Every finding on record at Optalis Health and Rehabilitation of Ann Arbor

Based on interview and record review, the facility failed to address and resolve grievances reported in Resident Council Meetings as stated during a confidential Resident Council meeting resulting in unresolved concerns, unmet resident needs and frustration. Findings include:During a Confidential Resident Council Meeting on 7/8/2026 at 3:00 PM there were 11 residents present with 10 residents who actively participated and appeared to be alert and oriented. In discussing staff response to call lights, 5 of 10 resident reported ongoing issue with slow response to call lights including greater than 1 hour on night shift. Residents reported this has been discussed at every Resident Council Meeting for months with no improvements and management staff say they are working on it. Residents gave examples of call light response times greater than one hour on night shift including residents who required two people assist to get back to bed. Three residents reported waiting at least 2 hours to be assisted to bed for evening shift. During the meeting the residents, including Resident [NAME] President, verified had discussed long call light response times at prior meetings and with Director of Nursing (DON) B several times with no improvements and continue to be greater than 1 hour call light wait times three times weekly on night shift. Ten of ten confidential residents were not aware where to locate or how to complete a grievance form or how the process worked.Review of six months of Resident Council Meeting minutes, dated 1/28/26 through 6/25/26, provided by Nursing Home Administrator (NHA) A reflected no mention on call light response times. Continued review of requested minutes and follow up revealed no concern forms. During an interview on 7/09/2026 at 2:00 PM confidential Resident X was observed in bed, able to answer questions without difficulty and confirmed routine attendance at Resident [NAME] Group meetings. Confidential Resident X verified every month residents report concern with long call light response times on night shift mostly on night shift at least three times weekly with no improvements noticed. During an interview on 7/09/2026 about 11:10 AM Nursing Home Administrator (NHA) A reported being in position for about 2.5 years. NHA A reported often attends Resident [NAME] meetings and reported residents are routinely asked about call light response times and residents have not reported concerns. NHA A reported would expect Resident [NAME] minutes to be accurate including resident reported concerns about call light response times. NHA A verified several, nursing concerns on grievance log including call light response times.

Based on observation, interview and record review, the facility failed to notify residents of where to find grievance forms and how to file a grievance as stated during a confidential Resident Council meeting and one sampled residents (R169), resulting in unresolved concerns, unmet resident needs and frustration. Findings include:Resident #169 (R169)Review of the Face Sheet and Minimum Data Set (MDS) with assessment reference date of 7/7/26, reflected R169 was a [AGE] year-old male with diagnoses that included hypertension (high blood pressure), heart disease, radiculopathy (nerve pain), chronic pain and anxiety. The MDS reflected R169 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact.During an observation and interview on 7/07/2026 at 3:45 PM, R169 was observed in room, appeared to be able to answer questions without difficulty. R169 reported ongoing concerns with long call light response times greater than two hours after requesting pain medications mostly on nights. R169 reported 7/6/26 was administered pain medications four times and usually received they five to six times daily to manage pain. R169 reported was unable to sleep last night and unable to go to therapy that morning related to uncontrolled pain and that is why he is at facility for rehab. R169 reported same situation had happened prior to last night but R169 reported getting frustrated and reported to unit manager that morning and was informed facility planned to change medication timing with no mention of addressing concern related to long call light response times. During a Confidential Resident Council Meeting on 7/8/2026 at 3:00 PM there were 11 residents present with 10 residents who actively participated and appeared to be alert and oriented. When asked if staff respond to call light timely, 5 of 10 resident reported ongoing issue with slow response to call lights including greater than 1 hour on night shift. Residents reported call lights response time are discussed at every Resident Council Meeting for months with no improvements and management staff say they are working on it. Residents gave examples of call light response times greater than one hour on night shift including residents who required two person assist to get back to bed with three residents who reported waiting at least 2 hours to be assisted to bed for evening shift. Residents verified they had discussed concerns at prior meetings and with Director of Nursing (DON) B several times with no improvements and continue to be greater than 1 hour call light wait times three times weekly on night shift. Ten of ten confidential residents were not aware where to locate or how to complete a grievance form or how the process worked. During an observation on 7/8/26 at about 4:15 p.m. this surveyor toured the entire facility and was unable to locate easily accessible facility grievance/concern forms. During an observation and interview on 7/09/2026 at about 11:05 AM Unit Manager (UM) Y reported grievance forms were located at the nurse station and UM Y was observed attempting to locate at Cyprus Nurse Station and reported was unable to locate and reported admissions coordinator had them in her office. UM Y reported Grievance forms were not available to residents and or family without asking. UM Y reported had completed grievance form for R169 on 7/7/26 related to pain medications. During an observation and interview on 7/09/2026 at 11:10 AM, Nursing Home Administrator (NHA) A reported had been in position for about 2.5 years. NHA A reported grievance forms were available at facility Nurse Stations including Cyprus. Observed NHA A attempting to located forms at Cyprus Nurse Station and reported was unable to locate and reported forms were not available without asking. NHA A reported would expect to be informed of reported concerns within 24 hours and completed within 7 days depending on issue. During an interview on 7/09/2026 at 1:06 PM, Director of Nursing (DON) B reported became aware of R169 medication concerns today upon questioning with UM Y. During an interview two days later, on 7/09/2026, at about 3:50 PM Nursing Home Administrator (NHA) A reported had not seen R169's concern form dated 7/7/26.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant affecting 143 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.Findings include:On 07/07/2026 at 12:48 P.M., an environmental assessment of resident room [ROOM NUMBER] was completed. The following items were noted: The 503-W drywall surface, located directly behind the bed headboard, was observed scraped, scored, and fragmented from the bed being raised and lowered numerous times. The damaged drywall surface measured approximately 3 feet-long by 2 feet-wide. The 503-W bed overhead light assembly lower bulb was also observed non-functional.On 07/07/2026 at 1:02 P.M., an environmental assessment of resident room [ROOM NUMBER] was completed. The following items were noted: The 510-D drywall corner and plastic protective edge guard assembly were observed heavily soiled and stained with a dark brown substance, adjacent to the restroom entrance door. Three pieces of transparent tape were also observed adhered to the plastic protective edge guard assembly. The soiled and stained surface measured approximately 2 feet-wide by 4 feet-long. The wall/floor juncture surfaces, located adjacent to the restroom entrance door, were further observed heavily soiled with accumulated and encrusted dust/dirt/grime. The wall/floor juncture surfaces were also observed to be extremely dark (black) in color.On 07/08/2026 at 8:25 A.M., an environmental tour of the facility Laundry Service was conducted with Director of Housekeeping and Laundry (DHL) Q. The following items were noted: Clean Laundry Room: 4 of 4 overhead clear plastic overhead light lens covers were observed soiled with accumulated and encrusted dust/dirt/dead insect carcasses. (DHL) Q indicated she would contact maintenance for necessary cleaning as soon as possible.Laundry Room: 12 of 12 overhead clear plastic overhead light lens covers were observed soiled with accumulated and encrusted dust/dirt/dead insect carcasses. (DHL) Q indicated she would contact maintenance for necessary cleaning as soon as possible.On 07/08/2026 at 8:45 A.M., an environmental tour of the facility was conducted with Director of Housekeeping and Laundry (DHL) Q. The following items were noted:Meadows (900 500-519): Central Bath: 1 of 3 shower stall grab bars were observed loose-to-mount. (DHL) Q indicated she would contact maintenance for necessary repairs as soon as possible.On 07/08/2026 at 9:40 A.M., (DHL) Q was interviewed regarding the facility maintenance work order system. (DHL) Q stated: We have written work orders and the (name of electronic maintenance monitoring) software system.On 07/09/2026 at 10:00 A.M., record review of the Policy/Procedure entitled: Preventative Maintenance Program dated 11/01/2020 revealed under Policy: A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Record review of the Policy/Procedure entitled: Preventative Maintenance Program dated 11/01/2020 further revealed under Procedure: (1) The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner.On 07/09/2026 at 10:15 A.M., record review of the Policy/Procedure entitled: Environmental Services Inspection dated 10/01/2022 revealed under Policy: It is the policy of this facility to regularly monitor environmental services to ensure the facility is maintained in a safe and sanitary manner and assessed on a regular basis.On 07/09/2026 at 10:30 A.M., record review of the Manual Maintenance Work Orders for the last 90 days revealed no specific entries related to the aforementioned maintenance concerns.

Based on interview and record review, the facility failed to ensure a Level I pre-admission screening was completed and referred for a Level II evaluation and determination for one (R14) of three reviewed. Findings include: Review of the medical record revealed R14 was admitted to the facility on [DATE] with diagnoses that included adjustment disorder with mixed anxiety and depressed mood and post-traumatic stress disorder (PTSD). The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/12/26 revealed R14 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R14's medical record revealed no Level I or Level II Preadmission Screening/Annual Resident Review (PASARR). In an interview on 07/08/2026 at 2:20 PM, Social Worker (SW) N reported they could not locate R14's Level I or Level II PASARR. SW N reported it was possible the admissions staff had a copy. R14's PASARR documents were requested from SW N. SW N reported the OBRA website did not indicate R14 had been referred for a Level II evaluation. On 07/09/26 at 9:19 AM, R14's Level I and Level II PASARR was requested from Nursing Home Administrator (NHA) A. In a telephone interview on 07/09/26 at 9:22 AM, Social Work Director (SWD) M reported R14 should have had a Level I PASARR in their medical record. On 07/09/26 at 12:27 PM, NHA A reported the facility had to call Veteran's Affairs (VA) to obtain R14's PASARR documents because they did not have the documents in the facility. NHA A provided the documents received from the VA on 7/9/26. Review of the DCH-3877 PASARR revealed R14's Level I screening was completed on 3/3/26. R14 was marked Yes to the following screening criteria:1. The person has a current diagnosis of mental illness.2. the person has received treatment for mental illness.3. The person has taken or been prescribed psychotropic medications within the last 14 days. The DCH-3877 revealed the person screened will require a comprehensive Level II OBRA evaluation if any of the above items are Yes UNLESS a physician, nurse practitioner or physician's assistant certifies on form DCH-3878 that the person meets at least one of the exemption criteria, or the CMHSP Coordinator determines a Level II is not needed.Review of R14's DCH-3878 revealed the form was signed by a physician on 3/4/26, however none of the exemption criteria were checked as selected. R14 was not referred to OBRA for a comprehensive Level II evaluation.

Based on interview, and record review, the facility failed to coordinate care with hospice to ensure the accuracy of advance directives for one (R14) of two reviewed. Findings include: Review of the medical record revealed R14 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of the pancreas, adjustment disorder with mixed anxiety and depressed mood, and post-traumatic stress disorder (PTSD). The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed R14 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R14 received hospice services. Review of R14's electronic medical record main profile page revealed R14 wanted full cardiopulmonary resuscitation (CPR). Review of a scanned in written Physician's Order dated [DATE] revealed R14's code status was DNR (Do Not Resuscitate). Review of the electronic Physician's Order dated [DATE] revealed R14's code status was Full Code. Review of the Social Work progress note dated [DATE] revealed Resident is a full code at this time pending a valid DNR signed by the DPOA [Durable Power of Attorney]. Review of the Physician Team-H&P (History and Physical) note dated [DATE] revealed Patient is DNR. Review of the Care Conference dated [DATE] revealed no indication that hospice staff were invited or attended. The Care Conference revealed R14 was a full code. Review of the hospice IDG Comprehensive Assessment and Plan of Care Update Report for benefit period dates of [DATE] through [DATE] revealed R14's code status was DNR as of [DATE]. The Social Work portion of the hospice documents also revealed R14's code status was DNR. The hospice binder located at the nurse's station had a DNR order signed by R14's DPOA and one witness (hospice staff) on [DATE]. A second witness and the physician did not sign the DNR order. In an interview on [DATE] at 2:20 PM, Social Worker (SW) N reported R14's code status was CPR-full code. SW N reported during the last care conference, R14's DPOA did not wish to change his code status to DNR. In a telephone interview on [DATE] at 3:18 PM, R14's DPOA W reported it was their understanding that R14's code status was going to be changed to DNR after the last care conference on [DATE]. DPOA W reported she was told she would have to sign something indicating the change, but the facility never followed through with her. DPOA W reported she had visited the facility since but had not been asked to sign anything. In an interview on [DATE] at 9:04 AM, Assistant Director of Nursing (ADON) L reported R14's code status was a full code. When asked why all of R14's hospice paperwork indicated his code status was DNR, ADON L reported they were not aware of that and would have to check with Social Work. ADON L reported hospice staff were not in the building for care conferences. When asked if they ever participated via telephone, ADON L reported hospice staff usually communicated with her when they were in the building. In a telephone interview on [DATE] at 10:33 AM, Hospice Social Worker (HSW) O reported R14's code status was DNR which was signed by R14's DPOA upon admission. HSW O reported their hospice company had requested to be included in care conferences; however, they were not directly contacted to participate.

