organic sleep apnea, asthma, urinary incontinence. Review of the MDS (minimum data set an assessment tool) dated 5/31/15 revealed Resident #3 was severely impaired for daily decision making skills, displayed continuous behaviors of inattention, disorganized thinking, was totally dependent requiring two staff for transfers, bed mobility (turning, positioning etc), one person assistance with dressing, toileting and personal hygiene and was incontinent of both bowel and bladder. Review of the Incident/Accident Reports dated 7/1/15 to 7/29/15 revealed Resident #3 had 3 falls on 7/1, 7/3, 7/29/15. Review of the Nursing Care Plan dated 12/14 revealed Fall: 2/28/15. Updated Intervention: 6/1/15 Do Not Leave Resident in Room When in Wheelchair. Fall Review Review of the Incident/Accident Report dated 7/1/15 revealed Resident #3 had a fall on 7/1/15 at 9:30 AM. The report revealed, tab alarm sounding resident sitting on floor in front of wheelchair, CNA's had gotten resident up for the day assisted into wheelchair 20 minutes prior to hearing alarm sound. The report indicated the care plan was not followed. Review of the Fall Risk Evaluation dated 7/1/15 scored 12. (Above 10 high risk for falls). Review of the Incident/Accident Report dated 7/3/15 at 7:30 AM revealed, Resident lying face down on floor in front of wheelchair. Staff statement assisted resident around 7 AM with getting washed up and in wheelchair, refused to leave room. The report indicated the intervention included to return resident to bed if refuses to leave room. X-ray's taken at the facility revealed Resident #3 received a fractured nose related to the fall. Review of the Incident/Accident Report dated 7/29/15 at 7:30 PM revealed Resident #3 had an unwitnessed fall in the Main Dining Room. According to the report, Resident #3 was sitting on the floor upright on the floor beside the wheelchair stated chair slipped from under me. Intervention : Sensor pad applied. Did the Resident require supervision NO was documented. Staff statement dated 7/29/15 by documented the last time Resident #3 had been toiled was around 3:30 PM. Review of the facility CNA Care Sheet dated 9/8/15 revealed an intervention, Do not leave unsupervised in room when in wheelchair. Additional Observation Resident #3 Resident #3 was observed on 9/14/15 during a Hoyer lift transfer from bed to wheelchair. CNA UU transferred Resident #3 from the bed and lowered Resident #3 onto the wheelchair seat. Noted present was a sensor pad alarm on the wheelchair seat. CNA UU did not check the sensor pad or alarm box prior to the transfer. When asked when the alarm was checked and how it was checked, CNA UU reported, We check it before putting the resident in the chair. When asked to demonstrate how the device was tested , CNA UU disconnected the cord from the box to test it. The alarm did not sound. CNA UU stated I should have checked it guess the battery must be dead. ( ) Resident # 4 Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], sent to the hospital from 6/30 to 7/6/15. hospitalized from 8/16 to 8/22/16, emergency room visit on 9/7/15 (was not admitted ) hosptalized on [DATE]. According to the Face Sheet, Resident #4 had a medical history which included Stage 3 kidney disease, congestive heart failure (weak heart), [DIAGNOSES REDACTED](irregular heart beat), depression, anxiety, skin cancer, pacemaker and a history of falls. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 was moderately impaired for daily decision making skills, displayed no verbal or physical behaviors, required extensive one person assistance with bed mobility, transfers, ambulating in room and hall, dressing, toileting and personal hygiene, and was totally dependent on one person assistance with bathing, frequently incontinent of urine and continent of bowel. Review of the facility provided Incident/Accident Reports dated 8/1/15 to 9/8/15 revealed Resident #4 had 6 falls: Fall Review Review of the Incident/Accident report dated 8/1/15 at 6:50 PM revealed Resident #4 had an unwitnessed fall in the hallway while picking something up off the floor. Review of staff statements revealed Resident #4 had been toileted 30 minutes prior to the fall. Interventions included changing the sensor alarm to a tab alarm.Resident #4 sustained a split in skin on bridge of his nose. Also a recent medication change Valium was discontinued and Ativan was started. Review of the fall risk assessment dated [DATE] revealed Resident #4 had a score of 22 (above 10 high risk). Review of the Incident/Accident report dated 8/3/15 at 9:30 PM revealed Resident #4 had an unwitnessed fall in the hallway. Per the report observed on floor in hallway in front of wheelchair. Resident was positioned by nurses medication cart for 1:1 supervision, nurse stepped into another resident's room to assist resident to bathroom. Nurse stepped out of room after hearing alarm to find resident on floor. Placed back in wheelchair. Interventions: Dycem to wheelchair to prevent sliding, new cushion to wheelchair. Documentation on the report indicated Resident #4 did require supervision. Review of the Staff statements revealed the Certified Nurse Aide (CNA) assigned to Resident #4 was on break at the time of the fall on 8/3/15. Review of the Incident/Accident report dated 8/31/15 at 10:15 PM revealed Resident #4 had an unwitnessed fall in his room and that staff heard an alarm sound and found the resident on his knees at bedside. Recent medications Trazodone 50 mg had been given at 8 PM, resident had also been straight cathed for urine at 10 PM (tube placed to remove urine). Interventions included: mat placed at bed and medication review. resident sustained [REDACTED]. Review of the Nursing Care Plan dated 8/3/15 revealed Resident #4 had an unwitnessed fall Dycem to wheelchair, tab alarm to wheelchair. No mention of the added intervention mat placed at bed on 8/31/15 was documented on the Nursing Care Plan. Review of the CNA Care Sheet dated 9/8/15 revealed no information regarding mat placed at bed. Review of the Incident/Accident report dated 9/3/15 at 7:30 PM revealed Resident #4 had an unwitnessed fall by the nurses station. The reports indicated Resident #4, was told by LPN he was observed sitting on wheelchair foot rests, stating needed to use restroom. Intervention: sensor pad in place while resident in wheelchair. No documentation was present regarding safety equipment with 0 noted. Witness Statement of Occurrence dated Staff statements: Last time toileted 3:30 PM; Resident at nurses station, caring for residents down the hall. On 9/14/15 at 10:45 AM this surveyor was looking for Resident #4. Registered Nurse (RN) AA reported that the resident was in the hospital because he fell out of bed and hit his head. Review of the Medical Record Nurses Notes dated 9/11/15 at 11:30 PM revealed Resident #4 was found on floor face down 1/2 laceration sent to ER. Documentation for 9/11/15 at 4:25 AM remains on 15 minute checks, last seen at 11 PM (30 minutes prior to fall) on 9/11/15. ( ) Resident #16 Resident #16 was admitted to the facility on ,[DATE] with a medical history, according to the Face Sheet, which included dysphagia (unable to swallow) psychosis, anxiety, intellectual disability, gastrostomy tube (feeding tube inserted through abdomen). Review of the Incident/Accident report dated 4/3/15 revealed Resident #16 had an unwitnessed fall at 10:45 AM resident sitting in front of wheelchair. Cause Determination Worksheet revealed the tab alarm was not sounding at the time of the fall. Interventions included: String shortened. Potentially change tab alarm to pressure alarm. Review of the Incident/Accident report dated 4/24/15 at 4 AM revealed Resident #16 had an unwitnessed fall in his room and was lying on left side on floor next to bed. The alam sounded. Interventions included floor mats at bedside. Review of the Incident/Accident report dated 7/18/15 at 4:25 PM revealed Resident #16 had an unwitnessed fall in his room. Report documented responding to alarm, entered room observed resident on floor on left side of bed lying over base of bedside table, prior to this resident had been in bed. Brief was checked at 3:50 PM. Intervention: wing mattress. Di resident require supervision? yes. Resident #16 was observed by this surveyor on 9/9/15 at 12 PM in the Main Dining Room sitting in a geri-chair. Noted present hanging from a cord from the back of the chair was an alarm box with no light blinking, when tested the alarm did not sound. Staff removed Resident #16 from the dining room stating. Resident #16 was observed on 9/11/15 in his room in bed. Noted present was a pressure alarm device sitting on the chair seat folder in 1/2. Resident #16 was observed on 9/14/15 at 12 PM in bed in his room with the alarm sitting in the chair seat folded in 1/2 and did not sound when tested . Review of the Manufacturer Information facility provided regarding the sensor pad revealed Testing: test the system battery level and pad life status before every use. Storage: Do not fold pad. In order for the device to alert caregivers that a resident wishes to get out of bed or chair, you must have the full, functioning, connected Alert system. Review of the Medication Record dated 4/15 revealed Tab Alarm to W/C (wheelchair) documented 4/2 to 4/3/15 and Sensor Alarm to bed documented on 4/2 and 4/3/15 and no documentation after those dates. During an interview on 9/14/15 at 12:15 PM, Director of Nursing (DON) reported that Resident #16 had gone out to the hospital on [DATE] for [DEVICE] placement and returned to the facility on [DATE]. The order for the alarms for the wheelchair and sensor was not carried from the March 2015 MAR (medication administration record) to the April MAR so has not been checked since April. ( )

This Citation pertains to MI 075 and MI 155 Based on observation, interview and record review the facility failed to provide adequate hydration in 1 of 21 (#4) sampled residents from a total sample of 21 residents reviewed for hydration resulting in decreased fluid intake and hospitalization for dehydration. Findings include: According to the Face Sheet, Resident #4 had a medical history which included Stage 3 kidney disease, [MEDICAL CONDITION] (weak heart), [MEDICAL CONDITION] (irregular heartbeat), depression, anxiety, [MEDICAL CONDITION], pacemaker and fall history. The medical record revealed Resident #4 was admitted to the facility on [DATE], sent to the hospital from 6/30 to 7/6/15. hospitalized from 8/16 to 8/22/16, emergency room visit on 9/7/15 (was not admitted ) hosptalized on [DATE]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 was moderately impaired for daily decision making skills, displayed no verbal or physical behaviors, required extensive one person assistance with bed mobility, transfers, ambulating in room and hall, dressing, toileting and personal hygiene, totally dependent on one person assistance with bathing, frequently incontinent of urine and continent of bowel. Review of the Nursing Care Plan titled Potential for fluid imbalance and activity intolerance related to (R/T) [MEDICAL CONDITIONS] and receives diuretic therapy dated 7/16/15 revealed Approach: Assess/report signs of dehydration (dizziness on standing, sitting, change in mental status, decreased urine output, concentrated urine, poor skin turgor, dry cracked lips, dry mucous membranes, sunken eyes, constipation, fever, electrolyte imbalance). Report abnormal labs indicative of dehydration elevated hemoglobin and hematocrit, potassium, chloride, sodium, [MEDICATION NAME], blood urea nitrogen (BUN) or specific gravity > 1.030. Review of the Laboratory (lab) results dated 7/7/15 revealed Resident #4's BUN (blood urea nitrogen - helps determine kidney function indicating a sign of dehydration) was 61 (normal 7-25), Creatinine 1.64 (normal 0.70-1.11) with handwritten > (increase) fluids, and potassium 5.4 (normal 3.5-5.3). Review of the Nutritional Review dated 7/9/15 revealed Resident #4 ate 75-100% food intake at meals. On 7/16/15 Resident #4 had a 4# weight loss this week, food intake 50-75%, 480 cc fluid each meal, (1440 cc total). On 7/24/15, Resident #4 had 75% intake with each meal, 480cc (fluid), recommend 90cc med pass twice a day related to weight loss, decreased appetite, nectar thick liquids. Resident #4's weight on 7/21/15 was documented at 161 lbs., on 7/29/15 was 157 lbs., on 8/7/15 at 155lbs,. and on 8/16/15 at 154 lbs. Review of Physician Note titled Psychiatry Consultant Initial Consultation dated 7/27/15 revealed down in bed sleeping, unable to wake him after 2 attempts. Review of the Nursing Notes dated 8/5/15 at 3 PM revealed Resident #4's med's (medications) were held he was lethargic and did not awaken until 12 PM. Got up for therapy for a few minutes, therapy staff brought him back as he was leaning forward in chair BP 90/58 Pulse 92. Review of the Nutritional Progress Note dated 8/5/15 revealed Resident #4's diet change to mechanical soft related to increased confusion. On nectar thick liquids related to coughing drinking thin liquids, needs to be fed now. Review of Resident #4's lab results dated 8/6/15 revealed the results for BUN (blood urea nitrogen indicates kidney function) was 77 and creatinine 1.52 again with > fluids handwritten with the date 8/10/15 signed by NP VV. A second set of lab results dated 8/6/15 from a 2nd lab revealed the BUN as 82 and Creatinine of 1.70 along with the dated handwritten of 8/10/15 by NP VV acknowledging the results. Review of Nursing Notes dated 8/12/15 at 2 PM revealed in bed eyes closed family in left needed to sleep, refused breakfast and lunch offered liquids had 240 cc of orange juice. Review of Nursing Notes dated 8/13/15 at 2 PM revealed Resident #4's BP 92/56, Temp 99 lethargic, responsive to verbal stimuli, heart rate irregular, skin warm pale, oral mucosa dry, fluids encouraged, 8/13 new orders for labs CBC and CMP stat. (complete blood count and comphrensive metabolic panel). Review of the lab results dated 8/13/15 revealed Resident #4 had a BUN of 87, Creatinine 2.4 and Sodium level of 153 (normal 135-145). The results were elevated from previous lab on 8/6/15. Review of the lab results information collected at 5:30 PM, resulted at 8:47 PM. Review of the Physician order [REDACTED]. Review of Nursing Notes dated 8/14/15 at 7 AM revealed Resident lethargic unable to swallow by mouth. IV (intravenous fluids) started at 100 cc hr. 5% D ([MEDICATION NAME] sugar). The note on 8/14/15 at 5 PM revealed current bag IV fluids completed, change IV fluids to NS (normal saline) at 100 cc/hr X 2 liters. The Nurses Note on 8/14 at 11:30 PM revealed ate approximately 20% of dinner, BP (blood pressure) 90/72. The note on 8/15/15 at 1 AM revealed BP 92/57, pulse 120. An the note on 8/15/15 at 8 PM revealed, IV finished at 8:30 PM appears weak but alert. Review of the MAR indicated [REDACTED]dehydration. Review of the emergency room lab results dated 8/16/15 at 11:44 AM revealed BUN 117, Creatinine 2.7, Sodium 156. Resident #4 had [DIAGNOSES REDACTED]. Review of the Data Collection Nutritional Evaluation dated 8/22/15 revealed Average daily fluid intake was 1440cc's and Resident #4's fluid needs were 1875-2250 cc/day. Nutritional Diagnosis: [REDACTED]. Problem: at increased risk for nutrition, wounds and dehydration. During an interview on 9/10/15 at 3 PM, Family Member CC reported that he and another family member could come at least every other day, and after the [MEDICATION NAME] was started at the beginning of August, he didn't know what was going on he couldn't stay awake and eat or drink, old food was in his mouth we would clean out, I came at dinner to make sure he was eating and drinking, he was always in bed and got to the point he was not eating or drinking, even after they started those IV's. He didn't get better and had to go to the hospital. Resident # 4 was observed on 9/8/15 at 1:20 PM lying in bed with the head of the bed elevated at 90 degrees and requested this surveyor to assist getting him up at the edge of the bed. Noted present at the bedside sitting on the over bed table not within reach of the resident was a white styrofoam glass full of clear liquid the glass was undated. When asked if he was able to reach the glass Resident #4 replied No. While in the room Certified Nurse Aide (CNA) M and FF entered the room to provide incontience care at 1:22 PM. Resident #4's brief was dry. CNA M reported that Resident #4, has been dry all day. He was dry at breakfast and tried to use the urinal before lunch but could not, he went to theER on ,[DATE] for a swollen penis. When asked if the nurse was told about Resident #4 not urinating all day, CNA M replied not yet and left the room. CNA M returned with Licensed Practical Nurse (LPN) J at 1:40 PM who reported the resident had been cathed at 7 AM and stated, I didn't know he hasn't voided all day. The CNA should be telling me about that. When CNA M was asked about how much fluids Resident #4 had up to that point CNA M stated, A glass of water at breakfast and lunch, maybe a 1/2 glass between meals that's all for me. Upon completing care both CNA's exited the room and did not offer Resident #4 a drink from the glass that was on the over bed table. ( ) During the confidential group meeting on 9/9/15 at 10:00 am, 2 of the 3 residents in attendance, stated that they were provided with one glass of ice water at their bedside for the entire day, they stated they were supposed to get fresh ice water every shift. One resident stated that she did not drink the water provided at her bedside I don't like warm water.

