Every finding on record at Optalis Health and Rehabilitation of Allen Park

This citation pertains to intake 2788112.Based on interview and record review the facility failed to notify the physician of an abnormal urinalysis result for one (R501) of five residents reviewed for quality of care.Findings include:According to R501's closed Electronic Health Record (EHR), R501 admitted to the facility on [DATE] with diagnoses that included history of stroke with weakness/paralysis to one side of the body, difficulty swallowing, and speaking. On 9/11/25 an Interact (change of condition) form indicated R501 had a change in their respiratory condition. Physician B ordered R501 to have blood work drawn and urinalysis (UA). On 9/17/2025, R501's UA report indicated R501 had elevated white blood cells and greater than 100,000 CFU/ml (colony forming units per milliliter) of a gram-negative bacteria in the urine specimen. There is no further documentation to indicate the physician or nurse practitioner were notified of the abnormal UA result. There are no orders to indicate R501 was treated for a UTI. On 10/1/25, R501 was transferred to the hospital for mental status changes. On 10/8/25 R501 returned to the facility with diagnoses of pneumonia and UTI.On 4/15/26 at 12:15 PM the Director of Nursing (DON) reviewed R501's EHR and confirmed the UA results on 9/17/25 indicated R501 was positive for a urinary tract infection (UTI) and there was no documentation to indicate the Physician had been notified. The DON said, We should have notified the doctor or the NP (nurse practitioner) of the positive results in the UA. No antibiotics were prescribed to treat the UTI. The resident did go out to the hospital shortly after this for another medical reason.On 4/15/26 at 12:30 PM Physician B reviewed R501's EHR and confirmed they were not notified of R501's abnormal UA results from 9/17/25. Physician B reviewed R501's hospital records and said, The resident was sent out to the hospital for changes in mental status condition and treated for a respiratory condition and UTI while there. There were no other signs they (R501) had a UTI except the UA result, but I should have been notified.On 4/15/2026 at approximately 2:00 PM during an interview with the Nursing Home Administrator (NHA) and the DON they said the facility did not have a policy regarding notifying a physician or physician extender of an abnormal UA result but that is was considered a standard of practice to do so.

This citation pertains to intake 1215649.Based on interview and record review the facility failed to prevent staff to resident abuse for one (R107) of four residents reviewed for abuse. Findings include:On 7/22/25 at 10:45 AM R107 was interviewed regarding an incident upon admission to the facility with Licensed Practical Nurse (LPN) C and said that LPN C did not want to admit her to the facility which caused a delay with her admission. R107 stated, The next day (5/27/25) LPN C came to my room and asked me if I reported her. I said that I didn't, but it was awkward, and I didn't appreciate that she accused me. Her tone was aggressive, and I was uneasy and fearful of her.Record review of the Electronic Health Record (EHR) revealed R107 was admitted to the facility on [DATE] with diagnosis of Right Tibia fracture, Lumbar Vertebra fracture, Injury in Motor Vehicle Accident. Review of the Minimum Data Set (MDS) dated [DATE] for R107 revealed a Brief Interview for Mental Status (BIMS) score of 14/15, which indicated intact cognition.Review of the facility's investigation report dated 5/28/25 conducted by the Nursing Home Administrator (NHA) and Director of Nursing (DON) revealed, Do you feel like the nurse (LPN C) was confrontational? -Yesterday she came in my room and accused me and my family of making a report on her. It was kind of intimidating and scary.On 7/22/25 at 12:55 PM, Registered Nurse (RN) A was interviewed and said LPN C confronted R107 after LPN C was suspended. RN A stated, The nurse should not have done that and that residents have the right to report concerns without the fear of retaliation.On 7/23/25 at 10:45 AM, the NHA and DON were interviewed and the DON said that on the morning of 5/27/25 she had a meeting with LPN C to notify her that LPN C was suspended pending an investigation regarding the incident with R107 and walked LPN C out of the building. The DON further said that after suspension LPN C reentered the building and talked to R107. The DON said the expectation was for employees to leave the building upon suspension and not to return until notified by a supervisor. The DON said LPN C was terminated. The NHA said that LPN C had abuse training upon hire and that she should not have gone back to talk to the resident after suspension. On 7/23/25 at 11:05 AM, LPN C was interviewed via phone and said that she spoke to R107 after the DON suspended her. When asked if LPN C accused R107 of reporting her LPN C did not provide and answer.Review of the facility policy titled Abuse, updated 5/24/25, revealed in part:Residents have the right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of resident property. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint that is not required to treat the patient/resident's medical symptoms.The facility will educate its staff upon hire, annually, and as needed which will include, but not necessarily be limited to, the following topics:Prohibiting and preventing all forms of abuse, neglect, mistreatment, exploitation, and misappropriation ofIdentifying what constitutes abuse, neglect, mistreatment, exploitation, and misappropriation of resident property.Reporting process for suspicions or allegations of abuse, injuries of unknown origin, neglect, exploitation, mistreatment, and misappropriation of resident property without fear of reprisal or retaliation.Providing residents, representatives, and staff information on how and to whom they report any allegations of abuse, neglect, mistreatment, exploitation, misappropriation of resident property, injuries of unknown origin, concerns, incidents, and grievances without the fear of retribution; and providing feedback regarding the concerns that have been expressed.The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to:Immediately removing the resident from contact with the alleged abuser.Providing a safe and secure environment for all patients.If a staff member is the alleged perpetrator, that staff member should be immediately removed from the facility and the schedule pending the outcome of the investigation.

This citation pertains to intake 2563789.Based on interview and record review the facility failed to complete a thorough investigation for fracture of unknown origin for one (R102) of four residents reviewed for abuse. Findings include: The State Agency (SA) received a complaint that R102 had a hip fracture of unknown origin.The complainant was attempted to be contacted on 7/23/25 at 10:32 AM and on 7/24/25 at 11:05 AM. According to R102's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] with diagnoses that included dementia and history of falls with left foot pain. On 11/26/24 the resident had a fall while in therapy. According to the Fall Report dated 11/26/24, R102 lost his balance during a self-transfer out of the wheelchair while in the therapy department. Therapy staff interfered with the fall and the resident was lowered to the floor by therapy staff. There was no injury or complaints of pain. Review of progress notes and pain assessments from 11/26/24 - 12/28/24 revealed that was no changes in resident's pain levels. On 12/28/24 at 6:18 PM a progress note written by Registered Nurse (RN) D documented the family wanted an x-ray of the resident's right leg due to a recent fall and complaints of pain. X-rays were ordered for resident's right tibia and fibula (lower leg bones, shin/calve area). The X-rays were negative for any acute (recent) fracture or soft tissue injury. There was no documentation to indicate R102 had a fall after 11/26/24. On 12/30/24 at 4:30 PM a Therapy note written by Occupational Therapist (OT) E documented the resident's family reported the resident had a fall over the weekend and X-rays of the right leg were taken. On 1/1/25 R102 was sent out to the hospital for mental status changes. On 7/23/25 at 1:35 PM RN D said they had no recall of R102 falling. They reviewed R102's EHR and confirmed there was no documentation to indicate the resident had a fall after 11/26/24. RN D said they honored the family's request for the x-ray and did not ask when the resident fell. RN D reported they had never been interviewed regarding why the X-ray was ordered or that the family had said the resident fell.On 7/23/25 at approximately 1:50 PM the Director of Nursing (DON) provided a 'soft file' for R102 that included the hospital's x-ray results dated 1/1/25. The X-ray results indicated R102 had a right mildly displaced femoral neck/intertrochanteric (upper part of femur). The DON said an investigation was initiated by the former DON on 1/1/25. A review of the investigation did not contain any interviews from staff, physician, residents, or R102's family. The investigation concluded that the fracture was the result of the fall on 11/26/24.On 7/23/25 at approximately 2:00 PM OT E was asked to review their note from 12/30/24 for R102. OT E said they were aware that R102 had been diagnosed with a hip fracture but did not know how it occurred. OT E confirmed they had never been interviewed by facility staff regarding R102.On 7/23/25 at approximately 2:50 PM the Nursing Home Administrator (NHA) was queried about R102's right hip fracture on 1/1/25. The NHA said they were on a medical leave during this time and was unaware that R102 had a hip fracture of unknown origin until today. The NHA reviewed the facility's investigation and confirmed that it was incomplete.According to the facility's Abuse policy last updated on 5/24/2023, it reads in part: The facility will develop and implement written policies and procedures that include: Investigating allegations of abuse, neglect, misappropriation, mistreatment, and exploitation to include protecting residents during the investigation, and taking necessary actions as a result of the investigation. The investigation process includes: Identifying staff responsible for the investigation. Determining the purpose of the investigation and issue(s) to be investigated, whether or not the alleged violation has occurred, the extent, and cause. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations (such as other residents, family members, staff who worked closely with the alleged perpetrator and/or alleged victim). Conducting observations of the alleged victim, including identification of any injuries as appropriate, the location where the alleged situation occurred, interactions and relationships between staff and the alleged victim and/or other residents, and interactions/relationships between resident to other residents as applicable. Identifying and reviewing all relevant medical records and facility documentation as applicable. If the alleged perpetrator is a staff member, review their employment records. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence). Providing complete and thorough documentation of the investigation. After completion of the investigation, the evidence should be analyzed, and the Administrator or designee will make a determination regarding whether the allegation is substantiated or unsubstantiated. The Administrator will determine if modifications to existing policies and procedures (or new policies and procedures) are needed to prevent similar incidents or injuries from occurring in the future in accordance with its QAPI Plan. The quality assurance investigative materials will be reviewed by the quality assurance committee in accordance with the facility QAPI Plan. The quality assurance committee will take all actions deemed necessary based upon their review.

This citation pertains to intake 2563789.Based on interview and record review the facility failed to report a fracture of unknown origin to the State Agency (SA) for one (R101) of four residents reviewed for abuse. Findings include:The State Agency (SA) received a complaint that R102 had a hip fracture of unknown origin.According to R102's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] with diagnoses that included dementia and history of falls with left foot pain. On 11/26/24 the resident had a fall while in therapy. According to the Fall Report dated 11/26/24, R102 lost his balance during a self-transfer out of the wheelchair while in the therapy department. Therapy staff interfered with the fall and the resident was lowered to the floor by therapy staff. There was no injury or complaints of pain. Review of progress notes and pain assessments from 11/26/24 - 12/28/24 revealed that was no changes in resident's pain levels. On 12/28/24 at 6:18 PM a progress note written by Registered Nurse (RN) D documented the family wanted an x-ray of the resident's right leg due to a recent fall and complaints of pain. X-rays were ordered for resident's right tibia and fibula (lower leg bones, shin/calve area). The X-rays were negative for any acute (recent) fracture or soft tissue injury. There was no documentation to indicate R102 had a fall after 11/26/24. On 12/30/24 at 4:30 PM a Therapy note written by Occupational Therapist (OT) E documented the resident's family reported the resident had a fall over the weekend and X-rays of the right leg were taken. On 1/1/25 R102 was sent out to the hospital for mental status changes. On 7/23/25 at 1:35 PM RN D said they had no recall of R102 falling. They reviewed R102's EHR and confirmed there was no documentation to indicate the resident had a fall after 11/26/24. RN D said they honored the family's request for the x-ray and did not ask when the resident fell. On 7/23/25 at approximately 1:50 PM the Director of Nursing (DON) provided a 'soft file' for R102 that included the hospital's x-ray results dated 1/1/25. The X-ray results indicated R102 had a right mildly displaced femoral neck/intertrochanteric (upper part of femur). The DON said an investigation was initiated by the former DON and was not reported to the SA. The DON said the fracture was of unknown origin and should have been reported to the SA within two hours of notification.On 7/23/25 at approximately 2:50 PM the Nursing Home Administrator (NHA) was queried about R102's right hip fracture on 1/1/25. The NHA said they were on a medical leave during this time and was unaware that R102 had a hip fracture of unknown origin until today. The NHA confirmed that this incident should have been reported to the SA.According to the facility's Abuse policy last updated on 5/24/2023 it reads in part. The facility will ensure that all allegations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, and crimes are reported immediately to the Administrator and: Reported to the State Survey Agency immediately but not later than two hours after the allegation is made if the allegation involves abuse or results in serious bodily injury and to other officials (including adult protective services and/or law enforcement, when applicable) OR Reported to the State Survey Agency no later than 24 hours if the allegation does not involve abuse and does not result in serious bodily injury to the State Survey Agency and to other officials (including adult protective services and/or law enforcement, when applicable).

This Citation Has Two Deficient Practice Statements. Deficient Practice Statement #1 Based on interview and record review the facility failed to maintain an infection control program that included a system for preventing, identifying, reporting, investigating and controlling infections. This deficient practice had the potential to affect all 124 residents residing in the facility. Findings include: On 6/3/25 at 2:20 PM, an interview was conducted with the facility's Infection Control Preventionist (ICP), Nurse 'A'. Nurse 'A' said they assumed the role as the ICP effective May 18, 2025. They further reported the previous ICP Nurse did not compile April 2025's data and May 2025's data was not finished. On 6/3/25 at 3:13 PM, a review of the facility's monthly infection control program data was reviewed and revealed no data, including: a monthly summary, a calculated infection rate, a list of facility infections, facility mapping for trends/outbreaks, line listings for appropriate antibiotic usage, pharmacy reports, laboratory reports, departmental surveillance, or any staff education provided regarding infection control for October, November, or December 2024. A review of the documents for January, February, and March 2025 included line listings, however; the line listings did not demonstrate prescribed antibiotics meeting McGeer's Criteria (a set of definitions to identify and track healthcare-associated infections). The monthly data was also noted to be missing mapping for trends/outbreaks, pharmacy reports, lab reports, departmental surveillance, and education. On 6/3/25 at 4:05 PM, an interview with the facility's Director of Nursing (DON) was conducted regarding the facility's monthly infection control program data. They admitted their knowledge the program was not comprehensively kept by the previous ICP Nurse and said they would be working with Nurse 'A' to improve the program. A review of a facility provided policy titled, Infection Control Surveillance dated 4/1/20 was conducted and read, The infection preventionist will conduct ongoing surveillance for Healthcare Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions .Information about infections is gathered, monitored, and tracked throughout the month by the infection preventionist or designee. The QAPI Committee may be involved in the interpretation of the data. The infection preventionist or designee will utilize surveillance tools to recognize the occurrence of infections, record their number and frequency, detect outbreaks and epidemics, monitor employee infection, monitor adherence to infection prevention and control practices, and detect unusual pathogens with infection control implications. The Infection Preventionist or designee will enter the resident infections into the line listing report throughout the month. The surveillance should include a review of the following information to help identify possible indicators of infection: Laboratory reports .Infection documentation records, pharmacy records, Antibiotic review .For residents with infections that meet the criteria for definition of infection for surveillance, the following information will be collected: Resident identifying information. Infection diagnosis and/or pathogen. admission date. Date of onset of infection (signs & symptoms, if known or positive test). Infection Site. Treatment measures and precautions .Calculating Infection rates .Outbreak Management .The Infection Preventionist or designee will analyze the monthly data to identify trends and present to the QAPI committee for review and potential recommendations to minimize the risk and control the spread of infection and multidrug resistant organisms, and improve outcomes through education, skills validation, or other initiatives as warranted. Deficient Practice Statement #2 Based on observation, interview, and record review the facility failed to ensure proper identification for enhanced barrier precautions (an infection control strategy that uses targeted use of gowns and gloves to reduce the transmission of multidrug-resistant organisms) for seven residents, (R#'s 126, 233, 235, 4, 234, 85, and 30) of seven residents reviewed for enhanced barrier precautions, resulting in the potential for the spread of infection. Findings include: On 6/2/25 at 10:27 AM, R30 was observed in their room; at that time it was noted they had a PICC (peripherally inserted central catheter) line to their right upper arm. They were asked about the line and said they were receiving intravenous antibiotics for a post-operative infection. An observation of the outside of the room did not reveal any signs to indicate they were on EBP. On 6/2/25 at 10:32 AM, R63 was observed lying in bed with a urinary catheter drainage bag hanging on the side of the bed. An observation of the outside of the room did not reveal any signs to indicate they were on EBP. On 6/2/25 at 10:36 AM, R233 was observed in their room. At that time, it was observed they had a PICC line to their right upper extremity. When asked, R233 said they line had been placed prior to discharge from the hospital so they could receive intravenous antibiotics through the course of their stay at the the facility. An observation of the outside of their room did not reveal any signs to indicate they were on EBP. On 6/2/25 at 11:07 AM, R126 was observed seated in their wheelchair at the nurses station. It was observed R126 had a urinary catheter drainage bag hanging under the seat of the wheelchair. An observation of R126's room did not reveal any signage to indicate they were on enhanced barrier precautions (EBP). On 6/2/25 at 11:14 AM, R234 was observed in their bed asleep. It was noted a urinary catheter drainage bag was attached to the side of the bed. The outside of R234's room did not reveal any signage to indicate they were on EBP. On 6/2/25 at 2:12 PM, a review of R30's clinical record revealed they admitted to the facility on [DATE] with a PICC line, however; order for EBP were not placed until 6/2/15. On 6/2/25 at 2:15 PM, a review of R63's clinical record revealed they re-admitted to the facility on [DATE] with a urinary catheter and had a physician's order for EBP dated 5/20/25. On 6/2/25 at 2:17 PM, a review of R233's clinical record revealed they admitted to the facility on [DATE] with a PICC line and had an order dated 5/22/25 for EBP. On 6/2/25 at 2:17 PM a review of R126's clinical record revealed they admitted to the facility on [DATE] with an indwelling urinary catheter. R126's orders did not include an order EBP. On 6/2/25 at 2:19 PM a review of R234's clinical record revealed they admitted to the facility on [DATE] with an indwelling urinary catheter, however; orders for EBP were not placed until 6/2/25. On 6/2/25 at 3:42 PM, R126's room was observed with no signage to indicate they were on EBP, despite R126 having an indwelling urinary catheter. On 6/2/25 at 3:49 PM, an observation of R234 and R85's room was observed to have a sign to indicate EBP, however; the sign did not specify whether R235, R85, or both residents were on EBP. An observation of R63 and R235's room revealed a sign to indicate EBP, however; the sign did not indicate if EBP was in place for R63, R235, or both residents. An observation of R233 and R4's room revealed a sign to indicate EBP were in place and the sign further indicated the EBP was only for bed A, R4's bed despite R233 having a PICC line. A review of R4's clinical record did not reveal any orders for EBP. On 6/3/25 at 8:15 AM and 2:30 PM, an observation of R234 and R85's room was again observed to have a sign to indicate EBP, however; the sign did not specify whether R235, R85, or both residents were on EBP. An observation of R63 and R235's room continued to reveal a sign to indicate EBP, however; the sign did not indicate if EBP was in place for R63, R235, or both residents. An observation of R233 and R4's room still revealed a sign to indicate EBP were in place for bed A (R4), despite R233 having a PICC line. R234's room was still without signage to indicate they were on EBP. On 6/3/25 at 2:40 PM, an interview was conducted with the facility's Infection Control Preventionist, Nurse 'A' regarding enhanced barrier precautions. They indicated residents with PICC lines, wounds, catheters, and tube feeding should be placed on EBP upon admission, signs should be placed outside the room, and the sign should indicate which resident (bed A, bed B, or both) was on EBP. A review of a facility provided policy titled, Enhanced Barrier Precautions issued 3/2024 was conducted and read, .Enhanced barrier precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms .Procedure: Residents admitted to the facility with or during their stay at the facility acquire a wound and/or an indwelling medical device will be placed in enhanced barrier precautions. A physician order is obtained .Enhanced Barrier Precautions signage will be posted on the door or wall outside of the resident's room .