Based on observation, interview, and record review, the facility failed to maintain infection control standards during eye drop administration for one (R170) of seven reviewed. Findings include: Review of the medical record revealed R170 was admitted to the facility on [DATE] with a diagnosis of glaucoma. Review of the Physician's Order dated 7/6/26 revealed an order for Cosopt ophthalmic solution 2-0.5% (Dorzolamide HCl-Timolol Maleate) instill one drop in right eye two times a day for glaucoma. On 07/08/2026 at 8:49 AM, Licensed Practical Nurse (LPN) J was observed administering dorzolamide 2% eye drops to R170's right eye. LPN J did not wear gloves, pulled down R170's right lower eye lid and placed one drop in R170's right eye. Review of the facility's Medication-Eye Drop or Ointment Administration dated 9/14/23 revealed Perform hand hygiene and don clean gloves.Use a barrier if you place the medication cap or bottle on a surface.Steady the hand holding the medication cap or bottle on a surface.With the other hand, pull down the lower eyelid to form a pouch of the conjunctival sac, instructing resident to look up.For eye drops: squeeze the prescribed number of drops into the conjunctival sac, avoiding placement of the drops directly on the eyeball .Remove gloves and perform hand hygiene. In an interview on 07/09/2026 at 12:29 PM, Director of Nursing (DON) B reported staff were expected to wear gloves while administering eye drops.

This Citation Pertains to Intake 3073823.Based on interview and record review, the facility failed to ensure an injury of unknown source was thoroughly investigated for one (Resident #98) of one reviewed for abuse.Findings include:Review of the clinical record revealed R98 was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included polyosteo arthritis and age-related cognitive decline. R98 was transferred to the hospital on 7/4/2026 for unrelated reasons and not in the facility at the time of the survey. Further review of the clinical record reflected English was not R98's primary language. Review of the facility reported incident dated 6/27/26 reflected after Certified Nursing Assistant (CNA) S gave R98 a shower, R98 had begun to hold her left elbow and cry out in pain, R98 was unable to give description of pain. A stat x-ray was ordered on 6/26/26 an revealed an acute transverse supracondylar fracture of the humerus with partial comminution at the medial epicondyle. Mild impaction of fracture fragments. R98 was transferred to the hospital and returned in the early morning hours of 6/27/26. The facility reported incident included one interview. The interview was dated 6/30/26 and conducted by Nursing Home Administrator (NHA) A and CNA S the interviewee. CNA S statement reflected I took resident to the shower room and gave her a shower without incident. After her shower she grabbed the bar in the shower with both hands and cried out in pain. I sat her down on her walker and got her dressed with 3 layers of clothes and she didn't cry out in pain when I dressed her. When I took her back to her room, I told the nurse of her pain. The facility reported incident did not include any interviews with R98, other residents, R98's nurse, or any staff from the current shift or previous shifts. On 07/09/2026 at 2:09 PM, during an interview with NHA A she reported she was the facility's' Abuse Coordinator and did the investigation regarding R98's fracture. NHA A stated she received a phone call on Saturday 6/27 from License Practical Nurse (LPN) T who reported R98 had an elbow fracture and they didn't know how it occurred. When queried why there was no written statement/interview with LPN T included in the investigation, NHA A stated because she called her an told her what happened, and she read LPN T nurses note and felt there was no need to interview her or obtain a statement. When queried why R98 wasn't interviewed, NHA A stated she contacted a translation service and attempted to interview R98, but the translator reported R98 was too confused and was not able to be interviewed. Upon asking for documentation of the attempted interview of R98 with a translator, NHA A stated it was not documented. When quired why additional staff from that shift and the prior shift along with other residents on R98's unit were interviewed. NHA A stated she reviewed R98's record and didn't find any concerns and thought additional interviews were not necessary. NHA A elaborated that R98's family visits often and they would know if there was a problem and would report it and hadn't. Thus, NHA A had no concerns. On 07/09/2026 at 3:03 PM, during an interview with CNA S, she reported R98 was not assigned to her on 6/26/26, but she was told to give R98 a shower and she did what she was told. CNA S reported working the afternoon shift and gave R98 at shower at 4:00 PM on 6/26/26. CNA S reported R98 routinely would make noises and cry out during care particularly showers. CNA S elaborated the shower on 6/26/26 was just like previous showers she had given R98, but R98 stood grabbed the bar and yelled a different type of yell but then was ok. CNA S stated she dressed R98 in 3 layers of shirts (R98 preference) and R98 never cried out or winced in pain. CNA S stated she and R98 speak the same native language and R98 was not able to articulate when/why/how the pain started.

Based on observation, interview and record review the facility failed to maintain complete and accurate medical records for 3 of 27 residents reviewed (Resident #10, #14 and #33). Findings include: Resident 14 (R14) Review of the medical record revealed R14 was admitted to the facility on [DATE] with diagnoses that included adjustment disorder with mixed anxiety and depressed mood, post traumatic stress disorder (PTSD), and anxiety disorder. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/12/26 revealed R14 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R14's medical record revealed no Level I or Level II Preadmission Screening/Annual Resident Review (PASARR). In an interview on 07/08/2026 at 2:20 PM, Social Worker (SW) N reported they could not locate R14's Level I or Level II PASARR. SW N reported it was possible the admissions staff had a copy. R14's PASARR documents were requested from SW N. On 07/09/26 at 9:19 AM, R14's Level I and Level II PASARR was requested from Nursing Home Administrator (NHA) A. In a telephone interview on 07/09/26 at 9:22 AM, Social Work Director (SWD) M reported R14 should have had a Level I PASARR in their medical record. On 07/09/26 at 12:27 PM, NHA A reported the facility had to call Veteran's Affairs (VA) to obtain R14's PASARR documents because they did not have the documents in the facility or in R14's medical record. Resident 33 (R33) Review of the medical record revealed R33 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/19/26 revealed R33 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R33's Physician's Orders revealed weekly Trulicity injections were first ordered on 4/2/26 and continued as an active order. On 07/09/2026 at 8:48 AM, R33 was observed in bed and reported he did not receive his Trulicity dose as ordered the previous day on 7/8/26 because it was not in stock. Review of R33's Medication Administration Record (MAR) revealed on 7/8/26, R33's Trulicity was documented as administered by Licensed Practical Nurse (LPN) J. In an interview on 07/09/2026 at 8:52 AM, LPN J reported she did not administer R33's Trulicity on 7/8/26 because it was not in stock and she had to reorder it. In an interview on 07/09/2026 at 8:55 AM, Assistant Director of Nursing (ADON) L reported they were not aware R33's Trulicity was not administered on 7/8/26 and reported another injection was received from the pharmacy on 7/8/26. Resident 10 (R10) Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] reflected Resident 10 (R10) was a [AGE] year old female admitted to the facility on [DATE] with diagnosis that included end stage renal disease and R10 received hemodialysis 3 times a week. Further review of R10's clinical record reflected R10 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status with diagnosis of end stage renal disease. Review of R10's medical record for 2026 contained communication sheets with dialysis center for the following dates: 1/1, 1/15, 1/27, 2/10, 2/26, 3/10, 6/16 and 6/16. During an interview with Medical Records staff V on 07/09/2026 9:55 AM she reported R10 goes out to dialysis 3 times a week, facility nursing staff fill out the top portion of the form (type of access, medications given, medications sent with resident, code status), the dialysis center completes the middle section of the form, which was to include post dialysis vital signs, total fluid removal, medications that were given and any complications. The bottom of the form was to be signed off by facility nursing staff and placed into Licensed Practical Nurse/ Unit Manager (LPN/UM) U filing basket which gets picked up by Medical Records staff V and then gets and scans into the electronic medical record. Medical record staff V offered no explanation as to why R10's medical record had 8 dialysis communication forms when there should be roughly 85 dialysis communication forms. On 07/09/2026 at 10:50 AM during an interview with LPN/UM U she reported she had some of R10's dialysis sheets in her office and were there because she needed to review and sign off on them. It was queried how floor staff know what occurred or if there was a problem at dialysis with the dialysis communication sheets for R10 in her office. On 07/09/2026 at 12:43 PM, during an interview with Director of Nursing (DON) B she was not aware there was a total of 8 dialysis communication sheets in R10s medical record and the remaining forms may be located in an office. DON B reported she had no knowledge of R10's medical record being incomplete but would look into it. On 7/09/2026 1:07 PM DON B presented 43 pages of R10's dialysis communication forms that were not part of the medical record. When queried why the documents were not in R10's medical record, DON B offered no explanation.

Based on observation, interview, and record review, the facility failed to ensure pain management was provided for a resident with severe pain in 1 resident (Resident #169) of 2 residents reviewed for pain management resulting in unrelieved pain that can impact the resident's functional status, quality of life, and increased their mental anguish. Findings include:Resident #169 (R169)Review of the Face Sheet and Minimum Data Set (MDS) with assessment reference date of 7/7/26, reflected R169 was a [AGE] year-old male with diagnoses that included hypertension (high blood pressure), heart disease, radiculopathy (nerve pain), chronic pain and anxiety. The MDS reflected R169 had a BIM (assessment tool) score of 15 which indicated his ability to make daily decisions was cognitively intact.During an observation and interview on 7/07/2026 at 3:45 PM, R169 was observed in room, appeared to be able to answer questions without difficulty. R169 reported ongoing concerns with long call light response times greater than two hours after requesting pain medications mostly on nights. R169 reported 7/6/26 was administered pain medications four times and usually received they five to six times daily to manage pain. R169 reported was unable to sleep last night and unable to go to therapy that morning related to uncontrolled pain and that is why he is at facility for rehab. R169 reported when staff answer call light he would reported need for as needed pain medication and return to inform R169 that nurse said R169 would get medications with scheduled medication during medication pass. R169 reported same situation had happened prior to last night but R169 reported getting frustrated and reported to unit manager that morning and was informed facility planned to change medication timing with no mention of addressing concern related to long call light response times. Review of R169 Medication Administration Record, dated 7/1/26 through 7/7/26, reflected several as needed pain medications had been administered with scheduled medication pass. Continued review reflected several occasions of pain assessments had been completed up to 12 hours after ordered. Review of R169 Care Plans, dated 7/1/26, reflected, At risk for pain and/or has pain related to: Syncope, Chronic Back Pain .Goal-Will express that pain management is within acceptable limits .Interventions/Tasks-Administer pain medication as ordered .Notify physician if pain frequency/intensity is worsening or if current analgesia regimen has become ineffective . During an observation and interview on 7/09/2026 at about 11:05 AM Unit Manager (UM) Y had completed grievance form for R169 on 7/7/26 related to pain medications. UM Y reported R169 complained of not receiving pain medications timely to her on 7/7/26 morning. UM Y reported physician was contacted and pain medications were changed to scheduled and resident was satisfied with response.