This Citation pertains to MI 3672 Based on interview and record review the facility failed to notify the attending physician and family members of an acute change of condition (low blood oxygen levels, declining mental status changes) and resident refusals for transfer to the emergency room in 1 of 3 sampled residents (#101) reviewed physician and family notifications, from a total sample of 3 residents, resulting in the physician not being involved in medical care decisions and the family not involved to assist in care decisions. Findings include: Resident #101 was admitted to the facility on [DATE] with a medical history which included according to the facility face sheet [MEDICAL CONDITION] (heart pumps inefficiently) kidney disease, [MEDICAL CONDITION] (swelling of legs), high blood pressure, sleep apnea, obesity and depression. Review of the facility document titled Therapeutic Interventions dated [DATE] and signed by Resident #101 with it is my desire that: CPR is administered and attending physician notified, paramedics will be contacted. Transfer to the hospital will occur. Review of the facility MDS dated [DATE] revealed Resident #101 was cognitively intact for daily decision making skills, was totally dependent on two people for transfers, totally dependent on one person assistance for toileting, all activities of daily living, bathing and extensive one person assistance with dressing, and was incontinent of both bowel and bladder. Review of the facility progress notes dated from [DATE] to [DATE] revealed daily nursing documentation. Nursing documentation was present in the medical record on [DATE] and the next nursing documentation was on [DATE] at 8 AM with the entry Resident lethargic (drowsy slow to arouse) [MEDICATION NAME] held (pain medication). [DATE] at 11 AM resident experiencing increased in sedation easily aroused, neuro checks intact O 2 sats 96% on room air. [DATE] 2 PM resting quietly in bed, no acute distress noted denies pain/discomfort. Review of the facility progress notes dated [DATE] at 5 PM resident continues to be lethargic, slow to respond verbally. Around 3:30 PM this nurse walked into room to find resident resting quietly lips and surrounding area bluish in color, O 2 sats 60% on room air (normal above 92%). Resident alert and oriented lung sounds clear on auscultation (listening) Denies shortness of breath, difficulty breathing will continue to monitor. Entry at 5:30 PM on [DATE] new order from nurse practitioner to send resident to emergency room (ER) due to [MEDICAL CONDITION] (low blood oxygen levels) increased sedation, slowness to respond to verbal stimuli, ambulance arrived, resident assessed, O 2 sats 89%. Resident refused to go to ER x 3 attempts. O 2 up to 90% on 2 L (liters how oxygen is given) of oxygen. 6 PM on [DATE] O 2 89% on 2 L oxygen, will continue to monitor. 9 PM on [DATE] O 2 90% on 2 L oxygen, denies shortness of breath, difficulty breathing, took med's, remains slightly lethargic, difficult to arouse from sleep. Nursing documentation on [DATE] at 5 AM O 2 sats 91% on 2 L oxygen via nasal cannula. On [DATE] at 2 PM remains sleepy O 2 sat on 2 L 88%, encouraged to wear C-pap O 2 with C-pap 94%, refused to keep C-pap on oxygen up to 3 L nasal cannula O 2 sats 91% at 3 L. Nursing documentation on [DATE] at 11:30 AM revealed O 2 76% on 2 L oxygen, blood sugar 153. Dr. See notified order to increase oxygen to 4 L apply C-pap for 1 hour, head of bed up, refused X 3 to wear C-pap. Doctor ordered to send resident to ER for evaluation, after increase of O2 to 4 L O 2 sats 91%, resident stating I have no Oxygen. At 2:15 PM resident lethargic O 2 sats 80% at 4 L oxygen, placed C-pap on Sats at 81%. Skin noted moist flushed red, explained need to go to ER resident nodded yes 911 called at 2 PM. family member called at 2:05 PM, doctor notified of transfer to ER at 2:20 PM. During an interview with RN N on [DATE] at 2:15 PM she reported that Resident #101 on [DATE] at 8 AM was sleeping, not wide awake and she held the [MEDICATION NAME] and fell back asleep but did talk to me, it was not unusual for him to be drowsy in the morning, he didn't eat breakfast but did eat lunch and when I checked him at 2 PM he told me he was fine, I was trying to figure out why his oxygen level was low and started oxygen I probably should have called the doctor but no I did not. When asked about the documentation on [DATE] was Resident #101 a regular oxygen user? NO, the C-Pap didn't seem to help I asked the Nurse Practitioner (NP) who was here (not the resident's regular NP) another resource I go to I increased the oxygen to 3 L on my own after that consult with the NP I didn't call the attending physician about what was going on. During an interview with RN O on [DATE] at 2:40 PM she reported that a CNA (certified nursing assistant) told her about Resident #101 having blue lips, at that time his O 2 sat was 60% on 2 L and came up to 80%, he was lethargic, arousable, the oxygen was started by standing orders, the NP was here so she saw him and the NP ordered him to go to ER. I called 911 and they came into the room tried to arouse him but he refused to go to the ER, he was only talking when asked questions the NP left the building I didn't call about his refusal to go to ER to the doctor or family, his lips were a better color, No I didn't call about the low oxygen levels. When asked if during the conversation with the attending physician on [DATE] at 6 PM did she discuss Resident 101's condition or update his status to the physician while taking with him about the INR or at 10:30 PM when the oxygen levels were 75%-89% was the physician notified No I passed it on to the night nurse and didn't call the doctor. When asked at any point was the family notifed to assist with talking with the resident about the transfer to ER, RN O replied he didn't want them called so I didn't. Review of the facility Nursing Care Plan dated [DATE] titled Potential for fluid imbalance and activity intolerance related to [MEDICAL CONDITION], Lower extremity [MEDICAL CONDITION]. Approach: Observe and report signs of respiratory distress, (cyanosis, dyspnea, confusion, restlessness, nasal flaring, increased respirations). Review of the facility face sheet revealed a list of 3 family members listed as Emergency contacts in case of emergency, no other documentation was present requesting family members not be notified in case of emergency or change of condition. During an interview with NP (nurse practitioner) M on [DATE] at 1:40 PM she reported that she was not notified of Resident 101's refusal to go to ER. I saw him because I was in the building it was a semi-emergent situation, I was not his NP of record but after examining him and talking to him about his condition and medications he told me that his coordination was off and was dropping things, I told him he needed to go to the ER and he agreed to go to the ER, I left the building thinking he was on his way to ER no even though I was not his NP of record I saw his condition warranted going to ER I don't what happened in the 20 minutes before EMT's arrived and I left him why he didn't go to ER, he consented for me, he needed to go out, I don't remember exactly but would have told them to notify the attending or who ever was on call about the situation and update them. I was shocked when I came in on Wed. ,[DATE] and he was still in the building I thought he was in the hospital . Review of Hospital document dated [DATE] revealed Resident #101 expired on [DATE]. discharged Condition: deceased . ( )

This Citation pertains to MI 3672 This Citation Contains Two Deficient Practice Statements, A and B. A. Based on interview and record review the facility failed to ensure the highest possible physical well-being by recognizing and adequate seek treatment for [REDACTED].#101) reviewed for change of condition, from a total sample of 3 residents, resulting in Resident #101 receiving a delay in treatment for [REDACTED]. Findings include: The profession standard of quality for notifying the physician of acute change in condition is to immediately report a sudden onset of an acute change in mental status to the physician. (Clinical Process Guideline for Acute Change of Condition, MDCH Clinical Advisory Panel, Memorandum dated [DATE]). A licensed nurse shall, in a complete, accurate and timely manner, report and document nursing assessments or observations, the care provided by the nurse for the client, and the patient or to recognize changes in a patient's condition. Failure to recognize the significance of changes or to communicate them clearly and promptly to the attending practitioner could endanger the patient. (McMahon & Associates. Nursing Standards of Practice. HGExperts.com. Retrieved [DATE], from http://www.hgexperts.com/article) Resident #101 was admitted to the facility on [DATE] with a medical history which included according to the facility face sheet [MEDICAL CONDITION] (heart pumps inefficiently) kidney disease, [MEDICAL CONDITION] (swelling of legs), high blood pressure, sleep apnea, obesity and depression. Review of the facility MDS dated [DATE] revealed Resident #101 was cognitively intact for daily decision making skills, was totally dependent on two people for transfers, totally dependent on one person assistance for toileting, all activities of daily living, bathing and extensive one person assistance with dressing, and was incontinent of both bowel and bladder. Review of the facility progress notes dated from [DATE] to [DATE] revealed daily nursing documentation. Nursing documentation was present in the medical record on [DATE] and the next nursing documentation was on [DATE] at 8 AM with the entry Resident lethargic (drowsy slow to arouse) [MEDICATION NAME] held (pain medication). [DATE] at 11 AM resident experiencing increased in sedation easily aroused, neuro checks intact O 2 sats 96% on room air. [DATE] 2 PM resting quietly in bed, no acute distress noted denies pain/discomfort. Review of the facility progress notes dated [DATE] at 5 PM resident continues to be lethargic, slow to respond verbally. Around 3:30 PM this nurse walked into room to find resident resting quietly lips and surrounding area bluish in color, O 2 sats 60% on room air (normal above 92%). Resident alert and oriented lung sounds clear on auscultation (listening) Denies shortness of breath, difficulty breathing will continue to monitor. Entry at 5:30 PM on [DATE] new order from nurse practitioner to send resident to emergency room (ER) due to [MEDICAL CONDITION] (low blood oxygen levels) increased sedation, slowness to respond to verbal stimuli, ambulance arrived, resident assessed, O 2 sats 89%. Resident refused to go to ER x 3 attempts. O 2 up to 90% on 2 L (liters how oxygen is given) of oxygen. 6 PM on [DATE] O 2 89% on 2 L oxygen, will continue to monitor. 9 PM on [DATE] O 2 90% on 2 L oxygen, denies shortness of breath, difficulty breathing, took med's, remains slightly lethargic, difficult to arouse from sleep. Nursing documentation on [DATE] at 5 AM O 2 sats 91% on 2 L oxygen via nasal cannula. On [DATE] at 2 PM remains sleepy O 2 sat on 2 L 88%, encouraged to wear C-pap O 2 with C-pap 94%, refused to keep C-pap on oxygen up to 3 L nasal cannula O 2 sats 91% at 3 L. Nursing documentation on [DATE] 6 PM Dr. notified of INR results 4.3 (blood test for residents on [MEDICATION NAME]) At 9:30 PM continues to be slightly lethargic, continues on O 2 2 L O 2 sat 90%. At 11:30 PM Refused to keep O 2 on with C-pap machine on, O 2 with C-pap on room air 75%. O 2 at 2 L applied sats 89%. Nursing documentation on [DATE] at 11:30 AM revealed O 2 76% on 2 L oxygen, blood sugar 153. Dr. See notified order to increase oxygen to 4 L apply C-pap for 1 hour, head of bed up, refused X 3 to wear C-pap. Doctor ordered to send resident to ER for evaluation, after increase of O 2 to 4 L O 2 sats 91%, resident stating I have no Oxygen. At 2:15 PM resident lethargic O 2 sats 80% at 4 L oxygen, placed C-pap on Sats at 81%. Skin noted moist flushed red, explained need to go to ER resident nodded yes 911 called at 2 PM. family member called at 2:05 PM, doctor notified of transfer to ER at 2:20 PM. During an interview with RN N on [DATE] at 2:15 PM she reported that Resident #101 on [DATE] at 8 AM was sleeping, not wide awake and she held the [MEDICATION NAME] and fell back asleep but did talk to me, it was not unusual for him to be drowsy in the morning, he didn't eat breakfast but did eat lunch and when I checked him at 2 PM he told me he was fine, I was trying to figure out why his oxygen level was low and started oxygen I probably should have called the doctor but no I did not. When asked about the documentation on [DATE] was Resident #101 a regular oxygen user? NO, the C-Pap didn't seem to help I asked the Nurse Practitioner (NP) who was here (not the resident's regular NP) another resource I go to I increased the oxygen to 3 L on my own after that consult with the NP I didn't call the attending physician about what was going on. During an interview with RN O on [DATE] at 2:40 PM she reported that a CNA (certified nursing assistant) told her about Resident #101 having blue lips, at that time his O 2 sat was 60% on 2 L and came up to 80%, he was lethargic, arousable, the oxygen was started by standing orders, the NP was here so she saw him and the NP ordered him to go to ER. I called 911 and they came into the room tried to arouse him but he refused to go to the ER, he was only talking when asked questions the NP left the building I didn't call about his refusal to go to ER to the doctor or family, his lips were a better color, No I didn't call about the low oxygen levels. When asked if during the conversation with the attending physician on [DATE] at 6 PM did she discuss Resident 101's condition or update his status to the physician while taking with him about the INR or at 10:30 PM when the oxygen levels were 75%-89% was the physician notified No I passed it on to the night nurse and didn't call the doctor. When asked at any point was the family notified to assist with talking with the resident about the transfer to ER, RN O replied he didn't want them called so I didn't. Review of the facility document titled Therapeutic Interventions dated [DATE] and signed by Resident #101 with it is my desire that: CPR is administered and attending physician notified, paramedics will be contacted. Transfer to the hospital will occur. Review of the facility face sheet revealed a list of 3 family members listed as Emergency contacts in case of emergency, no other documentation was present requesting family members not be notified in case of emergency or change of condition. During an interview with NP (nurse practitioner) M on [DATE] at 1:40 PM she reported that she was not notified of Resident 101's refusal to go to ER. I saw him because I was in the building it was a semi-emergent situation, I was not his NP of record but after examining him and talking to him about his condition and medications he told me that his coordination was off and was dropping things, I told him he needed to go to the ER and he agreed to go to the ER, I left the building thinking he was on his way to ER no even though I was not his NP of record I saw his condition warranted going to ER I don't what happened in the 20 minutes before EMT's arrived and I left him why he didn't go to ER, he consented for me, he needed to go out, I don't remember exactly but would have told them to notify the attending or who ever was on call about the situation and update them. I was shocked when I came in on Wed. ,[DATE] and he was still in the building I thought he was in the hospital . Review of the Ambulance Run Information dated [DATE] 1:58 PM Male having respiratory distress, on arrival sitting on edge of bed. Was told by nurse that patient has been having respiratory distress and decreased LOC (level of conciousness) for past few days. Has been refusing transport until today. Morbidly obese, with fluid retention in all extremities. Skin pale warm, wet, Respirations rapid, shallow, labored. Audible congestion noted. Pupils equal and reactive. Nursing home staff had applied C-Pap machine. Nurse stated initial SPO2 was 77%. increased to 84%. Very lethgaric, low LOC, opens eyes to verbal, did not speak, very weak not able to hold his head up. Administered O2 via NRB (non-rebreather mask) EKG showed A-Fib. ausculatation (listening) of lungs fluid congestion in all lobes. SPO2 low at 88%. Fire responder to ride along and assist in keeping head up and assist in bagging pt with BVM (ambu bag). Continued to bag during transport. Review of Hospital document dated [DATE] revealed Resident #101 expired on [DATE]. discharged Condition: deceased . ( ) B. Based on interview and record review the facility failed to document complete body assessments in 1 of 3 sampled residents (#101) from a total sample of 3 residents reviewed for skin assessments resulting in unrecognized skin impairment discovered upon hospital admission. Findings include: Resident #101 was admitted to the facility on [DATE] with a medical history which included according to the facility face sheet [MEDICAL CONDITION] (heart pumps inefficiently) kidney disease, [MEDICAL CONDITION] (swelling of legs), high blood pressure, sleep apnea, [MEDICAL CONDITION] and depression. Review of the facility MDS dated [DATE] revealed Resident #101 was cognitively intact for daily decision making skills, was totally dependent on two people for transfers, totally dependent on one person assistance for toileting, all activities of daily living, bathing and extensive one person assistance with dressing, and was incontinent of both bowel and bladder. Review of the hospital documentation titled Wound/Ostomy Consult Note dated [DATE] (one day after admission to the hospital) revealed Resident #101 was referred to the wound care nurse for evaluation and treatment of [REDACTED]. Family Member on way out of room asked about wound to left upper thigh and was unable to provide a history as to the cause. Assistance needed with rolling side-side total body check skin intact, no redness. Large heavy abdominal panis (large belly) with deep skin crease. Skin intact moist reddened irregular margins with strong fungal-like odor present. Left Upper Anterior Thigh (front part of thigh) Open wound irregular shape with few very small weeping serous fill blisters. Measure at widest margins 5 X 6 cm, open wound area depth 0.1 cm. Open wound is dark pink. Drainage amount small serous to serosangeous (clear to blood tinged fluid). Assessment: Abdominal and groin skin folds: Moisture Associated [MEDICAL CONDITION] with fungal component. Left Upper Anterior Thigh: presents as partial thickness wound, unknown cause of wound. Review of facility documentation titled Weekly Shower and Check Monitoring Form dated ,[DATE] revealed on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] revealed No new skin issues were documented. Review of the facility documentation titled Weekly Shower and Check Monitoring Form dated ,[DATE] revealed on ,[DATE], ,[DATE], ,[DATE] revealed No new skin issues were documented. Review of the facility documentation titled Monthly Nursing Summary dated [DATE] revealed in section Skin Condition; warm and dry, Braden Score 16 (if score 18 or below document preventative measures Section Preventative Skin Measures no documentation was present. Review of the facility Nursing Care Plan titled resident experiences bladder incontience related to [MEDICAL CONDITION], diuretic use and due to [MEDICAL CONDITIONS], and lower extremity [MEDICAL CONDITION] dated [DATE]. Goal: Resident will not exhibit skin breakdown. Intervention: Provide assistance with lifting stomach and urinal PRN (as necessary). Report any signs of skin breakdown (sore, tender, red or broken areas). Nursing Care Plan titled Pressure Ulcer dated [DATE] at risk for skin breakdown related to impaired mobility secondary to [MEDICAL CONDITIONS], lower extremity [MEDICAL CONDITION]. Approach: Conduct a systematic skin inspection weekly, pay attention to bony prominences, CNA to observe skin integrity with daily care. During an interview on [DATE] at 4:10 PM, when asked if during skin checks had she lifted the resident's belly to check the condition of the skin underneath Licensed Practical Nurse (LPN) I reported, I don't remember checking that. He was getting treatments for his legs, those were what I checked. I don't recall ever checking under his abdominal folds. ( )