Based on interview and record review, the facility failed to ensure seasonal influenza (flu) vaccines were offered and administered in a timely manner for five residents, (R28, R24, R26, R19, and R12) of five residents reviewed for influenza vaccines, resulting in the increased potential for contracting influenza. Findings include: A review of a facility provided policy titled, Vaccination-Influenza dated 10/2023 was reviewed and read, .Influenza vaccinations will be offered annually between September 1st (or when influenza vaccines become available) and March 31st . On 6/3/25 at 12:46 PM, R28's clinical record was reviewed and revealed their most recent re-admission to the facility occurred on 1/7/22. A review of R28's vaccination documentation in the clinical record revealed they were administered the 2024-2025 influenza vaccine on 3/25/25. 6/3/25 at 12:53 PM, R24's clinical record was reviewed and revealed they admitted to the facility on [DATE]. A review of R24's vaccination documentation in the clinical record revealed they were administered the 2024-2025 influenza vaccine on 3/25/25. On 6/3/25 at 1:00 PM, R26's clinical record was reviewed and revealed they admitted to the facility on [DATE] and most recently re-admitted on [DATE]. A review of R26's vaccination documentation in the clinical record revealed they were administered the 2024-2025 influenza vaccine on 3/25/25. On 6/3/25 at 1:07 PM, R19's clinical record revealed their most recent re-admission to the facility occurred on 7/26/23. A review of R19's vaccination documentation in the clinical record revealed they were administered the 2024-2025 influenza vaccine on 3/25/25. On 6/3/25 at 1:10 PM, R12's clinical record revealed they most recently re-admitted to the facility on [DATE]. A review of R12's vaccination documentation in the clinical record revealed they were administered the 2024-2025 influenza vaccine on 3/25/25. On 6/3/25 at 4:05 PM, an interview was conducted with the facility's Director of Nursing (DON) regarding the timing of the administration of the 2024-2025 influenza vaccine. The DON reported they were aware the former Infection Control Preventionist (ICP) did not offer the vaccine at the beginning of the 2024-2025 influenza season. They said the administrations were done in March when they (the DON) found out and told the former ICP to offer and administer the immunizations.

Based on observation, interview and record review the facility failed to ensure dental services were provided in a timely manner for one resident (R19) out of three residents reviewed for dental services. Findings include: On 6/2/25 at 10:44 AM, R19 was observed with crooked and uneven teeth. An interview was conducted with R19, the resident reported having broken teeth. R19 reported past dentist appointments, but had not heard anything else since last appointment. R19 stated, I have been waiting a long time to get dentures. Review of electronic medical record (EMR) revealed resident was admitted into the facility on 3/6/23 with a diagnosis of Parkinson's Disease (disorder that affects central nervous system). According the R19's Brief interview for Mental Status (BIMS) dated 3/12/25, R19 scored 14 out of 15 (intact cognition). Further review revealed resident required substantial/Maximal assistance with Activities of Daily Living (ADLs). Record review of Dentist Consultation dated 6/17/24 revealed R19 had a referral to have all teeth extracted. Further review of electronic medical record revealed resident had an appointment for oral surgery on 12/26/24 and 2/18/25 the procedure was not performed. Review of Dental Group dated 3/13/25, a new referral was written for resident to have all teeth extracted. R19 had appointment for oral surgery on 3/25/25, and procedure was not performed. Further review revealed a new appointment had not been scheduled. An interview conducted on 6/3/25 at 1:15 PM with Unit Clerk (UC) L, it was reported that each time resident went to appointment family had not shown for procedure and it was canceled. It was further reported that no future appointments had been scheduled after 3/25/25. An interview conducted on 6/3/25 at 2:16 PM with the Director of Nursing (DON), it was reported that staff should have followed up and scheduled another appointment for R19 to have teeth extracted. It was further reported that staff could have accompanied the resident to the appointment for assistance. Lastly, it was reported that the resident had not received dental care in a timely manner. Review of facility's policy Dental Services dated 3/10/25 it was documented, It is the policy of the facility to assist residents in obtaining routine and emergency dental care.

Based observation, interview and record review the facility failed to ensure prescription medication was properly stored for one resident (R21) of 27 residents reviewed for medication administration, resulting in unsecured medication and the potential for access to unauthorized persons to the medication. Findings include: On 6/3/2025 at 8:40 a.m. during a morning medication administration (Med Pass) on the Mackinaw unit with Licensed Practical Nurse (LPN) M a cup with two pills was observed on R21's bedside table. LPN M was interviewed regarding the medication at bedside. LPN M stated, I have no idea who put the pills on the resident's table near her breakfast tray. I just pulled my medications. LPN M verified the two pills as (Faxiga and Levothyroxine) and the R21 does not self-administer medication. LPN M stated, This was 6 a.m. scheduled meds and medication should not be left at bedside. On 6/3/2025 at 8:50 a.m. R21 was interviewed regarding the medications left at bedside. R21 stated, I don't know who sat the pills on my table (while reaching for the medication to take them). They do that all the time. They claim they can't wake me up. Record review revealed that R21 was initially admitted into the facility on 3/9/2023 and most recently readmitted on [DATE] with diagnoses which included, chronic obstructive pulmonary disease (COPD), dementia, psychotic disorder, schizoaffective disorder, major depressive disorder, type two diabetes mellitus, and generalized anxiety. R21's Quarterly Minimum Data Set Assessment (MDS) with a reference date of 5/8/2025 indicated R21 had moderately cognition impairment with a BIMS (brief interview for mental status) score of 10/15. A care plan initiated on 5/5/2025 for Activity of Daily Living (ADLs) had the following: Bed mobility modified independent. Transfer modified independent. The Electronic health record did not reveal a self-administration assessment form completed for R21. Review of the physician's orders revealed Faxiga oral tablet 2 milligrams give one tablet by mouth one time a day for diabetes give on empty stomach. Levothyroxine sodium 59 microgram tablet take one tablet by mouth every morning for hypothyroidism. On 6/4/2025 at 2:35 p.m. the Director of Nursing (DON) was interviewed regarding the medication left at bedside. The DON said it was not safe to leave medication at bedside because a resident could wheel into the room and take the medication. The DON stated, No nurse should leave them there. It's a hazard to leave medication at bedside. The medication should be storage in locked med cart. According to the facility's 5/4/2022 Medication & Treatment Cart Storage policy: It is the policy of this facility to ensure all supplies for treatments and medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendation and sufficient to ensure proper sanitation . Security. Compliance Guidelines as following: a. All drugs and biologicals will be stored in locked compartment (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms). c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

Based on observation, interview, and record review, the facility failed to ensure appropriate coordination of care between the facility and the contracted dialysis center for one resident (R15) out of one resident reviewed for dialysis services, resulting in the potential for resident to experience fluid overload. Findings include: On 6/2/25 at 1:03 PM, R15 was observed asleep in bed. A 20 oz. sized cup was observed on R15's overbed table. On 6/3/25 at 10:55 AM, R15 was observed awake in bed. A 20 oz. sized cup was observed on R15's overbed table. R15 was able to reach and shake the cup which appeared to be half full. R15 said that she enjoys drinking water. On 6/4/25 at 10:31 AM, an observation of R15 was conducted with Registered Dietitian (RD) F. R15 was observed awake in bed. RD F indicated R15 had a 20 oz. cup on the overbed table. R15 was able to reach and shake the cup which appeared to be full of ice. A review of the clinical record for R15 documented an admission date of 1/27/25 with diagnoses that included end stage renal disease (ESRD), hypertension, and atrial fibrillation. A Minimum Data Set assessment dated [DATE] documented intact cognition. Physician order dated 3/26/25 documented, No bedside water and one beverage per meal tray. Per HD (hemodialysis) clinic. Documents for R15 titled, Hemodialysis Communication Form, used to facilitate communication between the facility and the hemodialysis center, were reviewed. Section 2, completed by the dialysis center revealed the following: - 5/5/25: Nutrition concerns: Too much fluid - gaining more than we can take (off). - 5/16/25: Nutrition concerns: Pt. (patient) gaining more (sic) too much fluid than we can take off. Less fluid please. Cut portions. Watch liquidly foods/snacks. - 5/19/25: Nutrition concerns: Too much fluid intake - Swollen arm - High BP (blood pressure) - SOB (shortness of breath) - hospitalization. Post dialysis instructions: Hard candies, ice cubes, bubble gum (if able) will help with thirst. Review of R15's care plans documented in part the following: 1. Focus: The resident needs dialysis hemo r/t (related to) (sic). Initiated 1/28/25. Interventions: Coordinate dialysis care with dialysis center. Initiated 1/28/25. 2. Focus: Bowel Elimination Alteration; Constipation related to (sic). Initiated 1/28/25: Interventions: Encourage and assist as needed to consume fluids offered at and between meals. Initiated: 1/28/25 3. Risk for alteration in hydration related to (sic). Initiated 1/28/25. 4. Resident is at nutritional risk r/t ESRD with Hemodialysis Resident has increased nutrient needs and increased nutrient loss. Initiated 2/3/25. Interventions included: Encourage resident to maintain dietary restrictions and provide diet education as requested. Initiated 2/3/25. During an interview and review of R15's clinical record on 6/4/25 at 11:18 AM, Licensed Practical Nurse (LPN)/Unit Manager A said R15 should not have water or (20 oz. cup of) ice at her bedside. She should not be getting that much fluid. LPN A added, R15 should receive fluid as ordered because she was on dialysis and fluid overload was a problem because she cannot void on her own. A fluid restriction was not indicated and addressed on R15's Kardex (a guide Certified Nurse Aides used for patient care) or R15's care plan. LPN A said R15's fluid restriction should have been on the Kardex and care plan because they determine how we care for the resident. It's the order given by the dialysis center to ensure (R15) gets proper care. During an interview on 6/4/25 at 1:19 PM, the Director of Nursing (DON) said R15's has had urinary tract infection(s) and the physician wants to push fluids but R15 was on a fluid restriction because of dialysis. The DON stated, We should consult with the facility RD and hemodialysis. The DON acknowledged that this was not done. On 6/4/25 at 3:30 PM during the exit conference, the Nursing Home Administrator and Director of Nursing did not offer additional documentation or information pertaining to this citation when asked.

Based on observation, interview, and record review the facility failed to perform tube feed (a tube providing nutrients and medications directly to the stomach) insertion site care and dressing changes per physician order for one (R69) of two resident's reviewed for tube feeding, resulting in the potential for infection. Findings include: On 6/03/25 at 2:45 PM, R69 was observed in bed and stated, The staff are not changing my tube feed dressing. The tube feed dressing was observed with a date of 5/24/25. On 6/03/25 at 2:55 PM, R69's tube feed dressing was observed with Licensed Practical Nurse/Unit Manager LPN C. LPN C said the dressing was dated 5/24/25 and explained that was the date that the dressing was last changed. LPN C said the dressing should be changed daily on the night shift and there is a risk for infection if the site is not kept clean. Review of R69's Electronic Medical Record (EMR) revealed, R69 admitted to the facility on [DATE] with pertinent diagnoses which included dysphagia and gastrostomy status (presence of artificial opening to the stomach). Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R69 had intact cognition and required a feeding tube. Review of Physician orders 5/2/25 revealed, Enteral Tube Site Care: Cleanse site with soap and water, rinse with water and allow to air dry, apply split gauze date and initial every night shift for site care notify physician for any signs or symptoms of infection. On 6/4/25 at 11:30 AM the Director of Nursing (DON) was interviewed and said the expectation is for the nurses to follow physician orders and that R69's dressing should have been changed daily. Review of the facility policy titled Tube Feeding -Overview dated 8/9/2025 revealed in part: Feeding tubes (nasogastric, gastrostomy, jejunostomy) will be utilized in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Feeding tubes will be utilized according to physician orders.

This Citation Has Two Deficient Practice Statement. Deficient Practice Statement #1 Based on observation, interview, and record review the facility failed to remove medications from the back-up medication supply for administration to one resident (R30) of one resident reviewed for missed medications, resulting in R30 missing 18 of 21 scheduled doses of their their neuropathy medication. Findings include: On 6/2/25 at 12:00 PM, a review of R30's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included hereditary and idiopathic neuropathy (nerve pain). R30's physician's orders were reviewed and revealed an order for pregabalin (neuropathic pain medication) 75 mg (milligrams) twice daily scheduled for 9 AM and 9 PM. A review of R30's medication administration record (MAR) for May 2025 was reviewed and revealed the pregabalin medication documented as 7 (meaning the medication was held with an accompanying progress note documenting the reason) for the 9 AM doses on 5/22/25, and from 5/24/25 thru 5/30/25. The MAR further revealed the medication documented as a 7 for the 9 PM doses from 5/21/25 thru 5/29/25. The accompanying progress notes for why the medication was held were documented as:, Awaiting pharmacy delivery, dosage not available in backup, On order, Not in cart, and awaiting new script. On 6/3/25 at 11:00 AM, R30 was up in their wheelchair in the hallway. They were asked if they missed any medications and said when they first admitted to the facility they either ran out of or didn't have their Lyrica (pregabalin) medication. On 6/3/25 at 11:20 AM, the facility's Director of Nursing (DON) provided a list of medications kept on-site in the back-up medication supply. It was noted the facility had 25 and 50 mg tabs of pregabalin in the back-up supply. On 6/3/25 at 12:34 PM, an interview was conducted with the facility's DON regarding R30's missed pregabalin. They said the nurses should have checked the supply and pulled the medication if available. They also said given the duration of time (10 and a half days) and the amount of doses missed (18 of 21) someone should have followed up with the physician and the pharmacy to obtain the medication. A review of a facility provided document titled, ORDERING AND RECEIVING DRUGS AND BIOLOGICALS-EMERGENCY PHARMACY DELIVERY AND EMERGENCY KITS was reviewed and read, Emergency pharmacy service is available on a 24-hour basis. Emergency needs for medication are met by using the facility's approved medication supply or by special order from the pharmacy . Deficient Practice Statement #2 Based on observation, interview, and record review, the facility failed to ensure PICC (peripherally inserted central catheter) line care and maintenance were provided for two residents (R30 and R233) of two residents reviewed for PICC line care resulting in the potential for malfunction of the line and or the development of infection. Findings include: R233 On 6/2/25 at 10:36 AM, R233 was observed in their room with a PICC line to their right upper arm. An interview was conducted at that time and they said they admitted to the facility with the line for the delivery of intravenous antibiotics. They were asked if they would lift their sleeve so the dressing covering the line could be observed and they did. At that time, a transparent dressing covering the line insertion site was observed with multiple layers of tape securing the dressing to their arm. It further appeared a date had been written on one of the multiple layers of tape; however it could not be determined what date was written. R233 was asked about the last time the dressing had been changed and they said they didn't know but they were told when they discharged from the hospital it was supposed to be changed every seven days or sooner if needed. A review of R 233's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: aftercare following joint replacement surgery and infection following a surgical procedure. R233's admission assessment indicated they admitted to the facility with a PICC line. A review of R233's physician's orders, medication administration records (MAR) and treatment administration records (TAR) for May 2025 and June 2025 was conducted and revealed an order to flush the line with 10 milliliters of normal saline before and after medication administration, however; the boxes on the MAR where staff would sign off they performed the flushes all contained an X in them, not allowing staff to sign off they performed the flushes. Further review of the June 2025 TAR revealed Nurse 'B' signed off as changing the dressing for the PICC line on 6/1/25; however, that date was not observed on the dressing during the observation on 6/2/25 at 10:36 AM. R30 On 6/2/25 at 10:27 AM, R30 was observed in their room seated in their wheelchair. At that time, it was observed R30 had a PICC line to their right upper arm. R30 was asked if the dressing covering the line insertion site could be observed and they consented. R30 lifted the sleeve of their shirt and it was observed the transparent dressing covering the line was dated 5/20/25. They were asked the last time it was changed and they said they did not know and further queried how often the dressing should be changed. R30 in room up to wheelchair. Few months. On 6/2/25 at 11:30 AM, a review of R30's clinical record revealed they admitted to the facility on [DATE] with a PICC line placed upon discharge from the hospital for the delivery of intravenous antibiotics in the facility. R30's physician's orders and MAR and TAR for May and June 2025 were reviewed and revealed Nurse 'D' signed off on 5/25/25 they changed the dressing and Nurse 'B' signed off on 6/1/25 they changed the dressing despite the date on the dressing observed as 5/20/25. On 6/2/25 at 12:19 PM, R30's PICC line dressing was observed with Unit Manager 'C' and they confirmed the dressing to be dated 5/20/25. They were asked how often the dressings should be changed and said they were done every 7 days. At that time, it was shared with them two nurses documented they changed the dressing and signed off on the TAR. Unit Manager 'C' said they would look into what happened. A review of a facility provided document titled, Catheter Insertion and Care was conducted, however; the document did not address how often the PICC line dressings should be changed. According to the, National Institutes of Health guidelines at https://www.ncbi.nlm.nih.gov/books/NBK573064/ PICC dressings should be changed at least once a week, or more frequently if the dressing becomes loose, wet, or soiled.