Based on observation, interview and record review, the facility failed to provide medications timely and as prescribed for 2 residents (R33, R38) and failed to ensure physician orders for 1 resident (R26) of 27 residents reviewed. Findings include: Resident 26 (R26) A review of the clinical record revealed R26 was admitted into the facility on 1/20/23 with diagnoses that included: optic atrophy (right eye), muscle weakness, major depressive disorder and anxiety disorder. According to the Minimum Data Set (MDS) assessment dated [DATE], R26 scored 15/15 on the Brief Interview for Mental Status exam (which indicated intact cognition). On 7/7/26 at 10:52 AM, R26 was observed lying in bed on his back. He reported that when he wakes up in the morning his eyes burn, sometimes they are dry and irritated throughout the day, and that a provider had told him that they would order eye drops to help but he had not received any yet. R26 reported this had been ongoing for weeks. A review of R26's progress notes revealed the following: 7/3/26 .Examination of the eyes revealed PERRLA (pupils equal, round, reactive to light and accommodation).looks slightly irritated.Diagnosis: 1. Debility. 2. Dry eye syndrome.Medications were reviewed and approved for renewal.Continue artificial tears for dry eye syndrome. and 6/5/26 Patient is seen for monthly evaluation.He reports that his eyes are bothering him burning and itching. There is no discharge. Examination of the eyes revealed PERRLA.looks slightly irritated.Diagnosis: 1. Dry eye syndrome. 2. Hayfever.I advised the patient to use artificial tears for the dry eye syndrome. On 7/9/26 at 1:11 PM, during an interview with Unit Manager (UM) U, she reported not being aware of R26 experiencing dry eyes. UM U confirmed seeing progress notes indicating R26 had reported having dry eyes and that the notes indicated that the provider would order artificial tears to help. UM U further confirmed that a review of R26's physician orders revealed no active or discontinued order for artificial tears. Resident 38 (R38)On 7/7/26 at 10:05 AM, R38 was observed sitting up in a manual wheelchair at his bedside. R38 reported that he had not received his morning medications yet including his blood pressure medications. He added that they are frequently given late. R38 reported getting them late made him nervous because his blood pressure had been running high and that the staff are just not serious. A review of the clinical record revealed R38 was admitted into the facility on 3/15/24 with diagnoses that included: schizoaffective disorder, major depressive disorder and generalized anxiety disorder. According to the Minimum Data Set (MDS) assessment dated [DATE], R38 scored 15/15 on the Brief Interview for Mental Status exam (which indicated intact cognition). A review of R38's physician orders revealed active orders for amlodipine 5mg Give 1 tablet by mouth one time a day for HTN (hypertension-high blood pressure) to be given at 9 AM and Metoprolol Succinate ER (extended release) Give 1 tablet by mouth one time a day for HTN to be given at 9 AM. A review of Medication Admin (administration) Audit Report provided by the facility revealed for the last 30 days the resident received his amlodipine late (outside of the facilities one hour grace period) 7 times, 6/9 at 10:59 AM, 6/13 at 10:25 AM, 6/17 at 10:04 AM, 6/24 at 10:25 AM, 7/4 at 10:22 AM, 7/7 at 10:26 AM, 7/8 at 10:37 AM and received his Metoprolol late 3 times, 7/4 at 10:22 AM, 7/7 at 10:26 AM, 7/8 at 10:37 AM. On 7/9/26 at 12:40 PM, during an interview with Director of Nursing (DON), when asked what the expectation was for timeliness of medication administration, she replied that she expected her staff to administer medications as soon as they can, they can administer 1 hour before the scheduled administration time and 1 hour after and that staff tried to adhere to that. DON added that they do their best on that unit and that the nurses have to assist the certified nursing aides due to the workload. Resident 33 (R33) Review of the medical record revealed R33 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/19/26 revealed R33 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 07/07/2026 at 2:38 PM, R33 was observed sitting in a wheelchair in his room. R33 expressed frustration due to missed doses of Trulicity (weekly injection to help lower blood sugar) because the medication was not always available. R33 reported he was prescribed Trulicity in an attempt to lower his A1C (average blood sugar level over the past three months) so that he could have knee and oral surgery. Review of R33's Physician's Orders revealed weekly Trulicity injections were first ordered on 4/2/26 and continued as an active order. Review of R33's Medication Administration Records (MARS) and Progress Notes revealed the following: On 4/4/26 at 4/11/26, R33 refused the Trulicity. On 4/14/26 and 4/21/26, R33's Trulicity was documented as administered. On 4/28/26, Trulicity was not available. Trulicity was given the next day, on 4/29/26. On 5/6/26, R33's Trulicity was documented as administered. On 5/13/26, R33's Trulicity was not documented as administered and there was not an explanation in the progress notes. On 5/20/26, R33's Trulicity was documented as administered. On 5/27/26, R33's Trulicity was marked as 02 which indicated LOA (Leave of Absence) without medications. There was no documentation that R33 received his Trulicity after his LOA or a progress note explaining the situation. On 6/3/26, R33's Trulicity was not signed out as administered and there was not an explanation in the progress notes. On 6/10/26, R33's Trulicity was marked as 3 which indicated absent from home with medications. There was no progress note or anything that indicated R33 self-administered his Trulicity. On 6/17/26 and 6/24/26, R33's Trulicity injections were documented as administered. On 7/1/26, R33's Trulicity was marked as 07 which indicated Other/See Progress Note. The Progress Note revealed Medication currently unavailable. Pharmacy was called and medication was reordered. On 7/8/26, R33's Trulicity was documented as administered. Review of the pharmacy Packing Slips revealed R33's Trulicity was delivered on 5/13/26, 5/18/26, 6/3/26, 6/5/26, 6/17/26, 6/24/26, and 7/1/26. There was no delivery of Trulicity on 5/27/26 On 07/09/2026 at 8:48 AM, R33 was observed in bed and reported he did not receive his Trulicity dose the previous day as ordered on 7/8/26 because it was not in stock. Review of the MAR at that time, revealed R33's Trulicity was signed out as administered by Licensed Practical Nurse (LPN) J. In an interview on 07/09/2026 at 8:52 AM, LPN J reported she did not administer R33's Trulicity on 7/8/26 because it was not in stock and she had to reorder it. In an interview on 07/09/2026 at 8:55 AM, Assistant Director of Nursing (ADON) L reported there were times R33 refused Trulicity and then would complain it was not in stock at the facility. ADON L reported they were not aware R33's Trulicity was not administered on 7/8/26 and reported another injection was received from the pharmacy on 7/8/26. ADON L reported they would look into the missed documentations and administrations. On 07/09/2026 at 10:44 AM, ADON L reported on 5/13/26 R33 refused his insulin, however there was no documentation that he refused Trulicity. ADON L reported on 5/27/26, R33 was LOA and it was his pattern that he usually refused everything when he came back from LOA. ADON L reported there was no documentation that he refused Trulicity on 5/27/26. ADON L reported on 6/3/26 R33 went LOA and refused his insulin, however there was no documentation that he refused his Trulicity. ADON L reported on 7/1/26 the Trulicity was not available, pharmacy was contacted, and the Trulicity was delivered on 7/1/26. ADON L agreed there was no documentation that the Trulicity was administered but reported she would assume so since there were not any extra doses in the refrigerator. On 07/09/2026 at 11:45 AM, R33 was observed in his wheelchair in the common area. R33 reported the nurse attempted to administer his Trulicity that morning, however, was unsuccessful because the medication went all over the outside of his skin. R33 reported he occasionally refused insulin but had not refused Trulicity. Review of the eMAR Administration Note dated 7/9/26 revealed R33's Trulicity was not administered because pen injector did not break seal on skin .new pen has to be ordered. In an interview on 07/09/2026 at 12:29 PM, Director of Nursing (DON) B reported the facility reported R33 refused his Trulicity all the time. DON B reported her and ADON L have discovered the Trulicity needs to be ordered every week and that pharmacy would not automatically refill.

Based on interview, and record review the facility failed to post the actual daily Nursing Staffing Data resulting in the potential for all 143 Residents and/or family and/or visitors to be well informed of the facility's staffing information. Findings Included:During observation on 07/09/2026 at 09:24 a.m. the facility document entitled 8(SP)Resident Care & Complaint Intake Staff was observed to be posted in a glass case across from the Nursing Home Administrators office. The document demonstrated a date of 07/08/2026 and a Resident Census of 146. The document revealed two columns that were listed by shift (Day shift, Afternoon Shift, and Midnight Shift). Below each shift was listed job classification and listed total and total Hours. The same facility document listed the following:Day Shift Total Total Hours Total Total Hours RN 0 0 Agency-RN 0 0LPN 9 72 Agency-LPN 0 0CENA 13 97.5 Agency-CENA 0 0 MDS-RN 3 24 Restorative -LPN 0 0MDS-LPN (blank) (blank) Restorative -CENA (blank) (blank) Afternoon Shift Total Total Hours Total Total Hours RN 0.5 4 Agency-RN 0 0LPN 9 72 Agency-LPN 0 0CENA 11.5 86.25 Agency-CENA 0 0 MDS-RN (blank) (blank) MDS-LPN (blank) (blank) Midnight Shift Total Total Hours Total Total Hours RN 1 8 Agency-RN 0 0LPN 9 72 Agency-LPN 0 0CENA 10 75.0 Agency-CENA 0 0 MDS-RN (blank) (blank) MDS-LPN (blank) (blank) In an interview on 07/09/2026 at 10:08 a.m. Staffing Coordinator D explained that she was responsible for posting the 8(SP)Resident Care & Complaint Intake Staff document each day. Staffing Coordinator D explained that the hours record are scheduled hours to be worked and not actual hours worked for each shift. She explained that she had not been educated to post the actual hours worked at the end of the shift. In an interview on 07/09/2026 at 10:22 a.m. Director of Nursing (DON) B confirmed that the posted document entitled 8(SP)Resident Care & Complaint Intake Staff, dated 07/08/2026, had not included actual hours worked for each shift. DON D explained that she did not have knowledge that federal statue 483.35(iii) had the requirement that the facility must post information that included actual hours worked.