This citation refers to MI 043. Based on observation, interview, and record review, the facility failed to maintain the highest practicable physical well-being when suctioning was not provide per physician's orders [REDACTED].#103) reviewed for emergency response procedures, from a total sample of 4 residents, resulting in an Immediate Jeopardy when Resident #103, who was a full code, was found unresponsive on [DATE] at approximately 9:45 a.m. Facility staff did not provide Resident #103 with adequate oxygenation to her [MEDICAL CONDITION] during CPR and did not notify EMS until 10:01 a.m. Resident #103 had no brainstem activity upon arrival at the emergency room and subsequently died on [DATE] at 2:33 p.m. This deficient practice places 1 additional resident, who has a [MEDICAL CONDITION], at risk for serious harm, injury, and/or death. Findings include: Review of the policy titled "Emergency procedure for cardiopulmonary resuscitation (CPR)", revised [DATE], revealed "depending on the underlying cause, the chances of surviving SCA (sudden [MEDICAL CONDITION]) may be increased if CPR is iniated immedicately upon collapse. In potentially reversible situations, early delivery of a shock with a defibrillator plus CPR within ,[DATE] minutes of collapse can further increase chances of survival. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS (basic life support) shall initiate CPR unless: a. it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. there are obvious signs of irreversible death (e.g. rigor mortis). Review of the Face Sheet, dated [DATE], revealed Resident #103 was a [AGE] year old female who was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of Resident #103's Respiratory care plan, dated [DATE], revealed staff were to "provide suctioning as ordered/needed for secretions, cleanse inner cannula every shift, and site care and tubing change as ordered". Review of the Physician Orders, dated [DATE], revealed Resident #103 was to be suctioned every 4 hours and as needed and have the inner cannula of the [MEDICAL CONDITION] changed every shift. The Physician order [REDACTED]. Review of Resident #103's Medication Administration Record (MAR), dated ,[DATE], revealed Licensed Practical Nurse (LPN) "K" initialed the MAR on [DATE] at 12 a.m., at 4 a.m., and at 8 a.m. that he [MEDICAL CONDITION] on Resident #103. LPN " K " also recorded on the MAR that Resident #103's inner cannula was changed on both the ,[DATE] and ,[DATE] shift. In an interview on [DATE] at 4:00 p.m., LPN "K" (the nurse assigned to care for Resident #103) was shown Resident #103's February 2015 MAR and asked if the initials in the 12 a.m., 4 a.m., and 8 a.m. blocks on [DATE] for suctioning and the ,[DATE] and ,[DATE] shift blocks for changing the inner cannula of Resident #103's [MEDICAL CONDITION] were his. LPN "K" stated they were, " but there is variation with them." LPN "K" was asked if he had actually performed the inner cannula changes on the ,[DATE] and ,[DATE] shifts and the suctioning at 8:00 a.m. LPN "K" stated he had not. LPN "K" stated, "At 3:30 a.m., I noticed she (Resident #103) was slightly gurgley. I did suctioning. I didn't change the inner cannula on nights (night shift ,[DATE]) or on days (day shift ,[DATE]). I only change the inner cannula at night if she (Resident #103) is gunky or gurgley. After I do the med (medication) pass I change the inner cannula." Review of the nursing progress note, dated [DATE] at 9:55 a.m., revealed Resident #103 was "found unresponsive" . During the interview on [DATE] at 4:00 p.m., LPN "K" stated, "I went in the room to do my meds at 9:45 a.m. I looked at her (Resident #103) and I didn't see any breathing. I checked her pulse and couldn't feel anything. After I didn't find a pulse, I found (LPN "I") and asked her to check her (Resident #103). I went to the DON's (director of nursing) office at 9:50 (a.m.) to check code status (Resident #103's). I went back to the room with (DON "B") and told (LPN "I" ) she's (Resident #103) a full code and to do CPR. I cleared everything out of the room. (DON "B" ) started chest compressions and the crash cart arrived. They (clinical care coordinator (CCC) "F" ) pulled the ambu bag from the crash cart. I switched (back and forth) with (DON "B" ) to do chest compressions. We kept doing chest compressions until the paramedics arrived. I also helped with the ambu bag. When the paramedic arrived, he said something to (CCC "F" ) about the ambu bag and how it was to be connected. I heard the paramedic that was running things say "the connection should be changed" to the ambu bag. There was some adjustment, but I didn't see it because there were 2 paramedics between me and (CCC "F")." In a second interview on [DATE] at 7:10 a.m., LPN "K" stated, "I found her (Resident #103) at 9:45 a.m. and we started CPR at about 9:48 or 9:50 a.m. I had went into the room at 9:45 a.m. to give meds. I'm sure I found her at 9:45 because I had a resident that wanted his meds at 9:30. I gave him his meds. I then set up her meds and she had quite a lot of liquid meds to set up. It took about 10 minutes to set up the meds and then it took a little time to wash my hands and take them in the room. When I went in the room I didn't see her stomach moving or feel a pulse. I went to (LPN "I" ) who was around the nurse's station and said to her my patient (Resident #103) was unresponsive and I needed a second opinion. I don't remember if I went back to the room with (LPN "I") or if I went to the office to get (DON "B") next. I went into the office and told (DON "B"). (DON "B") and I went down to the room. I think (DON "B") started chest compressions first, then (CCC "F") started doing the bag (ventilations)." In an interview on [DATE] at 9:30 a.m., LPN "I" stated, "I was by the nurse's station when (LPN "K") came up to me. It was right before 10:00 a.m. He said "can you come here and check this person (Resident #103) for me?" He went down to the room with me. When I checked her (Resident #103) I couldn't find a pulse or respirations. I told him to go get help. (CCC "F") came in and checked for a pulse and breathing. (DON "B") came into the room and called for a crash cart. (CCC "F") grabbed the ambu bag from the crash cart and hooked the bag up to the concentrator. I don't remember how else it was hooked up. I remember she (CCC "F") wasn't sure how to hook it to the trach. (DON "B") told her it needed to be hooked up to the oxygen and oxygen tubing. I was doing compressions before the EMT's arrived." In an interview on [DATE] at 10:30 a.m., Director of Nursing (DON) "B" stated, "the nurse (LPN "K") came to my office around 9:55 a.m. and he said he found her (Resident #103) unresponsive. He had checked a pulse and there was no pulse. We were working on her chart and we looked and saw she was a full code. We immediately went to the room- myself, (LPN "K" ), (CCC "F"), and (LPN "I"). (CCC "E") called 911 (EMS). We had a CNA (certified nursing assistant), (CNA "H") go for the crash cart. We went into the room. I checked for a pulse. There was no pulse. She was not breathing. I tried a sternal rub and got nothing. By then the crash cart was there. We rolled her (Resident #103) over- myself and (confidential informant (CI) "G") and put the back board under her. I started chest compressions. We connected the AED (automated external defibrillator) to her. We waited for the AED to tell us to continue CPR or shock. It said to continue CPR and didn't administer a shock. I was doing chest compressions. (CCC "F") was ventilating (with the ambu bag). We continued CPR until the paramedics arrived. When they (the paramedics) arrived, they took over. We were doing CPR for ,[DATE] minutes before the paramedics arrived." According to the crash cart AED Log, dated [DATE], the AED was turned on at 10:04 a.m.on [DATE] (19 minutes after LPN "K" stated he found Resident #103 without a pulse or respirations and 9 minutes after DON "B" stated LPN "K" notified her that Resident #103 didn't have a pulse). In an interview on [DATE] at 10:55 a.m., CCC "F" stated, "This happened right after the morning meeting about 9:30-ish. I was in my office down (hall Resident #103's room was located on). The nurse (LPN "K") came in my office and said she (Resident #103) wasn't breathing. We- myself, (DON "B"), and (CCC "E") - went down the hall to the room. When we got to the room, I saw a nurse in the room. She (LPN "I" ) was assessing her (Resident #103). She was checking for a pulse. She (Resident #103) looked like she was sleeping, but no chest rise. (DON "B") went to the head of the bed. I went to get the crash cart. I saw someone (CNA "H") coming down the hall with the crash cart and I went with (CNA "H") to the room (with the crash cart). I grabbed the ambu bag and attached it to the oxygen and [MEDICAL CONDITION]. By then they had the back board under her. (DON "B") started compressions. I started bagging (ventilating with the ambu bag). I was squeezing the bag every 3 seconds. When I got the crash cart there, (DON "B") put the AED on her (Resident #103) and (LPN "K") took over compressions. We paused while it (the AED) analyzed, but I kept doing the oxygen because it doesn't affect anything. The AED said 'no shock advised, continue CPR'. We continued CPR. The EMT's (emergency medical technicians) arrived. They put their AED on her and told me to keep bagging. They took over compressions. At one point they had us stop and they listened (for a heartbeat and lung sounds). They had me continue bagging. They got a pulse, stopped compressions, switched her to their oxygen tank, and took her out." In an interview on [DATE] at 11:15 a.m., CNA "H" stated she had seen Resident #103 at 9:15 a.m. when she picked up her (Resident #103) roommate's breakfast tray. CNA "H" stated, "(Resident #103) seemed ok at that time. She looked at me. About 20 minutes later, we saw everyone running down there (to Resident #103's room). I heard 'we need the crash cart', so I ran down and got the crash cart. I ran to the room with the crash cart. I saw (DON "B") put on the pads. The box (AED) said it's ok to touch the patient, so she (DON "B") started compressions. (DON "B") said, 'I need the board (backboard)', we got it for her and shoved the board under her (Resident #103) and (DON "B") started compressions again. (CCC "F") was moving the bag. She was squeezing the bag while (DON "B") did compressions." In a second interview on [DATE] at 9:00 a.m., CCC "F" stated, "I took the ambu bag from the crash cart because it was close to me. I initially attached the bag (ambu bag) to the blue tubing (running to the humidifier). I attached the oxygen tubing to the oxygen concentrator. I turned the oxygen all the way up on the concentrator. I don't know how high the concentrators go. I think it's 5 or 6 liters. They were doing compressions, so I don't know if the chest was rising when the bag was hooked up to the blue tubing. We were doing everything at the same time. The EMT's showed up and someone said the ambu bag needed to be changed. The EMT pulled off the mask and told me to attach the ambu bag to the trach." Immediately after the interview, CCC "F" and this surveyor went to a resident's room who had a [MEDICAL CONDITION] and the same set up that Resident #103 had. CCC "F" pointed out to this surveyor (without actually disconnecting the resident's tubing) the manner in which she initially attached the ambu bag to the concentrator and blue tubing. According to the demonstration CCC "F" had disconnected the oxygen from Resident #103's [MEDICAL CONDITION] mask, attached the oxygen to the ambu bag oxygen tubing, and connected the ambu bag to the blue tubing that led into the humidifier and not to the [MEDICAL CONDITION] stoma. CCC "F" verbalized that this was the manner in which she had initially set up the ambu bag and had started ventilations. In a second interview on [DATE] at 10:30 a.m., DON "B" stated, "at the time I wasn't paying attention to how the ambu bag was attached. I just know initially the ambu bag was attached to the tubing and the concentrator, but I don't know what the tubing looked like. I don't know how much (oxygen) she (Resident #103) was getting through the concentrator. I believe the concentrators go up to 5 liters. When the paramedic showed up he had us disconnect the ambu bag from the tubing and attach it directly to the trach." In an interview on [DATE] at 10:00 a.m., CCC "E" stated, "(LPN "K") came into the nursing office after our morning meeting. It could have been 9:40 a.m. I don't honestly know the time. (LPN "K") said (Resident #103) wasn't breathing and she didn't have a pulse. We looked in the physician orders [REDACTED]. Her son hadn't been in yet to sign the code papers, so that is why we checked the physician orders. It was the first page after the physician order [REDACTED]. (DON "B") and (CCC "F") ran out of the room after we checked the chart. I immediately called 911." CCC "E" was shown that the EMT report stated the time of the event (the time Resident #103 was found unresponsive) was listed as 9:50 a.m., but the call wasn't placed until 10:01 a.m. and asked what could have caused a delay in calling 911. CCC "E" stated, "I can't think of any reason why the sheet would say 9:50 a.m. and the call was at 10:01 a.m. I called immediately." In an interview on [DATE] at 12:15 p.m., Paramedic (EMT) "L" stated, "When I arrived the staff were doing CPR compressions. They had the (ambu) bag attached to an extension that was attached to the stoma mask, not to the stoma itself. I immediately disconnected the bag and attached it to the stoma. With it (the bag) being attached to the mask, there is only air flow around the stoma not directly into it, so she (Resident #103) wasn't getting adequate oxygenation. I don't know if the staff knew that." Review of the facility personnel files revealed Director of Nursing (DON) "B", Clinical Care Coordinator (CCC) "F", LPN "I", and LPN "K" all had current CPR/BLS (Basic Life Support) certifications. Review of the EMS report, dated [DATE], revealed the "onset time" was 9:50 a.m. on [DATE] and the estimated time of arrest prior to EMS arrival was ",[DATE] minutes." The report revealed that the incident occurred at 9:50 a.m., the 911 call was made at 10:01 a.m., and EMS arrived on scene at 10:04 a.m. The report revealed, "Staff performing CPR and ventilating the pt (patient) through a stoma mask with a BVM (bag valve mask) hooked to an oxygen generator (oxygen concentrator). The BVM was attached directly to the stoma and CPR was continued. Asystole (flat line) was the initial rhythm noted. " Review of the emergency room note dated [DATE] revealed "She (Resident #103) is not awake or alert. Pupils fixed and dilated. No spontaneous movement. She requires [MEDICATION NAME] to maintain adequate blood pressure. Upon arrival, the patient was being bagged through a [MEDICAL CONDITION] site. She had overall poor air movement and it was difficult to bag the patient. I had the respiratory therapist remove the inner lumen of the trach, which revealed a large mucous plug. We had a new one replaced and were able to bag her quite easily. After replacement and bagging, we lost pulses once again and CPR was resumed." Review of the hospital Physician Encounter note, dated [DATE], revealed Resident #103 was "comatose with no brainstem reflexes. Unfortunate [MEDICAL CONDITION] due to [MEDICAL CONDITION] mucous plugging while at NH (nursing home)." Review of the hospital physician discharge summary, dated [DATE], the neurologist examined Resident #103. "Apnea testing revealed no spontaneous breath after 12 minutes" which along with lab results "meets the criteria for brain death." "Brain death at 1200 (12:00 p.m.), off ventilator support at 1416 (2:16 p.m.), asystole on bedside monitor at 1433 (2:33 p.m.)." Review of the physician encounter note, dated [DATE], revealed Resident #103's "cause of death: Severe hypoxic ischemic [MEDICAL CONDITION] secondary to cardiopulmonary arrest." On [DATE] at 2:20 p.m., Administrator (ADM) "A" was notified of the Immediate Jeopardy that began on [DATE] at 9:45 a.m. when Resident #103 was found unresponsive with no pulse or respirations and staff did not provide CPR per professional standards or immediately activate EMS. This surveyor verified that the facility implemented the following to remove the Immediate Jeopardy: 1. On [DATE], the facility initiated in-service training for CPR on a [MEDICAL CONDITION] resident conducted by a CPR Certified Trainer. On [DATE] 6 registered nurses (RN's) and 4 LPN's were educated. On [DATE] 6 LPN's were educated. The facility still had 7 RN's and 9 LPN's that needed to be trained prior to being allowed to work on the units. 2. On [DATE], the facility initiated in-service education on proper emergency procedures. As of [DATE], 58 of 142 staff members had been trained. The rest of the staff members will be trained before being allowed to work on the units. 3. On [DATE], ADM "A" reviewed the facility's policy and procedure for CPR. 4. On [DATE], the crash cart was checked for appropriate supplies and equipment. 5.. On [DATE], DON "B" and CCC "F" started Mock Code Drills. 6. ADM "A" will be responsible for continued compliance and reporting to the QA (Quality Assurance) Committee for review. While Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility had not completed all education and sustained compliance had not been verified by the State Agency. ( )

