Every finding on record at Oakpointe Senior Care and Rehab Center

Based on observation, interview, and record review, the facility failed to maintain general cleanliness and repair of the physical environment, affecting all residents in the facility. Findings include:On 08/26/2026 at 9:40 AM, black buildup was observed accumulated around the hand sink basin drain in the second floor north med room. On 08/26/2026 at 11:10 AM, heavy dust was observed accumulated around the internal frame of the door in the second floor bulk linen storage room. Environmental Services Director (EVSD) P acknowledged the buildup, and indicated staff do not come to this area. On 08/26/2026 at 1:13 PM, black buildup was observed accumulated on the air vent register in the first floor north soiled utility room. Further observation found the air duct was soiled with black buildup along the bottom and sides. In an interview at this time, EVSD P indicated the duct got dirty when construction was taking place previously. On 08/26/2026 at 1:20 PM, the shower head was observed resting on the floor in the first floor south shower room, with the holder used to secure the shower head missing. In an interview at this time, when asked about maintenance repairs, EVSD P indicated there is an online maintenance program where requests can be made. EVSD P indicated housekeeping staff and nursing staff have access to the platform. On 08/26/2026 at 1:36 PM, heavy dust was observed accumulated around the internal frame of the door in the second floor north storage and emergency water room. EVSD P acknowledged the buildup and indicated it would be addressed. Further observation found an air vent soiled, and approximately eleven ceramic tiles above the door frame were cracked, broken, and missing, leaving rugged edges. In the same area, a three-by-three-inch section of drywall was observed damaged and with black buildup accumulated around the edges. Dirt and debris was observed on the floor of the room. On 08/26/2026 at 1:48 PM, the air duct was observed soiled with black spots in the second floor south soiled utility room. EVSD P acknowledged the buildup. On 08/26/2026 at 1:50 PM, a ramp scale was observed in the second floor south shower room, adjacent to the scale was a moist rust colored accumulation on the floor. A puddle of standing water was observed adjacent, and partially under the scale. On 08/26/2026 at 1:54 PM, heavy dust was observed accumulated around the internal frame of the door in the second floor south maintenance storage room. EVSD P acknowledged the buildup and indicated they would have it taken care of. On 08/26/2026 at 1:59 PM, the shower head holder used to secure the shower head was observed missing in the first floor north shower room. On 08/26/2026 at 3:09 PM, one by one inch floor tiles were observed missing around the floor drain, and the drain cover absent in the first floor north janitor closet. Approximately four baseboard tiles were observed missing along the back side of the room adjacent to the mop sink. Dirt and debris were accumulated in corners at the wall junctures, on the walls, along the baseboards and within the janitor sink basin. On 08/26/2026 at 8:16 AM, the air vent was observed heavily soiled in the first floor south biohazard room. Further observation found two ceramic tiles on the wall near the entrance of the room cracked with sharp edges exposed. On 08/27/2026 at 8:19 AM, black buildup was observed accumulated on the air vent in the second floor north biohazard room. Further observation found black buildup across the bottom and side surface of the air duct in the room. On 08/27/2026 at 8:23 AM, an accumulation of grey buildup was observed in the corner of the wall surrounding the inner window frame in the beauty salon. The buildup extended across the wall above the length of the window. On 08/27/2026 at 8:25 AM, approximately thirteen baseboard tiles were observed missing in second floor north clean utility room. The window blinds had multiple partially broken slats. Further observation found a ceramic wall tile cracked, located on the wall near the entrance of the door. On 08/27/2026 at 8:39 AM, in an interview, EVSD P indicated housekeeping staff clean both the clean utility and soiled utility rooms every morning. When asked if staff clean the beauty shop, EVSD P indicated staff clean it in the mornings if it is being used, and clean it in the middle of the shift when it is not used. On 08/27/2026 at 8:49 AM, a ramp scale was observed in the second floor south shower room. In an interview at this time, EVSD P indicated the scale permanently stays in the room for new admits. Observation of the scale found paint chipped on the sides of the scale. On 08/27/2026 at 9:43 AM, in an interview, Maintenance Director (MD) Q indicated construction to remove dead legs within the facility's plumbing is currently ongoing, along with a roof replacement. MD Q indicated once construction is completed, the facility plans to renovate various rooms. On 08/27/2026 at 11:15 AM, in an interview, Nursing Home Administrator (NHA) indicated all rooms are planned to undergo renovation after construction is complete. NHA indicated a list of environmental concerns around the facility was developed and placed onto a list. When asked when the list was created, NHA indicated this year. When asked for the date of completion for these tasks, NHA indicated it is ongoing and is currently delayed currently due to other environmental concerns. On 08/27/2026 at 12:06 PM, in an interview, when asked about the environmental task sheet, MD Q indicated items that are highlighted on the sheet are completed. On 08/27/2026 at 1:36 PM, in an interview, EVSD P indicated housekeeping staff are responsible for cleaning the beauty room, including the floors, sink, and table. when asked about the window area, EVSD P indicated the window has not been cleaned yet, and the curtain was removed yesterday. Record review of the facility provided document titled HOUSEKEEPER GENERAL RESPONSIBILITIES states, It is the goal of [corporate name] to maintain a clean, fresh, inviting environment for our guests . This environment is maintained by assigning specific areas of responsibility to individual housekeepers. Record review of the facility provided task sheet includes a list of facility identified environmental tasks. The tasks included items such as, Deep clean janitors closet on 1 south . Replace broken Tile in soiled utility rooms . Remove toilet cover holder in 1 south public restroom and clean air vents. Most items on the list were not marked complete upon receiving list.

This citation contains two Deficienct Practice Statements Deficient Practice Statement #1. Based on observation, interview, and record review the facility failed to ensure that staff followed enhanced barrier precautions (EBP) and donned appropriate Personal Protective Equipment (PPE) for one resident (R1) out of two residents reviewed for EBP. This failure resulted in the potential for transmission of infectious organisms. Findings include: On 06/10/25 at 11:12 A.M., during an observation of resident care, licensed practical nurse (LPN) B was observed administering a 100 ml (milliliter) water flush through R1's percutaneous endoscopic gastrostomy (PEG) tube. LPN B did not don a gown prior to providing the care. Signage on R1's door indicated Enhanced Barrier Precautions and PPE (including gowns) being available outside R1's room. An interview was conducted with LPN B immediately following the observation. LPN B acknowledged that they should have worn a gown and gloves while administering the PEG tube flush and recognized there was EBP signage and PPE at the room door. On 6/11/25 at 9:50 A.M., an interview was conducted with the Director of Nursing (DON), who said staff are expected to follow the facility's Enhanced Barrier Precautions policy, which requires donning gown and gloves when performing high contact care activities such as device care (including feeding tubes.) The DON acknowledged that LPN B did not follow the required infection control protocols. A review of R1's clinical record noted that R1 was admitted on [DATE] with diagnosis including convulsions, dementia, failure to thrive, dysphagia (difficulty swallowing), and gastronomy status (PEG tube). A Minimum Data Set (MDS) assessment dated [DATE] indicated R1 was cognitively impaired with a score of 11 out of 15 on the Brief Interview for Mental Status (BIMS). A review of facility policy titled Enhanced Barrier Precaution with a revision date of 4/1/24, defined EBP as the expanded use of PPE, including gowns and gloves during high contact care involving medical devices such as central lines, feeding tubes, urinary catheters and tracheostomies. Deficient Practice Statement #2. Based on observation, interview and record review, the facility failed to ensure the proper storage of oxygen tubing when not in use for three residents (R30, R37, and R82) of three residents reviewed for oxygen therapy. This failure had the potential for cross contamination and the spread of infection. Findings include: On 6/10/25 at 2:13 P.M., R37 was observed seated in a [NAME] chair in the hallway. R37 nasal cannula tubing was hanging behind the chair and exposed to open air. There was no storage bag present for the nasal cannula to be placed in when not in use. On 6/10/ 25 at 2:14 P.M., LPN D also observed R37 sitting in the [NAME] chair with the nasal cannula tubing on the back of the chair with no bag present. LPN D was queried regarding the nasal cannula tubing and said it should have been in a bag. Record review revealed R37 was admitted on [DATE] with a diagnosis including obstructive sleep apnea and chronic respiratory failure. A (MDS) assessment dated [DATE] indicated that R37 was cognitively intact with a score of 13 out of 15 on BIMS. On 6/10/25 at 2:15 P.M., R82 was observed in bed. R82 nasal cannula tubing was connected to the back of their wheelchair. The nasal cannula tubing was attached to the back of their wheelchair and lying unsecured on the seat. No bag was present for storing the tubing. Record review showed R82 was admitted on [DATE] with a pertinent diagnosis of asthma, weakness and generalized anxiety disorder. A MDS assessment dated [DATE] indicated that R82 was cognitively intact with a score of 13 out of 15 on the BIMS. On 6/10/25 at 2:20 P.M., R30 was observed in a wheelchair being transferred back to R30's room. R30 had a oxygen tank on the back of the wheelchair but was not wearing an oxygen mask. Upon rising from the wheelchair, it was observed that R30 was sitting on the nasal cannula tubing. There was no bag on back of the wheelchair to store the nasal cannula tubing when it was not in use. R30's clinical record documented R30 was admitted [DATE] with a pertinent diagnosis of physical disability, right heart failure, pulmonary embolism, and cerebral infarction (stroke). On 6/10/25 at 2:30 P.M., Certified Nurse Assistant (CNA) C who transported R37 to the room was interviewed and acknowledged the nasal cannula tubing was not stored properly and should have been in a bag. On 6/10/25 at 2:35 P.M., the clinical coordinator (LPN) A accompanied the surveyor to the rooms of R82 and R37. LPN A was queried and confirmed the nasal cannula tubing was lying on the wheelchair seats. LPN A acknowledged the nasal cannulas should have been bagged. On 6/11/25 at 9:50 A.M., an interview was conducted with the DON, who said that staff are expected to follow the facility's on oxygen storage. The DON said oxygen should be stored in a plastic bag when not in use. Review of facility policy titled Oxygen Administration and Safety, with a revision date of 5/21/25, indicated the purpose of the policy is to ensure the safe administration of oxygen therapy to residents. The policy documented that oxygen tubing should be stored in a plastic bag when not in use.

Based upon interview and record review, the facility failed to act upon Pharmacy Recommendations in a timelly manner regarding discontinuing blood sugar checks four times a day for one (R92) of five residents reviewed for unnecessary medication regimen reviews, resulting in unnecesary monitoring and the potential for R92 to experience discomfort during multiple finger sticks. Findings include: According to R92's Electronic Health Record (EHR) the resident had multiple diagnoses that included type 2 diabetes (adult onset diabetes) without complications. On 4/11/24 the physician prescribed the following insulin orders: Novolog (fast acting insulin) injection per sliding scale (varies the dose of insulin injection based on the blood sugar level) before meals and at bedtime (4 times a day) as follows; for blood sugar reading; 0-200 = zero units of insulin, 201-250 = 1 unit of insulin, 251-300 = 2 units of insulin, 301-350 = 3 units of insulin, 351-400 = 5 units of insulin, and 401- 450 = 5 units of insulin, if over 450 call the physician. The Pharmacy Recommendation for R92 dated 4/22/24 read, This resident has an order for Novolog per sliding scale four times daily. There are currently no orders for scheduled long acting or meal time insulin, nor are there any oral medications for diabetes. Most recent A1C results from April was 4.9 (normal range is below 5.7) and blood sugars for the past 10 days ranged from 94 to 169. No units of sliding scale insulin were used over the past 10 days. Please consider discontinuing the Novolog sliding scale order, as high rates of finger sticks and insulin injections may add to patient discomfort and nursing time expenditures without significant long-term benefit in patient outcomes. On 6/13/24 at 8:30 AM review of R92's EHR did not reveal any documented follow-up from the physician for the Pharmacy Recommendation on 4/22/24. There were no physician or nursing progress notes regarding the resident's blood sugar readings or lack of sliding scale coverage. R92 continued to have blood sugars checked 4 times a day for 51 consecutive days after the Pharmacist's recommendation. A review of R92's Medication Administration Records (MARs) from 4/12/24 - 6/12/24 revealed that all the resident's blood sugar readings were below 200 and no insulin had been administered. On 6/13/24 at 9:19 AM, the Clinical Corporate Registered Nurse (RN) L was asked to review R92's Pharmacy Recommendation dated 4/22/24 and provide documentation the physician had been made aware of the recommendation. RN L confirmed that the facility had not followed up with the resident's physician regarding the recommendation. At this time RN L contacted R92's physician by phone and informed him of the Pharmacy Recommendations from 4/22/24 (51 days earlier). RN L said, There is no need to check the resident's blood sugar four times a day. The Physician is changing the order. According to the facility's Consultant Pharmacist Reports Policy dated 9/1/23 in part; The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding residents' medication therapies are communicated to those with authority and/or responsibility to implement the recommendations, and are responded to in an appropriate and timely fashion . A. A record of the consultant pharmacist's observations and recommendations is made available in an easily retrievable form to nurses, prescribers, and the care planning team. This should include: 1. Documentation of the date each medication regimen review is completed and notation of the findings in the medical record or other designated manner . C. Recommendations are acted upon and documented by the facility staff and/or the prescriber. If the prescriber does not respond to recommendation directed to him/her within 30 days, the Director of Nursing and/or the consultant pharmacist may contact the Medical Director. 1. If the prescriber that does not respond is also the Medical Director, the Director of Nursing and the Administrator will address the requirements with the Medical Director and/or pursue more formal actions if necessary to facilitate compliance.

Based on observation, interview, and record review the facility failed to follow the standards of infection control for proper glove use and hand hygiene, for two residents (R2 and R308) out of 20 sampled residents reviewed for infection control, resulting in the potential for increased cross-contamination of diseases which place a vulnerable population at high risk for infections. Findings include: R2 Review of an Admission Record revealed, R2 originally admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnosis which included Dementia and Type II Diabetes. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R2 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 12 out of 15. R308 Review of an Admission Record revealed, R308 originally admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnosis which included Type II Diabetes, Chronic Obstructive Pulmonary Disease (COPD), and Malignant Neoplasm (cancer) of Prostate. Review of a MDS assessment dated [DATE] revealed R308 had cognitive impairment with a BIMS score of 9 out of 15 and required an indwelling catheter. In observation on 6/11/24 at 10:08 a.m., Environmental Services Aide C cleaned R2 and R308's room with gloved hands. R2 and R308's room had an Enhanced Barrier Precautions (an infection control measure that uses personal protective equipment to reduce the spread of multidrug resistant organisms between residents) sign on the door. Environmental Services Aide C exited the room, removed gloves, and did not perform hand hygiene. In an observation on 6/11/24 at 10:09 a.m., Environmental Services Aide C put on a pair of gloves without performing hand hygiene. Environmental Services Aide C then entered another resident's room. In an observation on 6/11/24 at 10:10 a.m., Environmental Services Aide C exited the room and with the same pair of gloves took a spray bottle from the cart in the hallway. Environmental Services Aide C then entered the bathroom of the resident's room, exited the room, and leaned against the cart's trash can. In an interview on 6/11/24 at 10:11 a.m., Environmental Services Aide C reported gloves can be worn in the hall. Environmental Services Aide C was asked if hand hygiene should be performed after gloves are removed and stated, Not that I'm aware of. Environmental Services Aide C then reentered the room wearing the same gloves. In an observation on 6/11/24 at 10:13 a.m., Environmental Services Aide C removed gloves, put on new gloves with no hand hygiene before application and reentered the room. In an observation on 6/11/24 at 11:05 a.m., Environmental Services Aide C removed gloves in hallway and did not perform hand hygiene. In an interview on 6/13/24 at 11:03 a.m., Infection Preventionist B reported the environmental services staff is educated on hand hygiene and glove use. Infection Preventionist B reported hand Hygiene should be performed after glove use and gloves should not be worn in the hall. Review of a Handwashing and Hand Hygiene policy revised 4/29/20 documented, . To protect our residents, visitors, and staff, each facility will promote hand hygiene practices during all care activities and working in locations within the facility. Conditions which may require hand hygiene include but not limited to: Before and After applying gloves, after using restroom, after contact/potential contact with blood or body fluids .