Based on observation, interview and record review the facility failed to provide nail care for one resident (R45) out of 27 sampled residents, resulting in unmet resident personal hygiene needs. Findings include: R45 On 6/02/25 at 11:13 AM, R45 was interviewed about care in the facility and stated, I need my nails cut. R45's fingernails appeared long, jagged with debris. R45 said he had a bed bath over the weekend. On 6/03/25 at 8:30 AM, R45 was observed with long, jagged fingernails. On 6/04/25 at 9:26 AM, R45's fingernails were observed with Licensed Practical Nurse (LPN) C. LPN C said R45 had long, dirty nails. When LPN C asked R45 if he would like his nails trimmed R45 agreed. LPN C said R45 has had some refusal for care before but not for bed baths or nail care. Record review of R45's Electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses that included venous insufficiency (obstruction of blood flow), and chronic ulcers to right and left calves. Review of the MDS dated [DATE] for R45 revealed a Brief interview for Mental Status (BIMS) of 12/15 which indicated moderate cognitive impairment and dependent assistance for personal hygiene. Review of the EMR for May and June 2025 did not reveal refusals of bed baths, showers or refusals of nail care. Review of R45's care plan date initiated 10/21/2024 revealed Nail care to be provided twice a week on shower days, and as needed. On 6/5/25 at 11:30 AM the Director of Nursing (DON) was interviewed and said the expectation is for the Certified Nursing Assistants to complete nail care on bed bath/shower days or as needed and to document refusals of care.

Based on observation, interview and record review the facility failed to implement a dental care plan for one resident (R19) out of three residents reviewed for dental services. Findings include: On 6/2/25 at 10:44 AM, R19 was observed with crooked and uneven teeth. An interview was conducted with R19, the resident reported having broken teeth and had seen a dentist but had never heard anything about another appointment. Review of R19's care plans revealed no dental care plan had been implemented. Review of electronic medical record (EMR) revealed resident was admitted into the facility on 3/6/23 with a diagnosis of Parkinson's Disease (disorder that affects central nervous system). According the R19's Brief interview for Mental Status (BIMS) dated 3/12/25, R19 scored 14 out of 15 (intact cognition). Further review revealed resident required substantial/Maximal assistance with Activities of Daily Living (ADLs). Review of Dental Referral Memo dated 6/17/24, It was documented that R19 was planned for a full mouth extraction in the dentist's office. Review of Dental Group form dated 3/13/25, it documented that resident would like teeth removed and dentures fabricated. Review of Appointment Sheets dated 12/26/24 and 3/25/25 documented resident had appointments for Oral Surgery. An interview was conducted on 6/3/25 at 2:15 PM with the Director of Nursing (DON), after reviewing R19's EMR, it was reported that the facility should have been aware that R19 poor dental health, and the resident did not have a dental care plan implemented. It was further reported residents should have care plans implemented to meet their individual needs. Review of facility's policy Care Plan- Comprehensive and Revision dated 8/25/23 it was documented, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interview, and record review the facility failed to maintain complete and accurate medical records for one resident (R45) out of 27 sampled residents resulting in unmet resident care. Findings include: On 6/03/25 at 2:45 PM, R69 was observed in bed and stated, The staff are not changing my tube feed dressing. The tube feed dressing was observed with a date of 5/24/25. On 6/03/25 at 2:55 PM, R69's tube feed dressing was observed with Licensed Practical Nurse/Unit Manager LPN C. LPN C said the dressing was dated 5/24/25 and explained that was the date that the dressing was last changed. LPN C said the dressing should be changed daily on the night shift and there is a risk for infection if the site is not kept clean. On 6/04/25 at 8:57 AM, R69's May and June of 2025 Medication Administration Record (MAR) and Treatment Administration Records (TAR) were reviewed with LPN C. LPN C said R69's MAR/TAR was incorrect from 5/25/25 to 6/2/25 since the wound care and bandage change last occurred on 5/24/25. LPN C stated the last two entries were recorded by Registered Nurse (RN) E. LPN C stated, I spoke to RN E and informed her that that it is falsification of records for R69's chart and that treatment should only be documented after care has occurred. Review of R69's Electronic Medical Record (EMR) revealed, R69 admitted to the facility on [DATE] with pertinent diagnoses which included dysphagia and gastrostomy status (presence of artificial opening to the stomach). Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R69 had intact cognition and required a feeding tube. Review of Physician orders 5/2/25 revealed, Enteral Tube Site Care: Cleanse site with soap and water, rinse with water and allow to air dry, apply split gauze date and initial every night shift for site care notify physician for any signs or symptoms of infection. On 6/4/25 at 11:30 AM the Director of Nursing (DON) was interviewed and said the expectation is that medical records are correct and that patients get the treatments ordered.

This citation pertains to intake MI00149552. Based on interview and record review the facility failed to prevent verbal abuse for one resident (R3) of three residents reviewed for abuse, resulting in staff to resident verbal abuse. Findings include: Review of the Clinical Record revealed resident (R3) was readmitted to the facility on [DATE] with pertinent diagnoses of chronic respiratory failure, malignant neoplasm of the left breast, quadriplegia, hypertensive heart disease with heart failure, type 2 diabetes mellitus with diabetic, chronic kidney disease, major depressive disorder, morbid (severe) obesity, anxiety disorder, polyneuropathy (peripheral nerve disorder). Review of the Minimum Data Set (MDS) assessment with a reference date of 2/5/2025 revealed, R3 had a BIMS (Brief interview for mental status) score of 15/15, which indicated R3 was cognitively intact. Further review of the MDS indicated R3 was incontinent of bowel and bladder and was dependent on staff for toileting, hygiene and transfers. Review of the Facility's Reported Incident received by the State Agency on 1/6/2025 revealed on January 5, 2025, at 9:30 P.M., an allegation of alleged verbal abuse was reported. Review of the Investigation Summary documented Certified Nurse Aide (CNA E) While providing care to (R3) was heard calling and using derogatory language. The incident was witnessed by (Nurse C -Floor Nurse) and reported to (Nurse H -Supervisor) after hearing (CNA E) cursing at R3. According to the incident summary (R3) was in her room and activated the call light for care to be provided. (CNA E) entered the resident's room and communicated to (R3) she would be right back to help her out. After 45 minutes (R3) activated the call light again because (CNA E) never came back to change the resident. (CNA E) reportedly was called from her lunch break and went to assist (R3.) While changing (R3) (CNA E) wiped the resident one time, (R3) asked the aide to wipe again because (R3) did not feel clean. (CNA E) told (R3) she would not wipe her anymore. (R3) told (CNA E) to leave and get the nurse. (CNA E) then stated you can wipe your own ass and called the resident a Fucking bitch. (Nurse C) overheard (CNA E) while exiting the resident's room. The nurse intervened and reported the incident to (Nurse H) who approached (CNA E) and tried to calm the aide down but was unsuccessful. (CNA E) was walked out of the facility and was later terminated effective 1/5/2025. On 2/11/25 at 11:00 A.M. R3 was interviewed concerning the alleged verbal abuse. R3 indicated CNA E was new to her and had never provided care to her prior to the night of 1/2/25. R3 stated putting the call light on for care to be provided, CNA E responded, cut off the call light stating she would return. R3 indicated waiting 30 minutes or more before putting the call light on for a second time. I thought the aide forgot about me and went to lunch. About 10 minutes CNA E entered the room, I could tell she had an attitude when the door was slammed. The aide asked where my briefs were, I responded on the windowsill. CNA E turned me over and wiped me once, while being cleaned I asked her to wipe me one more time since I did not feel clean. CNA E stated she was not wiping anymore, stating I don't play in people asses. R3 responded is that your job? R3 indicated the aide was told to leave the room and get the nurse. R3 indicated both were talking loudly and as CNA E walked towards the door CNA E shouted You can wipe your own ass and then called R3 a Fucking bitch. On 2/11/25 at 1:06 P.M. CNA E was interviewed by telephone concerning the incident. CNA E denied cursing, displaying an attitude, or refusing to wipe R3 as requested. The aide indicated never cursing and indicated R3 cursed her first when CNA E informed R3 she could not dig bowel movement (BM) out of the resident's butt. CNA E indicated only the nurse could do that and R3 should not be talking to anyone like that. The aide indicated in part the nurse called her while on break and CNA E returned. CNA E indicated she felt she was set up since nurse C was standing outside the door as she left R3's room. On 2/11/25 at 1:44 p.m. Nurse 'C was interviewed by telephone. Nurse C stated working the floor the night of 1/5/25 reported to work at approximately 7:00 P.M. Nurse C reported responding to R3's call light when the resident stated she needed her aide because the resident had had a bowel movement. Nurse C reported checking for CNA E who was on break. R3 explained to Nurse C the call light had been put on earlier around 7:22 P.M. and CNA E had answered, cut off the light and never returned. Nurse C was later at the medication cart outside R3's room when she overheard CNA E cursing the resident calling her A bitch and I am not digging in your ass. On 2/11/25 at 3:00 P.M., Nurse H was interviewed by telephone. Nurse H indicated remembering the incident on 1/5/25. Nurse stated coming on duty about 7:00 pm observing R3's call light on and responding to the call light. Nurse H explained R3 stated she needed her aide to come and change her brief. Approximately 10 to 15 minutes later Nurse C came to the office upset and stated CNA E was cursing at R3. Nurse C reported being at the medication cart outside of R3's room and hearing the aide call the resident a Bitch. On 2/11/25 at 4:00 P.M., the Administrator and the Director of Nursing acknowledged the investigation confirmed the allegation of verbal abuse. On 2/11/25 at 4:20 p.m. review of the facility's Abuse policy updated 5/24/2023 stated in part: Verbal Abuse: use of oral, written, or gestured communication or sounds to residents within hearing disturbance of their age, ability to comprehend or disability. To include but not limited to harassment, mocking, insulting, ridiculing, yelling or hovering with the intent to intimidate, threatening, etc.

This citation pertains to intake MI00145468. Based on observation, interview, and record review, the facility failed to provide a proper bed frame extender for one (R405) of five residents reviewed for falls resulting in R405 rolling out of bed during patient care. Findings include: On 7/16/24 at 12:35 PM, R405 was observed in her room, lying in a 42-inch bed watching TV. R405 was asked about her fall out of bed and replied, I fell out of bed last month. I was getting help from a CNA (certified nursing assistant) to get cleaned up and I rolled towards the door, and right out of bed. The mattress slipped right off the bed. I have chronic back pain, but the fall didn't make it worse, I didn't get injured. The bed should have had a bed frame extender on it, but it didn't. After the fall maintenance came in and put on the bed extender. R405 then pointed to the bed extenders and stated, I haven't had any problems with the bed since then. Record review of electronic medical records revealed R405 was admitted into the facility on [DATE] with most recent readmission on 12/27/2023 with a pertinent diagnosis of acquired absence of right leg below knee, spinal stenosis, lumbar radiculopathy. The Minimum Data Set (MDS) dated [DATE] revealed R405 had intact cognition with a Brief Interview of Mental Status (BIMS) of 15/15 and was independent with bed [NAME] and required partial to moderate assist with toileting. Record review of the Incident and Accident report dated 6/13/2024 revealed in part The resident was in the room with her aide being repositioned when she slipped out of the bed and onto the floor. Maintenance was notified that the bed did not have extenders on the bed, and work order was placed, and extenders were applied to the bed. Extenders weren't on the bed to hold the mattress in place, so the bed was unsteady. CNA B stated When I was rolling her over in the bed she rolled over too far to the edge of the bed because the mattress doesn't fit inside the bed frame of the bed when she rolled over the mattress flipped and she started sliding out of the bed and by the time I was trying to catch her she was already slowly sliding. On 7/16/2024 at 1:35 PM Maintenance Worker (MW) A said that R405's 42-inch bed did not have right side extenders when he received the work order from 6/13/2024. MW A added the extenders because frame extenders are required to properly fit a 42-inch mattress to make the bed safe. On 7/16/24 at 2:00 PM the Director of Nursing (DON) was interviewed and agreed that a 42-inch mattress required bed frame extenders and that the lack of bed extenders contributed to R405's fall out of bed on 6/13/2024. Review of the facility policy titled Fall Management Guidelines dated 12/13/2023 revealed in part .A fall is defined as unintentionally coming to rest on the ground, floor, or other level with or without injury to the resident, extrinsic factors that may increase the risk of falls include, but are not limited to: assistive devices, and physical environment.

Based on observation, interview, and record review, the facility failed to ensure that a proper sanitizing product was used to kill Clostridium difficile (C. diff - a bacteria that can cause diarrhea) resulting in the potential spread in infection and disease, potentially affecting all residents who resided in the facility. Findings include: On 6/25/24 at 9:50 AM, Licensed Practical Nurse (LPN) I indicated the resident in room [ROOM NUMBER] was on transmission-based precautions because of a C. diff. infection. On 6/26/24 at 11:08 AM, signage outside of room [ROOM NUMBER] documented that staff were to used transmission-based precautions upon entering and exiting the room. On 6/26/24 at 11:16 AM, Housekeeper F was observed entering room [ROOM NUMBER] without donning PPE (personal protection equipment) with the exception of gloves. Housekeeper F mopped the floor in room [ROOM NUMBER]. Upon exiting the room, Housekeeper F took the gloves off, removed the mop bottom, and put it in a bag. Housekeeper F then used hand sanitizer. On 6/26/24 at 11:20 AM, Housekeeper F said she just wet mopped the floor in room [ROOM NUMBER] using product, Xcelente (a multi-purpose cleaner), mixed with water. Housekeeper F explained that at the end of the shift, the bag with the dirty rags is put with the dirty linen without any special designation that the mop used to clean the room of a resident diagnosed with C. diff. On 6/27/24 at 12:19 PM, Housekeeper F said the only product used on the floor in room [ROOM NUMBER] was the Xcelente. Housekeeper F said she was told today that she needs to use bleach water to adequately clean room [ROOM NUMBER]. Housekeeper F stated, I didn't know. On 6/28/24 at 3:22 PM, Infection Preventionist (IP) G stated bleach was required to clean C. diff. because It kills the spores. IP G added it was a concern that the correct cleaning product was not used because C. diff. could spread to other residents. On 7/2/24 at 1:38 PM, Housekeeping Supervisor A said Xcelente should not have been the only product used to clean and sanitize room [ROOM NUMBER]. Housekeeper Supervisor A said Housekeeper F went in and cleaned the floor with a regular cleaning product and there was a concern that C. diff. could spread. On 7/2/24 at 1:42 PM, the Nursing Home Administrator said he expects cleaning staff to use the proper products to disinfect and kill C. diff. On 7/2/24 at 3:15 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked.

Based on interview and record review, the facility failed to ensure proper completion of Advanced Directive information was in place for one (R8) of 19 residents reviewed for Advanced Directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility or other healthcare providers. Findings Include: Review of an Electronic Health Record (EHR) revealed, R8 had a code status of Do Not Resuscitate/No code (DNR). R8's Do-Not-Resuscitate (DNR) Order was signed by the guardian on 6/15/23. The document was signed by the Physician on 6/26/23 and two witnesses on 6/28/23. Review of an Admission Record revealed, R38 admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnosis which included dementia. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R8 had mild cognitive impairment with a Brief interview for Mental Status (BIMS) score of 13, out of 15. In an interview on 6/26/24 at 1:42 p.m., Social Worker (SW) K reported the Advance Directive form should be signed in front of two witnesses. SW K then reported the witness signature date should be the same as the resident's or guardian. Review of an Advance Directives - Code Status policy revised 10/5/23 documented, It is the policy of the facility that the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment . DNR must be documented on the Do-Not-Resuscitate (DNR) form for the DNR to be valid. Until the form is full filled out and signed by the resident or the resident's legal representative, two witnesses, and a physician, the resident will be a Full Code by default .

Based on interview and record review, the facility failed to complete an annual OBRA (Omnibus Budget Reconciliation Act) Level II Evaluation for one (R3) of seven residents reviewed for PASARRs (Preadmission Screen and Resident Review), resulting in the potential for unmet mental health services. Findings include: Review of the clinical record revealed Resident #3 (R3) was initially admitted into the facility on [DATE] and readmitted on [DATE]. R3's diagnoses included adjustment disorder with mixed anxiety and depressed mood, unspecified dementia, bipolar disorder, and major depressive disorder. A Minimum Data Set assessment dated [DATE] documented moderate cognitive impairment. The date of R3's most current Level II PASARR was 3/21/23. On 6/26/24 at 2:30 PM, a review of R3's most recent Level II PASARR, dated 2/20/23, was conducted with Social Worker (SW) K. SW K stated the local community mental health services modified the document on 3/21/23, and that we need to submit a new Level II. It was due 3/21/24. On 7/2/24 at 2:30 PM, the Nursing Home Administrator (NHA) stated he expects PASARRs to be completed upon admission, a change in condition, and annually. A review of the facility document titled, PASARR, dated April 2022, documented in part the following: The nursing facility is responsible for verifying that required PAS and ARR processes are completed appropriately and timely and documented in the resident's record. On 7/2/24 at 3:15 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked.