This citation refers to MI 043. Based on interview and record review, the facility failed to: 1.) follow professional standards for nursing practice in an emergency situation, and 2.) follow physician orders [REDACTED].#103) reviewed for emergency response procedures during a code and [MEDICAL CONDITION] care, from a total sample of 4 residents, resulting in inadequate ventilation, delay of emergency services, clogged [MEDICAL CONDITION], and subsequent. Findings include: A review of the American Nurses Association (ANA) Code of Ethics (2001), revealed Provision 3- "The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient (resident)". According to this provision "the nurse's primary commitment is to the health, well-being, and safety of the patient (resident) across the life span and in all settings in which healthcare needs are addressed". As an advocate for the resident, the nurse must take appropriate action (e.g. initiate CPR in a timely manner, perform CPR according to accepted standards of practice, immediately notify emergency medical services, and follow physician orders [REDACTED]." Review of the facility's emergency procedure for cardiopulmonary resuscitation (CPR), revised [DATE], revealed "depending on the underlying cause, the chances of surviving SCA (sudden [MEDICAL CONDITION]) may be increased if CPR is initiated immediately upon collapse. In potentially reversible situations, early delivery of a shock with a defibrillator plus CPR within ,[DATE] minutes of collapse can further increase chances of survival. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS (basic life support) shall initiate CPR unless: a. it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. there are obvious signs of irreversible death (e.g. rigor mortis). Review of Medical-Surgical Nursing- Critical Thinking for Collaborative Care (a nursing textbook), dated 2002, revealed "cardiopulmonary resuscitation (CPR) must be initiated immediately to help prevent brain damage and death. The nurse, finding an unresponsive client (resident), calls 911 or notifies the emergency response team before initiating CPR" (p.691). Review of the Face Sheet, dated [DATE], revealed Resident #103 was a [AGE] year old female who was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of Resident #103's respiratory care plan, dated [DATE], revealed staff were to "provide suctioning as ordered/needed for secretions, cleanse inner cannula every shift, and site care and tubing change as ordered" to Resident #103's [MEDICAL CONDITION]. Review of the physician orders, dated [DATE], revealed Resident #103 was to be suctioned every 4 hours and as needed. In addition, the physician orders [REDACTED]. The physician orders [REDACTED].#103 was a "full code". Review of Resident #103's February 2015 medication administration record (MAR) revealed Licensed Practical Nurse (LPN) "K" initialed on [DATE] the 12 a.m., 4 a.m., and 8 a.m. blocks for suctioning intitial on the ,[DATE] and ,[DATE] shift blocks for changing the inner cannula of Resident #103's [MEDICAL CONDITION] which indicated these tasks had been completed. Review of the nursing progress note, dated [DATE] at 9:55 a.m., revealed Resident #103 was "found unresponsive" . In an interview on [DATE] at 4:00 p.m., LPN "K" stated, "At 3:30 a.m., I noticed she (Resident #103) was slightly gurgley. I did suctioning. I didn't change the inner cannula on nights (night shift ,[DATE]) or on days (day shift ,[DATE]). I only change the inner cannula at night if she (Resident #103) is gunky or gurgley. After I do the (morning) med (medication) pass, I change the inner cannula." LPN "K" stated, "I went in the room to do my meds at 9:45 a.m. I looked at her (Resident #103) and I didn't see any breathing. I checked her pulse and couldn't feel anything. After I didn't find a pulse, I found (LPN "I") and asked her to check her (Resident #103). I went to the DON's (director of nursing) office at 9:50 (a.m.) to check (Resident #103's) code status. I went back to the room with (DON "B") and told (LPN "I") she's (Resident #103) a full code and to do CPR. I cleared everything out of the room. (DON "B") started chest compressions and the crash cart arrived. They (clinical care coordinator (CCC) "F") pulled the ambu bag from the crash cart. I switched (back and forth) with (DON "B") to do chest compressions. We kept doing chest compressions until the paramedics arrived. I also helped with the ambu bag. When the paramedic arrived, he said something to (CCC "F") about the ambu bag and how it was (supposed) to be connected. I heard the paramedic that was running things say "the connection should be changed" to the ambu bag. There was some adjustment, but I didn't see it because there were 2 paramedics between me and (CCC "F")." LPN "K" was shown Resident #103's February 2015 MAR and asked if the initials in the 12 a.m., 4 a.m., and 8 a.m. blocks on [DATE] for suctioning and the ,[DATE] and ,[DATE] shift blocks for changing the inner cannula of Resident #103's [MEDICAL CONDITION] were his. LPN "K" stated they were, "But there is variation with them." LPN "K" was asked if he had actually performed the inner cannula changes on the ,[DATE] and ,[DATE] shifts and the suctioning at 8:00 a.m. that he had signed as completed, LPN "K" stated he had not. In a second interview on [DATE] at 7:10 a.m., LPN "K" stated, "I found her (Resident #103) at 9:45 a.m. and we started CPR at about 9:48 or 9:50 a.m. I had went into the room at 9:45 a.m. to give meds (medications). I'm sure I found her at 9:45, because I had a resident that wanted his meds at 9:30. I gave him his meds and I then set up her meds and she had quite a lot of liquid meds to set up. It took about 10 minutes to set up the meds and then it took a little time to wash my hands and take them in the room. When I went in the room, I didn't see her stomach moving or feel a pulse. I went to (LPN "I") who was around the nurse's station and said to her my patient (Resident #103) was unresponsive and I needed a second opinion. I don't remember if I went back to the room with (LPN "I") or if I went to the office to get (DON "B") next. I went into the office and told (DON "B"). (DON "B") and I went down to the room. I think (DON "B") started chest compressions first, then (CCC "F") started doing the bag (ventilations)." In an interview on [DATE] at 10:30 a.m., Director of Nursing (DON) "B" stated, "the nurse (LPN "K") came to my office around 9:55 a.m. and he said he found her (Resident #103) unresponsive. He had checked a pulse and there was no pulse. We were working on her chart and we looked and saw she was a full code. We immediately went to the room- myself, (LPN "K"), (CCC "F"), and (LPN "I"). (CCC "E") called 911 (EMS). We had a CNA (certified nursing assistant), (CNA "H") go for the crash cart. We went into the room. I checked for a pulse. There was no pulse. She was not breathing. I tried a sternal rub and got nothing. By then the crash cart was there. We rolled her (Resident #103) over- myself and ((CI) "G") and put the back board under her. I started chest compressions. We connected the AED (automated external defibrillator) to her. We waited for the AED to tell us to continue CPR or shock. It said to continue CPR and didn't administer a shock. I was doing chest compressions. (CCC "F") was ventilating (with the ambu bag). We continued CPR until the paramedics arrived. When they (the paramedics) arrived, they took over. We were doing CPR for ,[DATE] minutes before the paramedics arrived." According to the crash cart AED log, dated [DATE], the AED was turned on at 10:04 a.m. (19 minutes after LPN "K" stated he found Resident #103 without a pulse or respirations and 9 minutes after DON "B" stated LPN "K" notified her that Resident #103 didn't have a pulse). In an interview on [DATE] at 10:55 a.m., CCC "F" stated, "This happened right after the morning meeting about 9:30-ish. I was in my office down (name of hall Resident #103's room was located on). The nurse (LPN "K") came in my office and said she (Resident #103) wasn't breathing. We- myself, (DON "B"), and (CCC "E") - went down the hall to the room. When we got to the room, I saw a nurse in the room. She (LPN "I" ) was assessing her (Resident #103). She was checking for a pulse. She (Resident #103) looked like she was sleeping, but no chest rise. (DON "B") went to the head of the bed. I went to get the crash cart. I saw someone (CNA "H") coming down the hall with the crash cart and I went with (CNA "H") to the room. I grabbed the ambu bag and attached it to the oxygen and [MEDICAL CONDITION]. By then they had the back board under her. (DON "B") started compressions. I started bagging (ventilating with the ambu bag). I was squeezing the bag every 3 seconds. When I got the crash cart there, (DON "B") put the AED on her (Resident #103) and (LPN "K") took over compressions. We paused while it (the AED) analyzed, but I kept doing the oxygen because it doesn't affect anything. The AED said "no shock advised, continue CPR." We continued CPR. The EMT's (emergency medical technicians) arrived. They put their AED on her and told me to keep bagging. They took over compressions. At one point they had us stop and they listened (for a heartbeat and lung sounds). They had me continue bagging. Then they had us continue. The EMT on the phone running the code was on the phone. He said they told him to try one more round of epi ([MEDICATION NAME]) and about 2 minutes of CPR and then they'll see if they would call it (time of death). After about 2 minutes, they stopped compressions and he (the EMT) got a femoral pulse on her. They stopped compressions, switched her to their oxygen tank, and took her out." In a second interview on [DATE] at 9:00 a.m., CCC "F" stated, "I took the ambu bag from the crash cart because it was close to me. I initially attached the bag (ambu bag) to the blue tubing (running to the humidifier). I attached the oxygen tubing to the oxygen concentrator. I turned the oxygen all the way up on the concentrator. I don't know how high the concentrators go. I think it's 5 or 6 liters. They were doing compressions, so I don't know if the chest was rising when the bag was hooked up to the blue tubing. We were doing everything at the same time. The EMT's showed up and someone said the ambu bag needed to be changed. The EMT pulled off the mask and told me to attach the ambu bag (directly) to the trach." Immediately after the interview, CCC "F" and this surveyor went to a resident's room who had a [MEDICAL CONDITION] and the same set up that Resident #103 had. CCC "F" pointed out to this surveyor (without actually disconnecting the resident's tubing) the manner in which she initially attached the ambu bag to the concentrator and blue tubing. According to the demonstration CCC "F" had disconnected the oxygen from Resident #103's [MEDICAL CONDITION] mask, attached the oxygen to the ambu bag oxygen tubing, and connected the ambu bag to the blue tubing that led into the humidifier and not directly into the [MEDICAL CONDITION]. CCC "F" verbalized that this was the manner in which she had set up the ambu bag and had started ventilations." Review of the American Heart Association (AHA) adult basic life support guidelines (2000) revealed a [MEDICAL CONDITION] "must be patent for either spontaneous ventilation or rescue breathing to occur. If the tube is not patent and you are unable to clear an obstruction or any secretions, remove and replace the tube. If a second tube is unavailable and the original tube is obstructed, remove the tube and provide rescue breathing through the stoma. Air escape is alleviated if you can provide ventilation through a [MEDICAL CONDITION] with an inflated cuff" (American Heart Association. Circulation. 2000; 102: I-22-I-59doi: 10XXX,[DATE].CIR.102.suppl_1.I-22). In an interview on [DATE] at 9:30 a.m., LPN "I" stated, "I was by the nurse's station when (name of LPN "K") came up to me. It was right before 10:00 a.m. He said "can you come here and check this person (Resident #103) for me?" He went down to the room with me. When I checked her (Resident #103) I couldn't find a pulse or respirations. I told him to go get help. (CCC "F") came in and checked for a pulse and breathing. (DON "B") came into the room and called for a crash cart. (CCC "F") grabbed the ambu bag from the crash cart and hooked the bag up to the concentrator. I don't remember how else it was hooked up. I remember she (CCC "F") wasn't sure how to hook it to the trach. (DON "B") told her it needed to be hooked up to the oxygen and oxygen tubing. I was doing compressions before the EMT's arrived." In a second interview on [DATE] at 10:30 a.m., DON "B" stated, "at the time I wasn't paying attention to how the ambu bag was attached. I just know initially the ambu bag was attached to the tubing and the concentrator, but I don't know what the tubing looked like. I don't know how much (oxygen) she (Resident #103) was getting through the concentrator. I believe the concentrators go up to 5 liters. When the paramedic showed up he had us disconnect the ambu bag from the tubing and attach it directly to the trach." In an interview on [DATE] at 10:00 a.m., CCC "E" stated, "(LPN "K") came into the nursing office after our morning meeting. It could have been 9:40 a.m. I don't honestly know the time. He said (Resident #103) wasn't breathing and she didn't have a pulse. We looked in the physician orders [REDACTED]. Her son hadn't been in yet to sign the code papers, so that is why we checked the physician orders. It was the first page after the physician order [REDACTED]. (DON "B") and (CCC "F") ran out of the room after we checked the chart. I immediately called 911." CCC "E" was shown that the EMT report stated the time of the event (the time Resident #103 was found unresponsive) was listed as 9:50 a.m., but the call wasn't placed until 10:01 a.m. and asked what could have caused a delay in calling 911. CCC "E" stated, "I can't think of any reason why the sheet would say 9:50 a.m. and the call was at 10:01 a.m. I called immediately. There is no way that there was a 10 minute delay." Review of the facility personnel files revealed Director of Nursing (DON) "B", Clinical Care Coordinator (CCC) "F", LPN "I", and LPN "K" were CPR/BLS certified. In an interview on [DATE] at 12:15 p.m., Paramedic (EMT) "L" stated, "When I arrived the staff were doing CPR compressions. They had the (ambu) bag attached to an extension that was attached to the stoma mask, not to the stoma. I immediately disconnected the bag and attached it to the stoma. With it (the bag) being attached to the mask, there is only air flow around the stoma, not directly into it, so she (Resident #103) wasn't getting adequate oxygenation. I don't know if the staff knew that. After I switched the bag onto the stoma site, I got adequate chest expansion." Review of the EMS report, dated [DATE], revealed the "onset time" was 9:50 a.m. and the estimated time of arrest prior to EMS arrival was ",[DATE] minutes." The report revealed that the incident occurred at 9:50 a.m., the 911 call was made at 10:01 a.m., and EMS arrived on scene at 10:04 a.m. The report stated, "staff performing CPR and ventilating the pt (patient) through a stoma mask with a BVM (bag valve mask) hooked to an oxygen generator (oxygen concentrator). The BVM was attached directly to the stoma (by EMT) and CPR was continued. Asystole (flat line) was the initial rhythm noted." Review of the emergency room note dated [DATE] revealed "She (Resident #103) is not awake or alert. Pupils fixed and dilated. No spontaneous movement. She requires [MEDICATION NAME] to maintain adequate blood pressure. Upon arrival, the patient was being bagged through a [MEDICAL CONDITION] site. She had overall poor air movement and it was difficult to bag the patient. I had the respiratory therapist remove the inner lumen of the trach, which revealed a large mucous plug. We had a new one replaced and were able to bag her quite easily. After replacement and bagging, we lost pulses once again and CPR was resumed." Review of the hospital physician encounter note, dated [DATE], revealed Resident #103 was "comatose with no brainstem reflexes. Unfortunate [MEDICAL CONDITION] due to [MEDICAL CONDITION] mucous plugging while at NH (nursing home)." Review of the hospital physician discharge summary, dated [DATE], the neurologist examined Resident #103. "Apnea testing revealed no spontaneous breath after 12 minutes" which along with lab results "meets the criteria for brain death." "Brain death at 1200 (12:00 p.m.), off ventilator support at 1416 (2:16 p.m.), asystole on bedside monitor at 1433 (2:33 p.m.)." Review of the physician encounter note, dated [DATE], revealed Resident #103's "cause of death: Severe hypoxic ischemic [MEDICAL CONDITION] secondary to cardiopulmonary arrest." ( )