Based on observation, interview, and record review the facility failed to follow the Standards of Practice during medication administration for three of five residents (R18, R68, and R52) resulting in the potential for medication errors. Findings include: Resident 52 On 6/12/24 at 9:14 AM on the 1 North Hall, Registered Nurse (RN) H was observed standing at the medication cart looking at the computer screen. There was a medication cup with 6 white pills of various shapes sitting on top of the medication cart. There were 2 separate pills inside white plastic pharmacy packaging identified as 'Lasix 20 milligrams (mg)'. There was no resident's name on the packaging. During interview RN H said she was going to pass the 6 pills in the medication cup to R52 but the medications did not match up to what was on R52's Medications Administration Records (MAR). RN H said she had just taken the medication cart from Licensed Practical Nurse (LPN) J and the pills were already in the cup. RN H confirmed she did not put the pills in the medication cup herself, did not know which resident's medications were in the cup, or which resident the two Lasix pills on top of the cart were for. At this time RN H said she was going to ask LPN J which resident's medications were in the cup and walked away from the medication cart leaving it unlocked with the computer screen open visibly displaying resident's health information and the 2 Lasix pills on top of the cart. At approximately 9:18 AM RN H returned to the medication cart with LPN J and LPN I to discuss which resident's medications were in the cup. A review of R52's MAR revealed the resident's AM dose of medications were not signed out as administered. R52 was not in the room to be interviewed. RN H could not determine if R52 had received his AM medications and placed the medication cup with the pills inside the medication cart in the section identified for R52 and proceeded to prepare medications for another resident. At approximately 9:40 AM LPN K reported to RN H that R52 was in the lobby being transported to an outside appointment and requested to have the AM medications prior to leaving the facility. LPN K observed the medications in the cup of R52's section of medication cart and said, These are not the right pills. RN H was preparing to administer medications to another resident (R18) and therefore did not administer the medication to R52 at this time. It could not be confirmed which resident's medications were in the cup and they were disposed of in the garbage bag attached to the medication cart by LPN K. On 6/12/24 at approximately 11:00 AM The Director of Nursing (DON) was asked about the medication administration protocol for the facility. The DON said the nurse who removes the medications from the pharmacy packaging and places them in the medication cup should administer those medications to the intended resident prior to handing off the medication cart to another nurse. The DON said a nurse should not administer medications to a resident unless they prepared the medications themselves. Resident 18 On 6/12/24 at 9:38 AM RN H was observed to administer all of R18's medications that were scheduled for 6/12/24 at the AM dose. On 6/13/24 at approximately 11:00 AM during reconciliation of R18's MAR it revealed that LPN J signed out the medications for R18 on 6/12/24 for the AM dose. On 6/13/24 at approximately 11:15 AM Clinical Corporate Director, RN L was asked to review R18's MAR to confirm that RN H did not sign out the medications on 6/12/24 during the AM dose. RN L reviewed the MAR and confirmed that LPN J had signed the MAR for R18 on 6/12/24 during the AM dose. RN L said, I can't explain why that happened. It is a standard of practice that the nurse who administers the medications signs them out on the MAR at the time of administration. Resident 68 On 6/12/24 at 10:15 AM during medication administration with LPN J and LPN I, LPN J was observed to crush the following medications and place in yogurt. 1) Ativan 0.5 mg two pills. 2) Senna 8.6 mg two capsules. Review of R68's MAR and physician's orders did not reveal any orders to crush the medications. During interview LPN J said she was in orientation and LPN I was observing her pass medications. LPN I said, The resident has trouble swallowing her pills whole that is why we crushed them. LPN I reviewed R68's EHR (electronic health record) and confirmed the resident did not have orders to crush the medications for administration. According to the facility's Medication Administration General Guidelines policy dated 1/2021 in part reads; Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices, and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication . Medication Preparation: 5. If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube-fed, using the following guidelines and with a specific order from prescriber. a. The need for crushing medications is indicated on the resident's orders and the MAR so that all personnel administering medications are aware of this need and the consultant pharmacist can advise on safety and alternatives, if appropriate Medication Administration: 4. Medications are to be administered at the time they are prepared. 5. The person who prepares the dose for administration is the person who administers the dose.

Based on observation, interview, and record review the facility failed to clarify an order for compression stockings per physician orders for one (R27) of one resident reviewed for compression stockings resulting in edema and the potential for increased compromised of R27's cardiovascular system. Findings include: On 6/11/2024 at 12:56 P.M., R27 was observed seated in a wheelchair in her room with her feet on the floor. During the observation R27 complained her feet were swollen and nothing had been done even though the concern had been observed and reported to staff. R27's feet were observed during the interview and appeared very swollen. At 2:00 P.M. during an observation on the unit, R27 stated, her feet had gotten worse, and her friend had brought a pillow into the facility to elevate her legs but that was difficult to do since the right leg rest of the wheelchair was removed and left under the bed. R27 stated, her feet started swelling about two-three weeks ago and both were worse at night or evening once she got out of bed. On 6/12/24 at 1:00 P.M. and 2:17 P.M., R27 was observed in therapy wearing yellow nonskid socks. The resident and Certified Nurse Aide (CNA) M voiced concerned to the therapy staff concerning R27's swollen feet and ankles. Record review of R27's Electronic Medical Record (EMR) revealed the resident was admitted to the facility on [DATE], with diagnosis of hemiplegia and hemiparesis following cerebral infraction (stroke), multiple sclerosis and overactive bladder. According to the Quarterly, Minimum Data Set (MDS) dated [DATE], R27 had a Brief Interview For Mental Status (BIMS) of 14 was (cognitively intact) and required one-person physical assistance to perform activities of daily living (ADLs). On 6/12/24 at 2:30 P.M., review of the physician orders revealed a written order dated 3/5/2024 Apply compression socks. The physicians order had no special instructions for application. Review of Medication Administration Record (MAR) and Treatment Administration Record (TAR) for June 2024 revealed no documentation of the compression socks being applied to R27's feet. Review of the Care Plan section of the Electronic Medical record (EMR) revealed no care plans or interventions addressing the resident's edema or special instructions. On 6/12/24 at 3:00 P.M., CNA M was interviewed concerning R27's compression socks. CNA M stated,R27 did not have an order for compression socks and staff had been applying the nonskid socks. CNA M stated, if R27 had an order for the compression socks, the nurse would have to order the compression socks. At 3:29 P.M., R27's physician orders were reviewed with Registered Nurse (RN) N. Documented on the June 2024 physician order summary was an order dated 3/5/24 compression socks. RN N examined the order and stated, staff did not follow through with the order, special instructions were not entered, and they did not enter the order into the computer. R27 should have compression socks. Someone should have contacted the physician and clarified the order and completed the other instructions for applying and removing the compression socks.

Based on observation, interview, and record review the facility failed to follow recommendations for restorative therapy for one resident (R89) out of three residents reviewed for positioning, resulting in the potential for contractures (shortening and hardening of muscles, tendons, and tissues). Findings include: During an observation and interview on 6/11/24 at 11:45 AM, R89 was observed sitting in a geri chair unable to move left side of body. Family Member G reported that R89 needed continued therapy. Record review of R89's electronic medical record (EMR) revealed admission into the facility on [DATE] with a diagnosis of hemiplegia/hemiparesis (paralysis) related to cerebral infarction (stroke). According to the Minimum Data Set (MDS) dated [DATE], R89 had impaired cognition and required substantial/maximal assistance with most Activities of Daily Living (ADLS). Record review of Restorative Nursing Referral dated 6/6/24 documented the following: Frequency: 2 times daily per Resident's tolerance for 8 wks (weeks). It was further documented that R89 was to receive passive range of motion (PROM), active range of motion (AROM), and assisted active range of motion (AAROM) for right and left upper and lower extremities -2 times daily for AM/PM care. Record review of R89's Kardex (a form documenting the specific daily needs of a resident to be followed by staff) dated 6/13/24, documented under Restorative Intervention/Programs- Encourage me to participate in my restorative plan. No specific needs or instructions were documented related to the recommendation from therapy. During an interview on 6/12/24 at 9:35 AM with Therapy Manager (TM) F, it was reported that it was the expectation that restorative nursing should follow recommendations to prevent residents from getting contractures. During an interview on 6/13/24 at 12:24 PM, with Director of Nursing (DON), it was reported that R89 did not have documentation that range of motion exercises had been performed twice a day as recommended by therapy. When asked, according to your policy should restorative nursing assess and monitor these therapy recommendations to see if these interventions have positive or negative outcomes, DON replied, Yes. When asked if there was any evidence that these recommendations were being followed, DON said, No. Record review of the facility's policy Restorative Program last revised 2/12/18, documented the following: Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition or choices demonstrate that such diminution was unavoidable. Further review of the policy revealed the following: 1.Following identification of need, the interdisciplinary team will put a plan in place that identifies the restorative approaches that will support the resident needs/choices. 2.The applicable restorative interventions will be assigned, which may include ROM, ambulation, transfer, ADLs, adaptive equipment, splinting, bed mobility, bathing, dressing, oral care, toileting, communication and/or dining. 3.The program(s) will be identified in the resident's medical record. 4.Periodically the Restorative Nurse or designee will review and discuss progress or lack of progress toward restorative goals with caregivers and the resident/representative. The residents plan of care and restorative program will be revised as indicated. 5.Monthly, the Restorative Nurse or designee will document a summary of the resident's participation and progress and determine the need to continue, revise, or discontinue the program based on the resident's needs, choices, and goals.

Based on observation, interview, and record review, the facility failed to secure smoking materials and complete a smoking assessment for one (R82) of one resident reviewed for smoking safety, accident, and hazards, resulting in the potential for injury to self and other residents. Findings include: In an observation on 6/11/24 at 11:27 a.m., a hand held cigarette lighter sat on top of a phone on R82's bedside table. R82 reported not having any cigarettes and is not currently smoking. R82 then reported getting the lighter from a family member and it usually is put in a purse. In an observation and interview on 6/11/24 at 11:38 a.m., Life Enrichment Director D reported cigarettes and lighters should be stored at the front desk. Life Enrichment Director D was asked should R82 have a lighter in the room. Review of an Admission Record revealed, R82 originally admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnosis which included hemiplegia and hemiparesis (paralysis) of the right side. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R82 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 14 out of 15. Review of nursing admission assessments dated 1/9/24 and 4/15/24 revealed R82 is a current smoker. R82 did not have a smoking assessment related to 1/9/24 or 4/15/24. In an interview on 6/12/24 at 10:24 a.m., the Nursing Home Administrator (NHA) reported R82 did not have a smoking assessment because R82 does not smoke. In an interview on 6/12/24 at 10:42 a.m., NHA reported cigarettes and lighters should be stored at the receptionist desk. In an interview on 6/12/24 at 2:21 p.m., Social Worker A reported all residents have a smoking assessment completed on admission. Social Worker A reported R82 did not have a smoking assessment. Social Worker A reviewed R82's nursing admission assessment dated [DATE] and confirmed that R82 was identified as a current smoker. In an interview on 6/12/24 at 2:30 p.m., NHA reported if an admission assessment reveals the resident is a current smoker someone should talk to them to see if they plan to smoke at the facility and a smoking assessment should be completed. Review of the facility's Safe Smoking policy revised 8/18/15 documented, Purpose: To promote the safety of residents in our (Corporation Name), who smoke by assessing and managing their smoking capabilities, thereby minimizing risk injury or harm to self and others . 1. Complete Admission Assessment to identify if Resident is a current smoker. If the resident is a current smoker or chooses to smoke at a later time proceed to Step 2. Before a resident can smoke independently a smoking assessment must be completed . 3. Complete the Safe Smoking Assessment . 6. Keep smoking materials in a central, designated area (determined by Center) .

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent when two medication errors out of 26 opportunities for error were observed for two (R18 and R68) out of five residents reviewed during the medication administration observation, resulting in a 7.69% error rate. Findings include: Resident 18 On 6/12/24 at 9:38 AM, Registered Nurse (RN) H was observed to administer medications to R18 during the AM dose. RN H was observed to deliver two puffs of the following inhaler; Breo-Ellipta Aerosol Powder Breath Activated 200-25 micrograms (mcg) ACT. According to R18's physician's order dated 4/24/24 and the Medication Administration Record (MAR) for June 2024, R18 was prescribed Breo-Ellipta Inhalation Aerosol Powder Breath Activated 200-25 mcg ACT one puff inhale orally in the morning. Resident 68 On 6/12/24 at 10:15 AM Licensed Practical Nurse (LPN) J along with LPN I was observed to administer medications to R68 during the AM dose. LPN J said she was in orientation and LPN I was training her. During medication preparation for R68, LPN J obtained one Ativan 0.5 milligram (mg) pill from the locked narcotic box inside the medication cart. LPN J obtained the Controlled Substance Proof-of-Use Record for R68 and signed out one Ativan 0.5 mg pill on the record for R68 and proceeded to crush the medication. Prior to administering the medication to the resident, LPN J and LPN I were asked to review the prescribed dosage of Ativan for R68's AM dose by the surveyor. According to R68's physician's order dated 5/31/24 and the Medication Administration Record (MAR) for June 2024, R68 was prescribed Ativan 1.0 mg by mouth two times a day at 9:00 AM and 9:00 PM. At this time LPN J confirmed that R68's Ativan dosage should be two Ativan 0.5 mg pills and re-opened the narcotic box inside the medication cart and obtained a second Ativan 0.5 mg pill. LPN J retrieved R68's Controlled Substance Proof-of-Use Record for Ativan 0.5 mg and wrote over the initial documentation of 'one' pill being removed to 'two' pills being removed. Further inspection of the R68's Controlled Substance Proof-of-Use Record for Ativan 0.5 mg revealed that only one Ativan 0.5 mg pill (half the resident's prescribed dose) had been administered to the resident for 4 consecutive doses, since 6/10/24's AM dose. According to the facility's Medication Administration General Guidelines Policy, dated 1/2021, read in part; Medication Preparation: 3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record. Compare the medication and dosage schedule on the resident's MAR with the medication label. If the label and MAR are different, and the container is not flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the prescriber's orders are checked for the correct dosage schedule. Apply a direction change sticker to label if directions have changed from the current label Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber

Based on observation, interview, and record review the facility failed to ensure that one resident (R68) was free from significant medication errors out of five residents reviewed for medication errors resulting in R68 only receiving half the prescribed dose of anti-anxiety medications for 4 consecutive doses. Findings include: According to R68's Electronic Health Record the resident had multiple diagnoses that included malignant neoplasm of the brain, generalized anxiety disorder, and major depressive disorder. On 5/21/24 the resident was admitted to Hospice care. R68's Minimum Data Set, dated dated dated [DATE] indicated that R68 had intact cognition with a brief interview for mental status (BIMS) score of 14/15. According to R68's physician's order dated 5/31/24 and Medication Administration Record (MAR) for June 2024, R68 was prescribed Ativan 1.0 milligram (mg) by mouth two times a day at 9:00 AM and 9:00 PM. On 6/12/24 at 10:15 AM, Licensed Practical Nurse (LPN) J along with LPN I was observed to administer medications to R68 during the AM dose. LPN J said she was in orientation and LPN I was training her. During medication preparation for R68, LPN J obtained one Ativan 0.5 milligram (mg) tablet from the locked narcotic box inside the medication cart. LPN J obtained the Controlled Substance Proof-of-Use Record for R68 and signed out one Ativan 0.5 mg tablet on the record for R68 and proceeded to crush the medication. Prior to administering the medication to the resident, LPN J and LPN I were asked to review the prescribed dosage of Ativan for R68's AM dose by the surveyor. At this time LPN J confirmed that R68's Ativan dosage should be two Ativan 0.5 mg tablets and re-opened the narcotic box inside the medication cart and obtained a second Ativan 0.5 mg tablet. LPN J retrieved R68's Controlled Substance Proof-of-Use Record for Ativan 0.5 mg and wrote over the initial documentation of 'one' tablet being removed to 'two' tablets being removed. Further inspection of the R68's Controlled Substance Proof-of-Use Record for Ativan 0.5 mg revealed that only one Ativan 0.5 mg tablet (half the resident's prescribe dose) had been administered to the resident for 4 consecutive doses, 6/10/24 at 9:00 AM, 6/10/24 at 9:00 PM, 6/11/24 at 9:00 AM, and 6/11/24 at 9:00 PM. On 6/13/24 at approximately 11:15 AM, Clinical Corporate Director RN L was asked to review R68's Controlled Substance Proof-of-Use Record for Ativan 0.5 mg. RN L confirmed that R68 had only received half (0.5 mg) of the prescribed dosage (1.0 mg) of Ativan for the last four consecutive administrations; 6/10/24 at 9:00 AM, 6/10/24 at 9:00 PM, 6/11/24 at 9:00 AM, and 6/11/24 at 9:00 PM. RN L acknowledged that is it the nurse's responsibility to administer the correct dosage of the prescribed medications and that two Ativan 0.5 mg tablets should have been administered to equal the prescribed dosage of Ativan 1.0 mg. According to the facility's Medication Administration General Guidelines Policy dated 1/2021 reads in part; Medication Preparation: 3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record. Compare the medication and dosage schedule on the resident's MAR with the medication label. If the label and MAR are different, and the container is not flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the prescriber's orders are checked for the correct dosage schedule. Apply a direction change sticker to label if directions have changed from the current label Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber

Based on observation, interview, and record review, the facility failed to post nurse staffing information for all 98 residents as well as visitors entering the facility, resulting in the necessary staffing information not being available. Findings include: On 6/11/24 at 9:30 A.M., behind the front receptionist desk in the lobby area a posted board was labeled with the facility's name and smudged out numbers and information related to nurse staffing. Observations on 2:30 P.M. and again at 4:30 P.M., revealed the nurse staffing board had the same smudged out information. The facility's nurse staffing numbers were not clearly visible. On 6/12/24 at 12:30 P.M. and 4:00 P.M., the nurse staffing board remained in the same condition as the previous day. On 6/13/24 at 10:00 A.M. the nurse staffing board had not been updated or changed. At 11:00 A.M., the Administrator was queried if the board in the front lobby was where the facility posted nurse staffing information. The Administrator identified the same board in the front lobby and stated Supervisor O was responsible for updating the nurse staffing board with current information. During the observation Supervisor O informed the Administrator someone had wrote on the board with the wrong kind of ink /marker and the information previously could not be changed or updated. Supervisor O acknowledged the nursing staff information had not been updated from the weekend but had failed to inform the Administrator or Director of Nursing.

Based on observation, interview, and record review the facility failed to utilize essential equipment to ensure a functional call light system resulting in call lights not answered in a timely manner, unmet care needs, and the potential delay in responding to emergency situations. This had the potential to affect all residents in the facility that utilize the call light. Findings include: On 6/28/23 at 10:26 a.m. during the initial pool process, R42 was observed resting in bed. The resident was alert, oriented x3, and able to make all needs known. During the interview, R42 voiced concerns with long call light response time, I have sat in bm (bowel movement) for three hours before. Sometimes I just want a cup of water and have to wait a long time. If I was having a heart attack, I could be dead before they would know. I have to flag someone down if they walk by the room to get their attention. They used to have pagers to let them know to come to the room. Now they have to look on the board at the nurse's station. R42 was asked did the facility give a hand-held bell to use. R42 stated, Do you see one . No, they didn't give me nothing. At 11:38 a.m. R42 was requested to activate the call light. The call light indicator that was located outside above the room's door and was not lit to indicate it was activated. Several minutes later, two nurse aides (identified by the color of their uniforms) were observed walking back and forth pass the room without acknowledging the residents call light being on. At 11:42 a.m. a monitor that was mounted to the wall at the nurse's station had R42's room (2 South- 4) displayed on it. There were three nurses at the nursing station. One was sitting at the desk (identified as the Assistant Director of Nursing), and the other two nurses were standing at the medication carts with their back to the monitor. After standing at the nurse's station with a clear view of the 2 South Hall for seven minutes, the nurses at the nurse's station did not look up at the monitor. Between 11:49- 11:57 am nurse aides walked pass the room without addressing the call light and housekeeper was also observed standing in the hall across from R42's room. The call light remained unanswered. At 11:58 a.m. nurse aide D responded to the call light. R42 wanted and requested a cup of water. The nurse was then queried about knowing when resident's call lights are on. Nurse Aide D stated, We used to have pagers. The Administrator was supposed to replace them. So, we just walk back and forth to the nurse's station and look at the board (monitor). It's been a while since we haven't had the pagers. I was told the pagers started disappearing because people were taking them home or losing them and not returning them especially the agency staff. On 6/28/23 at 12:08 p.m. during the initial pool R64 was observed sitting in a wheelchair at the bedside. The resident was alert, oriented x3, and able to make all needs known. During the interview, R64 voiced concerns with long call light response time. R64 stated, We used to have bells we can use but we don't even have those now. I can do a lot for myself, but my roommate will need help, so I have to get somebody's attention when they walk pass the room. We need help around here. What if something happened, we could die waiting for someone to come to the room. I'm glad I'm leaving this place on Friday. I just feel sorry for my roommate. The roommate was observed asleep and did not respond for an interview. On 6/29/23 at 11:00 a.m. the Resident Council Meeting minutes were reviewed for the months of April, May, and June. The minutes dated June 1, 2023, documented, Resident's on 1 South said that call lights are not being answered in a timely manner . The DON addressed the council concerns . Evidence of the call light concern being addressed was not provided. On 6/29/23 at 11:15 a.m. during the Confidential Resident Council meeting, there were 15 alert and oriented x3 residents in attendance. The residents that attended resided on various units within the facility (4- 1 South Hall, 4- 2 North Hall, 7- 2 South Hall). The residents on 2 South and 2 North Halls voiced most concerns with long call light response times. One resident from 2 South Hall said they had a fall and would have waited a long time if they hadn't screamed for help. This was after putting on the call light. Three residents from the 2 North Hall said they have had to wait long periods of time to get changed from toileting on themselves. Five of the residents from 2 South Hall nodded in agreement also having to wait long periods of time to get changed from toileting on themselves. The residents also voiced feeling like second class citizens in the facility. They also voiced feeling ignored by staff. The residents on 1 South Hall said they were given handheld bells once the pagers were not being used to answer the call lights. The residents on 2 North and 2 South Hall said they were not given hand-held bells. On 7/3/23 at 12:45 p.m. the Nursing Home Administrator (NHA) and Maintenance Director were interviewed regarding the call light system. They were queried what was put in place to ensure call lights were fully functioning and answered in a timely manner. The Maintenance Director stated, The call light system works. The monitors at the nurse's station work. The call light indicators outside of the rooms do not work because they were part of the old system and could not be linked to the new system. We do have handheld bells in the building but not given to the residents. The NHA stated, We have been without pagers for a while . at least since I started here in January. Some of the pagers were lost. We have new pagers now that had to get reprogrammed. They were reprogrammed earlier this month. I have been trying to come up with a system and protocols, so they won't be lost by staff. I have also been waiting to in-service new and old staff so we could in-service them all at once. The nurses and CNAs are to pay attention to the monitors, but nothing has been put in place for sound as an indicator. I planned to implement the pager system this week. Review of the facility's policy titled Call Light Policy dated 5/1/2017 documented the following: Call lights will receive consistent and adequate response in order to best meet the individual needs of each resident . Call light activation will be identified by a light above the resident doorway and an audible alarm at/near each nursing station or a paging system with monitors . Each staff member is responsible to respond to call lights and provide assistance as their level of training allows.

This citation pertains to intakes MI00130262 and MI00133274. Based on observation, interview, and record review, the facility failed to ensure medication was administered properly and per physician's orders for one resident (R35) of six residents reviewed for medication administration, resulting in the potential for less than therapeutic effect of the prescribed medication when medications were not taken or administered properly. Findings include: In an observation on 6/28/23 at 11:52 a.m., R35 laid in bed. A medication cup with multiple pills sat on R35's bedside table. R35 stated, this is something new, the nurse usually stands here to make sure I take the medication. In an observation and interview on 6/28/23 at 11:54 a.m., Licensed Practical Nurse (LPN) C reported medication should not be left at bedside. R35 reported she was sleeping and did not see the nurse bring in the medication. LPN C then stood by while R35 take the medication. LPN C acknowledged that she was not the assigned nurse for R35. Review of an admission record revealed, R35 admitted to the facility 10/25/21 with pertinent diagnosis which included Multiple Sclerosis and Hemiplegia and Hemiparesis affecting the left side. Review of a Minimum Data Set (MDS) assessment, with a reference date of 4/28/23 revealed R35 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 14 out of 15. Review of care plans revealed R35 did not have a self-administration of medication care plan. Review of Physician revealed R35 did not have a self-administration medication order. Review of a Medication Administration Record (MAR) for June 2023, revealed R35's 9:00 am medication documented as given by LPN B. R35 did not have a medication administration scheduled for 12:00 pm. In an interview on 6/29/23 at 8:59 a.m., LPN B reported the nurse should stay with the resident during medication administration to make sure the resident takes all the pills and that no other residents get the pills. In an interview on 7/03/23 at 9:45 a.m., the Director of Nursing (DON) reported the nurse should stay with the resident while they take their medication. The Director of Nursing (DON) reported if medications are not given per physicians orders the Physician should be notified. Review of a Medication Administration policy with a date of 01/21 revealed, Medications are administered as prescribed in accordance with manufacture's specifications, good nursing principles and practices . 3. Prior to administration, review and confirm medication orders or each individual resident on the Medication Administration Record. Compare the medication dosage schedule on the resident's MAR with the medication label . Medication Administration: 1. Medications are administered in accordance with written orders of prescriber . 4. Medications are to be administered at the time they are prepared. 5. The person who prepares the dose for administration is the person who administers the dose . 14. Medications are administered within 60 minutes of scheduled time . 20. The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR, and action is taken as appropriate .

Based on observation, interview, and record review the facility failed to administer medications accurately for two residents (R8 and R96) out of five residents during medication pass, resulting in a medication error rate of 13.79 %. Findings include: Resident #38 (R38) In an observation on 6/29/23 at 8:01 a.m., Registered Nurse (RN) A prepared medication for R38. RN A placed 10 medications in a cup which included, Digoxin (used to treat Atrial Fibrillation). RN A did not place Protonix (used to treat heartburn) in the mediation cup. In an observation on 6/29/23 at approximately 8:10 a.m., RN A entered R38's and obtained a blood pressure on a vital machine. R38's blood pressure was 118/71 and heart rate 57. R38 took the medication with water. RN A then exited the room and documented the medication administration. In an interview on 6/29/23 at 8:19 a.m., RN A reported R38 did not receive Protonix because it should be given at 6:00 a.m. Review of an admission record revealed, R38 admitted to the facility 1/30/22 with pertinent diagnosis which included Type 2 Diabetes and Atrial Fibrillation (abnormal heart rhythm). Review of a Minimum Data Set (MDS) assessment, with a reference date of 5/4/23 revealed R38 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15 out of 15. Review of Physician orders revealed R38 had an order, Digox Tablet 125 MCG (Digoxin) Give 1 tablet by mouth one time a day for afib hold for hr (heart rate) less then 60 and Protonix Tablet Delayed Release 20 MG (Pantoprazole Sodium) Give 20 mg by mouth in the morning. In an interview on 6/29/23 at 12:10 p.m., RN A reported she noticed the error of given the Digoxin with a heart rate of 57. RN A then reported R38's Protonix is scheduled for 9:00 am but is in the 6:00 am medication pack. Resident #96 (R96) In an observation on 6/29/23 at 8:50 a.m., Licensed Practical Nurse (LPN) B prepared medication for R96. LPN B placed seven medications in a cup. The medication did not include Folic Acid or Plavix (blood thinner used to prevent heart attack and stroke). LPN B entered R96's room and administered mediation, then exited the room and documented the medication administration. In an interview on 6/29/23 at 9:06 a.m., LPN B was asked to review the MAR (Medication Administration Record) to ensure all ordered mediations were given. LPN B confirmed R96's Folic Acid and Protonix were marked as given. LPN B reported Plavix was in the medication packet. After looking at the medication packet, LPN B acknowledged Plavix was not included in the medication packet. LPN B then stated, it's not in the pack. LPN B attempted to strike out the administration for R96's Plavix. LPN B then walked away from the medication cart and did not acknowledge the documented Folic Acid. LPN B did not administer the Folic Acid or Plavix. Review of an admission record revealed, R96 admitted to the facility 10/7/22 with pertinent diagnosis which included Anemia and Ventricular Fibrillation (abnormal heart rhythm). Review of a MDS assessment, with a reference date of 5/4/23 revealed R96 had no cognitive impairment with a BIMS score of 15 out of 15. Review of Physician orders revealed R96 had orders, Folic Acid Tablet 1 MG Give 1 tablet by mouth in the morning and Plavix Tablet 75 MG (Clopidogrel Bisulfate) Give 1 tablet by mouth in the morning. In an interview on 7/03/23 at 9:45 a.m., the Director of Nursing (DON) reported if medications are not given per physicians orders the Physician should be notified. The DON then reported medications should be given at the scheduled time even if the package has for a different time. Review of a Medication Administration policy with a date of 01/21 revealed, Medications are administered as prescribed in accordance with manufacture's specifications, good nursing principles and practices . 3. Prior to administration, review and confirm medication orders or each individual resident on the Medication Administration Record. Compare the medication dosage schedule on the resident's MAR with the medication label . Medication Administration: 1. Medications are administered in accordance with written orders of prescriber . 2. Obtain and record any vital signs as necessary prior to medication administration . Verify medication is correct three (3) times before administering the medication .

Based on observation, interview, and record review the facility failed to properly disinfect a Glucometer (medical device for determining the concentration of glucose in the blood) for one (R38) out of five residents reviewed for medication administration, resulting in the potential for the spread of infection. Findings include: In an observation on 6/29/23 at 7:35 a.m., Registered Nurse (RN) A prepared supplies to perform a blood glucose check for Resident #38 (R38). RN A placed a glucometer, strips, lancet, and alcohol swab on a tray and entered R38's room. RNA wiped R38's finger with a alcohol swab, poked finger with a lancet, and applied blood to the strip in glucometer. RN A cleaned up supplies and exited the room. In an observation on 6/29/23 at 7:38 a.m., RN A wiped the front of the Glucometer with a alcohol swab and placed it on medication cart without a barrier. In an interview on 6/29/23 7:40 a.m., RN A reported the Glucometer is cleaned with a alcohol swab. RN A then stated, we have bleach wipes, but I do not use them until after all the blood sugars are taken. Review of an admission record revealed, R38 admitted to the facility 1/30/22 with pertinent diagnosis which included Type 2 Diabetes. Review of a Minimum Data Set (MDS) assessment, with a reference date of 5/4/23 revealed R38 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15 out of 15. In an interview on 7/03/23 at 10:08 a.m., the Director of Nursing (DON) reported the appropriate cleaner for the glucometer is bleach wipes or purple top wipes. The DON then reported alcohol swabs should not be used to clean the glucometer. Review of a document titled Caring for Your System with no date revealed, To minimize the risk of transmission of blood-borne pathogens, the cleaning and disinfection procedure should be performed as recommended in the instructions below . This meter should be cleaned and disinfected after use on each patient . We have validated Clorox Healthcare Bleach Germicidal Wipes, Dispatch Hospital Cleaner Disinfectant Towels with Bleach, CaviWipes1, and PDI Super Sani-Cloth Germicidal Disposable Wipe for disinfecting .