Based on observation, interview, and record review the facility failed to 1) provide wound care according to treatment orders for one (R49) of six residents reviewed for skin conditions, resulting in unmet skin treatment needs, 2) failed to follow-up on pharmacist recommendations in a timely manner, 3) consistently hold antihypertensive medication per physician's order, and 4) consistently check blood pressure prior to administration of antihypertensive medication for two (R104, R1) of 23 residents reviewed for quality of care resulting in unmet care needs. Findings include: R49 On [DATE] at 12:24 pm R49 was observed in bed with a bandage on his left forearm dated [DATE] and a bandage on his right hand dated [DATE]. When R49 was asked what happened to your arms R49 reported I fell and tore up my hand and arm. On [DATE] at 9:09 am R49's left forearm and right-hand bandages were observed with dates of [DATE]. On [DATE] at 9:19 am Licensed Practical Nurse (LPN) V was interviewed and said R49's bandages and wound care should be performed daily. LPN V stated I forgot to change his bandages yesterday. I marked the treatment administration record that I provided the bandage change and wound care on [DATE] but I really didn't provide the wound care. It was my mistake. Record review of R49's Electronic Medical Record (EMR) revealed admission into the facility on [DATE] with pertinent diagnosis of Parkinson's Disease, falls. According to the Minimum Data Set (MDS) dated [DATE] R49 had moderately impaired cognition and moderate assistance with Activities of Daily Living (ADLS). On [DATE] at 9:41 AM R49's physician's orders and June Treatment Administration Record (TAR) were reviewed with Unit Manager D and revealed that wound care was to be provided daily and that LPN V performed wound care on [DATE]. Unit Manager D agreed the wound care entry for [DATE] was not accurate and said nurses should provide care first, then document. They should not document treatments that were not provided. On [DATE] at 9:09 AM the Director of Nursing (DON) was interviewed and agreed wound care should be performed per physician's orders and documentation should be accurate. 34901 Resident #1 - Review of the clinical record for Resident #1 (R1) documented an initial admission into the facility on [DATE] and readmission on [DATE]. R1's diagnoses included moderate protein-calorie malnutrition (PCM), type 2-diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), irritable bowel syndrome (IBS) without diarrhea, end state renal disease, and heart failure. A Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition. Chart review revealed R1 had multiple admissions and discharges from the facility, such as: admit: [DATE] and discharge: [DATE] admit: [DATE] and discharge: [DATE] admit: [DATE] and discharge: [DATE] admit: [DATE] and discharge: [DATE] admit [DATE] Review of monthly Medication Regimen Reviews (MMR) included the following pharmacist's recommendations: 1. MMR dated [DATE] - Order for Ranolazine ER 500 mg (given for chest pain) to give one tablet by mouth once daily. This medication is recommended to be dosed twice a day from the manufacturer. Please consider increasing to twice a day at this time. Physician agreed. - Order for Fluticasone-Salmeterol ,d+[DATE] (given for shortness of breath/COPD) to inhale 1 puff by mouth two times a day as a therapeutic interchange for Trelegy Ellipta once daily. Trelegy also contains a [NAME] (long-acting muscarinic antagonist - used to help control asthma long-term). Consider adding Incruse Ellipta 62.5 once daily to cover the [NAME] portion of a Trelegy inhaler. Physician agreed. 2. MMR dated [DATE] - Resident has an order for Ranolazine ER 500 mg to give one tablet by mouth daily. However, this medication is recommended to be dosed twice a day from the manufacturer. Please consider increasing to twice a day at this time. Physician agreed. 3. MMR dated [DATE] - Resident has an order for Fluticasone-Salmeterol ,d+[DATE] to inhale 1 puff by mouth two times a days as a therapeutic interchange for Trelegy Ellipta once daily. However, Trelegy also contains a [NAME]. Please consider adding Incruse Ellipta 62.5 once daily to cover the [NAME] portion of a Trelegy inhaler. Physician agreed. 4. MMR dated [DATE] - Resident has an order for Fluticasone-Salmeterol ,d+[DATE] to inhale 1 puff by mouth two times a days as a therapeutic interchange for Trelegy Ellipta once daily. However, Trelegy also contains a [NAME]. Please consider adding Incruse Ellipta 62.5 once daily to cover the [NAME] portion of a Trelegy inhaler. Physician agreed. Per (physician) - add Incruse Ellipta once daily. Order placed in (electronic medical record). Dated [DATE]. During an interview and record review on [DATE] at 12:30 PM with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), completed MMRs, containing the pharmacist's recommendations, are emailed to the DON. The MMRs are given to the Unit Managers to review. The Unit Managers are to contact the responsible physician for a decision regarding the pharmacist's recommendations. The MMRs are placed in the physician's folder for their signature. A review of R1's Medication Administration Records (MAR) revealed the following: 1. [DATE] MAR: confirmed no change in the orders for Ranolazine or Incruse Ellipta per pharmacist's recommendations and as agreed upon by the physician. 2. [DATE] MAR: confirmed Ranolazine was give once daily between [DATE] and [DATE]. The order for Ranolazine was changed to give twice daily on [DATE]. Incruse Ellipta was not administered per pharmacist's recommendation and as agreed upon by the physician. 3. [DATE] MAR: confirmed Incruse Ellipta was ordered on [DATE]. The DON said a determination of the pharmacist's recommendation should be completed within seven days. Resident #104 - A review of the clinical record for Resident #104 (R104) documented an initial admitted [DATE] and readmitted [DATE]. R104's diagnoses included persistent atrial fibrillation, hypotension, chronic kidney disease-stage 3, diabetes mellitus-type 2, and peripheral vascular disease. R104 expired in the facility on [DATE]. A MDS assessment dated [DATE] documented severe cognitive impairment. Review of R104's Medication Administration Record (MAR) documented an order for Midodrine HCL oral tablet 5 mg. Give 1 tablet by mouth every 8 hours for hypotensive, hold for systolic blood pressure less then 130. Start date [DATE]. Stop date [DATE]. On [DATE] at 11:59 AM, Attending Physician H said Midodrine should be held for systolic blood pressure greater than 130. On [DATE] at 12:14 PM, Licensed Practical Nurse (LPN) I said that nurses should check a resident's blood pressure prior to administering the blood pressure medication. LPN I said Midodrine should be held for blood pressure above 130. On [DATE] at 11:52 AM, during an interview and record review with the DON and ADON, the following was confirmed: Midodrine should have been held when R104's blood pressure was greater than 130. Midodrine was incorrectly administered to R104 on: [DATE] at 10:56 AM with a blood pressure of ,d+[DATE] [DATE] at 7:50 AM with a blood pressure of ,d+[DATE] [DATE] at 9:42 PM with a blood pressure of ,d+[DATE] Midodrine was scheduled to be administered at 6:00 AM, 2:00 PM and 10:00 PM. The DON confirmed that R104's blood pressure should be taken prior to each administration of Midodrine. R104's blood pressure was not obtained prior to the administration of Midodrine on the following dates and times: [DATE] at 6:00 AM, [DATE] at 6:00 AM, [DATE] at 6:00 AM, [DATE] at 2:00 PM, [DATE] at 10 PM, and [DATE] at 10:00 PM. On [DATE] at 3:15 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked.

This citation pertains to Intake #MI 395. Based on interview, and record review, the facility failed to assess and properly use a Hoyer lift (A assistive device that allows patients to be transferred by the use of electrical or hydraulic power) for one (R#131) out of a total sample of three Residents reviewed for activities of daily living (ADLs), resulting in a preventable injury while using the Hoyer lift, subsequently sustaining a fracture to the left femur which required hospitalization for further evaluation and treatment. Finding include: On 9/24/19 at 12:24 p.m., review of the clinical record revealed R#131 was initially admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the significant change Minimum Data Set (MDS) assessment dated [DATE], R#131 was cognitively intact, required extensive assistance of two person with a Hoyer lift for transfers, required extensive assistance of two person for bed mobility, required extensive assistance of one person for all ADLs. On 9/24/19 at 12:30 p.m., review of the resident's ADL care plan revision date 9/3/19 documented, Full mechanical-lift with 2-person dependent assistance for transfers (Extra Large/Blue Sling). On 9/24/19 at 12:50 p.m., review of the facility's investigation report dated 8/29/19 revealed, R#131 was being transferred via full mechanical lift by CNAs B and C. During this transfer the resident yelled out indicating that the sling being used was too tight and causing her pain. At that time the CNAs chose to use an inappropriately size sling which resulted in the resident slipping out onto the floor during the transfer. At that time the resident was found to have a left sided femur fracture and hospitalized . Corrective surgery was completed on 8/28/19. On 9/24/19 at 1:01 p.m., further review of the facility's investigation report revealed, Both CNA's was suspended pending investigation and report was made to state agency. Also, education was initiated to nurses and CNAs on ensuring they are using the appropriated size slings for their residents using full mechanical lifts. On 9/24/19 at 1:25 p.m., the facility's investigation report also revealed, CNA B was interviewed by the Assistance Director of Nursing (ADON) on 8/28/19, documented, We were (CNA B) and me putting R#131 on the Hoyer for her shower. We used the blue sling and she was yelling it was cutting into her legs. So, we got the orange sling and hooked it up properly, but when we got her on it, her butt slipped out of the sling. We lowered her to the floor. Nurse D came into the room and assessed her (R#131). She was complaining of left knee pain. R#131 was put back into the bed with the Hoyer. She (R#131) no longer wanted her shower. On 9/24/19 at 1:50 p.m., CNA B was contacted for an interview via telephone. CNA B was asked during an interview, what happened on the date of 8/27/19 with R#131. CNA B stated, We grabbed the Hoyer, everything was set up. The Resident was complaining the blue sling was pinching her, so we went to get another sling that was bigger, the orange sling. The Resident butt was coming out the sling when we (CNA C) went to put her on the shower chair. We tried to lower her down to reposition the sling. We saw her leg was kind of bent backward. We rolled her over to the side and straighten her leg out. The Resident no longer wanted her shower. We gave her a bed bath and notice bruises on the back of her thigh about five minutes afterward. She was complaining of pain. CNA B was asked, what is the difference in the colors of the Hoyer sling. CNA B stated, The color of the slings helps us to know what size to use on each resident. CNA B was asked, when R#131 fell , what color of sling were being used. CNA B stated, The orange sling. CNA B was asked, why was the orange sling used after the blue sling didn't fit. CNA B stated, Because it was bigger, but it was too big. On 9/24/19 at 2:15 p.m., the Administrator was asked during an interview, what was the conclusion of her investigation why R#131 fell . The Administrative stated, They used the wrong size of sling for the patient weight. The Administrative stated, they initial used a blue (extra Large) sling, then they used an orange (2X). The Administrative stated, the orange sling I think caused the fracture because it was too big. The Administrative was asked, who determined the size of the slings used for the Resident's Hoyer lift transfers. The administrative stated, When a Resident is admitted , the nurses does the evaluation and determines how the Residents are transferred and the CNAs determine the size because they weigh the residents. The Administrator was asked, are there documents or guide for the CNAs to follow to determine the size of the slings by the Residents weighs. The Administrator stated, No, but the CNAs knows what size they need, because they are out there with the Residents. The administrative was asked, have the CNAs been in-serviced on determining the sling sizes. The Administrator stated, No, but since the fall now the nurses have a systematic chart to guide them in the size of the sling each resident should use. The Administrator was asked, was there an assessment completed for the Hoyer lift sling prior to the fall, The Administrator stated, No assessment was done prior. The Administrator presented a chart titled Sling Color/Size Guide documented, adults weights of 55 to 77 pounds uses the brown slings (extra small), weights of 77 to 132 pounds uses the red sling (small), weights of 121 to 165 pounds uses the yellow sling (Medium), weights of 154 to 264 pounds uses the green sling (Large) . The Administrator stated, The size chart was introduced to the staff after the fall with the color coordination. The facility's investigation report revealed multiples of disciplinary actions titled Employee warning Notice dated 9/18/18 documented, Failure to have transfer status on Kardex for CNAs to be able to utilize in giving care. On 9/24/19 at 2:40 p.m., interviewed an unknown Therapist. The Therapist was asked, was R#131 assessed for the Hoyer lift transfer. The therapist stated, Yes, The Therapist was asked, how was the size of the Hoyer lift sling determined. The Therapist stated, We don't determine the size of the Hoyer sling, Nursing Department determines the sizes of the Hoyer slings. On 9/24/19 at 2:50 p.m., review of R#131's Admission Transfer assessment dated [DATE] revealed, R#131 transfer status was Hoyer lift with no size indicated on the size line indicator. Review of R#131's weight dated 4/27/19 revealed, the Resident weight was 204.8 pounds. According to the facility's Sling Color/Size Guide), Green (large, 154-264 lbs), indicated being the appropriate size sling for the Resident. On 9/24/19 at 2:55 p.m., review of the CNA's Kardex (A care guide for the CNA's) did not indicate R#131's transfer status. On 9/24/19 at 2:59 p.m., review of the Hospital discharge documentations dated 8/29/19 revealed, Findings consistent with acute fracture involving medial and distal aspect of the femur. On 9/24/19 at 3:30 p.m., a review of the facility's policy titled, Mechanical Lift revision date 4/2019 documented, Purpose: To move immobile or obese patients for whom manual transfer poses potential for staff or patient injury, Equipment: Mechanical Lift, Sling of appropriate size and type.

Based on interviews and record review, the facility failed to provide adequate assistance with bed mobility during ADL (activities of daily living) care for one of three residents (#501) reviewed for falls, from a total sample of three, resulting in R#501 fracturing both femurs when she rolled out of bed, during care. Findings include: A review of the facility's incident report, and investigation report dated 7/27/17 determined that R#501 was receiving ADL care, which included having her bed linens changed, on 7/26/17 at approximately 10:20 p.m., by Certified Nursing Assistant (CNA 'E'). R#501 rolled out of bed, on to the floor when CNA 'E' rolled the resident away from her during linen change. According to the investigation report, CNA 'E' was suspended during the investigation, and then terminated for violating the facility's policy for bed mobility practice. The facility's bed mobility practice is to roll the resident toward staff, not away from staff. The report also indicated that R#501's MDS (minimum data set) assessment indicated that she required two staff members for bed mobility. During a phone interview on 8/10/17 at 11:00 a.m., CNA 'E' said that she was terminated from the facility because she rolled R#501 away from her, and did not have another CNA assist with care. CNA 'E' said that R#501 could usually assist the staff with bed mobility, and that she (CNA 'E') had changed the resident's linen by herself repeatedly without incident. According to the medical record, reviewed on 8/10/17 at 1:00 p.m. R#501 had admitted to the facility in 2014 for multiple [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated R#501 had a BIMS (brief interview for mental status) score of 15/15, and impaired mobility of the left side for both upper and lower extremities. R#501 was determined to be 'at high risk' for falls due to impaired balance and poor coordination. R#501 required extensive assistance from two staff members for bed mobility. A care plan for ADL care included the following interventions; transfer resident with use of mechanical lift and two staff persons, large 42 inch bed, and encourage transfers and position changes to be done slowly. During an interview on 8/10/17 at 10:20 a.m., the Assistant Director of Nursing (ADON) said that R#501 had fallen to the floor during care and linen change and was sent out to the hospital for severe pain. R#501 was diagnosed to have fractures in both of her femurs. The resident did not return to the facility. The ADON said that during the investigation it was determined that CNA 'E's technique for repositioning the R#501 did not follow the resident's plan of care, or the facility's policy. Therefore we started training on all the direct care staff to ensure compliance with policy. The facility also determined that the 'kardex' (the care card to detail resident's care needs/CNA instructions) was not accurate. The facility conducted an audit of all resident's and ensured kardex accuracy. A review of the facility's Past Non Compliance Checklist dated 7/28/17 revealed that all direct care staff were to be trained on one person bed mobility and kardex instruction. The Program Attendence Record for Bed Mobility documenneted that the staff training was completed on 8/9/17.