This citation refers to MI 043 Based on interview and record review, the facility failed to perform [MEDICAL CONDITION] care according to physician orders [REDACTED].#103) reviewed for [MEDICAL CONDITION] care from a total sample of 4 residents, resulting in a clogged [MEDICAL CONDITION], cardiopulmonary arrest, severe ischemic [MEDICAL CONDITION], and subsequent death. Findings include: Review of the Face Sheet, dated [DATE], revealed Resident #103 was a [AGE] year old female who was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of Resident #103's Respiratory care plan, dated [DATE], revealed staff were to "provide suctioning as ordered/needed for secretions, cleanse inner cannula every shift, and site care and tubing change as ordered" to Resident #103's [MEDICAL CONDITION]. Review of the Physician Orders, dated [DATE], revealed Resident #103 was to be suctioned every 4 hours and as needed and have the inner cannula of the [MEDICAL CONDITION] changed every shift. The Physician order [REDACTED]. Review of Resident #103's Medication Administration Record (MAR), dated ,[DATE], revealed Licensed Practical Nurse (LPN) "K" initialed the MAR on [DATE] at 12 a.m., at 4 a.m., and at 8 a.m. that he [MEDICAL CONDITION] on Resident #103. LPN " K " also recorded on the MAR that Resident #103 ' s inner cannula was changed on both the ,[DATE] and ,[DATE] shift. In an interview on [DATE] at 4:00 p.m., LPN "K" (the nurse assigned to care for Resident #103) was shown Resident #103's February 2015 MAR and asked if the initials in the 12 a.m., 4 a.m., and 8 a.m. blocks on [DATE] for suctioning and the ,[DATE] and ,[DATE] shift blocks for changing the inner cannula of Resident #103's [MEDICAL CONDITION] were his. LPN "K" stated they were, "but there is variation with them." LPN "K" was asked if he had actually performed the inner cannula changes on the ,[DATE] and ,[DATE] shifts and the suctioning at 8:00 a.m. LPN "K" stated he had not. LPN "K" stated, "At 3:30 a.m., I noticed she (Resident #103) was slightly gurgley. I did suctioning. I didn't change the inner cannula on nights (night shift ,[DATE]) or on days (day shift ,[DATE]). I only change the inner cannula at night if she (Resident #103) is gunky or gurgley. After I do the med (medication) pass I change the inner cannula." Review of Medical-Surgical Nursing- Critial Thinking for Collaborative Care (a nursing textbook), dated 2002, revealed "[MEDICAL CONDITION] care keeps the [MEDICAL CONDITION] free of obstructing secretions, maintains a patent airway, and provides wound care" (p. 503). Review of the nursing progress note, dated [DATE] at 9:55 a.m., revealed Resident #103 was "found unresponsive" . In an interview on [DATE] at 4:00 p.m., LPN "K" stated, "I went in the room to do my meds at 9:45 a.m. I looked at her (Resident #103) and I didn't see any breathing. I checked her pulse and couldn't feel anything. After I didn't find a pulse, I found (LPN "I") and asked her to check her (Resident #103). I went to the DON's (director of nursing) office at 9:50 (a.m.) to check code status (Resident #103's). I went back to the room with (DON "B") and told (LPN "I") she's (Resident #103) a full code and to do CPR. I cleared everything out of the room (to make room for people and equipment). (DON "B") started chest compressions and the crash cart arrived. They (clinical care coordinator (CCC) "F") pulled the ambu bag from the crash cart. I switched (back and forth) with (DON "B") to do chest compressions. We kept doing chest compressions until the paramedics arrived. Review of the EMS report, dated [DATE], revealed the "onset time" (of cardiopulmonary arrest) was 9:50 a.m. and the estimated time of arrest prior to EMS arrival was ",[DATE] minutes." The report revealed that the incident occurred at 9:50 a.m., the 911 call was made at 10:01 a.m., and EMS arrived on scene at 10:04 a.m. Review of the emergency room note dated [DATE] revealed "She (Resident #103) is not awake or alert. Pupils fixed and dilated. No spontaneous movement. She requires [MEDICATION NAME] to maintain adequate blood pressure. Upon arrival, the patient was being bagged through a [MEDICAL CONDITION] site. She had overall poor air movement and it was difficult to bag the patient. I had the respiratory therapist remove the inner lumen of the trach, which revealed a large mucous plug. We had a new one replaced and were able to bag her quite easily. After replacement and bagging, we lost pulses once again and CPR was resumed." Review of the hospital Physician Encounter note, dated [DATE], revealed Resident #103 was "comatose with no brainstem reflexes. Unfortunate [MEDICAL CONDITION] due to [MEDICAL CONDITION] mucous plugging while at NH (nursing home)." Review of the hospital Physician Discharge Summary, dated [DATE], revealed the neurologist examined Resident #103. "Apnea testing revealed no spontaneous breath after 12 minutes" which along with lab results "meets the criteria for brain death." "Brain death at 1200 (12:00 p.m.), off ventilator support at 1416 (2:16 p.m.), asystole on bedside monitor at 1433 (2:33 p.m.)." Review of the physician Encounter note, dated [DATE], revealed Resident #103's "cause of death: Severe hypoxic ischemic [MEDICAL CONDITION] secondary to cardiopulmonary arrest." ( )

This citation pertains to intake number MI 223. Based on observation, interview and record review, the facility failed to adequately treat a pressure ulcer per facility policy in 1 of 2 sampled residents (#103) reviewed for pressure ulcers, from a total sample of 6 residents, resulting in Resident #103 sustaining a Stage IV pressure ulcer with osteo[DIAGNOSES REDACTED] (bone infection) requiring intravenous (IV-through the vein) antibiotic. Findings include: According to the facility Policy and Procedure "Prevention of Pressure Ulcers", dated 2001, under "General Guidelines", reflected "1. Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue...4. Pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (i.e., perspiration, feces, urine, wound discharge, soap residue, etc.)...5. Once a pressure ulcer develops, it can be extremely difficult to heal. Pressure ulcers are a serious skin condition for the resident...6. The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician and family, and addressed". Under "Interventions and Preventive Measures: General Preventive measures...2. For a person in bed a. Change position at least every two hours or more frequently if needed..." Under "Interventions and Preventive Measures: Risk Factor-Bowel/Bladder Incontinence a. Check Resident for incontinence at least every 2 hours and clean skin when soiled...b. Assess and treat urine leaks...". According to the facility Policy and Procedure "Pressure Ulcer Treatment", dated 2001, under "Purpose...is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers...General guidelines 1. The pressure ulcer treatment program should focus on the following strategies: a. Assessing the resident and the pressure ulcer (s), b. Managing tissue loads, c. Pressure ulcer care, d. Managing bacterial colonization and infection, e. Operative repair of the pressure ulcer (s) f. Education and quality improvement...Definitions and descriptions: Stage II Pressure Ulcer: Partial thickness loss of dermis presenting a shallow open ulcer with a red pink wound bed without slough (dead tissue)...Stage IV Pressure Ulcer: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (blackened tough dead tissue) may be present on some parts of the wound bed. Often include undermining and tunneling...Interventions/Care Strategies:..Stage II Protocol...1. Protect 2. Manage Drainage 3. Promote moist wound healing 4. Treatment...5. Manage pain...Follow up if wound does not improve in 2-3 weeks, notify physician. Consider a skin consult with a wound specialist...Stage IV Protocol 1. Protect: a. fill dead space including tunnels and undermining b. Manage drainage; and c. Promote moist wound healing...3. Treatment: a. Irrigate wound with normal saline or other designated wound cleanser. Use syringe to apply (4 to 15 psi-pounds per square inch); b. apply and alginate dressing, foam dressing or hydrogel to wound cavity;...". According to the "Resident Admission Record" (undated), Minimum Data Set ((MDS) dated [DATE], and physician's orders [REDACTED].#103 was a [AGE] year old female readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #103's BIMS (Brief Interview for Mental Status) score was 15/15 indicating Resident #103 was cognitively intact. The MDS indicated Resident #103 was dependent on 2 staff members for bed mobility, transfers, locomotion on and off unit, dressing, toilet use, personal hygiene and bathing. Resident #103 was dependent on one staff member for eating. Resident #103 had a Foley catheter and was always incontinent of bowel. During initial tour of the facility one 5/29/14 at 3:00 p.m. Resident #103 was observed to be in bed lying on her back in her room. Resident #103 was noted to be on a bed with an alternating air mattress. Resident #103 was alert and oriented and stated that she had a pressure ulcer on her buttocks. Resident #103 stated that she is unable to reposition/turn herself in bed and then demonstrated that she was only able to shrug shoulders and turn her head from side to side. Resident #103 stated that she has a Foley catheter in place to prevent urine getting in her wound on her buttocks. Resident #103 stated that the catheter leaks leaving her frequently wet stating "It has leaked since I got it.". On 5/29/14 at 4:10 p.m. Resident #103 was observed to be lying on her back in the same position as on the initial tour. Resident #103 stated that she had not been repositioned/turned in over 2 hours and that she is often not repositioned/turned but only once or twice a shift . Review of the "Alteration in Skin Integrity" care plan for Resident #103, dated 11/18/14 reflected under "Problem/Concern: Pressure area Right ischial...Goal: Area will be closed/resolved within 90 days...remain free of infection...Interventions: 1. Treatment as ordered 2. Monitor for signs and symptoms of infection every shift 3. notify physician if signs or symptoms of infection AND/OR if wound worsens 4. Notify dietary of wound 5. Perform weekly skin measurements 6. Supplements as ordered". There were no updating or review of care plan since the initiation date of 11/18/14. Review of the "Resident Care Guide" (Information on how to care for the resident) for Resident #103, with intervention start dates of 12-12-12, under reflected the following "Skin: wound location right lower buttocks, turn and repositioning q 2 hours, specialty mattress: air." Under "Comments" dated 12-12-12 reflected "Turn and reposition q hour". On 5/30/14 at 9:10 a.m. an interview with the CNA (certified nurse aide) "E" assigned to Resident #103 that day, when asked if she had repositioned/turned Resident #103 yet today, CNA "E" stated, "No, I haven't" CNA "E" stated that she had started her shift at 6:30 a.m. When asked if Resident #103 was on a reposition/turn schedule CNA "E" stated "No I don't think so...". During an observation and interview of the dressing change to Resident #103 right lower buttock on 6/2/14 at 11:40 a.m. with Registered Nurse (RN) "J" and CNA "K", Resident #103 required total assistance with turning on to left side for the dressing change. Resident #103 was observed not to have a dressing on right buttock/ischium wound. There was a blue barrier pad under Resident #103 that was wet, soiled with stool and drainage from wound, and a Foley catheter that was in place and unsecured (to her leg). It was observed when Resident #103 was turned urine would leak around catheter. CNA "K" reported that Resident #103 had a catheter for about a month. When CNA "K" was asked about a leg strap to secure Resident #103's Foley, CNA "K" stated, "...I don't even know where you would get a leg strap...". Resident #103 then stated, "...a leg strap has been used once..." since she had the Foley catheter. Resident #103 stated that "I wish they wouldn't move aides around to different halls. Once you get them trained they move on to another hall..." Observation of the wound on Resident #103's posterior right gluteal fold (area where the buttock meets the upper thigh) showed an irregular shaped wound approximately 6 cm (centimeters) x 5 cm with approximately 5 cm depth. The wound had a tunnel like appearance and was beefy red. Resident #103 was observed to have a bright red, angry looking yeasty looking rash on both posterior thighs that extended up both buttocks and up to her lower back. CNA "K" reported she had last provided personal care for Resident #103 at approximately 6:30 a.m. when Resident #103 turned on her call light. CNA "K" stated, "...I washed her up on the front side, but I have not turned her over to look at her back side until now...I didn't realize she had a rash or that there was not a dressing on her wound...it's hard to keep (resident name) dry because her catheter leaks all the time...". RN "J" reported being unaware that Resident #103 did not have a dressing on the wound and agreed that catheter is not effective at keeping Resident #103's skin dry. RN "J" reported that an ointment called "[MEDICATION NAME]" (moisture barrier cream) was being used on the rash area, but was not effective in treating yeast. On 6/2/14 at 3:10 p.m. with the Assistant Director of Nursing Registered Nurse (ADON) "B" stated that she has never seen the wound for Resident #103 as the Wound Care Nurse, LPN (Licensed Practical Nurse) "F" had been following the progress of Resident #103's wound. ADON "B" stated "she has had it since around 11/13...I don't know what happened to make it get so bad so fast...". ADON "B" stated that the facility had set up an appointment with the wound clinic prior to Resident #103 but had been admitted to the hospital prior to the appointment date. LPN "F" was on vacation out of state as of 5/30/14 and unavailable for interview during the survey from 5/29-6/2/14. According to the facility "Admission Evaluation and Interim Care Plan" dated 11/18/13, Resident #103 was readmitted to facility after hospitalization for pneumonia. Per the skin assessment with the same date it reflected that Resident #103 had a blackened lift heel. The Braden Scale (an assessment of a resident risk factors for skin breakdown) was 14, indicating Resident #103 was a moderate risk for skin breakdown. Review of Section E of the assessment not reflect breakdown on Right buttock/ischium. According to the weekly "Wound/Skin Record" dated 11/18/13, reflected the "Date of Onset" was 11/18/13, "Site/location:" Right ischium, but measurements or staging of the wound was not documented until 11/22/13 and reflected an unstageable wound measuring 0.9 cm x 0.5 cm with less that 0.1 cm depth. Review of the weekly "Wound/Skin Record's" for 11/29/13 to 12/27/13, Resident #103's right ischium wound was documented as a Stage II measuring 0.5 cm x 0.3 cm with less than 0.1 cm with little or no change in size or signs of healing. On 1/3/14 it was documented the stage II was "pinpoint" in size. On 1/17/14 the Stage II wound was 1.0 cm x 0.2 cm with less than 0.5 cm depth. On 2/7/14 the Stage II wound was 2.0 cm x 1.5 cm with less than 0.5 cm depth, "Response to Treatment" was checked as "deteriorated" "Plan of Care updated:" was checked "No". On 2/14/14 the stage II wound was 2.0 cm x 1.3 cm with 0.1 cm depth. On 3/7/14 the Stage II wound was 1.4 cm x 1.6 cm with less than 0.5 cm depth with "Exudate Type/Amount: small bleeds easily". On 4/11/14 Stage II 2.5 cm x 2.5 cm with 0.7 cm depth "Wound bed: 95% red 5% slough". "Response to Treatment" was checked as "deteriorated" "Plan of Care updated:" was checked "No". On 4/18/14 Stage II 2.5 cm x 2.5 cm with 0.7 cm depth "Exudate Type/Amount: SS (clear with blood) moderate amount". "Wound bed: 90% red 5% slough". On 4/25/14 Stage II 2.5 cm x 2.5 cm with 0.6 cm depth. "Wound bed: 90% red 90% slough". According to the "Medication Record" (sic) dated 11/18/13 to 11/30/13, reflected the following treatment "Right ischial, apply triad q (every) shift and PRN (as needed), call MD (doctor) if any S/S (signs and symptoms) of infection. Review of 12/13, 1/14, 2/14, 3/14 reflected no changes in treatment to wound was initiated to promote healing. According to the "Medication Record" (sic) for 4/14, on 4/22/ 14 the treatment was changed to Resident #103's "Right ischial- cleanse with NS (normal saline) apply calcium alginate to wound bed cover with DuoDerm change q 3 days and PRN". Review of the "Nurses Notes" 3/14 and 4/14 did not reflect that Resident #103's Physician was notified of the change in condition of right ischial pressure ulcer. Review of the "Nurses Notes" and the "Physician Orders" for 3/14 to 5/4/14 did not reflect a wound specialist was requested or ordered for Resident #103. Review of the "Nurses Notes" dated 4/23/14 at 10:00 a.m. Resident #103 was having loose stools. 4/30/14 "Foley catheter 22 French due to decubitus ulcer wound. 5/3/14 2:00 p.m. "New order right ischial wound; cleanse with NS apply/pack with calcium alginate then cover with ABD pad change q shift and PRN. Foley catheter on hold until larger catheter supplies are available". 5/4/14 7:10 a.m. "Call placed to (Physician name) answering service resident is coughing, sounds congested temp (temperature) 102.4 on call said to transfer resident to ER for eval (evaluation) and treatment". According to the hospital "Adult History and Physical" dated 5/4/14 under "Physical Exam [MEDICAL CONDITION]/chest: Effort normal and breath sounds normal. No respiratory distress. She has no wheezes. She has no rales. She exhibits no tenderness." under "Assessment/Plan: 1.[MEDICAL CONDITION] secondary to pneumonia. Increased risk of gram negatives (bad bacteria strain) [MEDICAL CONDITIONS]. Will cover with [MEDICATION NAME],[MEDICATION NAME]. This will cover the decub (decubitus) ulcer as well...4. Sacral decubitus ulcer, Stage IV. Wound care...". According to the hospital "Adult Progress Note" with "date of service" date of 5/7/14, for Resident #103 under "Assessment/Plan Active Problems: ...Acute osteo[DIAGNOSES REDACTED] of pelvic region--back to ECF (Extended Care Facility) on IV (thru the vein) antibiotics and wound care...". In an interview on 6/2/14 at 3:10 p.m., ADON "B" stated that all residents are on a q 2 hour turn schedule and that a alternating air mattress does not change the required frequency of turning. When asked about the current treatment of [REDACTED].#103 had been seen by the wound team at the hospital. ADON "B" stated Resident #103 would continue to be followed by the wound clinic as an outpatient. There was no documentation found in Resident #103's medical record that wound appointment was scheduled.