This citation pertains to intake 2801978.Based on observation, interview and record review, the facility failed to prevent missing controlled substance medication for one (R2) and maintain accurate controlled substance records for five (R6, R7, R8, R9, R10) in two of seven medication carts reviewed.Findings include:R2:Review of the medical record reflected R2 admitted to the facility on [DATE], with diagnoses that included low back pain, chronic pain and systemic lupus erythematosus. On 5/12/26 at 12:13 PM, R2 was observed in bed, watching TV, and declined to be interviewed. The January 2026 Medication Administration Record (MAR) included a Physician Order for 10 milligrams (mg) of oxycodone by mouth, every six hours, as needed, for ANALGESICS [pain relief]. A Facility Reported Incident investigation file reflected a blister pack of R2's oxycodone 10 mg went missing between the 7:00 AM and 7:00 PM nursing shift on 1/30/26. A Controlled Drug Receipt/Record/Disposition Form reflected 30 tablets of oxycodone 10 mg were received from the pharmacy, for R2, on 1/18/26. The last dose of oxycodone from that prescription pack was administered on 1/28/26 at 10:27 PM. A packing slip, dated 1/28/26, reflected the pharmacy delivered 30 tablets of oxycodone 10 mg for R2.The January 2026 MAR reflected oxycodone doses were signed out as being administered on 1/29/26 at 9:37 AM, 4:00 PM and 10:43 PM. On 1/30/26, doses were signed out as being administered at 5:02 AM and 12:18 PM. According to the facility's investigation, on 1/30/26 at 10:10 PM, a nurse (Registered Nurse (RN) H) attempted to administer a dose of oxycodone to R2 but discovered none was available on the medication cart. RN H attempted to reorder the medication through the pharmacy and was told it was too soon to provide more of the medication to the facility, as the medication had been delivered on 1/28/26. RN H notified the supervisor, who then called Director of Nursing (DON) B. According to the investigation, all nurses who had been in possession of the keys to the medication cart's controlled medication between 7:00 AM on 1/30/26 and 12:00 AM on 1/31/26 were suspended, pending investigation. The Controlled Substance Shift Inventory form for the medication cart reflected the out-going and on-coming nurses signed for the total number of controlled medications in the cart on 1/30/26 at 7:00 AM. The documentation for the total number of controlled medications at the start of the shift was unclear. One controlled medication was documented as being received from the pharmacy. The documentation for the total number of controlled medications at the end of the shift was unclear.The next entry on the Controlled Substance Shift Inventory form for the medication cart reflected the out-going nurse signed for the total number of controlled medications in the cart at 7:00 PM. The date was not completed. The documentation for the total number of controlled medications at the start of the shift was unclear. One controlled medication was documented as being received from the pharmacy. The documentation for the total number of controlled medications at the end of the shift was 9. The on-coming nurse did not sign the log for that entry.In an interview on 5/13/26 at 2:37 PM, DON B reported receiving a phone call around 12:00 AM or 1:00 AM that a package of oxycodone was missing. DON B reported the pharmacy had been called for a drop ship delivery of the medication, which was how the nurse (RN H) found out the medication was gone. It was reported the medication had just recently been delivered. RN H called the nurse manager, and they discovered a discrepancy with the total number of controlled medications in the medication cart. DON B reported RN H arrived for her shift around 7:00 PM (on 1/30/26), and the day shift nurse (Licensed Practical Nurse (LPN) G) was still charting. RN H then went to obtain vital signs. When LPN G was ready to leave, LPN F counted the controlled medications in the cart with LPN G. DON B described that there was a discrepancy with the total number of controlled medications in the cart when RN H took the medication cart over. DON B reported the oxycodone that was delivered for R2 on 1/28/26 was missing, and they were unable to find the count sheet (Controlled Drug Receipt/Record/Disposition Form) for the medication. On 5/14/26 at 11:55 AM, Registered Nurse (RN) L reported she was training Licensed Practical Nurse (LPN) M and they were responsible for Cypress Cart 1. RN L and LPN M were asked to demonstrate a controlled substance count. The following discrepancies were noted during their count:R6's oxycodone 5 milligrams (5mg) had 10 tablets documented in stock on the Controlled Drug Receipt/Record/Disposition Form, but only nine tablets were available in the medication cartR7's pregabalin 25 mg had 24 capsules documented in stock on the Controlled Drug Receipt/Record/Disposition Form, but only 23 capsules were available in the medication cartR8's morphine sulfate 15 mg had 22 tablets documented in stock on the Controlled Drug Receipt/Record/Disposition Form but only 21 tablets were available in the medication cartR8's methadone 10 mg had 20 tablets documented in stock on the Controlled Drug Receipt/Record/Disposition Form, but only 18 tablets were available in the medication cartR9's oxycodone 5 mg had 20 tablets documented in stock on the Controlled Drug Receipt/Record/Disposition Form, but only 19 tablets were available in the medication cart. RN L and LPN M reported all the medications were administered and signed out on the Medication Administration Record (MAR) and that they forgot to sign the medications out on the Controlled Drug Receipt/Record/Disposition Form. Review of the MARs revealed the above medications were administered at 10:06 AM, 9:00 AM, 10:36 AM, 6:00 AM, and 7:30 AM. On 5/14/26 at 12:12 PM, LPN N reported she was training LPN O and they were responsible for Cypress Cart 2. LPN N and LPN O were asked to demonstrate a controlled substance count. During the count, it was noted that R10's pregabalin 75 mg had 15 capsules documented in stock on the Controlled Drug Receipt/Record/Disposition Form, but only 14 capsules were available in the medication cart. LPN N reported the medication was administered at 8:52 AM, but she forgot to sign it out on the Controlled Drug Receipt/Record/Disposition Form. In an interview on 5/15/26 at 1:03 PM, Director of Nursing (DON) B reported nurses should sign controlled medications on the Controlled Drug Receipt/Record Disposition Form right away when the medication is removed from the medication cart. Review of the facility's Controlled Medication Guidelines dated 10/2019 revealed When the licensed nurse removes the controlled medication from the package, they will document the quantity removed and the quantity left on the Controlled Drug Receipt/Record/Disposition Form.