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO (1) CONSISTENTLY ASSESS AND IMPLEMENT INDIVIDUALIZED INTERVENTIONS NECESSARY TO PREVENT THE DEVELOPMENT OF A PRESSURE SORE FOR ONE (#419) OF SIX SAMPLED RESIDENTS REVIEWED FOR PRESSURE SORES; AND (2) FAILED TO ADMINISTER WOUND CARE TREATMENT AS ORDERED FOR ONE (#419) OF SIX SAMPLED RESIDENT REVIEWED FOR PRESSURE SORES, FROM A TOTAL SAMPLE OF 24 RESIDENTS, RESULTING IN THE DEVELOPMENT OF AN AVOIDABLE PRESSURE SORE AND THE POTENTIAL WORSENING OF A PRESSURE SORE. FINDINGS INCLUDE: ON 5/9/13 AT 11:45 A.M., RESIDENT #419 WAS OBSERVED AWAKE SEATED IN A WHEELCHAIR IN HER ROOM WITH HER FEET RESTING FLAT ON THE FOOT REST. WHEN QUERIED REGARDING THE BANDAGE ON HER LEFT FOOT RESIDENT #419 STATED, "MY FOOT USED TO HURT BEFORE AND THEY (THE FACILITY) STARTED TAKING CARE OF THE "SORE" ON MY FOOT." ON 5/9/13 AT 11:55 A.M., A WOUND CARE OBSERVATION FOR RESIDENT #419 WAS CONDUCTED WITH NURSE "D". AN UNSTAGEABLE (FULL THICKNESS TISSUE LOSS IN WHICH THE BASE OF THE ULCER IS COVERED BY SLOUGH (YELLOW, TAN, GRAY, GREEN, OR BROWN) AND/OR ESCHAR (DEAD TISSUE) (TAN, BROWN OR BLACK) IN THE WOUND BED) PRESSURE SORE WAS OBSERVED ON THE RESIDENT'S LEFT HEEL. NURSE "D" DESCRIBED AND MEASURED THE WOUND AND STATED THE UNSTAGEABLE PRESSURE ULCER MEASUREMENTS WERE 3.0 X 2.0 CENTIMETERS (CM). THE WOUND HAD 50% DARK GRAYISH TISSUE AND 50% PALE PINK GRANULATION (HEALING) TISSUE. THERE WAS A MODERATE AMOUNT OF SEROSANGUINEOUS (YELLOW/BLOODY) DRAINAGE ON THE OLD DRESSING. NURSE "D" CLEANSED RESIDENT #419'S LEFT HEEL PRESSURE SORE WITH NORMAL SALINE AND APPLIED A THIN LAYER OF [MEDICATION NAME] ([MEDICATION NAME] Gel helps hydrate dry wounds and helps provide antimicrobial protection with microscopic particles of controlled-release ionic silver--Medline Product Information) TO THE WOUND. NURSE "D" THEN APPLIED AN ABSORBENT PAD (ABD) AND SECURED THE HEEL DRESSING WITH A BULKY DRESSING. REVIEW OF THE ADMISSION FACESHEET AND CLINICAL RECORD FOR RESIDENT #419, REVEALED THE RESIDENT WAS readmitted INto the facility on [DATE], WITH [DIAGNOSES REDACTED]. THE FIVE DAY ADMISSION MINIMUM DATA SET ((MDS) dated [DATE], DOCUMENTED RESIDENT #419 HAD SEVERELY IMPAIRED COGNITION AND WAS PHYSICALLY DEPENDENT ON STAFF, REQUIRING TWO PLUS ASSISTANCE, FOR BED MOBILITY, TRANSFERS AND ALL ACTIVITIES OF DAILY LIVING. THE MDS DOCUMENTED THAT RESIDENT #419 WAS "AT RISK" FOR PRESSURE SORE DEVELOPMENT AND CODED THE RESIDENT AS NOT HAVING PRESSURE SORES AT THE TIME OF THE INITIAL ADMISSION ASSESSMENT. REVIEW OF THE NURSING SKIN assessment dated [DATE] REVEALED RESIDENT #419 HAD NO SKIN BREAKDOWN ON HER LEFT HEEL. THE MOST RECENT BRADEN SCALE (ASSESSMENT USED TO IDENTIFY PRESSURE SORE DEVELOPMENT RISK LEVEL), DATED 3/24/13, REVEALED RESIDENT #419 SCORED A "17". (ACCORDING TO THE BRADEN GUIDELINES, A SCORE OF 15-18 SUGGESTED "LOW RISK" FOR THE DEVELOPMENT OF PRESSURE SORES. REVIEW OF NURSING NOTES FROM 4/6/13 THRU 5/9/13 REVEALED THE FOLLOWING: 1. 4/6/13 AT 8:03 PM, "OPEN AREA TO LEFT HEEL CLEANSED WITH NORMAL SALINE APPLIED [MEDICATION NAME] (ANTIMICROBIAL WOUND GEL) COVERED WITH DRY DRESSING/KERLIX (BULKY GAUZE WRAPPING)". THERE WERE NO MEASUREMENTS NOR WOUND CHARACTERISTICS OF THE OPEN AREA DOCUMENTED. 2. 4/18/13 AT 4:02 AM, "...DENIES PAIN OR DISCOMFORT. LEFT HEEL DRESSING CHANGED--OPEN AREA 2 CM (CENTIMETER) IN WIDTH AND 3 CM IN LENGTH. AREA NECROTIC (DEAD TISSUE) REDNESS AND SLOUGH (DEAD TISSUE IN THE PROCESS OF SEPARATING FROM HEALTHY AND VIABLE BODY PART) IN CENTER...". 3. 4/18/13 AT 3:51 PM, "RESIDENT HAS STAGE III (FULL THICKNESS SKIN LOSS INVOLVING EPIDERMIS, DERMIS, OR BOTH) LEFT HEEL ULCER-2.5 X 2.0 X 0.5, CENTIMETERS (CM) 25% (PERCENT) NECROSIS AND 75% GRANULATION, MODERATE SEROUS DRAINAGE, SURROUNDING INTACT, NO PAIN. TREATMENT ORDERED, [MEDICATION NAME], COVER WITH DRY DRESSING (D/D) AND KERLIX." 4. 5/3/13 AT 3:53 PM, "WOUND ROUNDS COMPLETE. TREATMENT CONTINUED LEFT HEEL UNABLE TO DETERMINE (UTD) 1.9 X 1.7, 25% ESCHAR (DEAD TISSUE) AND 75% GRANULATION (NEW HEALING), MODERATE SEROUS DRAINAGE..". 5. 5/9/13 AT 8:46 AM, "WOUND ROUNDS COMPLETE. TREATMENT CONTINUED UNABLE TO DETERMINE LEFT HEEL-2.0 X 1.0, 50% ESCHAR 50% GRANULATION, MODERATE SEROUS DRAINAGE...". WORSENING OF PRESSURE SORE GRANULATION TISSUE. REVIEW OF "WOUND CARE SERVICE" PHYSICIAN CONSULT NOTES REVEALED THE FOLLOWING: 1. 4/24/13- "SEVERITY(DEGREE OF WOUND CONDITION): THE WOUND IS MILD SEVERITY. THE WOUND HAS BEEN PRESENT FOR OVER ONE WEEK. THE WOUND BEGAN AT THE NURSING FACILITY. THE PATIENT HAS BEEN WEARING A BRACE. IT IS UNCLEAR IF THE BRACE CAUSED THE WOUND. THE WOUND INVOLVES THE LEFT HEEL. THE WOUND IS RED, YELLOW, AND PURPLE. THE LEFT POSTERIOR HEEL NECROTIC TISSUE (UNSTAGEABLE). MEASUREMENTS ARE 1.9 CM X 1.5 CM. THERE IS A SMALL AMOUNT OF SEROSANGUINEOUS DRAINAGE NOTED. THE WOUND BED IS 26-50% ESCHAR, 1-25% SLOUGH, 1-25% GRANULATION. THERE IS NO ODOR. PRIMARY WOUND DRESSING ORDERED: SANTYL (AN OINTMENT THAT CONTINUOUSLY REMOVES NECROTIC TISSUE FOR THE WOUND)." 2. 5/1/13-"SEVERITY: THE WOUND IS MILD SEVERITY. LEFT POSTERIOR HEEL NECROTIC TISSUE (UNSTAGEABLE) PRESSURE ULCER. MEASUREMENTS 1.9 X 1.7 CM. THERE IS A MODERATE AMOUNT OF SEROUS DRAINAGE NOTED WHICH HAS A MILD ODOR. ADDITIONAL ORDERS: SCHEDULE DEBRIDEMENT (SURGICAL REMOVAL) OF THE WOUND FOR NEXT VISIT." 3. 5/8/13-"SEVERITY: THE WOUND IS NECROTIC SEVERITY. LEFT POSTERIOR HEEL NECROTIC TISSUE (UNSTAGEABLE) PRESSURE ULCER. MEASUREMENTS ARE 2.0 CM X 1.0 CM. THERE IS MODERATE SEROUS DRAINAGE. 50% ESCHAR 26-50% GRANULATION. ADDITIONAL ORDERS: SCHEDULE DEBRIDEMENT OF THE WOUND FOR NEXT VISIT." (WORSENING OF PRESSURE SORE). REVIEW OF THE FACILITY'S PHYSICIAN ORDERS [REDACTED]. 1. 2/25/13-"CHECK SKIN INTEGRITY UNDER LEFT LOWER EXTREMITY IMMOBILIZER EVERY DAY AND AS NEEDED." 2. 4/18/13-"CLEANSE LEFT HEEL WITH NORMAL SALINE APPLY [MEDICATION NAME] AND COVER WITH DRY DRESSING." 3. 4/24/13--"1. DISCONTINUE PREVIOUS HEEL WOUND CARE ORDER. 2. TREAT HEEL ULCER WITH SANTYL AND AND EVERY DAY AND AS NEEDED. 3. OFF LOAD PRESSURE TO HEELS." REVIEW OF "TREATMENT ADMINISTRATION RECORD" SHEETS (TARS) FOR APRIL AND MAY 2014 REVEALED THERE WAS NO DOCUMENTED EVIDENCE RESIDENT #419'S "SKIN CHECKS" UNDER THE IMMOBILIZER ON THE LEFT LOWER LEG WERE PERFORMED AS ORDERED. THE physician's orders [REDACTED]. AS A RESULT, THE RESIDENT'S WOUND, WHEN TREATMENT WAS DOCUMENTED AS BEING DONE, WAS DONE WITH [MEDICATION NAME] FROM 5/01-5/09/13 NOT "SANTYL OINTMENT" AS PRESCRIBED BY THE PHYSICIAN ON 4/24/13. THERE WAS NO DOCUMENTATION WOUND CARE WAS PROVIDED TO RESIDENT #419 ON 5/1/13, 5/2/13 OR 5/5/13. ON 5/9/13 AT 1:30 PM, DURING AN INTERVIEW AND RECORD REVIEW WITH THE DIRECTOR OF NURSING (DON), THE DON WAS ASKED WHAT NURSING INTERVENTIONS WERE IMPLEMENTED TO PREVENT SKIN BREAKDOWN RELATED TO THE FACT RESIDENT #419 REQUIRED A LEFT LEG IMMOBILIZER AT ALL TIMES AFTER FALLING AND BREAKING HER LEG AT HOME. REVIEW OF THE RESIDENT #419'S CLINICAL CARE PLAN SECTION REVEALED THERE WERE NO INTERVENTIONS TO PREVENT THE DEVELOPMENT OF PRESSURE SORES RELATED TO THE RESIDENT WEARING A LEFT LEG IMMOBILIZER AT ALL TIMES. THERE WAS NO CARE PLAN INTERVENTION TO "CHECK" THE RESIDENT'S SKIN UNDERNEATH THE LEFT LEG IMMOBILIZER EACH DAY AND "AN NEEDED" PER PHYSICIAN ORDERS, DATED 2/25/13. THE DON WAS ASKED ABOUT THE physician's orders [REDACTED]., AT WHICH TIME RESIDENT #419'S FEET WERE RESTING DIRECTLY ON THE FOOT REST AS SHE SAT IN THE WHEELCHAIR. AN "AT RISK FOR SKIN INTEGRITY" CARE PLAN DATED 2/25/13, DIRECTED STAFF TO: "FLOAT HEELS AS ABLE. USE PILLOWS/POSTIONING DEVICES AS NEEDED." THE DON WAS UNABLE TO EXPLAIN WHY THIS WAS NOT DONE. THE DON WAS QUERIED REGARDING RESIDENT #419'S WOUND TREATMENT OBSERVATION AND THE APPLICATION OF [MEDICATION NAME] INSTEAD OF SANTYL AS ORDERED, AND STATED, "THAT SHOULD NOT HAVE HAPPENED. THE ORDER (FOR SANTYL) SHOULD HAVE BEEN FAXED TO PHARMACY AND SHOULD HAVE BEEN LISTED ON THE MAY 2013 TREATMENT SHEET." ON 5/9/13 AT 2:20 P.M., DURING AN INTERVIEW WITH THE NURSE "D" WHEN QUERIED REGARDING THE APPLICATION OF [MEDICATION NAME] GEL FOR RESIDENT #419'S LEFT HEEL TREATMENT AND THE CURRENT PHYSICIan order for [REDACTED]." NO FURTHER EXPLANATION WAS PROVIDED. NURSE "D" WAS UNABLE TO SHOW EVIDENCE SKIN ASSESSMENTS WERE COMPLETED ROUTINELY BY NURSING AFTER THE RESIDENT'S READMISSION INto the facility on [DATE] AND THE ONSET OF THE PRESSURE SORE ON 4/6/13. IN ADDITION, NURSE "D" WAS NOT ABLE TO EXPLAIN WHY THE WOUND ASSESSMENT WAS COMPLETED ON 4/18/13--12 DAYS AFTER IT WAS FIRST IDENTIFIED ON THE RESIDENT'S LEFT HEEL. REVIEW OF THE FACILITY'S "SKIN PRACTICE GUIDE", DATED 1/2013, DOCUMENTED: "ADMISSION SKIN EVALUATION, A WEEKLY SKIN EVALUATION IS COMPLETED BY THE LICENSED NURSE FOR THOSE PATIENTS IDENTIFIED AS AT RISK FOR SKIN BREAKDOWN THAT DO NOT HAVE A PRESSURE ULCER. DOCUMENTATION OF SKIN EVALUATIONS IS COMPLETED ON THE TREATMENT ADMINISTRATION RECORD." ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO IMPLEMENT INTERVENTIONS TO PREVENT THE DEVELOPMENT OF ONE NEW PRESSURE SORES FOR ONE ( # 904) RESIDENT WITH A HISTORY OF PRESSURE SORES OUT OF FIVE RESIDENTS REVIEWED FOR PRESSURE SORES, FROM A TOTAL OF 24 SAMPLED RESIDENTS, RESULTING IN THE DEVELOPMENT OF ONE PRESSURE SORES ON THE RIGHT EARLOBE. FINDINGS INCLUDE: ON 5/1/12 AT 10:00 A.M., STAFF "A," REPORTED RESIDENT #904 HAD A FACILITY ACQUIRED STAGE THREE (III) ( FULL THICKNESS TISSUE LOSS. SLOUGH (DEAD TISSUE) MAY BE PRESENT) PRESSURE ULCER ON HER RIGHT EARLOBE. RESIDENT #904 WAS OBSERVED RESTING IN BED POSITIONED ON THE RIGHT SIDE AND A NECK PILLOW WAS OBSERVED AROUND RESIDENT #904'S NECK. HOWEVER, THE PILLOW DID NOT PREVENT THE RIGHT SIDE OF THE RESIDENT'S HEAD FROM RESTING ON THE STANDARD PILLOW LOCATED ON THE BED. THERE WAS A DRESSING ON RESIDENT #904'S RIGHT EAR DATED 4/30/12. ON 5/2/12 AT 1:00 P.M., RESIDENT #904'S PRESSURE ULCER TREATMENT TO THE RIGHT EAR WAS OBSERVED WITH THE WOUND CARE NURSE AND REVEALED A HEALING STAGE III PRESSURE SORE ON THE EAR LOBE THAT COVERED ALMOST THE ENTIRE EAR LOBE. A LARGE AMOUNT OF BROWNISH RED DRAINAGE POOLED IN THE BASE OF THE EAR. THE TISSUE AROUND THE EAR WAS PINK, REDDEN AND MOIST. RECORD REVIEW REVEALED THAT RESIDENT #904 WAS ORIGINALLY admitted INto the facility on [DATE] AND readmitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF RESIDENT #904'S MINIMUM DATA SET ((MDS) dated [DATE] INDICATED THAT RESIDENT #904 REQUIRED TOTAL PHYSICAL ASSISTANCE FROM STAFF FOR ACTIVITIES OF DAILY LIVING AND BED MOBILITY. THE RESIDENT HAD AN INDWELLING CATHTER, INCONTINENT OF STOOL, AND RECEIVED NUTRITION VIA PERCUTANEOUS ENDOSCOPIC [MEDICAL CONDITION] TUBE (PEG TUBE). REVIEW OF A PROGRESS NOTE DATED 3/14/12 INDICATED, "NECK TURNED TO RIGHT AND VERY RIGID...SEVERE DEFORMITY TO HANDS, ELBOW AND KNEES....RISK REDUCING INTERVENTIONS IN PLACE...TURN/REPOSITION EVERY TWO HOURS." NO OTHER INTERVENTIONS ADDRESSED THE POTENTIAL FOR BREAKDOWN ON THE EAR. REVIEW OF THE INITIAL CARE PLAN DATED 3/27/12 INDICATED A "BRADEN SCORE OF 11, WHICH INDICATED.... "HIGH RISK FOR SKIN BREAKDOWN. OTHER INTERVENTIONS INCLUDED: DIET AND SUPPLEMENT PER PHYSICIAN ORDERS, ENCOURAGE AND ASSIST AS NEEDED WITH TURN AND REPOSITION, USE ASSISTIVE DEVICES AS NEEDED, USE PILLOWS AND/OR POSITIONING DEVICES AS NEEDED. REVIEW OF A NURSING PROGRESS NOTE, DATED 4/10/12, "STAGE THREE PRESSURE SORE WAS IDENTIFIED AND MEASURED 3.0 CENTIMETER (CM) BY 0.5 BY 0.1 CM." THERE WAS NO OTHER DESCRIPTION OF THE PRESSURE ULCER DOCUMENTED. REVIEW OF RESIDENT #904'S SKIN CARE PLAN DATED 4/10/12 DOCUMENTED, "RESIDENT HAS STAGE TWO RIGHT EAR, RELATED TO INCONTINENCE, FRICTION, LEFT SIDED WEAKNESS." INTERVENTIONS WERE; " USE PILLOWS AND/OR POSITIONING DEVICES AS NEEDED." ON 5/3/12 AT 10:00 A.M., THE DIRECTOR OF PHYSICAL THERAPY WAS INTERVIEWED REGARDING PHYSICAL THERAPY'S INVOLVEMENT WITH RESIDENT #904. THE DIRECTOR OF THERAPY STATED "AFTER THE EAR BROKE DOWN, NURSING ASKED US TO ASSIST...WE ADDED THE COLLAR AND RECENTLY THE NECK PILLOW." ON 5/4/12 AT 11:00 THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED REGARDING THE DEVELOPMENT OF RESIDENT # 904 RIGHT EAR PRESSURE SORE. THE DON STATED, 'SPEAK WITH THE WOUND CARE NURSE." ON 5/4/12 AT 11:20 A.M., THE WOUND CARE NURSE WAS QUERIED REGARDING WHETHER INTERVENTIONS WERE IMPLEMENTED TO PREVENT THE DEVELOPMENT OF A PRESSURE SORE ON RESIDENT #904'S RIGHT EAR. THE WOUND CARE NURSE STATED, " THERE WERE NO SPECIFIC INTERVENTIONS PRIOR TO THE DEVELOPMENT OF THE PRESSURE ULCER. THERAPY BECAME INVOLVED AFTER THE EAR BROKE DOWN...THEY DO STRETCHING EXERCISES ON THE RESIDENT'S NECK AND ORDERED THE NECK PILLOW." THE DON WAS ASKED TO PROVIDE THE FACILITY'S PRESSURE SORE PREVENTION POLICY AND THE DON PRESENTED A SKIN PROCESS FLOW SHEET. ( )