This citation pertains to intake number MI 223. Based on observation, interview and record review the facility failed to provide adequate and appropriate care for a Foley catheter (tube inserted into bladder for drainage) to prevent complications in 1 of 6 sampled residents (#103) reviewed for catheter care, from a total sample of 6 residents, resulting in Resident #103 having catheter leakage and progression of a pressure ulcer. Findings include: According to the facility policy "Catheter Care, Urinary" dated 2001, under "General Guidelines...Changing Catheters...2. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh)..." According to the "Resident Admission Record" (undated), Minimum Data Set ((MDS) dated [DATE], and physician's orders [REDACTED].#103 was a [AGE] year old female readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #103's BIMS (Brief Interview for Mental Status) score was 15/15 indicating Resident #103 was cognitively intact. The MDS indicated Resident #103 was dependent on 2 staff members for bed mobility, transfers, locomotion on and off unit, dressing, toilet use, personal hygiene and bathing. Resident #103 was dependent on one staff member for eating. Resident #103 had a Foley catheter and was always incontinent of bowel. During initial tour of the facility on 5/29/14 at 3:00 p.m., Resident #103 was observed to be in bed lying on her back in her bed. Resident #103 was noted to be on a alternating air mattress. Resident #103 was alert and oriented and stated that she had a pressure ulcer on her buttocks. Resident #103 stated that she is unable to reposition/turn herself in bed and then demonstrated that she was only able to shrug shoulders and turn her head from side to side. Resident #103 stated that she has a Foley catheter in place to prevent urine getting in her wound on her buttocks. Resident #103 stated that the catheter leaks leaving her frequently wet. Resident #103 stated, "It has leaked since I got it.". Resident #103 catheter bag was observed to be hanging from the frame of the bed filled with yellow urine and was visible from the door for residents and visitors to see when walking past the door. During an observation and interview of the dressing change to Resident #103 right lower buttock on 6/2/14 at 11:40 a.m. with Registered Nurse (RN) "J" and CNA "K", Resident #103 required total assistance with turning on to left side for the dressing change. Resident #103 was observed not to have a dressing on right buttock/ischium wound. There was a blue barrier pad under Resident #103 that was wet, soiled with stool and drainage from wound, and a Foley catheter that was in place and unsecured (to her leg). It was observed when Resident #103 was turned urine would leak around catheter. CNA "K" reported that Resident #103 had a catheter for about a month. When CNA "K" was asked about a leg strap to secure Resident #103's Foley, CNA "K" stated, "...I don't even know where you would get a leg strap...". Resident #103 then stated, "...a leg strap has been used once..." since she had the Foley catheter. Resident #103 stated that "I wish they wouldn't move aides around to different halls. Once you get them trained they move on to another hall..." Observation of the wound on Resident #103's posterior right gluteal fold (area where the buttock meets the upper thigh) showed an irregular shaped wound approximately 6 cm (centimeters) x 5 cm with approximately 5 cm depth (Stage IV). The wound had a tunnel like appearance and was beefy red. Resident #103 was observed to have a bright red, angry looking yeasty looking rash on both posterior thighs that extended up both buttocks and up to her lower back. CNA "K" reported she had last provided personal care for Resident #103 at approximately 6:30 a.m. when Resident #103 turned on her call light. CNA "K" stated, "...I washed her up on the front side, but I have not turned her over to look at her back side until now...I didn't realize she had a rash or that there was not a dressing on her wound...it's hard to keep (resident name) dry because her catheter leaks all the time...". RN "J" reported being unaware that Resident #103 did not have a dressing on the wound and agreed that catheter is not effective at keeping Resident #103's skin dry. RN "J" reported that an ointment called "[MEDICATION NAME]" (moisture barrier cream) was being used on the rash area, but was not effective in treating yeast. According to the weekly "Wound/Skin Record" dated 11/18/13, indicated that Resident #103's pressure ulcer "Date of Onset" was 11/18/13, "Site/location:" Right ischium, but measurements or staging of the wound was not documented until 11/22/13 and reflected an unstageable wound measuring 0.9 cm x 0.5 cm with less that 0.1 cm depth. Review of the "Nurses Notes" 3/14 to 5/4/14 did not reflect urology consult was requested or that any interventions were implemented to determine cause of catheter leaking. Review of the "Nurses Notes" dated 4/23/14 at 10:00 a.m. revealed Resident #103 was having loose stools. 4/30/14 "Foley catheter 22 French due to decubitus ulcer wound. 5/3/14 2:00 p.m. "New order...Foley catheter on hold until larger catheter supplies are available". 5/4/14 7:10 a.m. "Call placed to (Physician name) answering service resident is coughing, sounds congested temp (temperature) 102.4 on call said to transfer resident to ER for eval (evaluation) and treatment". According to the hospital "Adult History and Physical" dated 5/4/14 under "Assessment/Plan: 1.[MEDICAL CONDITION] secondary to pneumonia. Increased risk of gram negatives (bad bacteria strain) [MEDICAL CONDITIONS]. Will cover with [MEDICATION NAME],[MEDICATION NAME]. This will cover the decub (decubitus) ulcer as well...4. Sacral decubitus ulcer, Stage IV. Wound care...". According to the hospital "Adult Progress Note" with "date of service" date of 5/7/14, for Resident #103 under "Assessment/Plan Active Problems: ...Acute osteo[DIAGNOSES REDACTED] of pelvic region--back to ECF (Extended Care Facility) on IV (thru the vein) antibiotics and wound care...". Review of the facility "Alteration in Skin Integrity" care plan for Resident #103, dated 11/18/13 reflected under "Problem/Concern: Pressure area Right ischial...Goal: Area will be closed/resolved within 90 days...remain free of infection...Interventions: 1. Treatment as ordered 2. Monitor for signs and symptoms of infection every shift 3. notify physician if signs or symptoms of infection AND/OR if wound worsens..." There were no updates or review of care plan since the initiation date of 11/18/13. Review of the "Urinary Incontinence" care plan for Resident #103, dated 8/13/13 reflected under "Problem/Concern: Resident experiences bladder incontinence R/T (related to) removal of Foley catheter at risk for skin issues...Goal: Resident will not exhibit skin breakdown, UTI (urinary tract infection), impaired social interaction, lowered self esteem secondary to incontinence...Resident has pressure area to coccyx...Approach:" included "Provide incontinence care after each incontinent episode...4/30: Foley catheter re-inserted D/T (due to) wound depth increasing" There were no interventions added or updates of the care plan after 4/30/14 date. Review of the "Resident Care Guide" (CNA guide for the care of residents) for Resident #103, with intervention start dates of 12/12/12, reflected the following: "Urinary/Bowel:" the following boxes were marked for Resident #103, Incontinent of urine, incontinent of bowel, briefs, pads, Foley (catheter) and Foley leg strap". On 6/2/14 at 3:10 p.m. an interview with the Assistant Director of Nursing/Registered Nurse (ADON) "B" stated that multiple Foley catheters had been tried for Resident #103, but had been unsuccessful at finding one that would keep her skin dry and that any resident with a Foley catheter would have a leg strap in place at all times and CNA's had been trained on the use with general catheter care.

This citation pertains to intake number MI 223. Based on observation, interview and record review, the facility failed to follow infection control practices during a dressing change of a pressure ulcer, to ensure that a dressing was covering Stage IV pressure ulcer for 1 resident (#103) of 2 residents observed from a total sample of 6 residents, resulting in potential cross contamination and infection of pressure ulcers. Findings include: According to the facility Policy and Procedure "Pressure Ulcer Treatment", dated 2001, under "Purpose...is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers". Under "Stage IV Protocol 1. Protect: a. fill dead space including tunnels and undermining b. Manage drainage; and c. Promote moist wound healing 3. Treatment: a. Irrigate wound with normal saline or other designated wound cleanser. Use syringe to apply (4 to 15 psi-pounds per square inch); b. apply and alginate dressing, foam dressing or hydrogel to wound cavity;...". According to the "Resident Admission Record" (undated), Minimum Data Set ((MDS) dated [DATE], and physician's orders [REDACTED].#103 was a [AGE] year old female readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #103's BIMS (Brief Interview for Mental Status) score was 15/15 indicating Resident #103 was cognitively intact. The MDS indicated Resident #103 was dependent on 2 staff members for bed mobility, transfers, locomotion on and off unit, dressing, toilet use, personal hygiene and bathing. Resident #103 was dependent on one staff member for eating. Resident #103 had a Foley catheter and was always incontinent of bowel. According to the weekly "Wound/Skin Record" dated 11/18/13, reflected the "Date of Onset" was 11/18/13, "Site/location:" Right ischium, but measurements or staging of the wound was not documented until 11/22/13 and reflected an unstageable wound measuring 0.9 cm x 0.5 cm with less that 0.1 cm depth. Review of the weekly "Wound/Skin Record's" for 11/29/13 to 12/27/13, Resident #103's right ischium wound was documented as a Stage II measuring 0.5 cm x 0.3 cm with less than 0.1 cm with little or no change in size or signs of healing. On 1/3/14 it was documented the stage II was "pinpoint" in size. On 1/17/14 the Stage II wound was 1.0 cm x 0.2 cm with less than 0.5 cm depth. On 2/7/14 the Stage II wound was 2.0 cm x 1.5 cm with less than 0.5 cm depth, "Response to Treatment" was checked as "deteriorated" "Plan of Care updated:" was checked "No". On 2/14/14 the stage II wound was 2.0 cm x 1.3 cm with 0.1 cm depth. On 3/7/14 the Stage II wound was 1.4 cm x 1.6 cm with less than 0.5 cm depth with "Exudate Type/Amount: small bleeds easily". On 4/11/14 Stage II 2.5 cm x 2.5 cm with 0.7 cm depth "Wound bed: 95% red 5% slough". "Response to Treatment" was checked as "deteriorated" "Plan of Care updated:" was checked "No". On 4/18/14 Stage II 2.5 cm x 2.5 cm with 0.7 cm depth "Exudate Type/Amount: SS (clear with blood) moderate amount". "Wound bed: 90% red 5% slough". On 4/25/14 Stage II 2.5 cm x 2.5 cm with 0.6 cm depth. "Wound bed: 90% red 90% slough". According to the hospital "Adult History and Physical" dated 5/4/14 under "Physical Exam Pulmonary/chest: Effort normal and breath sounds normal. No respiratory distress. She has no wheezes. She has no rales. She exhibits no tenderness." under "Assessment/Plan: 1. Sepsis secondary to pneumonia. Increased risk of gram negatives (bad bacteria strain) and MRSA (Methicillin Resistant Staphylococcus Aureus). Will cover with [MEDICATION NAME],[MEDICATION NAME]. This will cover the decub (decubitus) ulcer as well...4. Sacral decubitus ulcer, Stage IV. Wound care...". According to the hospital "Adult Progress Note" with "date of service" date of 5/7/14, for Resident #103 under "Assessment/Plan Active Problems: ...Acute osteo[DIAGNOSES REDACTED] of pelvic region--back to ECF (Extended Care Facility) on IV (thru the vein) antibiotics and wound care...". In an observation and interview during the dressing change to Resident #103 right lower buttock on 6/2/14 at 11:40 a.m. with Registered Nurse (RN) "J" and Certified Nurse Aide (CNA) "K", Resident #103 required total assistance with turning on to left side for the dressing change. Resident #103 was observed not to have a dressing in place, a blue barrier pad was observed under Resident #103 that was saturated with drainage from the wound and watery stool that was oozing from Resident #103's rectum. There was a Foley catheter in place that was unsecured to Resident #103's leg. Urine was observed to leak around the catheter when Resident #103 was turned. Observation of the wound on Resident #103's posterior right gluteal fold (area where the buttock meets the upper thigh) showed an irregular shaped wound approximately 6 cm (centimeters) x 5 cm with approximately 5 cm depth. The wound had a tunnel like appearance and was beefy red in appearance. RN "J" applied a pair of sterile gloves, cleansed the wound with 4 individual-Saline soaked 4 x 4 gauze, wiping out the wound. RN "J" did not irrigate or flush the wound to ensure that any possible stool or urine was washed from the wound. RN "J" did not change her gloves before she started to redress the wound, packing with 5 individual-Saline soaked 4 x 4 guaze pads. Resident #103 was also observed to have a bright red, angry looking yeasty looking rash on both posterior thighs and extended up both buttocks and up to lower back. CNA "K" stated that she had last provided personal care for Resident #103 at approximately 6:30 a.m. when Resident #103 turned on her call light. CNA "K" stated, "...I washed her up on the front side, but I have not turned her over to look at her back side until now...I didn't realize she had a rash or that a dressing was not in place on her wound...". CNA "K" stated, "I was assigned to (resident name) last week and this red rash was not there then". In an interview on 6/2/14 at 3:10 p.m. Assistant Director of Nursing Registered Nurse (ADON) "B" reported that it is not the facility practice to use sterile gloves with wound care unless it is ordered by the physician. ADON "B" reported that gloves were to be discarded/changed after removing soiled dressing and cleaning the wound, prior to applying a clean dressing.

This citation pertains to intakes: MI 704, MI 753. Based on observation, interview, and record review the facility failed to ensure each resident received adequate assistive devices to prevent accidents for 1 (Resident #103) of 7 residents out of a total sample of 7 residents all reviewed for accidents and safe environment when Resident #103 was transported in a broken Geri chair (wheeled recliner) resulting in an avoidable accident whereas Resident #103 sustained a broken leg. Findings include: Record review of a "Resident Admission Record" dated 11/07/2012, indicated Resident #103 was a [AGE] year old woman originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. to a slouching posture). According to the Minimum Data Set (MDS) Version 3.0 Resident Assessment and Care Screening Nursing Home Quarterly (NQ) Item Set dated 5/13/2013, Resident #103 did not complete a Brief Interview for Mental Status (BIMS) because she was rarely/never understood. A staff assessment for mental status indicated Resident #103 had moderately impaired cognitive skills for decision making, was totally dependent on two staff members for transfers and required total assistance for locomotion on and off the unit with the use of a wheeled chair, dressing, eating, toilet use and personal hygiene. Record review of "Nursing Notes" dated 7/14/2013 at 4:00 AM, indicated Resident #103 was "...holding right knee area, showing signs of grimacing, tearing up in eyes, like she is having more pain in that area than usual, dressed and left in bed to rest. Resident (#103) on routine Tramadol and Tylenol (pain relievers). Will continue to monitor and report to 7-3 (first shift) nurse." Record review of a "24 Hour Report/Change in Condition Report" dated 7/14/2013 indicated Licensed Practical Nurse (LPN) #21 noted Resident #103 had a "right knee tender-drawing leg up, right ankle swollen, blue bruising." During an interview on 7/24/2013 at 2:00 PM, LPN #21 said she first noted the bruising early in the morning of 7/14/2013, documented the concern on the "24 Hour/Change in Condition" report and let the oncoming nurse know of her findings. LPN #21 denied letting anyone else know of her concerns or of treating her findings as an injury of unknown origin. LPN #21 stated she worked the next night but on a different hall. LPN #21 stated that she had been "flagged down" by certified nurse aide (CNA) #5, who had first discovered the injury and found Resident #103's ankle was "much worse, more swollen, bluish in color, more changes in the ankle." Review of a "Resident Transfer Form" dated 7/15/13, Resident #103 was sent to a hospital with an acute distal fibula fracture. "Additional Pertinent Information" included on the transfer form described Resident #103 was guarding (a non-verbal indication of pain meant to protect the area of concern), had bruising and swelling to the right lower leg, ankle and foot. Record review of "Emergency Medical Services Field Notes" dated 7/16/13, indicated Resident #103 had ecchymosis (bruising) to her right lower leg with tenderness and crepitus (a medical term used to describe grating, cracking or popping sounds and sensations) to her right ankle. Record review of hospital "Imaging Results" dated 7/15/2013 at 17:38:00 (5:38 PM), Resident #103 sustained a distal tibial and fibular fractures with disruption of ankle mortise. During an interview on 7/22/2013 at 11:40 AM, family member #10, Resident #103's daughter and power of attorney said she first became aware her mother (#103) had a bruised ankle early in the morning on 7/15/2013 and that x-rays had been ordered. During an interview on 7/22/2013 at 1:15 PM, CNA #3 recalled having worked on the 11th of July 2013 and at one point bringing Resident #103 into the dining room for lunch via her Geri chair, however did not recall any incident that could have caused the injury to Resident #103. During an observation on 7/23/2013 at 11:30 AM, CNA #14 demonstrated the way she recalled the incident happening. The Director of Nursing (DON) #1 sat in the same Geri chair Resident #103 was using at the time of the alleged incident and CNA #14 directed CNA #20 to stand in the same place she recalled noticing for the first time Resident #103's foot was stuck under the chair on 7/11/2013. DON #1 positioned her foot in the same way CNA #14 recalled seeing Resident #103 positioned and it was determined that the incident that occurred on 7/11/13 was most likely the cause of Resident #103's fractured foot. CNA #14 said she did not report it to the nurse working that day because she did not think that Resident #103 was in pain as soon as she removed her foot from underneath the footrest on the Geri chair. An observation of the Geri chair, on 7/23/2013 after the re-creation on 7/23/13 at 11:30 AM revealed several defects, including faulty brakes, worn reclining mechanism, warped plywood sides, torn, soiled and stained upholstery, broken levers and squeaky wheels.