Based on observation, interview, and record review, the facility failed to ensure restorative exercises and assistance with orthotic devices (hand splint) were provided for one (R96) of four residents reviewed for restorative services resulting in the potential for deconditioning and worsening of contractures. Findings include: On 4/27/22 at 2:12 PM R96 was observed laying in bed with his left hand clenched/contracted in a fist. R96 said, I had therapy a while back but I am not doing anything now. R96 said he did not have a splint for his left hand and was not receiving any form of therapy. According to the Electronic Medical Record (EMR), R96 admitted to the facility on [DATE] with multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/24/21 the physician ordered; splint to left hand 4 hours everyday as tolerated. There was no further documentation regarding the left hand splint. A review of R96's care plan and 'tasks' in the EMR did not reveal any documentation regarding the left hand splint. On 4/29/22 11:25 AM, Therapy Directory (TD) K was asked about R96's left hand splint. TD K said R96 had been discharged from Physical Therapy on 10/23/21 and a 'restorative program' was initiated. A left hand splint 4 hours daily had been recommended for R96 to maintain joint integrity. TD K said the facility did not have a 'restorative nurse' at this time and there was no documentation in the 'restorative binder' to support R96 ever had restorative therapy or a left hand splint. TD K' said he would complete an evaluation on R96 and order the left hand splint today. On 4/29/22 at 12:03 PM the Administrator confirmed the facility did not have a restorative nurse at this time and the Therapy Director (TD) K had just been hired about 2 weeks ago. According to the facility's 'Restorative Program' policy dated 2/21/2018; Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition or choices demonstrate that such diminution was unavoidable. PROCESS: Candidates for a restorative nursing program may be identified in the following ways: *After discharged from a skilled therapy service or in conjunction with a therapy service. *Upon review during the admission process and/or RAI assessments identifying that the resident could benefit from restorative programming. 1. Following identification of need, the interdisciplinary team will put a plan in place that identifies the restorative approaches that will support the resident needs/choices. 2. The applicable restorative interventions will be assigned, which may include: ROM, ambulation, transfer, ADLs, adaptive equipment, splinting, bed mobility, bathing, dressing, oral care, toileting, communication and/or dining. 3. The program(s) will be identified in the resident ' s medical record. 4. Periodically the Restorative Nurse or designee will review and discuss progress or lack of progress toward restorative goals with caregivers and the resident/ representative. The resident ' s plan of care and restorative program will be revised as indicated. 5. Monthly, the Restorative Nurse or designee will document a summary of the resident ' s participation and progress and determine the need to continue, revise, or discontinue the program based on the resident ' s needs, choices, and goals.

This citation pertains to MI 283. Based on observation, interview, and record review, the facility failed to thoroughly investigate an injury of unknown origin (blisters to wrist/forearm area) for one (R70) of three residents reviewed for abuse, resulting in the potential for further injuries of unknown origin to go uninvestigated, untreated, and abuse to go undetected. Findings include: Complainant reported to the State Agency that R70 developed a large blister on her left wrist/forearm area and the cause was unknown. On 4/27/22 at 11:27 AM, R70 was observed seated in her wheelchair with her RP seated next to her. R70's RP said, I notified the staff about it (the blister) and then something was done about it. We did not know how she got it. She still has a scar. R70's RP pointed to a darkened area of cicatrix (scar of a healed wound) that approximated 1/2 inch wide and 4 inches long on R70's left wrist and forearm. R70 was unable to be interviewed due to severely impaired cognition status. During observation R70's eyes were closed, and she was nonverbal. R70 made repetitive involuntary movements with her left and right hands/arms. R70's left arm and hand were resting at her side with her left hand over the corner edge of the wheelchair seat. Her left hand and wrist were rubbing against the bar of the wheelchair's left armrest. There was no barrier between R70's left wrist/forearm and the metal bar of the armrest. According to the Electronic Medical Record (EMR) R70 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress noted written by Licensed Practical Nurse (LPN) 'D' dated 3/18/2022 reads, Document relevant information about the resident: resident has blisters on left hand and forearm, alert for wound care to see today. On 3/21/2022 (3 days later), the physician ordered an X-ray of R70's left forearm/hand area and prescribed: Antibiotic Ointment ([MEDICATION(S)]) apply to left hand/forearm topically two times a day and monitor blistered area twice a day. The skin assessment dated [DATE] documented; observed an intact serum filled blister L (length)=10.7 (centimeters) x W (width)=1.2 (centimeters) and a ruptured dry blister. On 4/28/22 at 11:44 AM LPN 'D' confirmed R70 had developed blisters on her left forearm/wrist area and the back of her left hand. LPN 'D' said, I'm not sure how she got them, but I think it's from the wheelchair. On 4/28/22 at 12:30 PM the Director of Nursing (DON) 'B' was asked about R70's left wrist/forearm blisters. DON B could not provide any documentation to support that a thorough investigation had been conducted for R70's blisters of unknown origin. DON 'B' said, We think it's from her reaching behind to scratch her back and rubbing her hand against the wheelchair. So, no formal investigation was done. On 4/28/22 at 4:00 PM the Regional Clinical Director (RCD) 'I' and Administrator (ADM) 'A' were asked about the facility's policy regarding 'injury of unknown origin'. RCD 'I' said that an investigation should be initiated as soon as the injury is discovered. Both RCD 'I' and ADM 'A' confirmed no investigation was done for R70's blisters. RCD 'I' said that the therapy department will assess and review R70's wheelchair for positioning, cushions, and 'sheep skin' covering of the armrest. According to the facility's 'Abuse, Neglect and/or Misappropriation of Resident Funds or Property' revised on 12/10/18; xi) Injury of Unknown Origin - is an injury that was not observed and could not be easily explained by the resident and the injury is suspicious do to the severity, location, or number of injuries at once or over time. e) Investigation i) (1) The investigation shall be initiated immediately, after the Administrator has knowledge of the incident . ii) (a) Interview the resident,,,and all witnesses. Witnesses shall include anyone who,,,(2) came in close contact with either resident the day of the incident (including .family members); (3) employees who worked closely with the .the victim the day of the incident. To the extent possible, all interviews should be summarized into a written statement, which is signed and dated. (e) Review the Unusual Occurrence Report and complete the sections identified to be completed by the Administrator.

This citation pertains to MI 283. Based on observation, interview and record review the facility failed to inform one resident's (R70) Physician and Responsible Party (RP) in a timely manner of a 'change in condition' resulting in the resident's Physician and RP being unable to make timely informed healthcare decisions when R70 developed a large blister on her left forearm/wrist area. Findings include: Complainant reported to the State Agency that the facility failed to notify the resident's responsible party (RP) when the resident acquired a large blister on her left wrist and forearm. On 4/27/22 at 11:27 AM, R70 was observed seated in her wheelchair with her RP seated next to her. R70's RP said he was not notified of the large blister that was on R70's left wrist/forearm last month. He said, I notified the staff about it (the blister) and then something was done about it. She still has a scar. R70's RP pointed to a darkened area of cicatrix (scar of a healed wound) that approximated 1/2 inch wide and 4 inches long on R70's left wrist and forearm. R70 was unable to be interviewed due to severely impaired cognition status. During observation R70's eyes were closed, and she was nonverbal. R70 made repetitive involuntary movements with her left and right hands/arms. R70's left arm and hand were resting at her side with her left hand over the corner edge of the wheelchair seat. Her left hand and wrist were rubbing against the bar of the wheelchair's left armrest. There was no barrier between R70's left wrist/forearm and the metal bar of the armrest. According to the Electronic Medical Record (EMR) R70 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R70's RP contact information was accurately identified on the EMR. A progress noted written by Licensed Practical Nurse (LPN) 'D' dated 3/18/2022 documented the following; Document relevant information about the resident: resident has blisters on left hand and forearm, alert for wound care to see today. There was no further documentation to indicate R70's RP or physician were notified. On 4/28/22 at 11:44 AM LPN 'D' said R70 had blisters on the left forearm/wrist area and the back of her left hand. LPN 'D' confirmed that she did not notify R70's RP on 3/18/22 when the blisters were identified. LPN 'D' said, Yes, the family should have been notified immediately, but I turned it over to wound care and thought they would notify the family. On 3/21/2022 (3 days later), the Physician ordered an X-ray of R70's left forearm/hand area, and the following medication prescribed: Antibiotic Ointment ([MEDICATION(S)]) apply to left hand/forearm topically two times a day. The skin assessment dated [DATE] documented the following; observed an intact serum filled blister L (length)=10.7 (centimeters) x W (width)=1.2 (centimeters) and a ruptured dry blister. On 4/28/22 at 12:30 PM the Director of Nursing (DON) 'B' could not provide any documentation to support that R70's RP had been notified on 3/18/22 of the blisters on the resident's left forearm/wrist area. According to the facility's 'Change of Condition - Resident Family/Responsible Party Notification' policy revised on 7/1/2018: Family and/or RP are notified anytime there is a change in the resident's condition or plan of care. Procedure: 1. Notification of any change in the resident's condition will be done in a timely manner.

This citation pertains to MI 283. Based on observation, interview, and record review, the facility failed to update a care plan for one (R70) of two residents reviewed for care plans after an injury of unknown origin was detected resulting in the potential for further injury and healthcare needs to go unmet. Findings include; Complainant reported to the State Agency that R70 developed a large blister on her left wrist/forearm area and the cause was unknown. On 4/27/22 at 11:27 AM, R70 was observed seated in her wheelchair with her RP seated next to her. R70's eyes were closed, and she was nonverbal. R70 made repetitive involuntary movements with her left and right hands/arms. R70's left arm and hand were resting at her side with her left hand over the corner edge of the wheelchair seat. Her left hand and wrist were rubbing against the bar of the wheelchair's left armrest. There was no barrier between R70's left wrist/forearm and the metal bar of the armrest. On 4/28/22 at 9:59 AM R70 was observed seated in her wheelchair with a long- sleeve shirt on. R70's wrist/forearm areas were not covered with the shirt and her skin was directly resting against the metal bar of the wheelchair's armrest. During R70's repetitive involuntary movements of her arms the back of her left hand/wrist and forearm areas rubbed against the metal bar of the armrest. According to the Electronic Medical Record (EMR) R70 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/21/22 the physician prescribed the following; X-ray of R70's left forearm/hand area and an Antibiotic Ointment ([MEDICATION(S)]) apply to left hand/forearm topically two times a day. Monitor blisters on left wrist/forearm area two times a day. A care conference on 3/29/22 indicated that 'geri-sleeves' (a sleeve to protect the skin from injuries caused by friction or shearing) would be implemented in the resident's plan of care. According to R70's care plan for 'Skin Management' last revised on 10/1/21 there were no interventions regarding monitoring for blisters or applying geri-sleeves to the resident. On 4/28/22 at 12:30 PM the Director of Nursing (DON) 'B' was asked about R70's left wrist/forearm blisters. DON B could not provide any documentation to support that a thorough investigation had been conducted for R70's blisters of unknown origin but reviewed the care conference notes dated 3/29/22. DON 'B' said, We discussed adding geri-sleeves to prevent her skin from rubbing on the wheelchair, but it's not on the care plan. DON B confirmed that there were no updates to R70's 'Skin Management' care plan since 10/1/2021 and no interventions regarding skin injury.