REFER TO INTAKES MI 945 AND MI 159. BASED ON OBSERVATIONS, INTERVIEWS, AND RECORD REVIEWS, FACILITY STAFF FAILED TO PREVENT ACCIDENTS (1) BY INAPPROPRIATE TRANSFERS FOR 2 (#501 AND #503) OF 5 SAMPLED RESIDENTS REVIEWED FOR FALLS IN A TOTAL SAMPLE OF 10, RESULTING IN A FRACTURED LEFT ULNA (LARGER BONE OF FOREARM) FOR RESIDENT #501, AND (2) BY FAILING TO REDUCE ENVIRONMENTAL HAZARDS FOR 1 (#502) OF 5 SAMPLED RESIDENTS REVIEWED FOR SAFE ENVIRONMENT IN A TOTAL SAMPLE OF 10 AS WELL AS 2 (#56 AND #57) NONSAMPLED RESIDENTS, RESULTING IN EXTENSIVE BRUISES OF THE FACE FOR RESIDENT #502. FINDINGS INCLUDE: RESIDENT #501 RESIDENT #501, [AGE] years OLD, WAS admitted to the facility on [DATE], PER THE FACILITY ADMITTING RECORD. HOSPITAL RECORDS, DATED 2/7/12, INDICATED THAT RESIDENT #501 fell on [DATE] AT THE NURSING FACILITY AND INJURED HER LEFT SHOULDER AND LEFT KNEE. X-RAYS OF THE PELVIS, LEFT SHOULDER, LEFT ELBOW, AND LEFT KNEE NOTED NO FRACTURE OR DISLOCATION, BUT SOME OSTEOPENIA (REDUCED BONE MASS) AND ARTHRITIC CHANGES IN LOCATIONS. THE LEFT WRIST AND HAND X-RAYS NOTED AN ACUTE NONDISPLACED FRACTURE INVOLVING THE ULNAR STYLOID PROCESS (ASSOCIATED WITH WRIST FRACTURE AND LIGAMENT INJURIES). THE CT (COMPUTERIZED TOMOGRAPHY) SCAN OF THE HEAD SHOWED NO ACUTE PROCESS. THE CT SCAN OF THE CERVICAL (NECK AREA) SPINE SHOWED A POSSIBLE MILDLY DISPLACED FRACTURE. THE resident had a history of [REDACTED]. RESIDENT #501 WAS OBSERVED SITTING IN A WHEELCHAIR IN HER ROOM ON 2/29/12 AT 1:45 P.M. SHE WAS ALERT AND ORIENTED AND ABLE TO CARRY ON A CONVERSATION. HOWEVER, SHE WAS HESITANT TO COMMENT ON HER INJURIES OF 2/7/12. FACILITY PHYSICAL THERAPY NOTES, DATED 1/10/12, DOCUMENTED THAT RESIDENT #501 HAD SEVERE BACK PAIN RADIATING TO THE RIGHT LOWER EXTREMITY. THE RESIDENT, ACCORDING TO THE NOTE, REQUIRED MODERATE ASSISTANCE FOR MOVING FROM A SITTING TO STANDING POSITION. THE PHYSICAL THERAPY NOTE INDICATED THAT NURSING STAFF WERE TO TRANSFER THE RESIDENT USING A SARA LIFT. A SARA LIFT IS A BATTERY OPERATED DEVICE WHICH ALLOWS A CAREGIVER TO RAISE THE RESIDENT FROM A SITTING TO STANDING POSITION. THERE IS A SUPPORT SLING WHICH IS PLACED AROUND THE LOWER BACK. THE RESIDENT PUTS HIS FEET ON A FOOT SUPPORT. THERE IS A KNEEPAD WITH STRAPS. IN AN INTERVIEW ON 2/29/12 AT 2:40 P.M. THE OCCUPATIONAL THERAPIST (O.T.) SAID SHE HAD BEEN TREATING RESIDENT #501 IN THE THERAPY ROOM ON 2/7/12. THE O.T. SAID SHE TOOK THE RESIDENT BACK TO HER ROOM IN HER WHEELCHAIR. THE RESIDENT TOLD THE O.T. SHE NEEDED TO USE THE TOILET IMMEDIATELY. THE O.T. SAID SHE TRANSFERRED THE RESIDENT TO THE TOILET USING A ONE PERSON ASSIST RATHER THAN USING THE SARA LIFT. THE O.T. SAID THERAPY HAD BEEN WORKING ON THIS SKILL (ONE PERSON TRANSFER), BUT THE RESIDENT WAS NOT SAFE ENOUGH TO BE TRANSFERRED THIS WAY BY NURSING STAFF. THE O.T. SAID SHE (THE O.T.) DID NOT USE A GAIT BELT FOR THE TRANSFER OF RESIDENT #501 ACCORDING TO POLICY. CNA (CERTIFIED NURSING ASSISTANT) #10 ENTERED THE ROOM WHILE THE RESIDENT WAS ON THE TOILET, ACCORDING TO THE O.T., AND SAID SHE WOULD ASSIST THE RESIDENT OFF THE TOILET. THE O.T. SAID SHE DID NOT DISCUSS TRANSFER INTERVENTIONS WITH THE CNA AT THAT TIME. THE O.T. SAID, "CNAS ARE EXPECTED TO USE DIRECTIONS GIVEN TO THEM ON THE RESIDENT INFORMATION SHEET, NOT WHAT THEY SEE US DO." THE FACILITY INVESTIGATION REPORT, DATED 2/10/12, STATED THE FOLLOWING: CNA #10 ASSISTED RESIDENT #501 FROM THE TOILET BACK TO HER WHEELCHAIR USING A ONE PERSON ASSIST WITHOUT A GAIT BELT. "THE CNA PROCEEDED TO TAKE THE RESIDENT TO THE SHOWER ROOM AND AS SHE ATTEMPTED TO TRANSFER RESIDENT FROM WHEELCHAIR TO THE SHOWER CHAIR, RESIDENT'S KNEES BUCKLED AND RESIDENT fell on THE FLOOR HITTING HER LEFT SHOULDER AND LEFT SIDE OF HER FOREHEAD. PATIENT INFORMATION SHEET INDICATED THAT A SARA LIFT SHOULD HAVE BEEN USED TO TRANSFER THE RESIDENT." AN ATTEMPT TO CONTACT CNA #10 WAS UNSUCCESSFUL. ACCORDING TO HER WRITTEN STATEMENT FOR THE NURSING FACILITY, THE CNA DOCUMENTED THAT SHE TRANSFERRED RESIDENT #501 FROM THE TOILET TO THE WHEELCHAIR AND TOOK HER TO THE SHOWER ROOM. "I TOOK HER TO THE SHOWER ROOM. I TOOK HER CLOTHES OFF AND WHEN I STOOD HER UP, I HAD MY HANDS ON THE BACK OF HER PANTS, HER KNEES BENT, SHE (RESIDENT) SAID "I DON'T WANT TO FALL." SHE (RESIDENT) ENDED UP KNEELING, AND LEANED OVER TO THE SIDE. I (CNA #10) WAS STILL BEHIND HER, HOLDING HER. HER HEAD TOUCHED THE GROUND. I DID NOT USE A GAIT BELT, I DID NOT USE THE SARA LIFT. I DID NOT HAVE MY PIW (A RESIDENT INFORMATION WORKSHEET UPDATED FREQUENTLY AS CHANGES IN THE RESIDENT'S CONDITION OCCUR.). I ASSUMED THAT SHE WAS GOING TO BE OK WITH THE TRANSFER BECAUSE OF WHAT THE THERAPIST TOLD ME." ACCORDING TO THE CNA'S DOCUMENTATION OF THE INCIDENT, "THE THERAPIST SAID, YOU CAN GET HER UP FROM THE TOILET. I ASKED IF SHE COULD WALK, SHE SAID "NO, BUT SHE CAN STAND". THE PIW, DATED 2/8/12 AT 4:34 A.M., INDICATED THAT RESIDENT #501 WAS hospitalized . ACCORDING TO THE PIW, TRANSFERS OF THE RESIDENT WERE TO BE DONE WITH THE SARA LIFT. THE DON (DIRECTOR OF NURSING) TOOK A STATEMENT FROM RESIDENT #501 ON 2/7/12, ACCORDING TO THE FACILITY INVESTIGATION REPORT. THE STATEMENT READ, "THE CNA TOOK ME TO THE SHOWER ROOM, SHE TOOK MY CLOTHES OFF, SHE ATTEMPTED TO TRANSFER ME TO THE SHOWER CHAIR, MY KNEES BUCKLED. THE CNA HAD ME FROM THE BACK - HOLDING MY PANTS. MY KNEES WENT DOWN, I LEANED TO THE SIDE AND HIT MY HEAD (LEFT SIDE) AND LEFT SHOULDER ON THE TOILET." THE SURVEYOR ATTEMPTED TO INTERVIEW RESIDENT #501 ON 2/29/12 AT 1:45 P.M. RESIDENT #501 SAID THE CNA TOOK HER TO THE SHOWER ROOM AND LEFT HER THERE BY HERSELF, AND SHE fell . THE RESIDENT SAID SHE SUSTAINED "A HAIRLINE FRACTURE OF MY HAND. THE CAST WAS REMOVED YESTERDAY." THE RESIDENT SAID SHE WAS "SCARED TO DEATH" OF HAVING ANOTHER SHOWER. SHE SAID SHE WOULD NOT HAVE ANOTHER SHOWER AT THE NURSING HOME. THE RESIDENT BECAME ANXIOUS AND REFUSED TO DISCUSS THE INCIDENT ANY FURTHER. RESIDENT #501 WAS TRANSFERRED TO THE HOSPITAL FOLLOWING THE FALL. CNA #10, ACCORDING TO A "LIFT PROGRAM SKILLS CHECK-OFF SHEET" HAD SUCCESSFULLY COMPLETED PROCEDURES FOR OPERATING THE SARA LIST AND DEMONSTRATED THE TASKS INVOLVED TO TRANSFER A RESIDENT. THE CNA WAS TERMINATED BECAUSE SHE "FAILED TO FOLLOW APPROPRIATE TRANSFER TECHNIQUE ON THE PIW RESULTING ON PATIENT TO FALL AND HAVE A WRIST FRACTURE", ACCORDING TO THE EMPLOYEE WARNING NOTICE, DATED 2/9/12. THE O.T. RECEIVED A "WARNING NOTICE" ON 2/9/12 FOR TRANSFERRING A RESIDENT WITHOUT THE USE OF A GAIT BELT. ( ) RESIDENT #503 ACCORDING TO THE FACILITY ADMITTING RECORD, RESIDENT #503, A [AGE] year OLD WOMAN, WAS ORIGINALLY admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. REVIEW OF THE NURSING NOTES FOR RESIDENT #503, DATED 1/20/2012 TO 1/31/2012, REVEALED THAT THE NOTES DID NOT DOCUMENT A FALL OR INJURY. A SKILLED NURSING NOTE, DATED 1/30/2012, INDICATED THE RESIDENT'S "LEFT LEG APPEARS SWOLLEN." PHYSICIAN ORDERS, DATED 1/30/2012, INCLUDED A DOPPLER STUDY OF LEFT LEG (A TEST FOR BLOOD CLOT) AND X-RAYS OF HER KNEE AND LEG. THE DOPPLER REPORT, RECEIVED ON 1/30/2012 AT 2:00 PM, WAS NEGATIVE FOR DEEP VEIN THROMBOSIS (BLOOD CLOT). THE X-RAY REPORT OF 1/30/2012 INDICATED ACUTE MILDLY DISPLACED SUPRACONDYLAR (ABOVE THE KNEE) FRACTURE OF THE FEMUR. THE PHYSICIAN WAS NOTIFIED OF THE RESULTS, AND THE RESIDENT WAS TRANSFERRED TO A LOCAL hospital on [DATE]. ACCORDING TO AN UNDATED WRITTEN STATEMENT, WHEN THE DIRECTOR OF NURSING (DON) INTERVIEWED THE RESIDENT'S DAUGHTER, SHE (THE DAUGHTER) SAID THE RESIDENT TOLD HER THAT "WHEN A CNA GOT HER UP TO HER WHEELCHAIR, THEY LOST HER BALANCE AND DROPPED HER." OBSERVATION OF RESIDENT #503 ON 2/29/2012 AT 2:30 PM, REVEALED THE RESIDENT LYING IN A 42 INCH LOW BED, EYES CLOSED. RESIDENT #503 RESPONDED TO HER NAME. MATS WERE IN PLACE ON THE FLOOR ON BOTH SIDES OF BED, THE RESIDENT ' S CALL LIGHT WAS WITHIN HER REACH, AND A SENSOR PAD WAS OBSERVED TO BE IN PLACE. WHEN ASKED WHAT HAPPENED TO HER LEG, THE RESIDENT RESPONDED, "IT BROKE WHEN I fell ." THE RESIDENT INFORMATION SHEET (RIS) INDICATED THE NURSING STAFF WERE TO TRANSFER THE RESIDENT USING A SARA LIFT WITH 1 PERSON ASSIST. A SARA LIFT IS A BATTERY OPERATED DEVICE WHICH ALLOWS A CAREGIVER TO RAISE THE RESIDENT FROM A SITTING TO STANDING POSITION. THERE IS A SUPPORT SLING WHICH IS PLACED AROUND THE LOWER BACK. THE RESIDENT PUTS HER FEET ON A FOOT SUPPORT PLATFORM. THERE IS A KNEEPAD WITH STRAPS THAT SECURED THE CALVES. CERTIFIED NURSING ASSISTANT (CNA) #13 WAS INTERVIEWED BY PHONE ON 2/29/12, AT 3:15 P.M. CNA #13 SAID SHE WAS ASSIGNED TO THE RESIDENT ON 1/29/2012 FOR A DOUBLE SHIFT. ACCORDING TO CNA #13, SHE (#13) TRANSFERRED RESIDENT #503 THREE TIMES ON THAT DAY (1/29/12). DURING THE DAY SHE TRANSFERRED THE RESIDENT, THE FIRST TIME, BY STANDING AND PIVOTING (TURNING) THE RESIDENT WITH THE ASSISTANCE OF CNA #11. A SECOND TIME SHE TRANSFERRED THE RESIDENT WITH THE SARA LIFT, BECAUSE NO ONE ELSE WAS AVAILABLE TO HELP. SHE SAID THE RESIDENT'S FOOT KEPT SLIPPING OFF THE PLATFORM, BUT SHE DID NOT THINK THE RESIDENT WAS HURT. THE RESIDENT DID NOT COMPLAIN OF PAIN. LATER IN THE EVENING, SOMETIME BETWEEN 8 AND 8:30 P.M., SHE TRANSFERRED THE RESIDENT FOR A THIRD TIME. ON THIS OCCASION, CNA #13 STATED THAT SHE (#13) TRANSFERRED HER ALONE, AGAIN WITH STANDING AND PIVOTING. SHE SAID THE RIS (RESIDENT INFORMATION SHEET) AND KIOSK (COMPUTER CHARTING RECORD) DID NOT MATCH REGARDING THE TRANSFER TECHNIQUE TO BE USED, SO "I DID THE BEST I COULD." CNA #13 DENIED DROPPING RESIDENT #503. CNA #11 WAS INTERVIEWED ON 2/29/2012 AT 2:30 PM. SHE SAID SHE HELPED CNA #13 TRANSFER RESIDENT #503 USING A GAIT BELT. SHE SAID THE PIW INDICATED HOW THE RESIDENT SHOULD BE TRANSFERRED. SHE DID NOT CHECK THE PIW OR THE KIOSK HERSELF. CNA #11 FELT SAFE WITH THIS TRANSFER. THE RESIDENT DID NOT COMPLAIN OF PAIN DURING THE TRANSFER. RESIDENT #503 WAS REadmitted to the facility on [DATE] AFTER SURGERY TO REPAIR A FRACTURED FEMUR (LEG BONE). THE HOSPITAL TRANSFER RECORD, DATED 2/6/2012, INDICATED RESIDENT #503 WAS admitted WITH [DIAGNOSES REDACTED]. A STATEMENT FROM THE ATTENDING PHYSICIAN, DATED 1/31/2012, OBTAINED BY THE DIRECTOR OF NURSING, INDICATED THAT "ANY TWISTING IN THE BED OR WHEELCHAIR COULD HAVE CAUSED THIS FRACTURE DUE TO HER MEDICAL CONDITIONS." A REVIEW OF THE EMPLOYEE FILE FOR CNA #13 INDICATED THAT SHE RECEIVED THREE ONE-ON-ONE INSERVICES FOR LIFT AND TRANSFER TECHNIQUES DATED 10/29/2010, 12/6/2010, AND 2/8/2011. RESIDENT #502 A REVIEW OF THE ADMISSION RECORD INDICATED RESIDENT #502 WAS A [AGE] year OLD WOMAN, admitted to the facility on [DATE]. THE HISTORY AND PHYSICAL, DATED 12/29/2011, DOCUMENTED [DIAGNOSES REDACTED]. ACCORDING TO THE NURSES NOTES, DATED 2/16/2012, CNA #12 NOTIFIED THE NURSE THAT WHEN SHE PULLED THE CURTAIN WHILE PROVIDING CARE TO RESIDENT #502'S ROOMMATE, SHE (#12) HIT THE POLE HOLDING A TUBE FEEDING PUMP, WHICH fell on RESIDENT #502, HITTING HER ON THE LEFT SIDE OF THE FACE. ICE AND COLD COMPRESSES WERE APPLIED. DOCUMENTATION INDICATED RESIDENT #502 RECEIVED A LUMP TO THE LEFT BROW AND A LACERATION BELOW THE LEFT EYE. TOPICAL ANTIBIOTIC OINTMENT WAS APPLIED AND NEUROLOGICAL CHECKS WERE STARTED. OBSERVATION OF RESIDENT #502, ON 2/29/2012 AT 11:25 AM, WHILE IN THE THERAPY ROOM, REVEALED THE RESIDENT SITTING IN A HIGH BACKED WHEELCHAIR, HER EYES CLOSED. AN ECCHYMOTIC (BLUE OR PURPLISH PATCH) AREA WAS NOTED OVER HER LEFT BROW AND CHEEK. ACCORDING TO PTA #15 (PHYSICAL THERAPY ASSISTANT), THE RESIDENT DOES NOT RESPOND TO OTHERS. ON 3/2/2012 AT 10:30 AM, DURING A PHONE INTERVIEW, CNA #12 SAID SHE WAS MAKING HER LAST ROUNDS FOR THE NIGHT. WHILE STARTING TO PROVIDE CARE TO THE RESIDENT IN BED A, SHE PULLED THE PRIVACY CURTAIN CLOSED. THE TELEVISION EXTENSION ARM WAS IN THE DOWN POSITION, AND SHE PUSHED IT OVER, AND THE TELEVISION HIT THE TUBE FEEDING POLE. THE POLE LANDED ON RESIDENT #502. CNA #12 SAID THAT SHE HEARD RESIDENT #502 SCREAM. SHE SAW THAT THE CURVED PART OF THE POLE HOOK HAD LANDED ON THE RESIDENT'S EYE AND THERE WAS BLOOD ON HER FACE. SHE CALLED FOR THE NURSE. SHE HAD TO MOVE THE OXYGEN CONCENTRATOR, ABOUT THE SIZE OF A SMALL END TABLE, AND THE TELEVISION OUT OF THE WAY TO GET THE POLE OFF THE RESIDENT. THERE WERE 2 MATS ON THE FLOOR BETWEEN THE BEDS AT THE TIME OF THE INCIDENT. ACCORDING TO THE CNA, THE POLE WAS SITTING ON THE MAT, CAUSING THE POLE TO BE UNBALANCED. DURING A TOUR OF THE UNIT WITH ASSISTANT DIRECTOR OF NURSING (ADON) ON 3/2/2012 AT 9:30 AM, RESIDENT #502'S ROOM WAS OBSERVED. THE TUBE FEEDING POLE WAS LOCATED BETWEEN THE TWO BEDS AND WAS OBSERVED TO BE STURDY. THERE WERE TWO TELEVISION SETS IN THE ROOM, EACH SUSPENDED ON MOVABLE EXTENSION ARMS, LOCATED ON THE WALL IN THE SPACE BETWEEN THE TWO BEDS. THE EXTENSION ARM ALLOWED EACH TELEVISION SET TO OVER ONE OF THE BEDS. AN OXYGEN CONCENTRATOR WAS LOCATED ON THE FLOOR IN FRONT OF THE TUBE FEEDING POLE AND BELOW THE TELEVISION. LEANING ON THE WALL ACROSS FROM THE BEDS, WERE 4 FLOOR MATS, TO BE PLACED ON THE FLOOR ON EITHER SIDE OF EACH BED WHEN THE RESIDENT WAS IN THE BED. THE SPACE BETWEEN THE BEDS WAS APPROXIMATELY 28 TO 30 INCHES. IN ANOTHER ROOM, ON THE SAME UNIT, TWO RESIDENTS, #56 AND #57, WERE OBSERVED IN THEIR RESPECTIVE BEDS. TWO TELEVISION SETS ON EXTENSION ARMS WERE LOCATED BETWEEN THE BEDS ALONG WITH A POLE HOLDING A TUBE FEEDING BAG. RESIDENT #57, IN BED "B", WAS WATCHING TV. RESIDENT #56, IN BED "A" HAD THE TV OFF, AND IT WAS BEHIND THE PRIVACY CURTAIN SEPARATING BED "A" FROM BED "B". WHEN THE ARM OF THE TV FOR BED "A" WAS LIFTED, IT DRIFTED DOWNWARD, HAVING THE POTENTIAL OF HITTING THE TUBE FEEDING POLE OF BED "B". THERE WERE TWO MATS ON THE FLOOR BETWEEN THE BEDS. THE POLE FOR THE TUBE FEEDING HAD 3 LEGS ON THE FLOOR AND 1 LEG ON THE MAT, MAKING IT OFF-BALANCED. THE DISTANCE BETWEEN BEDS WAS THE 28 TO 30 INCHES. A REVIEW OF THE EMPLOYEE FILE FOR CNA #12 INDICATED THAT SHE WAS DISCIPLINED ON 2/16/2012, REGARDING THE INJURY OF RESIDENT #502. ( ) ( )