This citation pertains to intake number #MI 118. Based on observation, interview, and record review the facility failed to prevent resident to resident abuse for 2 of 12 sampled residents (#501, #508), resulting in an immediate jeopardy when Resident #502, who had aggressive behaviors with multiple incidents of resident to resident abuse and was allowed to freely wander throughout the facility without supervision, and 1) who flipped Resident #501 over backwards in her wheelchair causing her to hit her head on the floor, causing a painful bump on the head and a skin tear to her right arm and 2) when Resident #502 began fist fighting with Resident #508 while having a conversation, placing Resident's #501, #508 and all other residents residing in the facility at risk for serious harm, injury, and/or death. Findings include: Observations of Resident #502 were conducted on 2/25, 2/28, 3/1, 3/2, 3/3, and 3/4/2011. On 2/25, 2/28 and 3/1/2011, Resident #502 was observed to be sitting on a couch in front of the nurses station next to the lobby. On 3/1/2011 at 1:00 PM Resident #502 was sitting on the couch with another resident sitting next to her talking. On 3/2 and 3/3/2011, Resident #502 was observed sitting at a table in the dining room for lunch with other residents at the same table. On 3/4/2011 Resident #502 was observed roaming the 300 hall without any staff around to supervise her. Per the facility face sheet Resident #502 was a [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of a "Minimum Data Set" ((MDS) dated [DATE] revealed that Resident #502 had a severe cognitive impairment. The MDS revealed that Resident #502 had periods of altered perception or awareness of her surroundings. The MDS revealed that Resident #502 only sometimes understood others. Record review of an "Annual Physical Examination" dated 6/23/2010 revealed that Resident #502 had Alzheimer's with significant confusion. Record review of Resident #502's "physician progress notes [REDACTED]." Record review of a "Psych History" note dated 7/22/2010 revealed that Resident #502 had voided three (3) times in a public place and was aggressive towards other residents. Medication changes were made, to include psychoactive medications, per the note. Record review of a "Consent For Use of Psychoactive Medications" dated 8/11/2010 revealed that Resident #502 was started on [MEDICATION NAME] and [MEDICATION NAME] in an attempt to control aggressive behaviors. Record review of a "Psychiatric Progress Note" dated 11/24/2010 revealed that Resident #502 would get into ""Scuffles" with other residents. The plan, noted on the progress note, was to continue with the current [MEDICAL CONDITION] medications. Record review of Resident #502's "Care Plan Conference Summary" dated 9/21/2010 revealed no indication of acknowledgement of Resident #502's aggressive behaviors towards other residents in the facility. Record review of Resident #502's care plan originally dated 6/28/2010, which was crossed out, and re-dated 11/15/2010 revealed a problem that Resident #502 was confused and at risk of displaying social inappropriate behaviors, resisting care, and physical aggression. The interventions were to, anticipate Resident #502's needs, identify her bathroom with a picture, toilet her before and after meds and at morning care, use a calm approach, alternate care provider, allow time and space for resident #502 to calm down. The care plan was renewed on 11/17/2010 and interventions added were to separate Resident #502 from other residents when aggression increases, explain to Resident #502 that she could not touch other residents belongings without permission, separate Resident #502 from other residents when agitation increases. The care plan was updated on 11/23/2010 to include placement of Resident #502 on a "Safety Check Log" and to monitor Resident #502 every 15 minutes times 4, every 30 minutes times 2, every hour times 4, and then every shift times 3 shifts to monitor behavior. The care plan also revealed that Resident #502 was not to have regular silverware because she had swung a knife at another (non sampled) resident who was sitting at the same table as her in the dining room. Another incident was noted on the care plan and revealed that Resident #502 had grabbed another resident's (#501) wheelchair by the arm rest and tipped the wheelchair over. No new interventions were added to the care plan. Another incident was noted on the care plan and revealed that Resident #502 grabbed another (non sampled) resident by the wrist aggressively as the resident was passing by in a wheelchair. Resident #502 stated to the other resident, "Don't come into my house, I will show you, you want to fight." No interventions were added to the care plan until 11/27/2011 which only included to obtain a urine sample. This care plan was not the care plan required for use per facility Policy and Procedure. Record review of the facility Policy and Procedure for "Behavioral Management" dated 3/2006 revealed that staff was to document and track behaviors, as behaviors occur in order to minimize future occurrences. The policy revealed that staff was responsible for preempting behavior problems before they occur. The policy revealed that at the first onset of anxiousness, agitation, or any behavior that signifies the resident was having difficulty, staff was responsible for immediately attempting to rule out, the need to eliminate, hunger/thirst, need to rest/sleep, comfort levels, physiological/medical problems. The policy revealed that if a resident was not trying to meet a basic physical need and a behavior develops or continues, the staff were to implement the "7-Step Problem-Solving Program". The program included, A). Describe causes related to the person. B). Describe causes related to the problem. C). Describe causes related to the physical and emotional health. D). Describe causes related to the environment. E). Describe causes related to the task. F). Develop problem solving strategies. G). Formulate and implement an intervention plan. The policy included the implementation of a behavioral care plan that was specific for residents who had an alteration in behavior and were physically aggressive towards other residents. Record review of the "Safety Check Log" dated 11/23/2010, revealed that Resident #502 was monitored as the care plan revealed. Beginning at 2:00 PM on 11/23/2010 every 15 minutes checks were done times 3, at 2:00, 2:15, 2:30 and then again at 3:00 PM. The log revealed the next check was at 3:30 PM then 4:00 PM and then every hour for 4 times. The log revealed that Resident #502 was checked for behaviors for three shifts and did not indicate any behaviors until 11/24/2010 when the log revealed that Resident #502 pulled a wheelchair out from under another resident, after which the log contained no more information and no behavior checks were documented after the incident. Record review of a "Behavior/Interventions Monthly Flow Record" Dated for the months of 9/2010, 10/2010, 11/2010, 12/2010, 1/2011, and 2/2011 revealed several incidents of Resident #502 having behavioral aggression and agitation. Outcomes for behaviors was not consistently documented. Record review of a pharmacy request dated 10/16/2010 revealed that Resident #502 was started on [MEDICATION NAME] (a sedative). Record review of the "Medication Administration Record" (MAR) dated for the months of October, November, December 2010, January and February 2011 revealed that Resident #502 received [MEDICATION NAME] as needed for aggression, and in February 2011 she received the [MEDICATION NAME] three times a day around the clock and as needed in between. The February MAR indicated [REDACTED]. Record review of a "Psychiatric Progress Note" dated 2/28/2011 revealed a notation that the [MEDICATION NAME] ordered to be given to Resident #502 on an as needed basis was to be discontinued because she was not requiring the use of it. Record review of the nurses' notes dated 7/21/2010 revealed that Resident #502 had a conversation with another (non sampled) resident and began to yell at the resident, this notation was timed at 9:30 PM. The note revealed, on the same date at 9:45 PM, Resident #502 was leaving the dining room when she walked by another (non sampled) resident and knocked her glasses off her face. Resident #502 was led away and sat in the lobby area of the facility. The notes dated 10/13/2010 revealed that Resident #502 would talk with other residents but then would start yelling at times and would raise her fist to other residents. The notes revealed that on 10/15/2010 Resident #502 pushed another (non sampled) resident's wheelchair and would not let go. Resident #502 began to curse and said that the other resident was her child and she was going to "Whip his bottom." The note revealed that Resident #502 remained delusional and was hallucinating. Resident #502 then went into another (non sampled) resident's room and would not leave. The note revealed that Resident #502 had become very mean, scratched at nursing staff, and tipped a bedside table over that was in the other resident's room. The note revealed that a physician order was received to administer [MEDICATION NAME] to Resident #502 and her husband was called to go into the facility to assist. The note revealed that Resident #502's husband was able to get her out of the other resident's room. On 10/17/2010 timed at 8:00 PM the nurses' note revealed that Resident #502 continued to wander around the facility hallways looking for her children and that she remained delusional. On 11/15/2010 the notes revealed that Resident #502 was in the dining room and grabbed the arms of another resident in aggression and had to be re-directed. On 11/23/2010 the notes revealed that Resident #502, a non-smoker, went outside where other residents were smoking and grabbed a resident's (non sampled) walker. Resident #502 was asked to leave the walker alone and she refused. Resident #502 hit the (non sampled) resident, who the walker belonged to, twice on the arm. A notation on 1/10/2011 timed at 5:00 AM revealed that Resident #502 would not go to bed and wandered all night. The notes revealed that on 1/23/2011 Resident #502 was witnessed sitting at a table in the dining room with a resident and had a verbal altercation, during which, Resident #502 had swung a knife at the other resident. The note revealed that the knife did not touch the other resident. The note revealed that on 1/24/2011, Resident #502 had a verbal altercation with another resident. The note revealed that the physician was notified the next day on 1/25/2011 of Resident #502's escalating behaviors and ordered a urine screen to rule out an infection. The notes revealed that on 1/26/2011 ,timed at 4:00 PM, Resident #502 was in the lobby of the facility when she got up out of a chair, as another resident went by in her wheelchair, and grabbed her on her arm aggressively and said, "Don't come in my house, do you want to fight, I'll show you," The notes did not reveal any intervention that was used for the aggressive behavior. The notes revealed a notation on 2/4/2011 timed at 11:05 AM that Resident #502 was very difficult to re-direct, causing harm to staff and other residents. The notes revealed that Resident #502 was assessed for placement at a hospital psychiatric ward for assistance. Resident #502 did not go to the hospital, because Resident #502 required a guardian to sign her into the hospital. Record review of the "Social Service Progress Notes" dated from 6/29/2010 through 10/15/2010 revealed two notations in regards to Resident #502's aggressive behaviors towards other residents, but no indication of interventions to protect other residents. Review of a "Social Service Evaluation" dated 9/21/2010 and 1/4/2011 revealed no notation in regards to Resident #502's aggressive behaviors. Record review of the facility incident reports revealed the following dates that Resident #502 had altercations with sampled and non sampled residents in the facility: 9/17/2010, Resident #502 fist fought with resident #508. No physical injury was noted. The steps taken to prevent re-occurrence were noted to be, separation of the two residents. 11/15/2010, Resident #502 aggressively grabbed the arm of another resident. The steps taken to prevent a re-occurrence were noted to be, keep Resident #502 away from close range of other residents as she may become aggressive. 11/23/2010, Resident #502 grabbed another resident's walker and hit the other resident twice on his arm. The steps taken to prevent a re-occurrence were noted to be, place resident on frequent behavioral checks. 1/23/2011, Resident #502 swung a knife at another resident who sat at the same table as she. The steps taken were noted to not allow Resident #502 to have regular silverware anymore, only plastic. 1/24/2011, Resident #502 flipped Resident #501 over backwards in her wheelchair. Resident #501 had a raised area to the back of her head after the fall. The steps taken to prevent a re-occurrence were to watch Resident #502 at all times. 1/26/2011, Resident #502 verbally attacked another resident and asked her if she wanted to "fight" telling her that she would "show her". There were no identified steps taken to prevent a re-occurrence. No documentation was noted. Staff Member #1, a Licensed Practical Nurse (LPN) and the Unit Manager, was interviewed on 2/28/2011 at 10:31 AM. She said that on the 11/23/2010 incident when Resident #502 was outside grabbing onto another resident's walker, Resident #502 was not able to re-directed. She said that Resident #502's behaviors started soon after her admission to the facility. She said that medication changes had been made, and Resident #502 was supposed to go to the hospital for treatment but did not go. LPN #1 said that Resident #502 would wander the facility and, "We try to keep a watch on the resident." She said the incident that occurred when Resident #502 flipped Resident #501 over backwards in her wheelchair occurred while Resident #501 was cleaning tables. LPN #1 said that no staff were in the dining room at the time of the incident, and that Resident #502 must have wandered back into the dining room. She said that the previous Social Worker did not do anything about Resident #502's aggressive behaviors and that she had recently quit working at the facility. She said that she did not know of any "One on One" documentation for Resident #502's supervision. She said that she knew that staff was watching Resident #502, but there was no documentation of it, that she knew of. LPN #1 said that no other interventions were initiated that she knew of, except for the [MEDICATION NAME]. Staff Member #2, a Registered Nurse (RN), was interviewed on 2/28/2011 at 11:10 AM. He said that on the day that Resident #502 flipped Resident #501 over backwards in her wheelchair, there was no staff in the dining room. He said that Resident #502 had left the dining room and then went back in the dining room. He said that Resident #501 was sitting on her bottom on the floor when he got into the dining room. He said Resident #502 was holding onto Resident #501' s wheelchair. He said it appeared as though Resident #502 pulled the wheelchair away and when Resident #501 went to sit down the wheelchair was not there. He said Resident #501 had a bump on the back of her head. He said that interventions put in place were to have Resident #502 sit at a different table in the dining room. RN #2 said that other residents could not provoke Resident #502 because she would get really "Nasty". He said that Resident #502 would get real aggressive and hallucinate. He said that medication was not the answer, and to his knowledge, Resident #502's care plan had no changes to address her behavior. Staff Member #3, an RN, was interviewed on 2/28/2010. She said that she did not know if any staff was in the dining room when Resident #502 tipped over Resident #501's wheelchair. She said that when she got into the dining room, Resident #501's wheelchair was tipped over. She said that Resident #501 had a bump o the back of her head which she had a CAT scan for the next morning. She did not know the results of the CAT scan. She said that she took Resident #501 back to her room after the incident. She said that Resident #501 told her that Resident #502 put her hand on the arm of her wheelchair with aggression. She said that Resident #501 told her that Resident #502 lifted her wheelchair up and tipped her over backwards and she (Resident #501) hit her head on the floor. RN #3 said that the only intervention that was done after the incident was that Resident #502 was re-directed. She said that " One on One" supervision was not initiated. She said that Resident #502 and #501 had an altercation in the dining room before, but she did not remember if Resident #502 had touched Resident #501, or if she wrote up an incident report, or told anyone about it. Staff Member #3 said that if someone was to just walk by Resident #502 she would get aggressive. She said that if Resident #502 yelled out a command and no one did it, then she would get mad. RN #3 said that one could tell when Resident #502 was getting upset because it would show in her face. She said that "One on One" supervision was not an intervention for Resident #502. She said that staff would just watch Resident #502 and wait for the next episode. RN #3 said that Resident #502 had things that she liked, such as singing, but those things were not on her care plan as interventions. Staff Member #4, a Certified Nurse Aid (CNA), was interviewed on 2/28/2011 at 12:36 PM. She said that Resident #502 could get mean if she didn't like something. She said that staff would attempt to re-direct Resident #502, but that it never helped. She said that Resident #502 was unpredictable with her moods and her outbursts. She said that no one knew when Resident #502 would explode against another resident. She said that she had taken Resident #502 to the back of the dining room before to sit with her. She said that she had never been asked to supervise Resident #502 on a "One on One" basis. She said that all she had been told to do was document Resident #502's behaviors on the behavior log and nothing more, other than try to re-direct her and talk with her. Resident #501 was interviewed on 2/28/2011 at 12:45 PM. She said that when Resident #502 tipped her over backwards in her wheelchair it was right after supper time in the dining room. She said Resident #502 had clothes protectors, plastic plates, and cardboard containers sitting on the ledge of the wall divider in the dining room. She said that she was cleaning up the tables, and when she reached to take the stuff off the wall