Based on interviews and record review, the facility failed to protect the resident's (R4) right to be free from neglect resulting in resident experiencing blunt force trauma and contributing to the resident's death. This citation pertains to intake number 2642837.Per the facility face sheet Resident #4 (R40 was an [AGE] year-old who resided at the facility since [DATE]. Diagnoses included muscle weakness, age related physical disability, and morbid severe) obesity due to excess calories. Review of an incident report dated [DATE] revealed Certified Nurse Aid (CNA) C informed a nurse that while providing a brief change R4 rolled out of bed onto the floor. The report further revealed R4 was assessed to have a skin tear to the left elbow, a hematoma (bruising) to the left knee, and left side of the head. Per the report R4 was transferred back to his bed with a mechanical lift, Neuro checks (checking id there is any possible brain injury) were started, and education was provided to CNA C. The incident report revealed that R4's Physician was notified at 2:40 AM. Review of the facility's investigation revealed that it was documented on an EMPLOYEE COUNSELING & CORRECTIVE ACTION RECORD dated [DATE], CNA C was suspended and given a Final Written Warning for a work rule violation, CENA (CNA C) Failed to Follow plan of care as written. The form revealed CNA C was suspended from 10/29 through [DATE]. Review of progress notes dated [DATE] and timed at 2:59 AM revealed, CNA (C) informed nurse that while providing brief change to resident (R4) he rolled out of bed onto the floor. Nurse entered room to find patient (R4) sitting on the floor, head against small refrigerator and legs bent at the knees, folded to the right side. Resident (R4) assessed and noted to have skin tear to left elbow, hematoma to left knee and left side of forehead, Resident transferred back to bed via Hoyer (mechanical lift) and two Staff members. The note also revealed that R4's Physician was notified and an X-ray was ordered for both of R4's legs. Review of R4's progress notes dated [DATE] and timed at 4:28 AM, revealed CNA informed nurse that while providing brief change to resident he rolled out bed onto the floor. Nurse entered room to find patient (R4) sitting on the floor, head against small refrigerator and legs bent at knees, folded to the right side. Resident (R4) assessed and noted to have skin tear to left elbow, hematoma to left knee and left side of forehead, Resident transferred back to bed via Hoyer (mechanical lift) and two Staff members. The note also revealed that R4's Physician was notified and an X-ray was ordered for both of R4's legs. Review of Physician's orders dated [DATE] revealed an order for bilateral (both sides) STAT (immediately) X-rays of both lower extremities. The order was not written until 8:20 AM. Review of an X-ray result dated 10:29/24 revealed R4 had a fracture of both his left and right femur bone. The X-ray report revealed that the X-ray was taken on [DATE], but not until 8:36 AM and was reported to the facility on [DATE] at 9:41 AM. Review of a progress note dated [DATE] at 10:00 AM revealed, IDT (Interdisciplinary Team) met to review the fall that (R4) had during staff assist on [DATE] at approximately 02:10hrs (2:10 AM). While CNA (C) was performing incontinence care (R4) rolled out of bed onto the floor, Nurse immediately assessed resident and noted that (R4) had a skin tear to left elbow. (sic) hematoma to left side of forehead, hematoma to left knee. Neuro checks were initiated and noted no immediate changes from baseline. The physician was notified and ordered x-rays, (sic) of both legs .Per POC (plan of care) pt (patient) (R4) is a 2 person assist with bed mobility immediate intervention: Assigned CNA (C) received education on following plan of care .Xray resulted in fracture of left femur. (Physician) made aware and ordered to be sent to the hospital . The facility did not identify that R4 also had a fracture of the right femur as revealed from the X-ray results. Review of an SBAR (Situation, Background, Assessment, and Recommendation) dated [DATE], revealed R4 had new pain that R4 scored at a 10 out of 10 in the left knee. The SBAR revealed that it was not until 10:00 AM that R4's Physician was notified of the X-ray results, and then an order was received to send R4 to the hospital.Review of another progress note dated [DATE] and timed at 11:22 AM, revealed it wasn't until 11:15 AM that R4 was transferred to the hospital due to abnormal X-ray results. There were no other progress notes regarding the incident, there were no further notes regarding the complaints of pain R4 had, there were no notes of any updates of R4's status from the time of the fall at 2:10 AM until R4 went to the hospital at around 11:15 AM on [DATE].Review of a Brief Interview for Mental Status (BIMS) dated [DATE] revealed R4 had a BIMS score of 10 out of 15 which indicated R4 had a moderate cognitive impairment, Review of R4's care plans that were in place and active at the time of R4's fall out of bed revealed a care plan with a Focus of At risk for falls due to functional deficits, reduced mobility .prefers to keep his bed in high position . The care plan had an intervention, Staff educated on reading Kardex (document with a resident's plan of care for CNA use) when providing care, dated [DATE], and another intervention that indicated R4 had a wide bed and that was dated [DATE]. Review of another care plan dated [DATE], with a Focus of Resident (R4) had an ADL (activities of daily living) self-care performance deficit r/t (related to): ADL Self care deficit as evidence by weakness related to: debility, full cares (sic) provided . The interventions on the care plan included, ADL-2 assist .Bed Mobility-2 assist., dated [DATE].In an interview on [DATE] at 12:17 PM, CNA C, who no longer worked at the facility, stated that she went to provide care for R4, and prior to had looked for another staff member to assist her with R4's care, but stated no one was on the floor or available. CNA C said she waited on the unit for about 20 minutes and then waited again but no other staff members were available to assist her with R4's care. CNA C then stated she had waited about 45 minutes and because could not locate another staff member she decided to perform R4's bed mobility care by herself. CNA C stated she completed R4's care, left R4's room, went back into R4'a room and found him on the floor. CNA C then proceeded to state that she thought maybe R4 had reach over his body with one arm, turned himself to his side, and reach all the way to the top of the refrigerator, that was up against the wall to grab a soda, and rolled himself out of bed onto the floor. CNA C said R4 had a large belly and she though R4's belly rolled over the side of the bed, which resulted in R4 rolling of the bed and onto the floor. CNA C stated she went and got the nurse but said she could not recall the' nurse's name. CNA C further stated that she believed R4 was care planned to be a two person assist for bed mobility. CNA C said R4 was soiled and she had waited and tried several times to finds assistance but could not, so she had decided to perform R4's bed mobility care without a two person assist and did the care by herself. In an interview on [DATE] at 10:18 AM, Licensed Practical Nurse (LPN) D stated that CNA C had come up to her and told her she had been changing R4's brief and R4 rolled onto the floor. LPN D said she went and did an assessment on R4 which showed R4 had bruising to his left knee, a hematoma (blood under the skin) to his left forehead, and when R4 was moved he complained of pain. LPN D said X-rays were ordered due to the hematoma on R4's left knee. LPN D said CNA C reported to her that R4 had rolled out of bed when she was changing his brief, and no one else was involved just CNA C. In an interview on [DATE] at 11:00 AM, Administrator A stated that the incident would be considered neglect, because R4's care plan required a two person assist for bed mobility, and CNA C performed R4's care by herself and neglected to follow R4's plan of care. In an interview on [DATE] at 9:49 AM, LPN E said when she arrived to work on [DATE] at about 8:30 AM, she went to the hall where R4 resided. LPN E said she took the incident report (IR) out of the managers box and took it with her to the managers morning meeting. LPN E stated that the incident was discussed and it was documented that the R4 rolled out of bed onto the floor, had a hematoma to the left side of forehead and left knee, then the Physician was notified and X-rays were ordered. LPN E stated that he X-ray results were received when the meeting was over that morning, could not recall the time. LPN E said the X-rays showed R4 had a fracture of the left femur and the Physician ordered R4 to be sent to the hospital. LPN E said R4 was sent out about 10:30-11:00 AM. LPN E said R4 was a two person assist with bed mobility, but according to the IR CNA C had reported while she was providing care, R4 rolled out onto the floor. LPN E said CNA C neglected to follow R4's care plan that requiredLPN E further stated that R4 was not able to turn himself in bed and said R4 would be scared to turn and get close to the side of the bed. LPN E said R4 did not help with care because he was totally dependent on staff, and continued to stated that R4 was total care, could not move himself to the side of his bed which was a bariatric bed, could no turn himself on his own, and would not be able to move himself from the middle of the bed to the side of the bed, turn himself to his side, and reach over and grab a can of soda off the refrigerator that was against the wall and fall onto the floor all by himself. LPN E said she had never seen R4 do that, nor he could do that, said he was not vocal and would not have been able to say he was falling or stop.Review of R4's death certificate revealed R4 died on [DATE] at 11:48 AM, at the hospital in the emergency room, The death certificate revealed under Part II. OTHER SIGNIFICANT CONDITIONS contributing to death ., Blunt force trauma to the right thigh., #39 MANNER OF DEATH *Accident, 41a. date of injury [DATE], 41c. DECSRIBE HOW INJURY OCCURRED The decedent fell., 41C. PLACE OF INJURY Nursing Home. The death certificate also had the facility's address documented for the location of the nursing home.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 134 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, reduced air quality, and inadequate sanitization of dishware and utensils. Findings include: On 04/07/25 at 09:20 A.M., An initial tour of the food service was conducted with Dietary Manager G. The following items were noted: The ceiling mounted return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. The soiled ventilation grill plate measured approximately 3-feet-wide by 4-feet-long. 6 of 25 food production kitchen overhead light assembly plastic lens covers were observed soiled with accumulated (dust/dirt/dead insect carcasses). Dietary Manager G indicated he would contact maintenance for necessary repairs as soon as possible. The 2022 FDA Model Food Code section 6-501.12 states: (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. (B) Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of FOOD is exposed such as after closing. One-half gallon of [NAME] Lactose Free Reduced Fat 2% Milk was observed within the Hoshizaki 2-door reach-in cooler, without an effective open or discard date. The manufacturer's use-by-date was also observed to read 4-24-25. Dietary Manager G indicated the facilities date marking procedure was currently day of opening plus 6 days for a total of 7 calendar days. The 2022 FDA Model Food Code section 3-501.17 states: (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. The can opener assembly was observed soiled with accumulated and encrusted food residue. Dietary Manager G stated: I will have staff clean the opener immediately. The 2022 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. The atmospheric vacuum breaker was observed broken and missing the cover plate on the dish machine room hand sink faucet assembly. The 2022 FDA Model Food Code section 5-205.15 states: A plumbing system shall be: (A) Repaired according to LAW; and (B) Maintained in good repair. The mechanical dish machine pounds-per-square-inch (psi) gauge was observed to read 45 (psi), during the final rinse cycle. The 2022 FDA Model Food Code section 4-501.113 states: The flow pressure of the fresh hot water SANITIZING rinse in a WAREWASHING machine, as measured in the water line immediately downstream or upstream from the fresh hot water SANITIZING rinse control value, shall be within the range specified on the machine manufacturer's data plate and may not be less than 35 kilopascals (5 pounds per square inch) or more than 200 kilopascals (30 pounds per square inch). On 04/07/25 at 10:45 A.M., An initial tour of the facility food service pantries was conducted with Dietary Manager G. The following items were noted: Pantry (100-200 Hall): The Vissani microwave oven face plate surface was observed (etched, scored, corroded, particulate). The damaged face plate surface measured approximately 1-inch-wide by 2-inches-long. Dietary Manager G indicated he would have maintenance replace the damaged microwave oven as soon as possible. Pantry (300-400 Hall): The ice machine dispensing spout was observed mineralized with accumulated and encrusted calcium/lime deposits. Dietary Manager G indicated he would have staff thoroughly clean and sanitize the ice machine dispensing spout assembly as soon as possible. Pantry (500 Hall): The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. The soiled ventilation grill plate measured approximately 12-inches-wide by 24-inches-long. Dietary Manager G indicated he would have maintenance thoroughly clean and sanitize the soiled ventilation grill plate as soon as possible. Pantry (600-700 Hall): The Sharp Carousel microwave oven was observed soiled with accumulated and encrusted food residue. Dietary Manager G indicated he would have housekeeping staff thoroughly clean and sanitize the microwave oven interior as soon as possible. The window ledge laminate surface was also observed (etched, scored, missing). The damaged laminate surface measured approximately 1-inch-wide by 10-inches-long. Dietary Manager G indicated he would have maintenance perform necessary repairs as soon as possible. Pantry (600-700 Hall): The Scotsman ice machine dispensing spout was observed mineralized with accumulated and encrusted calcium/lime deposits. Dietary Manager G indicated he would have staff thoroughly clean and sanitize the ice machine dispensing spout assembly as soon as possible. On 04/09/25 at 09:00 A.M., Record review of the Policy/Procedure entitled: General Kitchen Sanitation Policy dated 03/28/2025 revealed under Policy Overview: The facilities Department of Food and Nutrition Services shall maintain kitchen sanitation through compliance with a written cleaning schedule, Food Service Department (FSD) sanitation daily rounds, and monthly sanitation audits. On 04/09/25 at 09:15 A.M., Record review of the Policy/Procedure entitled: Preventative Maintenance Program dated 11/01/2020 revealed under Policy: A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Record review of the Policy/Procedure entitled: Preventative Maintenance Program dated 11/01/2020 further revealed under Procedure: (1) The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 138 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and reduced air quality. Findings include: On 04/07/25 at 03:50 P.M., An environmental tour of the facility Laundry Service was conducted with Director of Maintenance H and Director of Housekeeping and Laundry Services I. The following items were noted: Two 4-feet-wide by 6-feet-long padded floor mats were observed (etched, scored, particulate), adjacent to the three commercial dryers. The worn padded floor mats were also observed attached to the flooring surface with maroon colored duct tape. Director of Maintenance H indicated he would have staff remove and replace the worn floor mats as soon as possible. The flooring surface was observed (etched, scored, particulate), adjacent to the three commercial washers. The damaged flooring surface measured approximately 7-feet-wide by 10-feet-long. Director of Maintenance H indicated he would have staff replace the worn flooring surface as soon as possible. On 04/07/25 at 04:05 P.M., The corridor carpeted surface was observed stained and soiled, adjacent to resident rooms [ROOM NUMBERS]. The stained and soiled carpet surface measured approximately 2-feet-wide by 4-feet-wide. On 04/08/25 at 10:15 A.M., A common area environmental tour was conducted with Director of Maintenance H and Director of Housekeeping and Laundry Services I. The following items were noted: 200 Hall One clean linen cart cover (pink) was observed (etched, scored, threadbare). Director of Housekeeping and Laundry Services I stated: We need to replace that cover. 300 Hall - 400 Hall Nursing Station: 2 of 6 chairs were observed (etched, scored, threadbare, particulate), exposing the inner Styrofoam padding. Activity Room: 1 of 3 office chairs were observed (etched, scored, particulate), exposing the inner Styrofoam padding. Main Dining Room: The chair railing was observed missing. The missing chair railing measured approximately 12-14 feet-long. Director of Housekeeping and Laundry Services I stated: We have vending machines coming soon to fill the space. Physical Therapy: The hand sink basin faucet assembly was observed loose-to-mount. Director of Housekeeping and Laundry Services I indicated she would contact maintenance for necessary repairs as soon as possible. 500 Hall Meadows Room: 2 of 9 clear plastic overhead light lens covers were observed soiled with dust and dirt deposits. Shower Room: The shower wand assembly was observed missing an atmospheric vacuum breaker. Director of Housekeeping and Laundry Services I indicated she would contact maintenance for necessary repairs as soon as possible. 600 Hall Shower Room Restroom: The hand sink faucet assembly was observed loose-to-mount. Director of Housekeeping and Laundry Services I indicated she would contact maintenance for necessary repairs as soon as possible. Nursing Station: The small black oscillating desk fan was observed soiled with accumulated and encrusted dust/dirt deposits. Director of Housekeeping and Laundry Services I indicated she would have staff thoroughly clean and sanitize the soiled fan as soon as possible. Dining Room Kitchenette: The lower base cabinetry exterior/interior surfaces were observed soiled with accumulated and encrusted food residue. 2 of 4 base cabinet drawers were also observed broken and enlarged from moisture exposure. Director of Housekeeping and Laundry Services I indicated she would have staff thoroughly clean and sanitize the soiled cabinetry as soon as possible. Director of Housekeeping and Laundry Services I also indicated she would contact maintenance for necessary repairs as soon as possible. On 04/08/25 at 02:05 P.M., An environmental tour of sampled resident rooms was conducted with Director of Maintenance H and Director of Housekeeping and Laundry Services I. The following items were noted: 103: The Bed-D overbed light assembly upper 48-inch-long fluorescent light bulb was observed non-functional. 202: The restroom commode base caulking was observed (etched, scored, particulate). 209: The Portable Terminal Air Conditioning (PTAC) Unit filters were observed soiled with accumulated and encrusted dust/dirt deposits. The drywall surface was also observed (etched, scored, particulate), adjacent to the Bed-W headboard. The damaged drywall surface measured approximately 5-feet-wide by 5-feet-long. 304: The Portable Terminal Air Conditioning (PTAC) Unit filters were observed soiled with accumulated and encrusted dust/dirt deposits. The restroom vanity countertop laminate edge was also observed missing. The damaged laminate surface measured approximately 2-inches-wide by 26-inches-long. 305: The restroom commode base caulking was observed (etched, scored, particulate). The Portable Terminal Air Conditioning (PTAC) Unit filters were observed soiled with accumulated and encrusted dust/dirt deposits. 307: The restroom vanity countertop was observed (etched, scored, chipped). The damaged laminate surface measured approximately 3-inches-wide by 6-inches-long. The Portable Terminal Air Conditioning (PTAC) Unit filters were observed soiled with accumulated and encrusted dust/dirt deposits. 308: The restroom vanity countertop was observed (etched, scored, chipped), adjacent to the corner edge. The damaged laminate surface measured approximately 2-inches-wide by 12-inches-long. The Portable Terminal Air Conditioning (PTAC) Unit filters were also observed soiled with accumulated and encrusted dust/dirt deposits. 403: The restroom over sink light assembly was observed non-functional. The Portable Terminal Air Conditioning (PTAC) Unit filters (2) were also observed missing from the cabinet housing. 408: The Portable Terminal Air Conditioning (PTAC) Unit filters were observed soiled with accumulated and encrusted dust/dirt deposits. 409: 1 of 2 restroom light assemblies were observed non-functional. Director of Housekeeping and Laundry Services I indicated she would contact maintenance for necessary repairs as soon as possible. 503: The restroom commode base caulking was observed (etched, scored, particulate). The Bed-D (pillow, pillowcase, bed sheets, bedspread) were also observed soiled with accumulated and encrusted bodily fluids and food residue. Director of Housekeeping and Laundry Services I indicated she would have Certified Nursing Assistant (CNA) staff remove the soiled Bed-D bedding as soon as possible. 504: The restroom hand sink basin was observed draining very slow. Director of Housekeeping and Laundry Services I indicated she would contact maintenance for necessary repairs as soon as possible. 507: The restroom commode base caulking was observed (etched, scored, particulate). The Portable Terminal Air Conditioning (PTAC) Unit filters were also observed soiled with accumulated and encrusted dust/dirt deposits. The restroom vanity countertop laminate surface was further observed (etched, scored, particulate). The damaged laminate surface measured approximately 2-inches-wide by 12-inches-long. 508: The restroom commode base caulking was observed (etched, scored, particulate). 516: The restroom vanity countertop edge was observed (etched, scored, particulate). The damaged laminate surface measured approximately 2-inches-wide by 40-inches-long. The Portable Terminal Air Conditioning (PTAC) Unit filters were also observed soiled with accumulated and encrusted dust/dirt deposits. 702: The vanity countertop laminate surface was observed (etched, scored, particulate). The damaged laminate surface measured approximately 2-inches-wide by 30-inches-long. 704: The restroom commode base caulking was observed (etched, scored, particulate). The vanity countertop laminate surface edge was also observed (etched, scored, particulate). The damaged laminate surface measured approximately 2-inches-wide by 12-inches-long. 706: The restroom vanity countertop laminate edge strip was observed loose-to-mount. The damaged laminate surface measured approximately 2-inches-wide by 24-inches-long. 1 of 2 overhead light assemblies were also observed non-functional. The Bed-D overbed upper 48-inch-long fluorescent light bulb was further observed non-functional. 708: The Portable Terminal Air Conditioning (PTAC) Unit filters were observed soiled with accumulated and encrusted dust/dirt deposits. The restroom commode base caulking was also observed (etched, scored, particulate). 711: The restroom vanity countertop was observed (etched, scored, particulate), adjacent to the hand sink basin. The damaged countertop surface measured approximately 2-inches-wide by 4-inches-long. The Portable Terminal Air Conditioning (PTAC) Unit filters were also observed soiled with accumulated and encrusted dust/dirt deposits. The Bed-W drywall surface was further observed (etched, scored, particulate), adjacent to the headboard. The damaged drywall surface measured approximately 3-feet-wide by 5-feet-long. On 04/08/25 at 04:40 P.M., An interview was conducted with Director of Maintenance H regarding the facility maintenance work order system. Director of Maintenance H stated: We have manual work order forms that staff fill out for maintenance and housekeeping requests. On 04/09/25 at 10:00 A.M., Record review of the Manual Work Order form dated 11/2021 revealed the following information: (1) Facility Name, (2) Department/Wing/Room, (3) Date, (4) I.D. No, (5) Work Requested, (6) Justification, (7) Material Cost, (8) Labor Cost, (9) Signature of Department Head, (10) Date Received, (11) Date Work Completed, and (12) Disposition. On 04/09/25 at 10:15 A.M., Record review of the Policy/Procedure entitled: Cycle Cleaning dated 11/01/2020 revealed under Policy: It is the policy of this facility to identify the functional areas in the facility that require cleaning and to use cycle cleaning schedules to outline the frequencies and maintain regularly scheduled environmental service tasks. Record review of the Policy/Procedure entitled: Cycle Cleaning dated 11/01/2020 further revealed under Procedure: (1) Routine cleaning of environmental surfaces and non-critical resident care items shall be performed according to a predetermined schedule and shall be sufficient enough to keep surfaces clean and dust free. On 04/09/25 at 10:30 A.M., Record review of the Policy/Procedure entitled: Maintenance Inspection dated 11/01/2020 revealed under Policy: It is the policy of this facility to utilize a maintenance inspection checklist in order to assure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. On 04/09/25 at 10:45 A.M., Record review of the Policy/Procedure entitled: Routine Cleaning and Disinfection dated 08/2022 revealed under Policy: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. On 04/09/25 at 11:00 A.M., Record review of the Manual Work Order forms for the last 30 days revealed no specific entries related to the aforementioned maintenance concerns.