THIS CITATION REFERS TO INTAKE NUMBER MI 077. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO SUPERVISE AND MONITOR 2 OF 6 SAMPLED RESIDENTS (#502 AND #503) IDENTIFIED BY THE FACILITY AS HAVING DEMENTIA/ALZHEIMERS DISEASE, WHO EXITED THE FACILITY THROUGH FIRST FLOOR EXIT DOORS WITHOUT THE KNOWLEDGE OF FACILITY STAFF RESULTING IN, IMMEDIATE JEOPARDY FOR RESIDENTS #502 AND #503 AND PLACING 31 OTHER RESIDENTS, diagnosed with [REDACTED]. FINDINGS INCLUDE: RESIDENT #502: RESIDENT#502, AN [AGE] year OLD FEMALE, WAS admitted on [DATE] PER THE FACE SHEET. A REVIEW OF THE CLINICAL RECORD FOR RESIDENT #502 REVEALED A PSYCHOLOGY CONSULT DATED 8/30/10 WHICH DOCUMENTED RESIDENT #502 WAS ORIENTED TO PERSON AND PLACE ONLY, SHORT TERM MEMORY LOSS WAS SEVERE, LONG TERM MEMORY LOSS WAS MODERATE, SELF-AWARENESS/SAFETY JUDGEMENT WAS SEVERE WITH NO INSIGHT. MOOD WAS DOCUMENTED AS ANXIETY, DEPRESSION, LOSS, TRAUMA, FEAR, ANGER, IRRITABLE, SUSPICIOUS, BITTER, DEFENSIVE AND "WONDERS WHY HERE?" THE CONSULT DOCUMENTED BEHAVIORS AS RESTLESS, AGITATED, ANGRY, VERBAL AGGRESSION WITH SUNDOWNING AND NOTED "CONFUSION ADDS TO ANGER AND RESTLESSNESS. [DIAGNOSES REDACTED]. THE CONSULT RECOMMENDED BEHAVIORAL THERAPY/STAFF INTERVENTIONS, PSYCHIATRY, AND OVERALL HELP WITH DECISION MAKING. RECORD REVIEW OF THE MINIMUM DATA SET ((MDS) dated [DATE] INDICATED RESIDENT #502 HAD SHORT TERM MEMORY PROBLEMS AND COGNITIVE SKILLS WERE MODERATELY IMPAIRED. RESIDENT # 502 SELF PROPELLED HER WHEELCHAIR. SHE REQUIRED EXTENSIVE ASSISTANCE OF 1 FOR ACTIVITIES OF DAILY LIVING (ADL'S). THE RESIDENT ASSESSMENT PROTOCOL (RAP) DATED 8/30/2010 REVEALED; RESIDENT #502 WAS MORE CONFUSED AND HAD A NEW [DIAGNOSES REDACTED]. ON 10/15/10 AT 1:45 PM, PER A PHONE INTERVIEW, THE SURVEYOR INTERVIEWED THE PSYCHOLOGIST WHO PERFORMED THE CONSULTATION ON 8/30/10. SHE STATED SHE RECALLED RESIDENT #502 AND HER SON VERY WELL. THE PSYCHOLOGIST STATED "RESIDENT #502 HAD A SIGNIFICANT DECLINE IN COGNITION FROM HER PREVIOUS ADMISSION AT THE FACILITY. SHE WAS diagnosed with [REDACTED]. "THE PSYCHOLOGIST STATED, "I USUALLY DO NOT SEE THAT DEGREE OF DECLINE, UNLESS THERE IS DELIRIUM OR A CVA (STROKE) OR OTHER CONTRIBUTING FACTOR. RESIDENT #502 WAS EXTREMELY ANXIOUS AND DID NOT UNDERSTAND WHY SHE WAS AT THE FACILITY AND WAS ASKING FOR FAMILY SO SHE COULD GO HOME. SHE WAS TOO CONFUSED TO MAKE MEDICAL, FINANCIAL, SAFETY OR CARE NEED DECISIONS. SHE NEEDED FAMILY INTERVENTION, THERE WAS NO WAY SHE COULD HAVE DONE IT ON HER OWN". THE PSYCHOLOGIST STATED SHE RECOMMENDED, " PSYCHIATRY FOLLOW-UP AND OVERALL ASSISTANCE WITH ALL DECISION MAKING". SHE STATED SHE MET WITH THE FACILITY TEAM AND GAVE THEM HER RECOMMENDATIONS FOR TREATMENT AND STAFF INTERVENTIONS. RECORD REVIEW OF RESIDENT #502'S CLINICAL RECORD REVEALED NO ELOPEMENT ASSESSMENT OR CARE PLAN, DESPITE RESIDENT #502'S STATEMENTS TO THE PSYCHOLOGIST OF NOT UNDERSTANDING WHY SHE WAS AT THE FACILITY AND WANTING TO GO HOME. RESIDENT #502 DID NOT HAVE A WANDERGUARD BRACELET (AN ALARM THAT SOUNDS WHEN THE PERSON WEARING IT APPROACHES AN ALARMED DOOR) ON HER PERSON. RECORD REVIEW OF THE FACILITY INCIDENT REPORT DATED 9/20/10 REVEALED, ON 9/20/10 AT 9:30 PM, RESIDENT #502 WAS OBSERVED IN HER WHEELCHAIR OUTSIDE THE FACILITY, ACROSS THE STREET (A FIVE LANE ROAD) AT THE GAS STATION. THE REPORT IDENTIFIED THE INCIDENT AS AN ELOPEMENT. IT DOCUMENTED RESIDENT #502 EXITED THE FACILITY, WITHOUT NOTIFYING STAFF, WITH RECEIVING POSSIBLE ASSISTANCE FROM FAMILY OR AN UNKNOWN PERSON. ON 10/7/10 AT 11:05 AM, IN A PHONE INTERVIEW, CERTIFIED NURSE ASSISTANT (CNA #1) STATED THAT ON THE EVENING OF 9/20/10 AFTER THE RECEPTIONIST WAS GONE AND IT WAS DARK, HE AND ANOTHER STAFF NURSE WERE ALERTED BY A VISITOR KNOCKING ON THE FACILITY SOUTH DOOR WHO STATED THAT " A RESIDENT (#502) WAS IN THE STREET WAVING TRAFFIC DOWN". CNA #1 STATED HE LOOKED OUT THE SOUTH DOOR AND SAW A MAN PUSHING RESIDENT #502 IN HER WHEELCHAIR UP THE RAMP OF THE GAS STATION ACROSS THE STREET (A FIVE LANE ROAD). CNA #1 SAID HE YELLED, "WHAT ARE YOU DOING", AND BY THE TIME "TRAFFIC CLEARED" AND HE WAS ABLE TO CROSS THE STREET, THE MAN WAS PUSHING HER TOWARDS HIS TRUCK. CNA #1 STATED THE MAN TOLD HIM "SHE WAS TRYING TO GET A RIDE HOME". CNA #1 STATED IT WAS NOT HER SON AND HE DID NOT RECOGNIZE THE MAN. CNA #1 SAID HE TOOK RESIDENT #502 AND BEGAN PUSHING HER BACK TO THE FACILITY WHILE SHE WAS YELLING AND SCREAMING "I DON'T WANT TO GO BACK". CNA #1 IDENTIFIED THE VISITOR WHO HAD ALERTED HIM THAT RESIDENT #502 WAS OUTSIDE THE FACILITY TO THE SURVEYOR AND STATED HE BELIEVED HE HAD IDENTIFIED HIM TO THE DIRECTOR OF NURSING ON THE NIGHT OF THE INCIDENT. HE WAS NOT ABLE TO IDENTIFY THE MAN AT THE GAS STATION. ON 10/7/10 AT 12:00 PM AND 10/8/10 AT 9:00 AM, IN A PHONE INTERVIEW, VISITOR # 3, WHO ALERTED CNA #1 OF RESIDENT #502'S ELOPEMENT, STATED THAT ON 9/20/10 JUST AS IT WAS GETTING DARK ABOUT 8:00 PM, HE WAS COMING TO THE FACILITY TO VISIT ANOTHER RESIDENT AND "SAW AN OLD FRAIL LADY IN A WHEELCHAIR WHEELING HERSELF INTO THE ROAD". HE STATED HE ATTEMPTED TO PUSH HER BACK UP TO THE FACILITY BUT SHE WAS RESISTING, PUTTING HER FEET DOWN AND YELLING " I DON'T WANT TO GO BACK IN THERE THEY ARE TRYING TO KILL ME". HE STATED HE PUSHED HER UP TO THE CURB OF THE SIDEWALK, BUT WAS AFRAID SHE WAS GOING TO GET HURT SO HE LEFT HER AND HE RAN TO THE SOUTH DOOR, WHICH WAS LOCKED, KNOCKED AND TOLD STAFF SHE WAS OUTSIDE. HE STATED BY THE TIME STAFF RAN OUT SHE (RESIDENT #502) WAS ACROSS THE STREET (A FIVE LANE ROAD) GOING UP THE RAMP OF THE GAS STATION. VISITOR #3 STATED "SHE (RESIDENT #502) COULD WHEEL HERSELF PRETTY GOOD. I WAS SURPRISED AT HOW FAST SHE WENT". HE STATED HE DID NOT SEE ANYONE WITH HER. VISITOR #3 SAID THAT HE WAS WEARING A BASEBALL CAP AT THE TIME. ON 10/7/10 AT 11:30 AM, AND 12:30 PM, IN A PHONE INTERVIEW, CNA # 2 AND CNA #4, RESPECTIVELY STATED THAT ON 9/20/10 BETWEEN 8:00- 9:00 PM, THE NORTH UNIT EXIT DOOR ALARM SOUNDED, BOTH CNA'S LOOKED OUT AND OBSERVED A MAN IN A HAT AND SWEATER, PUSHING RESIDENT # 502 TOWARDS THE SOUTH DOOR. CNA# 2 STATED SHE ASSUMED THE MAN WAS RESIDENT #502'S SON, AND BOTH CNA'S RETURNED TO WORK. CNA #4 STATED ABOUT 10-30 MINUTES AFTER RETURNING TO WORK, SHE HEARD ANOTHER CNA (CNA # 6) SAY (RESIDENT #502) IS OUT AND POINT ACROSS THE STREET TO THE GAS STATION. CNA # 4 STATED SHE OBSERVED CNA # 1 ACROSS THE STREET WITH (RESIDENT #502) AND THE RESIDENT WAS "SWINGING AT HIM". CNA #4 WENT ACROSS THE STREET AND HELPED BRING RESIDENT #502 BACK TO THE FACILITY. SHE STATED SHE DID NOT SEE ANYONE ELSE AT THE GAS STATION. WHEN QUERIED BY THE SURVEYOR CNA #4 STATED RESIDENT #502 SELF PROPELLED HER WHEELCHAIR UP AND DOWN THE HALLS DAILY. CNA #2 STATED SHE LATER HEARD RESIDENT #502 WAS FOUND ACROSS THE STREET AT THE GAS STATION, AND STATED "I GUESS I SHOULD NOT HAVE LEFT (AND RETURNED TO WORK) UNTIL SHE (RESIDENT #502) WAS INSIDE". ON 10/7/10 AT 2:15 PM PER PHONE, CNA # 6 STATED THAT ON 9/20/10 IT WAS DARK, ABOUT 7:50-8:00 PM WHEN A VISITOR CAME IN THE SOUTH DOOR AND STATED ONE OF YOUR PATIENTS IS ACROSS THE STREET AT THE GAS STATION. CNA #6 STATED HE LOOKED OUT BUT COULDN'T SEE BECAUSE IT WAS DARK. HE SAID HE WENT OUT THE SOUTH DOOR AND OBSERVED RESIDENT #502 IN HER WHEELCHAIR NEAR THE CURB AT THE GAS STATION ACROSS THE STREET WITH CNA #1. HE DID NOT SEE ANYONE ELSE IN THE AREA. HE WENT ACROSS THE STREET TO ASSIST CNA #1 AND STATED RESIDENT #502 WAS AGITATED AND SAID "I'M NOT GOING ANYWHERE". WHEN QUERIED BY THE SURVEYOR CNA # 6 STATED RESIDENT #502 'SELF PROPELLED HERSELF UP AND DOWN THE HALLS AND INTO THE DINNING ROOM EVERY DAY". ON 10/8/10 AT 11:35 AM, IN A PHONE INTERVIEW, NURSE #12 STATED THAT ON 9/20/10 APPROXIMATELY 8:00-9:00 PM SHE WAS ALERTED BY ANOTHER NURSE THAT STAFF WAS BRING RESIDENT #502 BACK INTO THE FACILITY. WHEN SHE LOOKED OUT THE DOOR SHE OBSERVED CERTIFIED NURSING ASSISTANTS (CNA'S) (WHO WERE NOT IDENTIFED BY THE NURSE) ACROSS THE STREET IN THE DRIVEWAY OF THE GAS STATION WITH RESIDENT #502. WHEN THE CNA'S BROUGHT RESIDENT #502 BACK IN, NURSE #12 STATED SHE ASSESSED RESIDENT #502 TO BE UNINJURED AND RESIDENT #502 SAID "SHE JUST WANTED TO GO HOME". NURSE #12 STATED SHE ASKED RESIDENT #502 HOW SHE GOT OUTSIDE OR IF SHE HAD SEEN HER SON AND RESIDENT #502 WAS UNABLE TO EXPLAIN. NURSE #12 STATED CNA'S #2 AND #4 TOLD HER THEY HAD OBSERVED A MAN IN A CAP PUSHING RESIDENT #502 IN HER WHEELCHAIR OUTSIDE IN FRONT OF THE BUILDING EARLIER AND HAD ASSUMED IT WAS HER SON. ON 10/8/10 AT 8:30 AM, IN A PHONE INTERVIEW, RESIDENT #502'S SON STATED THE FACILITY CALLED HIM ON 9/20/10 BETWEEN 9:00 AND 10:00 PM AND INFORMED HIM HIS MOTHER WAS FOUND OUTSIDE THE FACILITY. HE STATED THEY ASKED HIM IF HE HAD BEEN THERE AND HE TOLD THEM NO. HE STATED THE NEXT DAY HE WENT TO THE FACILITY AND MET WITH THE DIRECTOR. HE STATED IT WAS DEFINITELY NOT HIM WHO HAD TAKEN HIS MOTHER (RESIDENT #502) OUT OF THE FACILITY ON LOA, AND HE DID NOT KNOW WHO IT MAY HAVE BEEN. THE SON STATED THE STAFF ASKED HIM TO QUESTION HIS MOTHER, AND HE TRIED BUT SHE JUST KEPT GETTING CONFUSED. HE STATED HIS MOTHER TOLD HIM A MAN HAD PUSHED HER, AND THEN ASKED HER SON IF IT WAS HIM. ON 10/8/10 AT 12:05 PM, PHYSICAL THERAPIST # 13 STATED RESIDENT # 502 WAS ABLE TO SELF PROPEL HER WHEELCHAIR USING HER FEET FROM THERAPY TO HER ROOM (APPROXIMATELY 100 FEET) SLOWLY. HE REVIEWED THE 9/14/10 PHYSICAL THERAPY EVALUATION SHEET, AND STATED IT DOCUMENTED RESIDENT #502'S WHEELCHAIR MOBILITY AS, MODIFIED INDEPENDENCE, ABLE TO SELF PROPEL SLOWLY (EXTRA TIME /DEVICE REQUIRED). ON 10/8/10 THE SURVEYOR OBSERVED RESIDENT #502 SELF PROPEL IN HER WHEELCHAIR FROM HER ROOM TO THE TV ROOM USING HER FEET AND HANDS (APPROXIMATELY 70-80 FEET) IN A APPROXIMATELY 2-3 MINUTES. THE RESIDENT, QUERIED BY THE SURVEYOR, WAS UNABLE TO ANSWER QUESTIONS ABOUT THE INCIDENT. RESIDENT #503: RESIDENT #503, A [AGE] year OLD FEMALE, WAS admitted to the facility on [DATE] PER THE FACE SHEET. A 12/15/09 PHYSICIAN HISTORY AND PHYSICAL DOCUMENTED [DIAGNOSES REDACTED].