divider and put the stuff on the table, Resident #502 told her to leave the stuff alone because it was for sale. She said she tired to explain to Resident #502 the stuff was garbage. She said Resident #502 said to her, "Damn you" and grabbed her wheelchair and flipped her over backwards. Resident #501 said that Resident #502 then lifted her foot up and put it over her face as if she was going to stomp on her face with her foot. She said that was when she yelled for help. She also said that when she reached up to take the stuff off the wall Resident #502 grabbed her right arm and dug her nail into her arm taking the skin off and causing her arm to bleed. She said another time while she was in the dining room getting water, Resident #502 told her to stop doing that, grabbed her arm bruising it, and spilling the water. Observation of Resident #501's right arm on 2/28/2010 at 12:45 PM revealed a scar about the size of a nickel. Resident #501 verified that was the spot that Resident #502 had dug her nails into her arm. Resident #508 was unable to participate in an interview. Staff Member #5, an LPN, was interviewed on 2/28/2011 at 1:27 PM. She said that Resident #502 would wander the halls of the facility. She said that Resident #502 at one time had gone into another resident's room and would not leave. She said the two residents were in bed and asked her to get Resident #502 out of their room. She said Resident #502 thought it was her room and refused to leave. She said Resident #502 sat down on one of the beds, and then on a wheelchair that was in the room. She said Resident #502 got mad and flipped over the bedside table that was in the room. She said nothing was on the table and no one got hurt. LPN #5 said that Resident #502 would have unexpected outbursts. She said that things would set Resident #502 "Off". Staff Member #5, the Director of Nursing (DON) was interviewed on 2/28/2011 at 2:30 PM. She said that no interventions were done to prevent resident to resident abuse in the facility. She said she noticed that when she had begun working at the facility about 3 weeks ago. She said that she had not begun to make any changes. She said that Resident #502's care plan had not been updated, nor had any interventions been added for Resident #502. The Social Worker that was employed at the facility was unable to be reached for an interview. Observation of the dining room on 3/3/2011 at 11:30 revealed 17 residents in the dining without any staff present. The Administrator was notified on 3/8/2011 at 3:13 PM of the Immediate Jeopardy that began on 1/24/2011 as a result of the facility's failure to prevent verbal, physical and/or mental abuse from Resident #502 towards Residents #501 and #508 and other residents in the facility. On 3/9/2011 the surveyor confirmed that the facility implemented the following to remove the Immediate Jeopardy: 1). On 3/4/2011 at 4:00 PM Resident #502 was put on "One on One" supervision. At 7:00 PM on 3/4/2011 Resident #502 was transferred to the hospital for evaluation. 2). Beginning 3/8/2011, the intake process (admission process) will include a review of social history, recent nurses' notes, and other background information as appropriate to assist in identifying residents at risk for inappropriate behaviors. 3). Effective 3/4/2011 a new Social Worker had been hired to assist in working with residents that would have a tendency for inappropriate behaviors and those residents that are on [MEDICAL CONDITION] medications. 4). On 3/4/2011 the Social Worker began assessing all resident for behavioral issues. As of 3/6/2011, 10 of 61 residents currently residing at the facility had been assessed. Six of the 10 had been identified to be at risk for behaviors. Interventions for the six identified residents will include updated care plans that will include interventions such as distraction with activities, pain medications, if indicated, and toileting. 5). Beginning 3/9/2011, residents who have had an altercation with Resident #502 will have 1 to 1 visits with the Social Worker three times per week for 5 visits. As of 3/9/2011 4 residents out of 61 had been identified and referred to the Social Worker for follow-up. 6). Beginning 3/4/2011, residents identified with potential behavioral issues will be monitored and placed on a 24 hour sheet that will be reviewed daily and communicated at the daily department meetings. Any resident identified with extreme behavior will be monitored 1 on 1 until a behavioral plan is initiated. 7). On 3/7/2011 a new Certified Activity Director was hired. This individual had certification in mental health and behaviors. 8). Beginning 3/6/2011 all staff will be educated regarding abuse reporting, Michigan guidelines on abuse, and who to report suspected abuse to. As of 3/9/2011 43 of 87 employees had attended the in-service. 9). Beginning 3/8/2011, any abuse identified will immediately be addressed by the abuse coordinator who will follow-up with the State Agency. Any staff involved will be suspended pending investigation. The facility ' s abuse coordinator is identified to be the Administrator. 10). On 3/8/2011, the behavior management process was reviewed and revised to include the use of a documentation tool (Behavioral/intervention flow sheet) for all residents with identified behavioral issues. 11). Effective 3/8/2011 Social Services will coordinate with nursing in weekly/monthly behavioral management meetings, with the Social Service Director tracking and managing referrals to the psychiatrist and other interventions as needed. The results of the meeting will be reported to a QI committee monthly. 12). Beginning 3/9/2011 all staff will be educated by the Director of Nursing regarding behavioral management techniques, including interventions and actions in the instance of an increase or change in resident behavior. Staff will be educated that they can report suspected abuse to the abuse coordinator, DON, or any department head without fear of any repercussions. Employees unable to attend the educational sessions scheduled 3/9/2011 will be required to attend an education session before they will be allowed to work on the floor. 13). On 3/4/2011 the guidelines for reporting abuse were posted a the time clock. Although the Immediate Jeopardy was removed on 3/9/2011, the facility remained out of compliance at a scope and severity of isolated with no actual harm, but the potential for more than minimal harm due to all staff had not been educated, all residents had not been assessed for behaviors, and all residents identified to have been affected by abuse, had not received 1 on 1 visits from the Social Worker and sustained compliance had not been verified by the State agency. ( )

This citation pertains to intake number MI 340 Based on observation, interviews, and record review, the facility failed to provide adequate supervision and prevent the fall of 1 of 12 residents (Resident #504) when Resident #504, who was identified to be a fall risk, and was left alone in the dining room unsupervised by staff when she had fallen, resulting in a fractured left hip that required her to be admitted to the hospital for surgical repair of the fractured left hip. Findings include: Per the facility face sheet Resident #504 was a [AGE] year old female originally admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the "Minimum Data Set" ((MDS) dated [DATE] revealed that Resident #504 had moderately impaired decision making skills, required limited assistance with ambulation, and had a fall within the last 30 days. Record review of a facility incident report dated 7/29/2010 revealed that Resident #504 was found lying on the floor next to the nursing station. The incident report included steps to take to prevent any future falls, 1) proper foot wear, and 2) train Resident (#504) to use wheelchair all the time. Another incident report dated 11/30/2010 revealed that Resident #504 was found on the floor, lying on her side, in the dining room. The incident report revealed that Resident #504 received a skin tear and a bump on her head as a result of the fall. The intervention placed after the fall was to add an alarm to Resident #504's wheelchair. Record review of a "Care Plan" for "Falls" dated 5/4/2009 revealed a problem that Resident #504 was at risk for injury from falls due to impaired cognition and impaired mobility. The goal was for Resident #504 to have no injury from falls. The approaches/interventions included, supervise Resident #504 with all ambulation, provide assistance with transferring. Another "Care Plan", originally dated, 8/11/2010 and renewed on 10/12/2010 revealed that Resident #504 continued to be at risk for falls. The approach/interventions included, supervise with ambulation, apply auto lock breaks to wheelchair, no alarms per family request except the use of a bed alarm. Staff Member #19, the Certified Nurse Aid (CNA) who cared for Resident #504, was interviewed on 3/3/2011 at 11:35 AM. She said that she did not see Resident #504 fall. She said that she did not know who took Resident #504 into the dining room for dinner the evening of her fall. She said that after residents were done with their meals they were brought out of the dining room. Staff Member #19 said that Resident #504 at one time was able to walk. She said that Resident #504 got to a point to where she could not walk anymore. CNA #19 said that on the day of her fall, in the dining room, Resident #504 was not able to ambulate and required the use of her wheelchair to be mobile. CNA #19 said that Resident #504 thought she could walk and would always try to stand up and walk. She said that nursing staff would put a tab alarm on Resident #504 (an alarm that clips to the residents shirt and alarms when disconnected, such as, when standing up). She said that Resident #504's daughter did not want the alarm on Resident #504. Staff Member #189 said that on the day of her fall in the dining room, Resident #504 did not have an alarm on her. She said that she was told by nursing staff to watch Resident #504 and all other residents. CNA #19 said that she knew she that Resident #504 required increased supervision, because she was a fall risk. CNA #19 said that on the day of Resident #504's fall in the dining room, she had put Resident #504 up to a table. She said that she thought she had taken Resident #504 out of the dining room, but she was mistaken and stated that she had not taken Resident #504 out of the dining room before she (Staff Member #19) went to lunch. CNA #19 said that Resident #504 was left unsupervised while in the dining room. CNA #19 said that she went to lunch around 7:30 PM and was told that Resident #504 had fallen around 8:00 PM. CNA #19 said that she had not told any other staff that Resident #504 was still in the dining room before she went to lunch, because she forgot Resident #504 was still in the dining room. CNA #19 said that she typically takes her residents out of the dining room after they are finished with their meals, but did not know what happened on 11/30/2010. Staff Member #14, a CNA, was interviewed on 3/1/2011 at 2:40 PM. She said that Resident #504 was required to be taken out of the dining room immediately after finishing her meal. She said Resident #504 was required to be placed in a supervised area. She said Resident #504 would get anxious and lean forward in her wheelchair and that was very dangerous. She said Resident #504 was required to be in a high populated area. CNA #14 said that she and all staff knew Resident #504 required supervision and to be placed in a populated area several weeks before her fall on 11/30/2010. She said that CNA #19 knew that she could not leave Resident #504 in the dining room. She said that CNA #19 said that she had taken Resident #504 out of the dining room, but Resident #504 was not able to move her wheelchair forward, and that her wheelchair had automatic brakes on it so that it could not move backward. CNA #14 said that no staff were in the dining room at the time of Resident #504's fall, because they were busy putting their assigned residents to bed for the evening. CNA #14 said that the kitchen staff left at 8:00 PM. She said that was why she could not understand why Resident #504 was left in the dining room. She said that a CNA never was to leave a resident unattended and go to break. She said that all residents were to be out of the dining room before a CNA was to go on break. Staff Member #15, a CNA, was interviewed on 3/2/2011 at 11:18 AM. She said that Resident #504 had alarms on at one time, and the alarms would sound all the time, due to Resident #504 attempts to stand up. She said that Resident #504 would not stay sitting in her wheelchair. She said that Resident #504 was never to be left alone in a room while she was in her wheelchair. She said that she knew Resident #504 was to be watched at all times. Staff Member #16, a laundry room staff member, was interviewed on 3/2/2011 at 11:50 AM. She said that she saw Resident #504 sitting in her wheelchair in the dining at a table on 11/30/2011. She said it was a little past 8:00 PM. Laundry room staff #16 said that when she saw Resident #504 there were no other staff members in the dining room at the time. She said that she figured that someone would go back into the dining room and get Resident #504. Laundry room staff #16 said that she did not know if Resident # 504 could be left alone, and she did not tell anyone that Resident #504 was still in the dining room. She said that when she left the facility for the evening it was a bit past 8:00 PM and Resident #504 was totally alone in the dining room. Staff Member #17, a dietary aid, was interviewed on 3/2/2011 at 12:05 PM. He said that he saw Resident #504 sitting in the dining room at about 7:25 PM. He said that typically by 7:15 PM all resident were out of the dining room. Dietary aid #17 said that Resident #504 was able to walk at one time but had recently declined and required the use of a wheelchair, prior to her fall on 11/30/2010. Staff Member #3, a Registered Nurse (RN), was interviewed o 3/2/2011 at 12:24 PM. She said that when she went into the dining room after Resident #504's fall, there were no staff members present. She said Resident #504 was the only resident in the dining room at 8:15 PM. RN #3 said that all residents were to be out of the dining room by 7:15 PM. She said that no alarms had sounded when she entered the dining room to assist with Resident #504's fall. RN #3 said that Resident #504 had a recent decline and was only walking a few steps prior to her fall. RN #3 said that Resident #504 should not have been left alone in the dining room. She said that Resident #504 had complained of pain because of a bump on her and a quarter size skin tear that was present on her left arm. Staff Member #20, a Dietary Aid, was interviewed on 3/3/2011 at 12:20 PM. She said that she was cleaning the dining room after the dinner meal from 7:00 PM to 7:30 PM and she saw Resident #504 in the back of the dining room. She said that she saw Resident #504 walking around. She said she saw Resident #504 pushing another resident around in her wheelchair. She said that Resident #504 would get up and down from her wheelchair and that was normal for Resident #504, stating that Resident #504 did that all the time. Dietary Aid #20 said that residents were not to be left in the dining room past 7:00 PM, if they were done eating their dinner. Dietary Aid #20 said that no staff had gone into the dining room to check on Resident #504 while she was cleaning. She said that no staff member was with Resident #504 while she was in the dining room. She said that Resident #504 fell between 8:00 PM and 8:20 PM. Staff Member #20 said that when staff found Resident #504 no alarms had sounded. She said that Resident #504 had alarms on her before but she did not know why the alarms had been removed. Dietary Aid #20 said that she had seen Resident #504 fall before and the facility needed to get control of that. Staff Member #21, a CNA, was interviewed on 3/3/2011 at 1:50 PM. She said that Resident #504 was in the back of the dining room when she saw her, and she was in her wheelchair. She said that if Resident #504 took a few steps she needed to hang onto something, stating that Resident #504 was not stable with ambulation. CNA #21 said that staff knew Resident #504 required supervision by "Word of Mouth" and the requirement was not documented on the CNA care cards. She said that Resident #504 did not have alarms on because the Administrator said alarms were too disturbing for Resident #504. CNA #21 said that Resident #504's daughter did not request for Resident #504 to not have alarms. CNA #21 said that she thought Resident #504 should have had alarms on her person. CNA #21 also stated that Resident #504 would not have been able to push another resident in her wheelchair safely. She said that Resident #504 would not have been able to safely walk around the dining room independently and that is most likely why she fell . CNA #21 said Resident #504 needed to be in view of staff all the time because Resident #504 would attempt to stand up on her own. Staff Member #9, the Dietary Manager and Resident #504's daughter, was interviewed on 3/9/2011 at 11:00 AM. She said that even if Resident #504 ambulated she required supervision. She said Resident #504 did not have an alarm on her at the time of the fall. She said Resident #504 was only able to "Shuffle" when she walked. She said that Resident #504 had falls prior to her 11/30/2010 fall and that she wanted an alarm on Resident #504. Dietary Manager #9 said that it was not until the next day that it was discovered that Resident #504 had broken her left hip. Record review of a "Fall Risk Evaluation" dated 8/17/2010 revealed that Resident #504 scored a 22 on the risk evaluation. The "Fall Risk Evaluation" revealed, "A Resident who Scores a 10 or Higher is at Risk." Record review of hospital records dated 12/1/2010 revealed that Resident #504 was admitted to the hospital with [REDACTED]. Review of the hospital "Pre-Operative History and Physical" dated 12/2/2010 revealed that Resident #504 presented to the emergency room after an unwitnessed fall at the nursing home. The pre-operative note revealed that Resident #504's left hip was found to be fractured at the neck of the femoral bone. Review of an "Operative/Procedural Record" revealed Resident #504 had a repair of the fracture on 12/2/2010. Observation and attempted interview of Resident #504 was conducted on 2/25/ at 2:30 PM. Resident #504 was lying in bed and a bed alarm was present and functioning. Resident #504 was not able to answer questions due to confusion and only mumbled incomprehensible words. ( )