This citation pertains to MI 525. Based on interview and record review, the facility failed to implement measures to ensure resident received sufficient fluids to prevent dehydration in a timely manner for one resident (#55) of six residents reviewed for dehydration, resulting in a hospital admission with primary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: A review of the clinical record for Resident #55 (R55) documented an admitted [DATE] and readmitted [DATE]. R55's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) dated [DATE] documented severe cognitive impairment and total dependence upon staff for eating and drinking. A MDS dated [DATE] documented severe cognitive impairment and extensive one-person physical assistance for eating and drinking. A review of R55's lab results, progress notes, and hospital notes from the 9/29/2021 hospitalization revealed in part the following: 1. Physician note of 4/30/2021: .Patient seen on a routine monthly visit and lying in bed and responsive to the name calling and appears to be at her baseline and no issues reported by the nurses .assessment/plan .[CONDITION(S)] .gastrocutaneous fistula (an abnormal connection between the stomach and skin) .check labs . 2. Labs of 5/14/2021 documented the following results deemed abnormal: Sodium 148 (reference range [ref. range] 136-145) - High Chloride 113 (ref. range 98-110) - High BUN 30 (ref. range 7-25) - High Creatinine 1.5 (ref. range 0.60-1.30) - High GFR 40 (ref. range >60) - Low Hemoglobin (Hgb) 9.3 (ref. range 12.0-16.0) - Low Hematocrit 27.6 (ref. range 36.0-46.0) - Low 3. Nurse progress note of 5/18/2021: Lab results. Note lab results in from 5/14/21. Notified (Physician G R55's primary care physician) of lab results, no new orders. 4. Physician note of 5/31/2021: .afebrile and alert and no change from her baseline .will continue present medication and follow. 5. Labs of 9/29/2021 documented the following results deemed critical or abnormal: Sodium 165 (reference range [ref. range] 136-145) - Critically High Chloride 132 (ref. range 98-110) - Critically High BUN 61 (ref. range 7-25) - High Creatinine 2.4 (ref. range 0.60-1.30) - High GFR 23 (ref. range >60) - Low Hemoglobin 4.3 (ref. range 12.0-16.0) - Critically Low Hematocrit 14.5 (ref. range 36.0-46.0) - Low 6. Progress note of 9/29/2021 at 9:34 PM: Lab reported critical sodium (165), chloride (132) and hemoglobin (4.3). Dr. notified. Physician ordered for resident to be transferred to hospital for follow up care . 7. Hospital GI (gastrointestinal) consult dated 9/30/2021: .This patient came to the emergency department via EMS as a medical resuscitation for laboratory abnormalities .Nursing home sent her to the emergency department because of laboratory abnormalities including a sodium of 165, chloride of 128 PEG (percutaneous endoscopic gastrostomy) tube insertion is consulted given the patient's dysphagia. 8. Hospital GI consult dated 9/30/2021: .Adequate hydration to correct her [CONDITION(S)] at this time . 9. Transition of care (hospital discharge document) dated 10/25/2021: -Primary Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Surgical Procedure: endoscopic procedure with PEG During an interview and record review on 11/3/2021 at 3:12 PM of R55's 5/14/2021 lab results, Physician G said the labs of 5/14/2021 were suggestive of dehydration specifically mentioning the elevated sodium, BUN, and creatinine. Physician G stated, Besides the clinical picture of a history of vomiting and diarrhea, and poor dietary intake, I recommended starting IV (intravenous) fluids and encouraged (oral) fluids. I remember ordering IV fluids. During an interview on 11/4/2021 at 9:05 AM, Physician G stated, I've been following (R55) for about six years maybe more. She has a history of PEG tube and a fistula that oozes. The GI specialist said if (R55) was kept on parental nutrition that may have helped the fistula to heal but that never happened. Lately she has had CKD ([CONDITION(S)]) but is not followed by a nephrologist for that. I am monitoring her CKD. She has [CONDITION(S)]. Physician G said he couldn't explain the Hgb of 4.6. It's probably from her GI-track. She was losing weight recently. During an interview and review on 11/3/2021 at 4:00 PM of R55's clinical record conducted with Director of Nursing (DON B) and Assistant Director of Nursing (ADON C), the following was revealed: -In reference to R55's labs of 5/14/2021, ADON C stated, This is close to her being dehydrated. I know for a fact that she had diminished intake. ADON C added, (R55) was on [MEDICATION(S)] (at the time) which causes runny stools which is a risk factor for dehydration. A review of the nurse progress note of 5/18/2021, documented the physician was notified of R55's lab results and no new orders were put in place. ADON C stated, I would encourage fluids because I noticed she was declining. The nurses and CNAs (Certified Nurse Aides) were told to offer (R55) water. You had to hand (R55) water and assist her. ADON C said no formal order to encourage fluids was included as part of the daily CNA plan of care for R55. ADON C stated, The doctor could have written an order to encourage fluids and then it would be carried over to the Kardex (CNA plan of care). I think (R55) took in less than we thought. IV fluids would have been beneficial. -In referenced to R55's labs of 9/29/2021, ADON C stated, (R55) needed her (feeding) tube back because then we can ensure she gets what she needs. Her oral intake was declining. -DON B said R55 was not on a fluid restriction prior to her hospitalization . A review of the following progress note documented a reference to R55's fluid intake but not the sufficiency of the volume of fluids consumed. The referenced comprehensive nutrition assessments were focused primarily on R55's weight status, calorie needs, and protein needs: 1. Per DON B, the life enrichment note of 7/13/2021 documented .(R55) also likes to drink juices and eat snacks. According to ADON C, the life enrichment note did not indicate the amount of fluid R55 consumed. 2. Comprehensive Nutrition assessment dated [DATE]: Current diet order is regular diet with mechanical soft and thin liquids. HS (hour of sleep) Magic cup given. Supplement: Magic Cup every day and nutritional juice every day, providing 490 kcal, 15 grams of protein. Adequate fluid intake. Estimated fluid needs: 1590-1855 ml/day. Recommendations and Plan: Continue diet and supplement as ordered. Staff to provide extensive feeding assistance at each meal. Resident to consume 75% or more of meals and 100% intake of supplement to meet nutrition needs .If weight starts to decline, will recommend nutrition juice to be increased to twice daily (400 kcal and 12 grams of protein) and weight to be obtained weekly. Nutritional interventions: Magic Cup every day; Nutritional Juice every day; whole milk every day, oatmeal cookie as HS snack three times a week, vanilla pudding as HS snack four times a week. 3. Comprehensive Nutritional assessment dated [DATE]: Current diet order is regular diet with pureed texture and thin liquids (downgraded on 6/15/21). HS ordered Magic cup given. Supplement: Magic Cup every day and nutritional juice every day, providing 490 kcal, 15 grams of protein. Adequate fluid intake. Estimated fluid needs: 1590-1855 ml/day. Evaluation and Summary: .Requires extensive feeding assistance with meals .Per staff, eating pureed foods better; likes supplements .100% acceptance of supplements .Receives multiple supplements to aide in weight stability. Recommendations and Plan: .Nutritional interventions: Magic Cup every day, Nutritional juice every day, whole milk every day . Review of the following nutrition progress notes do not reference a nutritional concern, or recommendation related to ensuring sufficient fluids to prevent dehydration: 1. Progress note dated 5/27/2021: Nutritional concerns: avoid unplanned weight loss; maintain skin integrity; continue good dietary and supplement intake. Recommendations: Continue current diet and supplement as ordered. Staff to continue to provide extensive feeding assistance at all meals. Weight to be obtained per policy, if weight decreases significantly will have weight checked weekly and increase supplements. 2. Progress note dated 6/29/2021: Nutritional concerns: avoid unplanned weight loss; maintain skin integrity; continue good dietary and supplement intake. Recommendations: Continue current diet and supplement as ordered. Staff to continue to provide extensive feeding assistance at all meals. Weight to be obtained per policy, if weight decreases significantly, will have weight checks weekly and increase Mighty Shake, twice daily: providing 400 kcals and 14 gm protein. 3. Progress note dated 7/16/2021: Resident triggered for significant weight change of 9% in 30 days likely related to low dietary/supplement intake and fluid shifts from [CONDITION(S)]. Per staff, requires lots of encouragement but intake remains low; use to drink all of supplement, however may consume 50%; receives extensive feeding assistance at all meals. 4. Progress note dated 7/31/2021: Body weight has been stable for one week likely related to improved dietary/supplement intake and acceptance of new supplement initiated on 7/16/2021. 5. Progress note dated 8/31/2021: Nutritional concerns: avoid unplanned weight loss; maintain skin integrity; continue good dietary and supplement intake. Recommendations: Continue current diet and supplement as ordered. Staff to continue to provide extensive feeding assistance at all meals. Weight to be obtained weekly and until no significant weight changes for 90 days. If weight decreases significantly, recommend nutrition juice be increased to twice daily; providing 400 kcal and 14 gm protein. 6. Progress note dated 9/20/2021: Nutritional concerns: avoid unplanned weight loss; maintain skin integrity; continue good dietary and supplement intake. Recommendations: Increase Nutrition juice to twice daily, providing 400 kcals and 12 gm of protein. Continue current diet and Med Pass as ordered. Resident to receive assistance at meals from restorative team. Weight to be obtained weekly and until no significant weight changes for 90 days, if weight continue to decline, will recommend appetite stimulant to be initiated. Interviews and review of R55's clinical record were conducted with Registered Dietitian (RD) F on 11/3/2021 at 4:43 PM and 11/4/2021 at 10:31 AM. On 11/3/2021, RD F said she did not have concerns regarding R55's hydration status because she was taking the liquid supplements. On 11/4/2021, RD F stated, (R55) was provided adequate fluids at each meal and through supplements to meet her nutritional and fluid needs. (R55's) fluid needs at the time were 1500 ml/day. RD F stated, Her fluids were coming from the juice and supplements. Per review with RD F, Nutritional Juice eight ounces once daily, Magic Cup six ounces once daily, and whole milk eight ounces once daily provided 22 ounces or 660 ml fluid daily. The facility document titled, Hydration and Electrolyte Management Program, dated 7/15/2015 was reviewed and revealed in part the following: -Sufficient fluid means the amount of fluid needed to prevent dehydration that results from output far exceeding intake. The amount of fluid needed for each resident fluctuates as the resident's condition fluctuates (e.g., fever, diarrhea, draining wounds). -Risk factors for dehydration: repeated refusal of fluid or change in food intake; weight loss; blood chemistries; draining wounds or pressure wounds. -Residents identified at risk for dehydration will receive extra fluids as clinically indicated. This information is to be placed on MAR (Medication Administration Record) This is to be evaluated with the physician and is resident specific. On 11/4/2021 at 4:55 PM during the exit conference, Nursing Home Administrator A and DON B were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not.

This citation has 2 deficient practices- Deficient practice #1 Based on observation, interview, record review, the facility failed to ensure that the face plate for the bathroom light switch was safely secured to the wall to prevent exposure and contact to a live electric current for one sampled resident (#915) of 15 residents sampled for accident hazards in a total census of 118, resulting in electric shock and sparks and the potential for serious harm including electrocution, fire, and death when the light switch was turned on. Findings include: The Immediate Jeopardy was identified on 4/24/17 at 3:00 p.m. and the facility Administrator was asked for a plan of removal of the immediacy at 4:30 p.m. The IJ was removed on 4/25/17 at 10:30 a.m. based on the providers implementation of corrective actions as verified onsite during the completion of the extended survey. Although the Immediate Jeopardy was removed, the facility's deficient practice was not corrected and remained out of compliance at a scope of isolated with actual harm. During the environmental tour of the facility, on 4/24/17 at 3:00 p.m., the light switch in Resident #515's bathroom produced multiple sparks when flipped on, cascading sparks onto the surveyors hand. The faceplate moved freely on the wall only attached by the wires behind it. Maintenance Staff AZ, present at the time, said, Did that just spark?, and flipped the switch on and off again causing another cascade of sparks from behind the face plate that fell a few inches before burning out. The Administrator was immediately made aware of the sparking light switch, on 4/24/17 at 3:01 p.m., and the administrator proceeded to Resident #515's bathroom. The light switch was flipped and sparks were evident behind the face plate of the switch. Neither the Administrator or the Maintenance Director had any explanation and both had been unaware of the sparking light switch. During an interview, on 4/24/17 at 3:30 p.m., the Maintenance Director indicated that there had been nothing reported to maintenance for the loose light switch plate in Resident #515's bathroom. During an interview, on 4/24/17 at 4:30 p.m., the Administrator indicated that Resident #515 was in the process of being temporarily relocated and would not be going into the room until a certified electrician looked at the electric fixtures in the room and bathroom. During an interview, on 4/25/17 at 9:00 a.m., the Administrator indicated that the entire facility had been inspected by an electrician the night before and no other issues were found. During an interview, on 4/25/17 at 10:15 a.m., CNA Y indicated that they had provided morning care to Resident #515 on 4/24/17. Resident #515 had gotten up around 9:00 a.m. and CNA Y had went into the bathroom to set up and wash their hands, however, the light was already on and the switch had not been used. CNA Y indicated that Resident #515 was able to and often went in and out of the bathroom unassisted and preferred to have the light left on. It was not known how the light was turned off. Review, on 4/25/16 at 10:30 a.m., of the clinical record revealed that Resident #515 was admitted into the facility on [DATE] with a [DIAGNOSES REDACTED]. According to the most recent quarterly Minimum Data Set (MDS), Resident #515's cognition was intact and required limited supervision for locomotion. Review, on 4/25/17 at 9:30 a.m., of the documentation provided by the contracted electrician confirming the work order had been finished, dated 4/25/17, revealed, Found that switch in bathroom had shorted against box due to loose switch. Checked outlets for polarity and if grounded all check ok. Went through entire building checking all outlets for polarity grounding and switches making repairs as they were found. Changing outlets, switches, broken covers, tightening devices. A phone call to the electrician to review the findings was made and a message to call was left. The electrician had not returned the phone call as of survey exit. A policy or procedure for ensuring and reporting electrical outlets and switches in resident areas were safe and functional was requested, however, none was received by the end of the survey on 4/26/17.