#503 ' S COGNITIVE SKILLS WERE MODERATELY IMPAIRED. SHE WAS ABLE TO SELF PROPEL HER WHEELCHAIR AND REQUIRED EXTENSIVE ASSISTANCE OF 1 FOR ADLS. THE 8/26/10 RAP REVEALED RESIDENT # 503 HAD ALZHEIMER'S DEMENTIA WITH SHORT AND LONG TERM MEMORY LOSS. STAFF WAS TO ANTICIPATE HER NEEDS. RECORD REVIEW OF physician progress notes [REDACTED]. RECORD REVIEW REVEALED THAT RESIDENT #503 WAS NOT ASSESSED TO BE AN ELOPEMENT RISK, SHE WAS NOT WEARING A WANDERGUARD BRACELET, AND NO CARE PLAN WAS NOTED FOR ELOPEMENT RISKS FOR RESIDENT #503. RECORD REVIEW OF THE FACILITY INCIDENT REPORT REVEALED THAT ON 8/1/10 AT 6:45 PM, RESIDENT #503 WAS OBSERVED OUTSIDE THE FACILITY SELF PROPELLING IN HER WHEELCHAIR. THE INCIDENT REPORT REVEALED A VISITOR WHO WAS UNAWARE RESIDENTS NEEDED TO BE ACCOMPANIED BY STAFF, ALLOWED THE RESIDENT TO GO OUT TO THE FRONT PORCH. RECORD REVIEW OF NURSE'S NOTE DATED 8/1/10 AT 6:45 PM AND SIGNED BY RESIDENT #503 ' S NURSE (#16) REVEALED, A VISITOR (UNIDENTIFIED) CAME IN AND INFORMED HER (NURSE #16) THAT A RESIDENT WAS OUTSIDE THE SOUTH DOOR OF THE BUILDING. NURSE #16 OBSERVED RESIDENT OUTSIDE SELF PROPELLING IN WHEELCHAIR. IN AN INTERVIEW ON 10/8/10 AT 1:25 PM NURSE # 16 STATED THAT ON 8/1/10 IN THE AFTERNOON A VISITOR CAME IN AND TOLD HER RESIDENT #503 WAS OUTSIDE (BY THE FRONT DOOR) AND SHE (NURSE #16) ASSUMED SOMEONE HAD LET HER OUT. NURSE #16 STATED SHE WAS NOT AWARE (RESIDENT # 503) WAS OUTSIDE UNTIL THE VISITOR INFORMED HER. SHE STATED RESIDENT #503 WAS OUT FRONT AT THE SOUTH DOOR (WHICH IS UNALARMED UNTIL 8:00-8:30 PM). RESIDENT #503 WAS RETURNED TO THE FACILITY UNHARMED, BY NURSE #16. NURSE #16 WAS NOT ABLE TO IDENTIFY THE VISITOR. ON 10/8/10 AT 2:40 PM, IN A PHONE INTERVIEW, RESIDENT # 503'S SON STATED THE FACILITY NOTIFIED HIM BY PHONE ON THE EVENING OF 8/1/10 THAT A VISITOR HAD INFORMED STAFF HIS MOTHER (RESIDENT #503) HAD APPARENTLY WHEELED HERSELF OUTSIDE IN FRONT OF THE BUILDING. WHEN QUERIED BY THE SURVEYOR AS TO WHETHER THE FACILITY INFORMED HIM OF HOW SHE GOT OUT HE STATED "I GUESS THEY WERE NOT OBSERVING HER". HE STATED RESIDENT #503 WAS ABLE TO SELF PROPEL IN HER WHEELCHAIR. ON 10/7/10 AT 1:40 PM THE SURVEYOR WITH THE DON (DIRECTOR OF NURSING) TOURED AND OBSERVED ALL OF THE FACILITY EXIT DOORS. THE DON STATED THE NORTH AND SOUTH MAIN DOORS WERE UNLOCKED AND UNALARMED FROM 8:00AM TO 8:00-8:30 PM. EXCEPT FOR RESIDENTS WITH SECURE CARE BRACELETS, VISITORS, STAFF AND RESIDENTS CAN ENTER AND EXIT THROUGH THE NORTH AND SOUTH DOORS WITHOUT SOUNDING AN ALARM. THE NORTH DOOR IS MONITORED BY A RECEPTIONIST FROM 8:00 AM TO 8:00-8:30 PM Monday THROUGH Friday, AND FROM 10:00 AM TO 5:00-5:30 PM ON Saturday AND Sunday. ALL FACILITY EXIT DOORS HAVE A NOTICE POSTED TO ALERT VISITORS/ VENDORS NOT TO ALLOW ANYONE TO EXIT WITHOUT VERIFYING WHO THEY ARE. IT ALSO DIRECTS VENDORS AND VISITORS TO SIGN IN, AND RESIDENTS TO CHECK WITH THEIR NURSE AND SIGN OUT BEFORE EXITING THE BUILDING. ON THURSDAY 10/7/10 AT 9:00AM, THE SURVEYOR ENTERED THE FACILITY THROUGH THE NORTH DOOR (MAIN) ENTRANCE. NO ALARM SOUNDED. THE RECEPTIONIST AT THE DESK, STAFF # 14, STATED THE NORTH AND SOUTH DOORS WERE NOT ALARMED DURING THE HOURS THE RECEPTIONIST WAS AT THE FACILITY, WHICH WERE THE HOURS OF, Monday THROUGH Friday 8:00 AM TO 8:00-8:30 PM AND Saturday AND Sunday 10:00 AM TO 5:00 OR 5:30 PM. GUESTS WERE TO SIGN IN AND OUT HERE AT THE NORTH DOOR, BUT THEY DID NOT ALWAYS SIGN IN AND OUT. GUESTS COULD ENTER AND EXIT THE SOUTH DOOR ALSO, AND THERE WAS NO SIGN IN/OUT BOOK LOCATED AT THE SOUTH DOOR. IN AN INTERVIEW ON 10/7/10 AT 3:25 PM, THE UNIT SECRETARY FOR THE NORTH UNIT STATED, FAMILY MEMBERS OR ALERT AND ORIENTED RESIDENTS WHO LEAVE THE FACILITY WERE TO SIGN IN/OUT IN THE LOA (LEAVE OF ABSENCE) BOOK AT EACH NURSES STATION AND INFORM THE UNIT SECRETARY OR WHOMEVER IS AT THE DESK. SHE STATED THAT NOT EVERYONE SIGNED THE BOOK OR INFORMED STAFF THEY WERE LEAVING. ON 10/7/10 AT 3:35 PM THE SURVEYOR REVIEWED THE SOUTH UNIT (AT THE NURSES' STATION AND NOT LOCATED LITERALLY AT THE DOOR) LOA BOOK. THE LOA BOOK DID NOT CONTAIN ANY NOTIFICATIONS/SIGNATURES FOR RESIDENT #503. ON MONDAY 10/11/10 AT 9:00 AM, THE SURVEYOR ENTERED THE FACILITY THROUGH THE SOUTH UNIT DOOR. NO ALARM SOUNDED, BECAUSE THE ALARMS WERE SHUP OFF BETWEEN THE HOURS OF 8:00AM THROUGH 8:00PM. THE ADMINISTRATOR AND DIRECTOR OF NURSING WERE NOTIFIED ON 10/12/10 AT 4:36 PM OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 9/20/10 AT APPROXIMATELY 8:00-9:00 PM FOR RESIDENT #502, WHO HAD DEMENTIA/ALZHEIMER'S DISEASE, AND WHO EXITED FIRST FLOOR EXIT DOORS WITHOUT THE KNOWLEDGE OF FACILITY STAFF, AND CROSSED OVER A FIVE (5) LANE ROAD TO GO INTO A GAS STATION, AND ON 8/1/10 AT 6:45 PM FOR RESIDENT # 503, WHO HAD DEMENTIA/ALZHEIMER'S DISEASE, AND WHO EXITED THE FRONT DOOR OF THE FACILTY, WITH THE ASSISTANCE OF A VISITOR, TO GO TO THE FRONT PORCH AREA AND WAS RETURNED INTO THE FACILITY BY A VISITOR, WITHOUT THE KNOWLEDGE OF FACILITY STAFF, PLACING 31 OTHER RESIDENTS WITH [DIAGNOSES REDACTED]. ON 10/13/10 THE SURVEYOR VERIFIED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1) ON 10/12/10 BY 6:30 PM, CITED RESIDENTS #502 AND #503 WERE RE-ASSESSED FOR ELOPEMENT RISK BY THE DON. 2) ON 10/12/10 RESIDENT #503'S CARE PLANS AND PATIENT INFORMATION CARE SHEET WERE REVIEWED FOR INCLUSION OF APPROPRIATE EXIT SEEKING INTERVENTIONS AND INCLUDED APPLICATION OF A SECURE CARE BRACELET. RESIDENT #503 HAD A SECURE CARE BRACELET APPLIED ON 8/1/2010 IMMEDIATELY AFTER HER ELOPEMENT, AND HAS NOT DEMONSTRATED EXIT SEEKING BEHAVIOR SINCE THAT TIME. 3) ON 10/12/10 RESIDENT #502 WAS HER OWN RESPONSIBLE PARTY AND HAS BEEN EDUCATED ON THE LEAVE OF ABSENCE POLICY. RESIDENT #502'S RE-ASSESSMENT, DATED 10/12/2010, DID NOT INDICATE SHE WAS AT RISK FOR ELOPEMENT. RESIDENT #502 HAS BEEN COMPLIANT WITH THE LOA POLICY SINCE THE 9/20/10 ELOPEMENT. RESIDENT #502'S CARE PLANS AND PATIENT INFORMATION CARE SHEET WERE REVIEWED AND UPDATED FOR ELOPEMENT. 4) ON 10/12/10 THIRTY OF THE 31 RESIDENTS IDENTIFIED BY THE FACILITY WITH DEMENTIA AND/OR ALZHEIMER'S DISEASE, AND IDENTIFIED AT RISK ON THE NOTIFICATION OF IMMEDIATE JEOPARDY, WERE ASSESSED FOR ELOPEMENT RISK. CARE PLANS AND PATIENT INFORMATION CARE SHEETS WERE REVIEWED AND INTERVENTIONS IMPLEMENTED AS INDICATED TO INCLUDE SECURE CARE BRACELETS. THE REMAINING 1 RESIDENT IS CURRENTLY IN THE HOSPITAL AND WILL BE ASSESSED UPON RE-ADMISSION. NEWLY admitted RESIDENTS WITH [DIAGNOSES REDACTED]. 5) BY 8:00 PM ON 10/12/10 THE SOUTH DOOR WAS SECURED WITH A CODED ALARM TO PREVENT UNALARMED EXITING. A PREVIOUSLY POSTED SIGN ON THE EXIT DOORS WAS UPDATED TO INFORM VISITORS AND FAMILY THAT THE DOOR WILL NO LONGER BE UTILIZED AS A PUBLIC ENTERANCE/EXIT DOOR. 6) ON 10/12/10 A LETTER HAS BEEN COMPOSED AND MAILED TO FAMILIES OR RESPONSIBLE PARTIES TO COMMUNICATE THE LOA PRACTICES TO INCLUDE: RESIDENTS MAY LEAVE THE CENTER ONLY BY THE PRIMARY PUBLIC ENTRANCE, THE NORTH DOOR. RESIDENTS/FAMILY/VISITORS WILL BE REQUIRED TO VALIDATE THAT LOA PRACTICE HAS BEEN FOLLOWED. A COPY OF THE LETTER WILL BE INCLUDED IN THE NEW ADMISSIONS PACKET. 7) BY 9:00 AM ON 10/13/10 136 OF 199 FACILITY STAFF RECEIVED EDUCATION ON WANDERING PATIENT GUIDELINES TO INCLUDE ALARM RESPONSE AND LOA PRACTICES. BY DEPARTMENT, 3/3 ACTIVITY STAFF, 9/10 ADMINISTRATIVE STAFF, 14/18 DIETARY STAFF, 5/8 HOUSEKEEPING STAFF, 2/4 LAUNDRY STAFF, 2/2 MAINTENANCE STAFF, 4/4 MEDICAL RECORDS/MEDICAL SUPPLY STAFF, 35/47 LICENSED NURSES, 39/56 CERTIFIED NURSING ASSISTANCE, 36/36 THERAPY STAFF AND 2/3 SOCIAL SERVICES STAFF HAVE ALL RECEIVED THE EDUCATION. ANY EMPLOYEE WHO IS UNAVAILABLE FOR EDUCATION AT THIS TIME WILL COMPLETE THE EDUCATION PRIOR TO THE START OF THEIR NEXT SCHEDULED SHIFT OF WORK. 8) BEGINNING 10/12/10 ROUTINE ROUNDS WILL BE COMPLETED THROUGHOUT THE DAY BY NURSES/DESIGNEE TO VALIDATE RESIDENT'S WHEREABOUTS. THE ADMINISTRATOR/DESIGNEE WILL SUMMARIZE THE FINDINGS AND REPORT TO THE QUALITY ASSURANCE COMMITTEE WEEKLY UNTIL OTHERWISE ADVISED. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 10/13/10, THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF PATTERN AND A SEVERITY OF NO ACTUAL HARM, BUT POTENTIAL FOR MORE THAN MINIMAL HARM, BUT NO IMMEDIATE JEOPARDY DUE TO ALL STAFF HAD NOT BEEN INSERVICED AND SUSTAINED COMPLIANCE HAS NOT BEEN VERIFIED BY THE STATE AGENCY. ( )