Based on observation, interview and record review, the facility failed to consistently honor a resident's choices regarding his daily routine and failed to facilitate the ability to go outside when requested, in one of two residents reviewed for choices (Resident #117). Findings include: Resident #117 (R117) Review of the medical record reflected R117 was admitted to the facility on [DATE], with diagnoses that included multiple sclerosis, depression, bipolar disorder, and anxiety. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/3/25, reflected R117 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 04/08/25 at 10:45 AM, R117 was observed dressed and seated in a motorized wheelchair. During the observation, R117 shared that he had always been a busy body and, for many years, was up and at work by 7:00 AM. He expressed that having to wait until after lunch for staff assistance to get out of bed kills something in my soul. R117 reported that this delay in receiving morning assistance has been a recurring issue and stated he recently brought it to the attention of staff. R117 stated that he required the sit to stand and staff assistance to transfer out of bed and into his chair. He further expressed feeling incredibly depressed lately. R117 shared that he greatly missed being outdoors. He stated he had been an avid outdoorsman his entire life and strongly desires sunshine and fresh air. Despite being his own responsible party, R117 stated that the facility does not allow him to go outside on his own. He reported making multiple requests for assistance to go outdoors but was consistently told by staff that he is not allowed to do so when he attempts to sign himself out. R117 emphasized that being kept in bed through the morning hours and being restricted from going outside are really messing with my mood. R117 stated that he recently reported to staff that he wanted to drive his chair in front of a bus but explained that he made the comment out of frustration after being left in bed until after 2:00 PM and had no desire to act on any plan. R117 stated it was a statement made out of frustration. R117 stated that he was being told he is now permitted from leaving the building and denied staff offering to supervise him outside. Review of a Progress Note dated 4/8/25 at 7:57 AM stated, writer spoke with resident regarding concerns-resident [R117] voiced that he would like to be an early morning get up, writer will adjust midnight get up list. Review of the Care Plan and Kardax revealed an absence of preference instructions regarding R117's desired morning routine. On 4/09/25 at 11:04 AM, R117 was observed in bed, dressed in a hospital gown. R117 expressed that he is very disappointed and anxious because he was still in bed, despite the facility promising to ensure he would be assisted out of bed in the morning at his desired time. Review of R117's Physician Ordered dated 3/24/25 revealed an active order which stated, may go loa (leave of absence). Review of the Kardax revealed a care instruction which stated monitor location while up in motorized wheelchair. Do not allow to exit facility while in motorized wheelchair. In an interview on 04/10/25 at 12:51 PM, Director of Nursing (DON) B stated that residents should be allowed up at their requested time and that staff should offer to take R117 outside when he desires.

Based on observation, interview and record review, the facility failed to ensure oral care was provided to one (R81) of two reviewed. Findings include: Review of the medical record reflected R81 admitted to the facility on [DATE], with diagnoses that included atherosclerotic heart disease and essential tremor. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/20/25, reflected R81 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), had impairment on one upper extremity and one lower extremity and required setup or clean-up assistance for oral hygiene. On 04/08/25 at 11:18 AM, R81 was observed lying in bed. R81 stated their teeth had not been brushed since admitting to the facility, and staff did not provide supplies for them to be able to brush their teeth. R81 reported they would have been able to brush their own teeth, if they had the supplies. On 04/09/25 at 2:06 PM, R81 was observed in bed, watching TV. R81 denied brushing their teeth that day and stated they had not been offered set-up assistance by staff to do so. R81 reported their teeth had not been brushed throughout their admission at the facility. On 04/09/25 at 2:15 PM, Certified Nurse Aide (CNA) N reported their shift started at 7:00 AM and would end at 3:00 PM that day. CNA N reported R81 transferred via hoyer lift and had heavy care needs. CNA N reported R81 mostly required set-up assistance to brush their teeth, unless staff noticed R81 struggling. CNA N reported they had not asked R81 if they wanted to brush their teeth that day, reporting R81 did not feel well that morning. Upon observation of R81's personal care items, with CNA N, it was noted that R81's toothbrush was located in a basin, in their room. The toothbrush was in a sealed, clear, plastic package. R81 did not have toothpaste in their room, upon observation with CNA N. Review of R81's oral hygiene task for the prior 30 days reflected that on 4/9/25 at 12:50 PM, CNA N documented R81 performed oral hygiene with Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. On 04/10/25 at 1:08 PM, R81 was observed lying in bed. R81 reported they had been provided with assistance to brush their teeth the prior afternoon, after the State Agency had been in their room with staff, as well as that morning (4/10/25). R81 reported staff set them up with supplies, and they brushed their own teeth, while in bed. An open toothbrush (no longer in a sealed plastic package) and a tube of toothpaste were observed in a basin in R81's room. R81 reported their mouth had felt dirty due to not having their teeth brushed until the day prior. R81's medical record reflected an order dated, 3/17/25, for the nurse to prepare a toothbrush for oral care after medication pass in the morning and at bedtime. The March 2025 and April 2025 Medication Administration Record (MAR) reflected the order was being documented as completed. In an interview on 04/10/25 at 1:19 PM, Director of Nursing (DON) B reported residents should have been provided oral care at least once a day but could receive oral care as often as they requested. DON B reported the order for the nurse to prepare a toothbrush for oral care in the morning and at bedtime was verification that the resident had supplies for oral care to be done and that the CNA was asked to do oral care.

Based on observation, interview and record review the facility failed to exercise reasonable care for the protection of one of two resident's, Resident #117 (R117) personal property from loss, resulting in loss of personal clothing and potentially affecting resident's psychological wellbeing. Findings include: Resident #117 (R117) Review of the medical record reflected R117 was an initial admission to the facility on [DATE] and readmitted on [DATE]. Diagnoses of Parkinsons Disease with Dyskinesia, Heart Disease, Bi-Polar, Multiple Sclerosis, Chronic Pain, Depression and Anxiety. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/19/2025 revealed R117 had a Brief Interview of Mental Status (BIMS) of 15 (Cognitively Intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R117 required moderate assistance with care. Record review revealed the concern/grievance logs did not contain a complaint form or grievance form that was completed for R117 on any of his missing clothing items. During an interview and observation on 04/10/25 at 10:05 AM, R117 was dressed in a light green Carhartt shirt, the residents name was boldly written on his front t shirt pocket. R117 pulled out an acrylic pen from his front pocket and stated that his son wrote his name on my shirt so he would stop losing items. R117 stated that he had to buy the marker himself. R117 stated he was tired of replacing clothes, so he started marking stuff on the front and inside with his name. R117 stated he didn't know what they did with his clothes they lose. R117 was observed in a hospital gown yesterday because he didn't have any clothes to wear. During an interview on 04/10/25 at 1:20 PM, Director of Nursing (DON) B stated R117 did not tell her that he was missing multiple clothing items, he told her that he lost a pair of grey pants, which he was wearing. Writer asked why he was wearing a hospital gown yesterday? DON B stated he only told her about the grey pants. DON B stated, if he had told her about missing clothes, she would have filled out a concern form or grievance form and turned it in to the administrator A. DON B also stated that she talked with this resident all the time and he never told her about having clothes missing other than the pants. During an interview on 04/10/25 at 1:38 PM, R117 stated he did tell the DON B several times that he has had clothes missing. R117 stated he had to buy some more clothes because he didn't have anything left to wear and he only had $50-$60 left a month after paying the cost of this facility. R117 also stated he still had multiple clothing items missing. Writer asked R117 if he had ever filled out a concern or complaint form reporting the missing items and he stated no, he didn't know he had to. R117 shared frustration of not having his own clothes to wear. R117 also stated that it was embarrassing to not have clothes to wear.

Based on observations, interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act in one (R102) of four residents reviewed for abuse. Review of the medical record reflected R102 was admitted to the facility on [DATE], with diagnoses that included anxiety disorder, vascular dementia, and dementia with behavior disturbances. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/20/25, reflected R102 scored 11 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of a Nursing-Progress Note dated 3/8/25 at 4:26 PM revealed Resident [R102] verbally abusing resident. Resident stated he would smack another resident. The note author was identified as Licensed Practical Nurse (LPN) T. In an interview on 3/19/25 at 1:14 PM, LPN T stated that she was familiar with R102. LPN T stated that she did write the Progress Note on 3/8/25, however, could not recall details of the verbal abuse allegation and that R102 gets into arguments with other residents often. LPN T did not report the allegation. In an interview on 3/19/25 at 1:50 PM, Nursing Home Administrator (NHA) A reported that she was unaware of the Progress Note on 3/8/25 and that the expectation would be to maintain safety of both residents and report any abuse allegations immediately.

Based on interview and record review the facility failed to, investigate allegations of abuse for one out of four residents (Residents #102). Findings Include: Review of the medical record reflected R102 was admitted to the facility on [DATE], with diagnoses that included anxiety disorder, vascular dementia, and dementia with behavior disturbances. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/20/25, reflected R102 scored 11 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of a Nursing-Progress Note dated 3/8/25 at 4:26 PM revealed Resident [R102] verbally abusing resident. Resident stated he would smack another resident. The note author was identified as Licensed Practical Nurse (LPN) T. In an interview on 3/19/25 at 1:14 PM, LPN T stated that she was familiar with R102. LPN T stated that she did write the Progress Note on 3/8/25, however, could not recall details of the verbal abuse allegation and that R102 gets into arguments with other residents often. LPN T did not report the allegation. In an interview on 3/19/25 at 1:50 PM, Nursing Home Administrator (NHA) A reported that she was unaware of the Progress Note on 3/8/25 and that the expectation would be to maintain safety of both residents and report any abuse allegations immediately.