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ADMINISTER AN ANTIBIOTIC/ANTI-FUNGAL MEDICATION TO [MEDICAL CONDITION] AND A URINARY TRACT INFECTION [MEDICAL CONDITION] FOR ONE (51) OFF-SAMPLED RESIDENT OF SEVEN RESIDENTS OBSERVED DURING THE MEDICATION PASS, RESULTING IN A SIGNIFICANT CHANGE IN CONDITION TO INCLUDE MENTAL STATUS CHANGES, AND PAIN AS INDICATED BY GRIMACES AND RESTLESS BEHAVIOR. FINDINGS INCLUDE: RECORD REVIEW ON 01/12/12 AT 10:59 A.M., REVEALED THAT RESIDENT #51 WAS readmitted INto the facility on [DATE] AFTER BEING hospitalized for [REDACTED]. OTHER [DIAGNOSES REDACTED]. ON 1/12/12, AT 10:50 A.M., RESIDENT #51 WAS OBSERVED ON HER BACK IN BED AND APPEARED VERY RESTLESS, ANXIOUS AND IN INTENSE DISCOMFORT. THE RESIDENT GRIMACED, APPEARED ANXIOUS/RESTLESS, AND DID NOT RESPOND TO QUESTIONS REGARDING PAIN AND/OR LEVEL OF PAIN. THE RESIDENT DID NOT ENGAGE IN CONVERSATION. BASED ON THE MOST RECENT MINIMUM DATA SET, COMPLETED 12/19/11 (PRIOR TO HOSPTIALIZATION), RESIDENT #51 HAD A MENTAL STATUS CHANGE THAT WAS NOT ADDRESSED BY THE FACILITY. REVIEW OF THE MDS, dated [DATE] REVEALED RESIDENT # 51 HAD "CLARITY OF SPEECH", WAS USUALLY UNDERSTOOD, COMPREHENDED CONVERSATIONS, AND HAD VISION IMPAIRMENTS, THOUGH SHE WAS ABLE TO SEE LARGE PRINT. RESIDENT #51 WAS DESCRIBED AS ABLE TO MAKE CONSISTENT REASONABLE DECISIONS. BEHAVIORAL SYMPTOMS WERE IDENTIFIED AS BEING "SHORT -TEMPERED AND EASILY ANNOYED". RESIDENT #51 WAS TOTALLY DEPENDENT ON THE PHYSICAL ASSISTANCE OF ONE STAFF MEMBER FOR TRANSFERS AND OTHER ACTIVITIES OF DAILY LIVING. DURING AN INTERVIEW WITH UNIT MANAGER "A" ON 1/12/12 AT 3:15 P.M., IT WAS REPORTED RESIDENT #51 HAD A SIGNIFICANT CHANGE IN CONDITION AND NURSE #A CONFIRMED THAT THE FACILITY FAILED TO ADMINISTER THE ANTIFUNGAL/ANTIBIOTIC MEDICATION AS ORDERED SINCE 12/31/11. THE NURSE WAS UNABLE TO EXPLAIN THE DIFFERENCE WITH THE MINIMUM DATA SET DESCRIPTION OF THE RESIDENT AND THE RESIDENT'S PRESENT CONDITION. REVIEW OF THE HOSPITAL RE-ADMISSION RECORD AND PHYSICAL, DATED 12/26/11, INDICATED THAT RESIDENT #51 HAD A COMPLICATED URINARY TRACT INFECTION [MEDICAL CONDITION]. ORGANISMS IDENTIFIED WERE [MEDICATION NAME] (BACTERIA) AND [MEDICAL CONDITION](YEAST), AND INFECTIOUS DISEASE WAS CONSULTED. REVIEW OF THE PHYSICIANS PROGRESS NOTE DATED 12/29/11, INDICATED RESIDENT #51 HAD A RECENT URINARY TRACT INFECTION WITH BACTERIA AND [MEDICAL CONDITION] WHICH THE PATIENT WAS PRESCRIBED ANTIBIOTIC AND ANTI-FUNGAL TREATMENT. REVIEW OF THE NURSE'S NOTES DATED 1/1/12, INDICATED AN ANTIBIOTIC FOR UTI WAS "IN PROGRESS" HOWEVER, THE MAR indicated [REDACTED]. THE NURSE'S NOTES DATED 1/9/12, INDICATED RESIDENT IN ACUTE DISTRESS, PAIN MEDICATION INEFFECTIVE. REVIEW OF PHYSICIANS ORDERS ON 1/12/12, AT 1:45 P.M., REVEALED RESIDENT #51 WAS PRESCRIBED FLUCONAZOLE (A MEDICATION USED TO TREAT FUNGAL AND YEAST INFECTIONS) 600 MG DAILY ON 12/26/11. WHEN COMPARING PHYSICIAN ORDERS [REDACTED]. AS A RESULT, RESIDENT #51 DID NOT RECEIVE HER ANTIFUNGAL MEDICATION PRESCRIBED FOR "SEPSIS" THE ENTIRE MONTH OF JANUARY 2012. RESIDENT #51 WAS PRESCRIBED THIS MEDICATION WHILE IN THE HOSPITAL FOR PRIMARY [DIAGNOSES REDACTED]. REVIEW OF RESIDENT #51'S COMPREHENSIVE PLAN OF CARE ON 1/12/12, AT 3:38 P.M., FAILED TO ADDRESS GOALS AND INTERVENTIONS TO MANAGE, PREVENT AND [MEDICAL CONDITION] AND INFECTIONS. IN AN INTERVIEW ON 1/12/12 AT 3:15 P.M., WITH THE UNIT NURSE MANAGER #A ON 2 NORTH, IT WAS CONFIRMED THE FACILITY FAILED TO ADMINISTER THE ANTIFUNGAL MEDICATION AS ORDERED. THE DIRECTOR OF NURSING DON WAS INTERVIEWED ON 1/12/12, AT 3:50 P.M., AND OFFERED NO FURTHER EXPLANATIONS. THE DON COULD NOT EXPLAIN THE STATUS OF RESIDENT #51'S SEPTIC CONDITION, SIGNIFICANT CHANGE IN CONDITION, OR PHYSICIANS INVOLVEMENT BY THE END OF THE SURVEY. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ADMINISTER PAIN MEDICATIONS TO ONE (#410) OF SIX SAMPLED RESIDENTS REVIEWED FOR PAIN FROM A TOTAL OF 15 SAMPLED RESIDENTS, RESULTING IN COMPLAINTS OF "VERY SEVERE" PAIN. FINDINGS INCLUDE: ON 2/29/12 AT 11:40 A.M., RESIDENT #410 WAS OBSERVED IN BED, POSITIONED ON HER LEFT SIDE. THE RESIDENT WAS OBSERVED TO GRIMACE UPON MOVEMENT. WHEN QUERIED, THE RESIDENT STATED, "I'M NOT GOOD." TEARS WERE OBSERVED RUNNING DOWN BOTH OF HER CHEEKS AND SHE STATED, "I'M IN F---ING PAIN AND ALL THEY GIVE ME IS F---ING [MEDICATION NAME]!" ([MEDICATION NAME] AND [MEDICATION NAME] USED TO RELIEVE MODERATE TO SEVERE PAIN). AT 12:00 P.M., RESIDENT #410'S CLINICAL RECORD WAS REVIEWED AND REVEALED THE FOLLOWING: PER THE FACE SHEET, RESIDENT #410 WAS ORIGINALLY admitted to the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. THE ADMISSION Minimum Data Set, dated dated [DATE], INDICATED RESIDENT #410 WAS ABLE TO MAKE HER NEEDS KNOWN AND WAS CODED AS BEING COGNITIVELY INTACT. THE INITIAL ASSESSMENT (UNDATED) DOCUMENTED THAT RESIDENT #410 WAS IDENTIFIED AS BEING BEDBOUND AND REQUIRED TWO PERSON PHYSICAL ASSISTANCE WITH BED MOBILITY. THE FACILITY "PAIN ASSESSMENT," DATED 2/16/12 AND 2/17/12, INDICATED THAT RESIDENT #410 FREQUENTLY USED AND RECEIVED PRN (AS NEEDED). BASED ON THE PAIN INTENSITY SCALE (AN ASSESSMENT TOOL USED TO DESCRIBE PAIN--PAIN IS RATED ON A SCALE OF 0 TO 10. A "0" EQUALS NO PAIN, 2 = MILD PAIN, 4 = MODERATE PAIN, 6= SEVERE PAIN, 8 = VERY SEVERE PAIN AND 10 = WORST PAIN POSSIBLE). THE PAIN INTENSITY SCALE ASSESSMENT INDICATED THE RESIDENT WAS ABLE TO VERBALIZE WHEN SHE WAS EXPERIENCING PAIN. THE FORM ALSO DOCUMENTED THAT THE RESIDENT WAS OBSERVED COMPLAINING, MAKING FACIAL GRIMACES AND EXPRESSING ANGER IN RESPONSE TO PAIN. THE ASSESSMENT TOOL ALSO DOCUMENTED THAT THE RESIDENT EXPERIENCED PAIN "ALL THE TIME", ROUTINE MEDICATION AND PRN (AS NEEDED) MEDICATION WERE TO BE ADMINISTERED AND THAT A "PAIN PRESCRIPTION WAS TO BE OBTAINED." THE ADMISSION CARE PLAN, DATED 2/16/12 DIRECTED STAFF TO "ADMINISTER PAIN MEDICATIONS AND MONITOR FOR SIDE EFFECTS AS WELL AS MONITOR PAIN RESPONSE PER SCALE-- BEFORE AND AFTER MEDICATION ADMINISTRATION." THE PHYSICIAN ORDERED THE FOLLOWING MEDICATIONS FOR PAIN: 1. [MEDICATION NAME] 10/325 MG (MILLIGRAMS) ONE TABLET BY MOUTH EVERY FOUR HOURS AS NEEDED. 2. [MEDICATION NAME] SULFATE 15 MG ONE TABLET BY MOUTH EVERY 12 HOURS. 3. [MEDICATION NAME] PATCH 12.5 MCG (MICROGRAMS) EVERY THREE DAYS, TO BE APPLIED AT 6 AM. THE PRN [MEDICATION NAME] RECORD/PAIN FLOW SHEET" REVEALED RESIDENT #410 REQUESTED ADDITIONAL MEDICATION BECAUSE SHE HER PAIN WAS NOT CONTROLLED. THE FLOW SHEET REVEALED THE FOLLOWING: ON 2/17/12 AT 9:00 P.M. AND AT 12 P.M., RESIDENT RATED PAIN AT AN "8" (VERY SEVERE PAIN). ON 2/18/12 AT 12 P.M., 4 P.M., AND AT 8:00 P.M., RESIDENT RATED PAIN AT A "7-8" (SEVERE TO VERY SEVERE PAIN). ON 2/18/12 AT 4:00 P.M., RESIDENT RATED PAIN AT "8"(VERY SEVERE PAIN). ON 2/19/12 AT 1:30 P.M. AND 6:00 P.M., RESIDENT RATED PAIN AT A "7-8" (SEVERE TO VERY SEVERE PAIN). ON 2/20/12 AT 1:00 P.M., RESIDENT RATED PAIN AT A "8" (SEVERE PAIN). ON 2/21/12 AT 3:00 P.M. AND 7:00 P.M., RESIDENT RATED PAIN AT "7-8" (SEVERE TO VERY SEVERE PAIN). ON 2/22/12 AT 6:00 P.M. AND AT 10:00 P.M., RESIDENT RATED PAIN AT A "8" (VERY SEVERE PAIN). ON 2/23/12 AT 6:00 P.M., RESIDENT RATED PAIN AT A "7" (SEVERE PAIN). ON 2/24/12 AT 6:00 P.M., RESIDENT RATED PAIN AT A "8" (SEVERE PAIN). ON 2/25/12 AT 7:00 A.M., RESIDENT RATED PAIN AT A "8" (VERY SEVERE PAIN). ON 2/27/12 AT 1:40 A.M., RESIDENT RATED PAIN AT A "8" (VERY SEVERE PAIN). ON 2/28/12 AT 12:00 A.M., RESIDENT RATED PAIN AT A "10" (WORST PAIN IMAGINABLE) ON 2/29/12 AT 1:45 A.M., RESIDENT RATED PAIN AT "10 PLUS" (WORST PAIN IMAGINABLE). AT 12:45 P.M., THE MEDICATION ADMINISTRATION RECORD WAS REVIEWED WITH NURSE 'A' AND REVEALED THAT RESIDENT #410 DID NOT RECEIVE THE [MEDICATION NAME] ([MEDICATION NAME]) PATCH ON 2/16/12, 2/20/12, 2/23, NOR ON 2/26/12 AND 2/29/12. THE REASON WAS DOCUMENTED ON THE BACK OF THE MAR: "[MEDICATION NAME] UNAVAILABLE." NURSE 'A' WAS QUERIED ABOUT THE BLANK AREAS ON THE MAR FOR THE DATES OF APPLICATION (2/23/12 AND 2/26/12) AND STATED, "THE RESIDENT DIDN'T GET THEM THOSE DAYS." FOR THE DATE 2/29/12, THERE WERE "CIRCLED" INITIALS DOCUMENTED ON THE MAR. NURSE 'A' STATED, "THE CIRCLE MEANS THAT THE PATCH ([MEDICATION NAME]) WAS NOT APPLIED. MAYBE IT WASN'T AVAILABLE BECAUSE THE DOCTOR HAS TO COMPLETE A CONTROLLED SUBSTANCE FORM." NURSE 'A' SAID "PAIN IS WHAT THEY (RESIDENTS) SAY IT IS" AND THAT RESIDENT #410 NEEDS HER MEDICATION BECAUSE, " SHE'S IN CONTINUOUS PAIN. " AT 1:00 P.M., NURSE 'B' WAS QUERIED REGARDING RESIDENT #410'S [MEDICATION NAME] PATCH AND REPORTED PATCHES WERE ADMINISTERED BY THE NURSE ON THE MIDNIGHT SHIFT. WHEN ASKED WHETHER RESIDENT #410 HAD A PATCH ON, NURSE 'B' SAID THAT SHE DID NOT CHECK TO SEE IF THE RESIDENT HAD ON A PATCH. AT 1:10 P.M., RESIDENT #410 WAS OBSERVED IN BED LYING ON HER LEFT SIDE WITH A GRIMACE ON HER FACE. RESIDENT #410 WAS ASKED IF SHE HAD GOTTEN A [MEDICATION NAME] PATCH AND YELLED, "THE LAST PATCH I RECEIVED WAS WHEN I WAS IN THE HOSPITAL. I NEED SOMETHING FOR MY HEADACHE, BACKACHE,...I HAVE A MIGRAINE!" WHEN ASKED IF THE MEDICATIONS HELPED TO MANAGE THE PAIN, THE RESIDENT BECAME TEARFUL AND SAID, "THEY GIVE ME ONE ([MEDICATION NAME] SULFATE) IN THE MORNING AND ONE AT NIGHT AND I HURT THROUGH THE WHOLE DAY!" RESIDENT #410 CRIED. AT 1:30 P.M., THE CLINICAL RECORD WAS THEN REVIEWED WITH NURSE 'B'. THE PHYSICIAN'S NOTES, NURSES NOTES, "INDIVIDUAL RESIDENT'S CONTROLLED SUBSTANCE RECORDS," AND PHARMACY REVIEW SHEETS WERE EXAMINED. THERE WAS NO DOCUMENTED EVIDENCE THAT STAFF ATTEMPTED TO ACQUIRE THE [MEDICATION NAME] PATCH THAT WAS ORDERED BY THE PHYSICIAN ON 2/16/12. FURTHER REVIEW REVEALED THAT THE PHYSICIAN COMPLETED THE CONTROLLED SUBSTANCE FORM. NURSE 'B' STATED, 'THE CONTROLLED SUBSTANCE FORM WAS COMPLETED BY THE PHYSICIAN BUT IT PROBABLY WAS NOT SENT TO THE PHARMACY. WHEN ASKED HOW SHE KNEW IT WAS NOT SENT TO THE PHARMACY, NURSE 'B' STATED, "THERE IS NO CONFIRMATION LETTER." AT 2:00 P.M., THE DIRECTOR OF NURSING (DON) WAS QUERIED AND COULD NOT EXPLAIN WHY RESIDENT #410 DID NOT RECEIVE THE [MEDICATION NAME] PATCH TO ADDRESS HER "SEVERE TO VERY SEVERE" PAIN. THE FACILITY POLICY ENTITLED, "PAIN MANAGEMENT", DATED 10/8/10 DOCUMENTED, "INITIATE IMMEDIATE INTERVENTIONS TO PROMOTE COMFORT." PHARMACOLOGICAL INTERVENTIONS INCLUDED, "ADMINISTRATION OF ROUTINE MEDICATIONS." POLICY AND PROCEDURE FOR PAIN MANAGEMENT WAS REQUESTED; HOWEVER, NOT PROVIDED. PER THE "NURSING 2001 DRUG BOOK", SPRINGHOUSE 21ST EDITION, THE [MEDICATION NAME] SYSTEM ([MEDICATION NAME] SKIN PATCH) WAS DESIGNED TO SLOWLY RELEASE 12.5 MICROGRAMS OF [MEDICATION NAME] (OPIATE) EACH HOUR FOR 72 HOURS TO CONTROL PAIN AND PREVENT SEVERE, PROLONGED INTENSITY OF PAIN. PER THE NURSING CONSIDERATIONS, " MOST PATIENTS EXPERIENCE GOOD CONTROL OF PAIN FOR THREE DAYS (72 HOURS) WHILE WEARING THE [MEDICATION NAME] SYSTEM." ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO IDENTIFY, MONITOR , ASSESS, AND IMPLEMENT INTERVENTIONS TO PREVENT PRESSURE ULCERS FOR TWO (#301 AND 313) OF 8 RESIDENTS REVIEWED WITH PRESSURE ULCERS FROM A TOTAL OF 24 SAMPLED RESIDENTS RESULTING IN THE DEVEOPMENT OF PRESSURE ULCERS. THE FACILITY ALSO FAILED TO PROMOTE HEALING OF A PRESSURE ULCERS FOR ONE (#303) OF EIGHT RESIDENTS REVIEWED FOR PRESSURE ULCERS RESULTING IN A DELAY IN HEALING OF AN EXISTING PRESSURE ULCER. FINDINGS INCLUDE: ON 1/11/12 AT 9:45 A.M., A CHART REVIEW WAS CONDUCTED ON RESIDENT #313 AND IT REVEALED THAT RESIDENT #313 WAS admitted to the facility on [DATE] AND WAS diagnosed with [REDACTED]. ON 1/11/12 AT 9:10 A.M., RESIDENT #313 WAS INTERVIEWED REGARDING HIS WOUNDS, PAIN, ABILITY TO AMBULATE AND ASSISTANCE WITH DRESSING AND HYGIENE. RESIDENT #313 WAS OBSERVED SITTING IN A WHEELCHAIR, IN HIS ROOM. THE RESIDENT WAS FULLY DRESSED AND WORE A UNNA BOOT (SOFT COVERED BOOT FOR PROTECTION) ON HIS RIGHT FOOT AND A PARFO BOOT (A COVERED BOOT WITH METAL BRACKETS INSIDE OF BOOT USED TO AIDE IN AMBULATION) ON HIS LEFT FOOT. THE TUBING OF THE CATHETER WAS OBSERVED INSIDE THE VELCRO STRAPPING OF THE PARFO BOOT. THE CATHETER WAS NOT ANCHORED. RESIDENT #313 WAS COMPLAINING OF PENILE PAIN. RESIDENT #313 WAS ASKED, WHO ASSISTED HIM TO GET DRESSED AND STATED THAT HE DRESSED HIMSELF. ON 1/11/12 AT 11:50 A.M., RESIDENT #313 WAS OBSERVED FOR A SKIN AND WOUND ASSESSMENT, THAT WAS CONDUCTED BY THE DIRECTOR OF NURSING SERVICES (DON). THREE OPENED AREAS WERE OBSERVED AROUND THE HEAD OF PENIS AFTER THE FORESKIN WAS RETRACTED. RESIDENT #313 WAS NOT CIRCUMCISED. THE CATHETER WAS INTACT. DURING THIS ASSESSMENT, THE DON STATED RESIDENT #313 DID NOT HAVE A CATHETER ANCHOR ATTACHED TO HIS LEG TO PREVENT TRAUMA FROM THE CATHETER. RESIDENT #313 SUSTAINED THREE FACILITY ACQUIRED PRESSURES ULCERS TO THE HEAD OF THE PENIS. THE WOUND CARE MEASUREMENT RESULTS WERE AS FOLLOWED; WOUND #1 LOCATED ON LEFT OUTER ANTERIOR HEAD OF PENIS WAS IDENTIFIED BY THE FACILITY AS A "STAGE III" PRESSURE ULCER (FULL THICKNESS TISSUE LOSS. SUBCUTANEOUS FAT MAY BE VISIBLE BUT BONE, TENDON OR MUSCLE IS NOT EXPOSED), MEASURING 1.9 CM (CENTIMETERS) X 1.8 CM DRAINING SERO-SANGUINOUS FLUID (CLEAR FLUID WITH BLOOD). NO DEPTH OF WOUND NOTED. WOUND #2 LOCATED AT LEFT OUTER ANTERIOR HEAD OF PENIS WAS IDENTIFIED BY THE FACILITY AS A "STAGE III" PRESSURE ULCER MEASUREMENTS WERE 2.0 CM (CENTIMETERS) X 2.0 CM DRAINING SERO-SANGUINOUS FLUID. NO WOUND DEPTH NOTED. WOUND #3 LOCATED AT RIGHT ANTERIOR HEAD OF PENIS WAS IDENTIFIED BY THE FACILITY AS A "STAGE III" PRESSURE ULCER MEASURING 2.0 CM (CENTIMETERS) X 1.9 CM DRAINING SERO-SANGUINOUS FLUID. NO DEPTH NOTED. THE NURSING ADMISSION DATA COLLECTION SKIN ASSESSMENT, DATED 12/20/11, INDICATED THERE WAS NO SKIN BREAKDOWN AROUND THE HEAD OF THE PENIS AT ADMISSION. ON 1/10/12 AT 10:00 A.M., 1/11/12 AT 1:00 P.M. AND 1/12/12 AT 1:00 P.M., RESIDENT #313 VERBALLY STATED THAT NO FACILITY STAFF ASSISTED HIM WITH HIS PERSONAL HYGIENE CARE. RESIDENT #313'S MINIMUM DATA SET (MDS), dated [DATE], STATED THAT RESIDENT REQUIRED LIMITED ASSISTANCE (RESIDENT HIGHLY INVOLVED IN ACTIVITY; STAFF PROVIDE GUIDED MANEUVERING OF LIMBS OR OTHER NON-WEIGHT -BEARING ASSISTANCE), OF ONE STAFF PERSON TO ASSIST WITH PERSONAL HYGIENE CARE AND DRESSING. THE RESIDENT CARE GUIDE USED BY THE NURSE AIDES, DATED 12/30/11, PROVIDED NO INSTRUCTIONS TO THE NURSE AIDES TO ASSIST THE RESIDENT WITH PERSONAL HYGIENE NEEDS AND DRESSING. THE FACILITY POLICY ON CATHETER CARE (NRS-132) DATED JULY 1, 2008, INSTRUCTED STAFF MEMBERS, "TO PREVENT INFECTION AND REDUCE IRRITATION FACILITY STAFF ARE TO ASSIST OR PROVIDE (RESIDENTS) CLEANSING OF PERINEUM WITH SOAP AND WATER". RESIDENT #313'S WEEKLY DEHYDRATION AND SKIN ASSESSMENT WERE REVIEWED ON 1/11/12. IT WAS REVEALED THAT THE FACILITY FAILED TO COMPLETE THE WEEKLY HYDRATION AND SKIN ASSESSMENT FOR RESIDENT #313 ON 12/21/11, 12/28/11, 1/06/12 AND 1/10/12. THE FACILITY WOUND MANAGEMENT PROGRAM POLICY (NRS-245A), DATED JULY 1, 2008, REVISED OCTOBER 8, 2010, STATED, "TO COMPLETE WEEKLY HYDRATION AND SKIN ASSESSMENT ACCORDING TO SCHEDULE". AN INTERVIEW WAS CONDUCTED ON 1/11/12 AT 10:45 A.M., WITH STAFF "C". STAFF "C" WAS ASKED WHO WAS RESPONSIBLE FOR COMPLETING THE RESIDENT'S SKIN ASSESSMENT AND REPLIED, "SKIN ASSESSMENT ARE DONE BY THE NURSE A COUPLE OF TIMES A WEEK ON THE RESIDENT'S SHOWER DAYS". ON 1/11/12 AT 9:45 A.M., RESIDENT #313'S CARE PLANS WERE REVIEWED AND THE FACILITY DID NOT HAVE A FOLEY CATHETER OR SKIN INTEGRITY CARE PLAN THAT INCLUDED INTERVENTIONS THAT WERE IN PLACE TO PREVENT SKIN BREAKDOWN FOR FOLEY CATHETER AREA AND PENIS. THE FACILITY WOUND MANAGEMENT PROGRAM POLICY (NRS-245A), DATED JULY 1, 2008, REVISED OCTOBER 8, 2010, STATED, "TO PLACE INITIAL INTERVENTIONS FOR RESIDENTS AT RISK FOR DEVELOPMENT OF SKIN BREAKDOWN ONTO: THE ADMISSION CARE PLAN, IF IDENTIFIED WITHIN 21 DAYS AND ON THE RESIDENT CARE GUIDE". ( ) ON 1/10/12 AT 9:45 A.M., RESIDENT #303 WAS OBSERVED IN BED POSITIONED ON HER BACK. THE RESIDENT HAD A SPECIALTY MATTRESS THAT WAS SET AT "REGULAR" WITH THE DIAL POSITIONED AT "11 O'CLOCK". THERE WAS NO MARKING OR "NUMBER" TO INDICATE WHERE THE DIAL WAS TO BE POSITIONED FOR THE RESIDENT. THERE WAS NO INDWELLING CATHETER. THE RESIDENT WAS QUERIED AND STATED, "I GOT A SORE ON MY BACK (BUTTOCK). SOMETIMES IT HURTS." ON 1/10/12 AT 3:05 P.M., REVIEW OF RESIDENT #303'S CLINICAL RECORD REVEALED THE FOLLOWING: RESIDENT #303 WAS admitted to the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. PER THE MOST RECENT MINIMUM DATA SET (MDS), dated [DATE], THE RESIDENT WAS CODED AS BEING COGNITIVELY INTACT. THE RESIDENT REQUIRED EXTENSIVE PHYSICAL ASSISTANCE OF ONE PERSON FOR ALL ACTIVITIES OF DAILY LIVING (ADL'S) WITH THE EXCEPTION OF EATING. THE PRESSURE ULCER ASSESSMENT, DATED 12/07/11, INDICATED RESIDENT #303 WAS "AT RISK" FOR THE DEVELOPMENT OF PRESSURE ULCERS AND WAS INITIALLY admitted WITH A STAGE FOUR PRESSURE ULCER ON THE SACRUM. THE STAGE FOUR PRESSURE ULCER (AT THE TIME OF THE FIRST ADMISSION 8/05/11) WAS DESCRIBED AS HAVING SLOUGH AND MEASURED 6.0 CM'S (CENTIMETERS) X 8.5 CM'S X 3.5 CM'S. THE PHYSICIAN'S PROGRESS NOTE, DATED 12/9/11, DOCUMENTED THAT THE PRESSURE ULCER WAS A STAGE IV WITH, "NO ODOR." THE WOUND CARE PLAN, LAST UPDATED ON 11/16/11, DOCUMENTED THE FOLLOWING INTERVENTIONS: "PRESSURE RELIEVING DEVICE ON THE BED, ADMINISTER TREATMENTS AS ORDERED AND MONITOR FOR EFFECTIVENESS. REPORT IMPROVEMENTS AND DECLINES TO THE MEDICAL DOCTOR, FOLEY CATHETER" THERE WERE NO PRESSURE RELIEVING DEVICE PARAMETERS NOTED ON THE CARE PLAN AND THE RESIDENT WAS NOT CATHETERIZED. ON 1/12/11 AT 10:00 A.M., RESIDENT #303 WAS IN THE BED ON HER BACK WHEN THE TREATMENT NURSE AND THE NORTH UNIT CLINICAL COORDINATOR (NURSE) PERFORMED WOUND CARE TO THE RESIDENT'S SACRAL AREA. THE TREATMENT NURSE DESCRIBED THE WOUND AS HAVING A COPIOUS AMOUNT OF DARK BROWN DRAINAGE. THE CENTER OF THE WOUND WAS DESCRIBED AS HAVING, "YELLOW SLOUGH", THE WOUND PRESENTED WITH UNDERMINING AROUND THE EDGES OF THE WOUND AND A FOUL ODOR. THE WOUND MEASURED 9.0 CM'S X 11.0 CM'S BY 4.7 CM'S. THE CLINICAL CARE NURSE WAS QUERIED REGARDING THE USE OF THE INDWELLING CATHETER TO HELP KEEP THE WOUND CLEAN AND REPORTED THE CATHETER WAS INSERTED ON 1/12/12 AND NOT 11/16/11 AS IDENTIFIED ON THE PLAN OF CARE. THE NORTH CLINICAL COORDINATOR STATED THAT THE CATHETER WAS INSERTED ON 1/11/12. WHEN ASKED THE REASON FOR THE CATHETER SHE STATED, "FOR NO PARTICULAR REASON." THE TREATMENT NURSE WAS ASKED THE PURPOSE OF THE FOLEY CATHETER AND SHE STATED, "TO PREVENT SKIN BREAKDOWN AND PREVENT URINE FROM GETTING INTO THE WOUND." THE TREATMENT NURSE WAS ASKED THE PURPOSE OF THE SPECIALTY MATTRESS AND SAID THAT IT TOO WAS FOR THE IMPROVEMENT OF THE PRESSURE ULCER. WHEN QUERIED ABOUT THE SPECIFIC SETTINGS REQUIRED FOR RESIDENT #303, THE TREATMENT NURSE STATED THAT SINCE SHE JUST STARTED HER JOB AS THE TREATMENT NURSE SHE WAS GOING TO IDENTIFY RESIDENTS THAT USED A SPECIALTY MATTRESS AND IDENTIFY THE PROPER SETTINGS. THE TREATMENT NURSE WAS UNABLE TO CONFIRM IF THE RESIDENT'S SPECIALTY MATTRESS WAS ON THE CORRECT SETTING. WHEN QUERIED, THE TREATMENT NURSE WAS UNABLE TO EXPLAIN WHY THE WOUND HAD INCREASED IN SIZE AND WHY THE WOUND HAD AN ODOR (A SIGN OF INFECTION). ON 1/12/12 AT 3:10 P.M., THE DIRECTOR OF NURSING (DON) REVIEWED THE CLINICAL RECORD AND WAS QUERIED REGARDING RESIDENT #303'S PRESSURE ULCER AND THE INCREASE IN THE SIZE OF THE WOUND. THE DON WAS ASKED WHY THE RESIDENT DID NOT HAVE AN INDWELLING CATHETER PRIOR TO 1/11/12. THE DON STATED THAT THE RESIDENT SHOULD HAVE HAD AN INDWELLING CATHETER AND SPECIALTY MATTRESS TO PROMOTE HEALING. THE DON WAS UNABLE TO EXPLAIN WHY INTERVENTIONS TO PROMOTE WOUND HEALING OF RESIDENT #303'S PRESSURE ULCER WERE NOT IMPLEMENTED. THE DON REVIEWED THE WEEKLY PRESSURE ULCER WOUND DOCUMENTATION, DATED 12/30/11 AND 1/4/12, WHICH REVEALED THAT THE WOUND HAD INCREASED IN SIZE. THERE WERE NO WEEKLY PRESSURE ULCER WOUND DOCUMENTATION FOR THE MONTH OF DECEMBER PRIOR TO 12/30/11. THERE WAS NO DOCUMENTED EVIDENCE THAT THE DECLINE IN THE WOUND WAS REPORTED TO THE PHYSICIAN AND THERE WAS NO UPDATE OR CHANGE IN INTERVENTION ON THE CARE PLAN TO ADDRESS THE PRESSURE ULCER. THERE WAS NO EVIDENCE PROVIDED TO SHOW THE INCREASE IN SIZE OF THE PRESSURE ULCER WAS "AVOIDABLE". THERE WERE NO PHYSICIAN WOUND CARE NOTES AFTER 12/9/11. NURSES NOTES WERE REVIEWED FROM 12/11/12 THROUGH 1/1/12 AND REVEALED THAT THERE WAS NO DOCUMENTED EVIDENCE THAT THE RESIDENT HAD AN INDWELLING CATHETER INTACT DURING THAT PERIOD OF TIME. THE DON HAD NO FURTHER EXPLANATION. THE FACILITY POLICY ENTITLED "WOUND MANAGEMENT PROGRAM" REVISED ON 10/10 DOCUMENTED THE FOLLOWING, "COMPLETE THE FOLLOWING DAILY (CHARGE NURSE) VERIFY THAT RESIDENT-SPECIFIC CARE PLAN INTERVENTIONS ARE IN PLACE... COMPLETE THE FOLLOWING FORM WEEKLY (WEEKLY PRESSURE ULCER WOUND DOCUMENTATION)... COMPLETE THE FOLLOWING STEPS IF PRESSURE ULCER FAILS TO SHOW EVIDENCE OF IMPROVEMENT/HEALING WITHIN TWO TO FOUR WEEKS. REVIEW THE RECORD TO IDENTIFY ANY NEW CLINICAL RISKS THAT MAY HAVE DEVELOPED. CONTACT THE PHYSICIAN TO CONSIDER CHANGE IN TREATMENT." THE FACILITY DID NOT FOLLOW THEIR WOUND MANAGEMENT PROGRAM. ( ) ON 1/10/12 AT 8:30 A.M., RESIDENT (#301) WAS OBSERVED IN BED. NURSE (B) STATED RESIDENT #301 HAD RECENTLY ACQUIRED A NEW PRESSURE ULCERS ON THE RIGHT AND LEFT BUTTOCK THAT WAS CAUSED BY FRICTION AND SHEARING FROM THE BRIEFS THAT RESIDENT #301 HAD BEEN WEARING. A REVIEW OF THE CLINICAL RECORD REVEALED THE FOLLOWING: THE ADMISSION RECORD, DATED 12/27/11, INDICATED RESIDENT #301 WAS RE-admitted to the facility on [DATE] AFTER A SHORT STAY AT A LOCAL HOSPITAL WITH [DIAGNOSES REDACTED]. THE Minimum Data Set, dated dated [DATE], INDICATED RESIDENT #301 HAD SEVERELY IMPAIRED COGNITIVE SKILLS FOR DECISION MAKING, WAS NON-AMBULATORY AND TOTALLY DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING INCLUDING BED MOBILITY AND TRANSFERS. THE CAA (CARE AREA ASSESSMENT), DATED 12/15/11, INDICATED RESIDENT #301 WAS INCONTINENT OF URINE AND STOOL AND UTILIZED "THE BRIEF SYSTEM". THE ADMISSION NURSING ADMISSION ASSESSMENT, DATED 12/23/11, INDICATED RESIDENT #301 WAS readmitted INTO THE FACILITY WITHOUT ANY PRESSURE ULCERS. THE BRADEN SCALE (TOOLS USED TO PREDICT PRESSURE SORE RISK), DATED 12/30/11 AND 1/04/12, INDICATED RESIDENT #301 WAS AT "MODERATE RISK" FOR THE DEVELOPMENT OF PRESSURE ULCERS/SORES. NURSING NOTES DATED 1/04/12, INDICATED RESIDENT #301 HAD A NEW OPEN AREA OF SHEARING TO THE LEFT AND RIGHT BUTTOCK, WITH THE RIGHT BUTTOCK MEASURING 3.0 X 0.5 CM AND THE LEFT BUTTOCK MEASURING 4.0 X 0.5 CM. A physician progress notes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

THIS CITATION PERTAINS TO INTAKE: MI 727 BASED ON INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND ASSISTANCE TO PREVENT FALLS IN 1 OF 4 RESIDENTS ( RESIDENT # 101) WHICH RESULTED IN RESIDENT # 101 FALLING FROM HER BED AND SUSTAINING A LEFT SUBFRONTAL HEMATOMA (A MASS OF BLOOD CONFINED INSIDE THE SKULL) THAT SUBSEQUENTLY REQUIRED SURGICAL INTERVENTION. FINDINGS INCLUDE: ACCORDING TO THE FACILITY'S INCIDENT REPORT DATED 1/5/11, ON 1/3/11 AT APPROXIMATELY 2:45 P.M., RESIDENT # 101 fell OFF THE BED WHEN CERTIFIED NURSING ASSISTANT (CNA) # 6 LEFT RESIDENT # 101 UNATTENDED AND UNSUPPORTED WHILE SHE TURNED TO REPOSITION THE WHEELCHAIR. ACCORDING TO THE HOSPITAL'S emergency room (ER) REPORT DATED 1/4/11, RESIDENT # 101 WAS UNRESPONSIVE WITH UNEQUAL PUPILS UPON ARRIVAL. THE RESIDENT OF CONCERN HAD A LARGE HEMATOMA ( 5 CENTIMETERS X 6 CENTIMETERS) ON THE LEFT SIDE OF HER FOREHEAD. A CAT SCAN OF THE HEAD REVEALED A LARGE RIGHT SUBDURAL HEMATOMA WITH LEFT SUBFALCINE AND UNCAL HERNIATION ( INCREASED INTRACRANIAL PRESSURE CAUSING THE BRAIN TO SHIFT AWAY FROM MIDLINE AND HERNIATE). RESIDENT #101 WAS RESUSCITATED PER ADVANCED CARDIO LIFE SUPPORT PROTOCOL AND PREPARED FOR NEUROSURGERY. RESIDENT # 101 UNDERWENT A CRANIOTOMY (SURGICAL HOLE IN THE SKULL) TO RELIEVE THE INTRACRANIAL PRESSURE (PRESSURE ON THE BRAIN). IN AN INTERVIEW ON 2/3/11 AT 12:20 P.M., CNA # 7 SAID WHEN SHE WAS PREPARING TO TRANSFER RESIDENT # 101 FROM HER BED TO THE WHEELCHAIR , SHE TURNED AWAY FROM THE RESIDENT AND LET GO OF HER TO REACH FOR THE WHEELCHAIR FOR 1 SECOND. IN THAT SHORT AMOUNT OF TIME RESIDENT # 101 fell OFF THE BED AND HIT HER HEAD ON THE FLOOR. CNA # 7 SAID THAT SHE DID NOT KNOW RESIDENT # 101'S LEFT SIDE WAS THAT WEAK BECAUSE IT WAS THE FIRST TIME SHE HAD EVER CARED FOR THE RESIDENT. RESIDENT # 101 HAD JUST ARRIVED TO THE FACILITY THE EVENING BEFORE AND HAD NOT GOTTEN UP YET. HOWEVER, CNA # 7 SAID SHE DID KNOW THAT RESIDENT # 101 WAS A FALL RISK AND ON FALL PRECAUTIONS WHICH MEANT SHE WAS NOT TO BE LEFT UNATTENDED. ACCORDING TO RESIDENT # 101'S MEDICAL RECORD, SHE WAS AN [AGE] year OLD FEMALE WHO HAD ARRIVED AT THE FACILITY ON 1/3/11 DURING THE AFTERNOON SHIFT WITH A HISTORY OF A FALLS AT HOME WITH LEFT SIDED WEAKNESS. RESIDENT # 101 WAS ASSESSED AS A FALL RISK AND WAS PLACED ON FALL PRECAUTIONS. RESIDENT # 101 WAS NOT RESIDING IN THE FACILITY AT THE TIME OF THE ON-SITE INVESTIGATION. ON 2/3/11 AT 11:00 A.M., THE ADMINISTRATOR SAID RESIDENT # 101 HAD RESIDED AT THE FACILITY FOR LESS THAN 24 HOURS, BUT WAS IDENTIFIED AS A FALL RISK UPON ADMISSION. THE ADMINISTRATOR SAID CNA # 7 WAS TERMINATED FROM THE FACILITY FOR NOT FOLLOWING THE FACILITY'S FALL PREVENTION PROTOCOL. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 975. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROTECT 1 OF 5 RESIDENTS (RESIDENT #101) FROM ACCIDENTS RESULTING IN AN INTERTROCHANTERIC FRACTURE OF THE HIP (HIP FRACTURE). FINDINGS INCLUDE: RESIDENT #101 ' S MEDICAL RECORD CONTAINS A CARE PLAN FOR FALLS DATED 09/29/09 WITH AN ONSET OF 09/30/09 THAT SAID RESIDENT #101 IS AT RISK FOR FALLING DUE TO ALZHEIMERS AND DEMENTIA, HTN (HYPERTENSION, HIGH BLOOD PRESSURE), GENERALIZED (INCORRECTLY SPELLED, GERALIZED, ON CARE PLAN) MUSCLE WEAKNESS, MOOD DISORDER, TAKING ANTIDEPRESSANT MEDICATION, OSTEOARTHRITIS (A GROUP OF MECHANICAL ABNORMALITIES INVOLVING DEGRADATION OF JOINTS), USE OF DIURECTIC MEDICATION (MEDICATION THAT CAN INCREASE URINARY OUTPUT), IMPAIRED MOBILITY, INCONTINENCE, RESISTIVE TO ASSISTANCE, USE OF BLOOD PRESSURE MEDICATIONS AND POOR SAFETY AWARENESS. THIS CARE PLAN SAID, UNDER APPROACH(S) SECTION, RESIDENT #101 IS A ONE PERSON ASSIST WITH TRANSFER AND WILL BE UP IN W/C (WHEELCHAIR) DAILY. RESIDENT 101 ' S MEDICAL RECORD CONTAINED AN MDS (MINIMUM DATA SET) ANNUAL ASSESSMENT LAST DATED 09/30/09 THAT SAID RESIDENT #101 HAD IMPAIRED VISION, NEEDED EXTENSIVE ASSISTANCE TO SELF-PERFORM TRANSFER, NEEDED ONE PERSON PHYSICAL ASSIST TO TRANSFER, AND DID NOT WALK IN ROOM OR CORRIDOR DURING THE PAST 7 DAYS. THIS MDS ALSO SAID, UNDER SECTION I DISEASE [DIAGNOSES REDACTED]. RESIDENT #101 ' S MEDICAL RECORD CONTAINED A STATEMENT OF COMPETENCY DATED 10/22/09 AND SIGNED BY PHYSICIAN THAT SAID RESIDENT #101 WAS INCOMPETENT TO MAKE OWN MEDICAL DECISIONS. RESIDENT 101 ' S MEDICAL RECORD CONTAINED AN MDS (MINIMUM DATA SET) QUARTERLY REVIEW ASSESSMENT LAST DATED 03/09/10 THAT SAID RESIDENT #101 NEEDED EXTENSIVE ASSISTANCE TO SELF-PERFORM TRANSFER, DID NOT WALK IN ROOM OR CORRIDOR DURING THE PAST 7 DAYS, AND WAS TOTALLY DEPENDENT FOR TOILETING USE. RESIDENT #101 ' S MEDICAL RECORD CONTAINED A FOLLOW-UP PSYCHIATRIC EVALUATION AND MANAGEMENT FORM DATED 04/26/10 THAT SAID RESIDENT #101 had a history of [REDACTED]. THIS FORM ALSO LISTED SPECIFIC PSYCHIATRIC [DIAGNOSES REDACTED]. RESIDENT #101 ' S MEDICAL RECORD CONTAINED A FALL RISK ASSESSMENT LAST DATED 04/28/10 THAT SAID RESIDENT #101 WAS A MODERATE RISK FOR FALLING. THIS ASSESSMENT SAID RESIDENT #101 HAS A HISTORY OF FALLS, HAD BEHAVIORAL/COGNITIVE ISSUES, HAD VISION ISSUES, HAD MOBILITY ISSUES, HAD BALANCE ISSUES, HAD HEALTH CONDITIONS, AND WAS PRESCRIBED 3 OR MORE MEDICATIONS. RESIDENT #101 ' S MEDICAL RECORD CONTAINED NURSE ' S NOTES DATED 04/28/10 AND SIGNED BY LICENSED PRACTICAL NURSE (LPN) #6 THAT SAID RESIDENT #101 WAS IN ROOM WITH CNA (CERTIFIED NURSE ASSISTANT,UNIDENTIFIED) RECEIVING TOTAL CARE WHEN THE CNA HAD TO LOWER RESIDENT #101 TO THE FLOOR. THESE NURSE ' S NOTES SAID THE CNA CALLED FOR HELP AND TWO STAFF MEMBERS INCLUDING LPN #6 WENT TO ASSIST AND FOUND RESIDENT #101 LYING FLAT ON BACK WITH RIGHT FOOT TURNED AND COMPLAINING OF PAIN. RESIDENT 101 ' S MEDICAL RECORD CONTAINED A RESIDENT TRANSFER FORM DATED 04/28/10 (NO TIME NOTED) THAT SAID TRANSFER RESIDENT #101 TO AN OUTSIDE HOSPITAL FOR COMPLAINTS OF SEVERE RIGHT HIP PAIN. RESIDENT 101 ' S MEDICAL RECORD CONTAINED A PHYSICIAN ORDER [REDACTED].#101 TO AN OUTSIDE HOSPITAL. RESIDENT #101 ' S MEDICAL RECORDS FROM OUTSIDE HOSPITAL CONTAINED A RADIOLOGY REPORT DATED 04/28/10 AT 5:14 PM THAT SAID, UNDER CONCLUSION, RESIDENT #101 HAS AN INTERTROCHANTERIC FRACTURE OF THE RIGHT HIP. RESIDENT #101 ' S MEDICAL RECORD CONTAINED AN UNUSUAL OCCURANCE FORM LAST DATED 04/30/10 THAT SAID, ON 04/28/10 AT 3:15 PM INSIDE RESIDENT #101 ' S ROOM, RESIDENT #101 WAS LOWERED TO FLOOR AND HAD COMPLAINTS OF RIGHT HIP PAIN. THIS FORM SAID EQUIPMENT WAS INVOLVED. THIS FORM SAID RESIDENT #101 WAS SENT TO OUTSIDE HOSPITAL FOR FURTHER MEDICAL EVALUATION. THIS FORM SAID PATIENT WAS RESISTING TREATMENT AND fell . THIS FORM SAID RESIDENT #101 WAS AMBULATING WITH ASSISTANCE. RESIDENT #101 ' S MEDICAL RECORDS FROM OUTSIDE HOSPITAL CONTAINED A DISCHARGE SUMMARY WITH A discharge date of [DATE] THAT SAID RESIDENT #101 HAD A RIGHT HIP FRACTURE status [REDACTED]. DURING AN INTERVIEW WITH CERTIFIED NURSE AIDE (CNA) #4 ON 10/15/10 AT 12:15 PM, CNA #4 SAID SHE WAS ASSIGNED TO CARE FOR RESIDENT #101 ON 04/28/10 WHEN RESIDENT #101 fell TO FLOOR. CNA #4 SAID THIS FALL OCURRED ON 04/28/10 AROUND 3:00 PM IN RESIDENT #101 ' S ROOM. CNA #4 SAID SHE WAS ALONE IN THE ROOM WITH RESIDENT #101 WHEN RESIDENT #101 fell TO FLOOR. CNA #4 SAID IT WAS GETTING CLOSE TO THE END OF HER WORK SHIFT AND SHE WANTED TO COMPLETE HER DUTIES IN A TIMELY MANNER SO SHE TRANSFERRED RESIDENT #101 FROM A SITTING POSITION IN BED TO A STANDING POSITION IN WALKER NEXT TO BED TO PERFORM PERINEAL CARE (CLEANSING OF SOILED AREAS AROUND THE VAGINA AND ANUS). CNA #4 SAID WHILE RESIDENT #101 WAS STANDING IN WALKER FACING WALL, CNA #4 POSITIONED CLEANING SUPPLIES WITHIN REACH TO FACILITATE PERINEAL CARE. CNA #4 SAID BOTH SHE AND RESIDENT #101 WERE STANDING. CNA #4 SAID WHEN SHE STARTED TO CLEAN RESIDENT #101 ' S PERINEAL AREA (AREAS AROUND THE VAGINA AND ANUS), RESIDENT #101, STILL STANDING IN WALKER, BECAME VERBALLY AND PHYSICALLY AGGRESSIVE. CNA #4 SAID RESIDENT #101 CALLED HER " ALL KINDS OF B ' S ([***] ES) " AND RESIDENT #101 SWUNG HER ARM AT CNA #4 IN A PHYSICALLY AGGRESSIVE MANNER. CNA #4 SAID WHEN RESIDENT #101 SWUNG ARM IN A PHYSICALLY AGGRESSIVE MANNER, RESIDENT #101 LOST BALANCE AND fell TO FLOOR. CNA #4 SAID WHEN RESIDENT #101 fell , CNA #4 IMMEDIATELY CALLED FOR HELP AND LICENSED PRACTICAL NURSE (LPN) #6 AND CNA #5 ENTERED ROOM TO ASSIST. CNA #4 SAID RESIDENT #101 ' S TRANSFER ORDERS WERE FOR ONE PERSON PHYSICAL ASSISTANCE. CNA #4 SAID SHE WAS PHYSICALLY ASSISTING RESIDENT #101 TO STAND IN WALKER AND PERFORMING PERINEAL CARE SIMULTANEOUSLY. CNA #4 SAID RESIDENT #101 WAS WELL KNOWN TO HAVE BEHAVIORAL PROBLEMS, INCLUDING BEING VERBALLY AND PHYSICALLY AGGRESSIVE TOWARD OTHERS. DURING AN INTERVIEW WITH CERTIFIED NURSE AIDE (CNA) #5 ON 10/15/10 AT 12:30 PM, CNA #5 SAID ON 04/28/10 AT AROUND 3:00 PM SHE HEARD CNA #4 CALLING FOR HELP FROM RESIDENT #101 ' S ROOM. CNA #5 SAID SHE ENTERED ROOM TO ASSIST CNA #4 AND SAW RESIDENT #101 LYING ON FLOOR IN A CONTORTED POSITION. CNA #5 SAID RESIDENT #101 WAS WELL KNOWN TO HAVE BEHAVIORAL PROBLEMS, INCLUDING BEING VERBALLY AND PHYSICALLY AGGRESSIVE TOWARD OTHERS. CNA #5 SAID RESIDENT #101 DID NOT LIKE TO BE TOUCHED BY PEOPLE, WILL " HIT PEOPLE " , AND " CURSE YOU OUT " . CNA #5 SAID RESIDENT #101 ONCE " SNATCHED " A CLEANSING CLOTH FROM HER HANDS DURING PREVIOUS PERINEAL CARE. ATTEMPTS TO INTERVIEW LICENSED PRACTICAL NURSE (LPN) #6 ON 10/15/10 AT 1:20 PM WERE UNSUCCESSFUL. DURING AN INTERVIEW WITH REHABILITATION COORDINATOR (RHB) #7 ON 10/18/10 AT 11:45 AM, RHB #7 SAID THE DEFINITION OF ONE PERSON PHYSICAL ASSISTANCE IS THAT ONE PERSON HAS TO BE PHYSICALLY ASSISTING THE RESIDENT AT ALL TIMES AND THAT 60% TO 70% OF THE EFFORT NEEDED TO COME FROM THE PATIENT. RHB #7 SAID SHE DID NOT KNOW IF RESIDENT #101 WAS SUPPOSED TO USING A WALKER WHEN SHE fell [DATE]. DURING AN INTERVIEW WITH RESIDENT #101 ON 10/19/10 AT 10:00 AM, RESIDENT #101 SAID SHE REMEMBERED FALLING AT THE FACILITY BUT CANNOT REMEMBER SPECIFIC DETAILS REGARDING THE INCIDENT.