Based on observation, interview, and record review, the facility failed to ensure coordination and timely follow-up related to medical appointments required for a surgical procedure for one resident (R3) of 26 residents reviewed for quality of care, resulting in an avoidable emergent surgery and overall decline in a resident's health condition and psychosocial harm with increased feelings of anxiety and mistrust. Findings include: Review of the face sheet revealed R3 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included post-polio syndrome (deterioration of nerve cells called motor neurons over many years that leads to loss of muscle strength and dysfunction), major depressive disorder, anxiety disorder, bipolar disorder, adjustment disorder with anxiety, schizoaffective disorder, calculus of kidney (kidney stone, a hard deposit that forms in the kidneys), hydronephrosis (excess fluid in a kidney due to a backup of urine) with renal and ureteral calculus obstruction, obstructive and reflux uropathy, and malignant neoplasm of prostate. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/5/24 revealed R3 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). The same MDS reflected that R3 required assistance from two people for most activities of daily living. R3 discharged from the facility. In an observation and interview on 03/19/24 at 12:49 PM, R3 was in his room wearing headphones and listening to a device. R3 was understood and easily conversant. R3 expressed that he had grown increasingly anxious over the past few months over some recent health concerns including a new diagnosis of prostate cancer and a recent surgery. R3 stated that back in June he had an appointment with a doc (doctor) that does kidney stones (urologist) and was informed that he would need to have the kidney stones removed from both sides. R3 stated that he came back from the appointment and provided the facility with the information from the urologist. R3 stated that he found out a month later that the facility doesn't know anything about the required surgical procedure. R3 stated that the process to have the kidney stones removed took so long and eventually he ended up getting real real sick from the kidney stones and spent some time in the hospital. R3 stated that he felt that the facility didn't pay attention after his hospitalization in March (2023) and failed to follow up timely, which resulted in his emergent kidney stone removal in December. Review of a Change in Condition Note dated 3/18/2023 at 4:44 AM revealed Upon conducting routine rounds, noted patient to be less responsive, pale. States to staff I'm not ok. Assessed O2 SAT [oxygen saturation] = 50% (percent) . Color pale, patient continues to state that he doesn't feel well. MD [medical doctor] notified and ordered patient sent to ER [Emergency Department] for further evaluation . Review of the Hospital Inpatient Consult dated 3/18/23 revealed that R3 presented to the Emergency Department with altered mental status and shortness of breath. R3 was intubated to protect his airway and underwent testing which revealed hydronephrosis and probable 13 mm (millimeter) stone at the right ureteropelvic junction (where the pelvis of the kidneys meets the ureter). There are also questionable stones on the left renal pelvis . The same consult stated that no acute intervention was needed at this time and that R3 needed treatment with antibiotocs and to follow up with urology. Additionally, R3 was diagnosed with pneumonia and fluid overload due to congestive heart failure. Review of the After Visit Summary dated 3/22/23 revealed that during hospitalization , the hospital arranged a Urology appointment for R3 with the date of 4/24/23. Review of a General Progress Note dated 3/22/2023 at 7:21 PM revealed Resident [R3] arrived in the facility via stretcher. Hospital diagnosis was pneumonia and CHF (congestive heart failure). MD (medical doctor) notified with medication and diet changed from the hospital. New diet put on the [name redacted-the electronic medical record/EMR program] and sent to the kitchen. Review of R3's medical record revealed no indication that R3 attended the Urology appointment. Furthermore, there was no Physician order for the 4/24/23 appointment. In an interview on 03/21/24 at 8:58 AM, Registered Nurse Unit Manager (UM) N stated that she was familiar with R3. UM N stated that the process for ensuring recommended follow up for residents after an appointment or hospitalization is to obtain the paperwork from the facility or resident and review the paperwork for the recommendations. After reviewing, the nurse puts the order in for the recommendations including any lab work or appointment requests and places the paperwork in the unit manager mailbox. The Unit Manager reviews the paperwork and does any other needed follow up. UM N stated that she was not the unit manager for R3 at the time of his 3/22/23 hospitalization . UM N stated that the Urology follow up was brought to her attention either by care conference or a progress note. UM N acknowledged that there was a delay in the process for R3 but was not sure how it occurred. In an interview on 3/21/24 at 10:13 AM, Unit Secretary (US) X reported that she arranges outside appointments for the residents. US X stated that she is made aware of required appointment requests when a physician or nursing staff put an order in or notify her via email or mailbox, which she stated that she checks daily. A request was made and fulfilled for all appointments that R3 was scheduled for the past year. When the paper list was produced, there was no scheduled urology appointment for 4/24/23. When asked for documentation for R3's urology appointment on 4/24/23, US X stated that she does not have anything for that appointment including an after-visit summary. In an interview on 03/21/24 at 11:10 AM, US X stated that R3 had called and cancelled the 4/24/23 appointment because he was not feeling well. Review of R3's medical record revealed that there was no indication that R3 was not feeling well around the dates of 4/24/23. Additionally, there was no indication that the appointment existed in the medical record and that R3 had canceled his own appointment. In a telephone interview on 03/21/24 at 11:43 AM, R3's urologist office confirmed that R3's appointment was canceled. The notes read canceled by patient. The urologist stated that they were unsure who they spoke to but stated that the appointment was rescheduled for the date of 6/15/23 on the same phone call. In an observation and interview on 03/21/24 at 11:37 AM, R3 was in bed wearing headphones. When asked who R3's urologist was, R3 stated he wasn't sure but knew the name of the building and what level the office was on. When asked how he contacts the urologist, R3 reports that he doesn't know how to contact his urologist and that he doesn't handle that stuff. When asked who handles his appointments, R3 stated that his daughter and [US X] take care of his appointments for him. When asked if he has ever refused to go to any appointments, R3 stated that he did not want to attend his colonoscopy appointment in July. When asked if he called and canceled that appointment, he stated he did not, and that staff canceled for him. When asked if he ever refused or canceled any Urology appointments, R3 stated that he has not. Review of a General Progress Note dated 4/29/23 at 2:59 AM revealed PT (patient) had c/o (complaints of) occasional dysuria (painful urination); pt stated he felt a little extra pressure. PT urinary output is dark in color; observed x2 (twice) . Review of a Medical Practitioner Note dated 5/2/2023 at 2:35 PM revealed R3 has some urinary symptoms today and UA (urinalysis) was suggestive of UTI (urinary tract infection). She [sic] was started on Bactrim with some improvement in his symptoms . BPH (Benign prostatic hyperplasia) F/U (follow up) with urology. Monitor for urinary retention. Bladder scans ordered. Nephrolithiasis. F/U with urology . Review of the Physician Consultation/Visit Notes and Orders Note dated 6/15/23 from R3's Urology appointment revealed the reason for visit was kidney stones. The Physician Assessment/Notes section stated, will plan for left PCNL (Percutaneous nephrolithotomy a minimally invasive inpatient procedure performed under general anesthesia to remove kidney stone) followed by right ureteroscopy with laser lithotripsy in 2-7 weeks. Review of a General Progress Note dated 7/13/2023 at 9:46 AM stated results of ekg (Electrocardiography) for surgical clearance: normal sinus rhythm with right bundle branch block. doctor aware. Review of a General Progress Note dated 7/18/2023 1:31 PM stated writer was informed by staff that pt (patient) has up coming surgery for kidney stones. writer called [Urology] to see if anything was scheduled as of today the order was just sent to surgery scheduler. writer will be called when surgery is scheduled to set transportation for PT. The writer for this note was identified as US X. In an interview on 03/21/24 at 9:42 AM, US X reported that she was made aware of the required Urology appointment when she discovered a handwritten note stating that the Urology office had called the nurses station and informed the nursing staff that R3 had a kidney stone that needed removed and the urologist wanted to get it scheduled. US X learned that the Urologist needed R3 to have cardiac clearance before the surgery. US X stated that she called the cardiologist that R3 was previously seeing to make the appointment for the clearance, however, there were no appointments available until October and R3's previous cardiologist was no longer available at that location. When asked if US X called around in an attempt to get a sooner available appointment for R3, US X stated that she did not. Review of a General Progress Note dated 7/21/2023 at 2:40 PM revealed R3 seems to have a lot of anxiety about everyday occurrences [sic] such as appointments, the difference in each CENA's (certified nursing aides) way of doing things, changes in routine, etc. reassurance offered . Review of a Physician Team -Progress note dated 7/24/2023 11:58 PM revealed that R3 had requested a psychotherapy session to discuss concerns. The session revealed Emotionally, clt (client) suggested that he has been recently frustrated and expressed the frustration of being dependent on others. Again, clt refused to have another colonoscopy in July 2023 and had asked staff to cancel the appt (appointment) as he will not go again. Per clt, he already had a colonoscopy some months ago and does not want to go through the prep and procedure again. Clt expressed awareness of the risks of not having the colonoscopy. Per clt, he did accept surgery for the large kidney stones that he recently found out to have. He is a waiting to hear the date of surgery. Review of a Physician Team-Progress Note dated 8/3/23 at 2:28 PM revealed R3 Continues to have urinary frequency and hesitancy no burning. Patient needs cardiology clearance for surgery. His ECG was abnormal. Review of a General Progress Note dated 8/3/2023 at 3:26 PM revealed MD (medical doctor) requested cardiology appointment for abnormal EKG before urology operation. The abnormal EKG was discovered on 7/13/23. Review of a Physician Team-Progress Note dated 9/5/2023 at 1:33 PM revealed R3 had an EEG [sic] done recently which shows right bundle branch block. Urology is planning on left PCNL and right ureteroscopy and needed clearance. He was referred to cardiology but cardiology appointment is not available until October. Review of R3's appointment list revealed a cardiology appointment scheduled for 10/16/23. Review of the Physician Consultation/Visit Notes and Orders paper from R3's 10/16/23 cardiology appointment revealed the reason for visit was abnormal ECG. The Physician Assessment/Notes section stated, see letter. A sticky note was observed on the paper which reflected no letter attached or found -Medical Records 10/31/23. Review of R3's appointment list revealed R3 had another Cardiologist appointment on 11/9/23 for an echocardiogram (test that uses ultrasound to view the heart). Review of a General Progress Note dated 11/9/2023 at 2:52 PM revealed resident [R3] had cardiology appointment this morning. returned approx. (approximately) 9:30 (AM) with no new orders. seems very anxious about appointments and upcoming surgery for kidney stones. asked to speak to SW (social work). SW was made aware. In an interview on 03/26/24 at 12:09 PM, Social Worker (SW) W confirmed that she was familiar with R3. SW W stated that she stops in and visits with R3 frequently. SW W stated that R3 struggled with anxiety regarding his appointments. R3 is anxious about ensuring that he did not miss any of his appointments. SW W stated that he is in constant communication with facility staff regarding his appointments and communicates his appointment needs to staff and scheduling. Review of R3's Care Plan revealed a Care Plan for at risk for mood and behavior symptoms initiated on 1/22/24 which disclosed a history of mistrust of others, worrying that something bad is going to happen to him, irritability, and difficulty sleeping. Review of a General Progress Note dated 12/6/2023 at 8:21 PM revealed MD (medical doctor) notified of acute mental status change; n/o (new order) to send PT (patient) to ED (Emergency Department). PT lethargic, unable to maintained [sic] conversation . Review of the Hospital Documentation dated 12/7/23 revealed that R3 was found altered at the facility and presented to the Emergency Department (ED) with hypoglycemia (low blood sugar), hypotensive (low blood pressure), altered mental status, and lethargic. R3 was in severe decompensated respiratory failure with mixed respiratory (failure of ventilation and accumulation of carbon dioxide) and metabolic acidosis (buildup of acid in the body due to kidney disease or kidney failure) and septic shock (a life-threatening condition caused by a severe localized or system-wide infection). R3 was emergently intubated and required vasopressors for blood pressure support. The notes indicated the root cause of the septic shook was due to bilateral hydronephrosis due to bilateral renal calculi (a condition where one or both kidneys become stretched and swollen due to the accumulation of urine) and bilateral nephrolithiasis (kidney stones). The hospital notes also indicated that R3 had prior clearance by cardiology for the left PCNL. Ultimately, R3 underwent emergent cystoscopy (bladder scope) with bilateral ureteral stent placement (tube inserted into the ureter to prevent or treat obstruction of the urine flow from the kidney). The surgical notes indicated that the right stent placement was very difficult due to impacted mid ureteral stone). R3 was critically ill and admitted to the intensive care unit. Review of the same Hospital Documentation revealed R3's imaging performed at the hospital discovered 2 adjacent calculi (kidney stones) are present on the left ureter, the larger of which measure 9mm (millimeter). 3 other smaller calculi are present in the mid left ureter, the largest of which measures approximately 6mm. Multiple other calculi and clusters of calculi are present in the left renal pelvis, some of which are large. An oval calculus measuring 15 mm is present in the proximal to mid right ureter. At least 3 other calculi are present in the right kidney, measuring up to 8mm. In an interview on 03/26/24 at 1:33 PM, Assistant Director of Nursing (ADON) C stated that R3 cancelled his 4/24/23 urology appointment because he had COVID and was ill, however, documentation determined that R3 tested positive for COVID on 3/27/23 and there was no documentation to support that he cancelled his own appointment and was not feeling well. ADON C stated that R3 wanted to wait for the cardiologist appointment because he wanted to see his regular cardiologist, however, in an interview with US X, R3 had to see a different provider due to his previous provider being unavailable. When asked if any attempt to get R3 into a cardiologist any sooner was made, ADON C was unable to answer. When asked if R3 had ultimately received the cardiac clearance for his surgery, ADON C was unable to answer and required time to follow up. In an interview on 03/26/24 at 2:54 PM, ADON C provided documentation via photographs of text messages between the facility Physician and the Urologist. Review of the Photographs revealed that the facility Physician for R3 requested the clearance forms for [R3's] surgery on 10/27/23. Per the Urology office response, the clearance forms were faxed on 10/30/23. Review of the same Photograph revealed that the Urology office received the clearance forms for R3's surgery on 11/8/23. In an interview on 03/26/24 at 2:54 PM, when asked if there was any follow up with the Urology office regarding R3's surgery, ADON C denied having any further conversation with Urology after the Urology office received the cardiac clearance for R3 surgery on 11/8/23.

This citation pertains to intake number MI00141165. Based on observation, interview, and record review the facility failed to prevent a fall for one out of three residents (Resident #3) resulting in right and left tibia (shinbone), and right femur (large upper leg bone) fractures. Findings Included: Per Resident #3's (R3) Minimum Data Set (MDS), R3 was discharged to the hospital on 11/17/2023 with an anticipated return to the facility. Review of an MDS dated [DATE], revealed R3 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 (moderately impaired cognition). The assessment revealed that both of R3's legs were impaired, and also R3 was totally dependent on staff for rolling right to left while in bed. Review of R3's list of diagnoses revealed R3 had multiple sclerosis (MS-a disease that affects the central nervous system). Record review of a care plan that was in place for activities of daily living (ADLs) dated 11/30/2018 and revised on 10/17/2023, revealed R3 had an, ADL Self care deficit related to weakness, impaired mobility .MS, CVA (stroke) .limited ROM (range of motion-movement) to bilateral (both) lower extremities and left upper extremity related to MS. An intervention was in place that required two staff members to assist R3 with bed mobility, and ADLs. The intervention was last revised on 5/22/2023. Review of a Kardex (a resident care guide for Certified Nurse Aids), no date, revealed R3 required two staff members to assist with bed mobility and ADL's. Review of a facility reported incident (FRI) revealed that on 11/17/23 around 2:30 PM, Certified Nurse Aid (CNA) C provided a bed bath to R3. The report revealed CNA C had R3's bed raised up to her waist level (approximately 3-4 feet), R3 was lying on her back when CNA C turned R3 away from her to R3's right side. The report revealed CNA C was on the left side of R3's the bed, she rolled R3 onto her right side and tucked her left leg under her right leg. The report further revealed that R3, .yelled out, my leg is moving and I am starting to roll ., CNA C then, leaped over the resident (R3), holding onto her upper body and was able to lower the resident to the floor . Further review of the same report revealed R3 was not able to be assisted back into her bed due to, .the severe pain in her legs . The report revealed R3 was transferred to the hospital, and around 9:30 PM during a follow-up phone call the hospital reported R3 had, .sustained a left and right tibia fracture, right femur fracture and a right patella (knee) fracture . Review of a written statement by CNA C dated 11/17/2023, revealed CNA C knew R3 was a two person assist. The statement revealed R3's bed was raised up to waist level, CNA C was on the left side of R3's bed, CNA C tucked R3's left leg under her right leg, and then rolled R3 away from herself which placed R3 onto her right side. Per CNA C's statement R3 said, .oh no my legs are moving, and I am starting to roll ., then both of R3's legs fell over the side of the bed, CNA C then leaped over the bed, held onto R3's upper body, and slowly lowered R3 to the floor. Review of a written interview dated 11/20/2024, that Administrator A held with CNA C, revealed CNA C stated she knew R3 was a two person assist, and tired to get a co-worker to help her give R3 a bed bath, but her co-worker was to busy. The interview revealed that while R3 was turned to her right side, CNA C went to R3's left side to clean her back and back side, when R3 said that she was slipping. CNA C then leaped over (the bed), grabbed R3 under both of her arms, lowered her to the floor, and then R3 immediately complained about pain in her right leg. In an interview on 12/4/2023 at 11:41 AM, Licensed Practical Nurse (LPN) D stated that she was the nurse on 11/17/2023 that CNA C reported to. LPN D said CNA C told her that when she was giving R3 a bed bath, R3 fell out of bed onto the floor. LPN D said CNA C told her that when she had R3 lying on her side her legs slipped off the bed. LPN D said CNA C informed her that she was on the other side of R3's bed (behind R3), and she tried to grab R3 over the bed but was not able to. LPN D said when she entered R3's room she observed R3 to be on the floor next to her bed flipped around (head at the foot of the bed and feet at the head of the bed), the bed was raised up to waist level, and R3 was complaining of pain in her right leg so she left R3 on the floor and called an ambulance for transfer to the hospital. During the interview LPN D further stated that CNA C was aware that R3 was a two person assist for bed baths and ADLs, and told her that she did not get help from another staff member because everyone was busy. In an interview on 11/30/2023 at 2:36 PM, Registered Nurse (RN) E said CNA C had approached her to go into R3's room to help her. RN E said when she enter R3's room she observed that R3's bed was way up approximately 4 feet high. RN E said R3 was on the floor next to her bed and in a lot of pain. RN E also stated that R3 had never rolled out of bed before. In an interview on 11/30/2023 at 12:47 PM, CNA C stated that on 11/17/2023 she gave R3 a bed bath. CNA C said she asked another staff member for help with R3's bed bath her, but said all the other staff were to busy. CNA C said she wanted to clean R3 up before she ended her shift, because R3 was soiled. CNA C said she pulled R3 towards herself and placed R3 on her right side, then went around the bed to the the left side of R3 to put a brief underneath her. CNA C said R3 told her that her leg was slipping, and she saw her falling off the bed, so she went over and across the bed, grabbed R3 from her under her arms from R3's backside, but could not hold onto R3 any longer so she had to lower R3 to the floor. CNA C said she had R3's bed raised up about 4 feet high, and when asked what R3's legs hit when she rolled out of bed, CNA C said she could not say that anything hit R3's legs, and she was surprised that R3 had fractures. During the same interview CNA C further stated that she knew R3 was care planned as a two person assist for turning her while in bed, but said she was not able to find another staff member to assist her. CNA C said she could not leave R3 with a dirty brief and no bath, so she told R3 that she would clean her up, but it would just be her providing the care, which CNA C said R3 was okay with. In an interview on 11/30/2023 at 2:00 PM, R3 was observed in her room in her bed, which was observed to be a large wide bed. R3's bed was observed to be raised up approximately 3 feet high. R3 stated that on 11/17/2023 CNA C had given her a bed bath by herself. R3 said her bed bath had been completed, and CNA C was doing something in her room (did not know what) when she told CNA C that she was slipping off the bed. R3 said she had no control of either of her legs because of her MS diagnosis, and she was not able to pull her legs back up onto the bed to stop herself from rolling off her bed, so she fell from 4 feet up onto her full body weight landing on the floor. R3 said after she fell on to the floor her legs started to hurt. R3 also stated that CNA C did not grab her underneath her arms from her backside when began to roll off her bed and lower her to the floor, and that CNA C had only came to her side when she was already on the floor. Record review R3's weights revealed that on 11/3/2023 R3 weighed 238 pounds. Review of an, EMPLOYEE COUNSELING & CORRECTIVE ACTION RECORD dated 11/21/2023, revealed CNA C was given a written warning due to Carlessness (sig) or Negligence in the performance of the job assignment. The record also revealed, On 11/17/2023 you (CNA C) did not follow, name redacted, (R3's) plan of care. CNA C signed the record on 11/21/2023. Review of a hospital discharge summary date 11/24/2023 revealed under, Hospital Course, .admitted after fall from bed at her facility with multiple closed fractures of both lower extremities . New orders for immediate release pain medication Oxycodone. Review of the hospital X-ray notes dated 11/17/2023 revealed, R3 had right femur, right tibia, and left tibia fractures.

Based on observation, interview and record review, the facility failed administer medications as ordered in 7 of 29 residents reviewed for allegations of abuse (Resident #10, #103, #300-3, #300-5, #400-7 & 400-9), resulting in and unmet needs and hospitalization (Resident #64). Findings include: Resident #64 (R64) In review of R64's May 2023's Medication Administration Record (MAR), an order instructed to administer Furosemide (Lasix) 40 milligram (mg) tablet (diuretic to treat fluid retention), 2 tablets by mouth daily at 6:00 AM for congestive heart failure. The same MAR indicated Furosemide was not signed as administered on 5/14/23 at 6:00 AM. The same MAR revealed Gabapentin 100 mg capsule, give 2 capsules at bedtime for neuropathy; was documented as given on 5/13/23; however, the medication was not signed out on the Controlled Substance Record on 5/13/23. R64's May 2023 MAR indicated Ultram 50 mg was administered at bedtime on 5/13/23, the medication was not signed out of the Controlled Substance Record. R64's Humulin 70/30 insulin, 5 units at bedtime was signed as administered on 5/13/23 at 9:00 PM. A Medication Administration Audit Report indicated the insulin was not actually signed at administered until the next day, on 5/14/23 at 3:51 AM. There were no nurses' notes explaining rationale for late administration/documentation of medications or documentation of resident assessment on 5/13/23. Progress Note dated 5/14/23 at 5:28 PM revealed R64 had a change in condition. Her blood pressure was 188/69, her temperature was 101 degrees Fahrenheit. R64 was wheezing. In review of Witness Statement, not dated, R64 was asked if she received her scheduled medication on 5/13/23 at 9:00 PM; R64 replied no, she got 3 pills and did not know what they were and no insulin. R64 reported on the same statement that she received her medications in the morning of 5/14/23. In review of R64's Medication incident report dated 5/13/23, there was no mention her Lasix was not signed out as administered or that her blood pressure wasn't documented on 5/14/23 at 6:00 AM. R64's Blood Pressure Summary indicated the following: 5/13/23 at 11:38 PM was 128/58, 5/14/23 at 2:09 PM as 162/54, 5/14/23 at 4:41 PM was 188/69. There was no documentation blood pressure measurement was obtained at 6:00 AM on 5/14/23. Physician order dated 5/14/23 at 5:21 PM indicated to send R64 to the emergency room STAT for shortness of breathe, wheeze and fever. Hospital Notes dated 5/14/23 indicated R64 received nebulizer treatments, 2 doses of Lasix 40 mg intravenously, and antibiotics while at the emergency department. The same notes indicated R64 had plus 2 pitting edema (fluid build-up in the body, when pressure applied to area indentation remained) in both legs to the knee. R64 was admitted to the hospital. Social Work note dated 5/31/23 at 8:29 AM revealed Social Work had completed a readmission interview and review. R64's Brief Interview for Mental Status Score (BIMS), a short performance-based cognitive screener, score was 15 (13-15 Cognitively intact). R64's Patient Health Questionaire-9 (PHQ-9, depression assessment) prior to hospitalization score was 1/27 (1-4, minimum depression) and current PHQ-9 score of 6/27 (5-9, Mild Depression). Resident #300-6 (R300-6) On 6/06/23 at 8:40 AM R300-6 was observed sitting in his room. R300-6 stated he did not like agency staff, he had a nurse that he didn't see the entire night and did not give him his medications. R300-6 stated he had to sign a paper to make sure that nurse did not come back to work at the facility. R300-6 Minimum Data Set (MDS) assessment dated [DATE] indicated he had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 13 (13-15 Cognitively Intact). In review of R300-6's Witness Statement, dated 5/14/23, he indicated he did not receive his scheduled medication on 5/13/23 at 9:00 PM or 5/14/23 at 6:00 AM, he did not receive anything at all the entire night; the nurse did not come in at all. In response to the question Do you have any concerns about how you were treated last night?; R300-6's response was none of my medications were given to me. I asked for Tylenol at 9 PM, and he did not give me anything. He never gave me my inhalers. I couldn't breath. They had to put my oxygen on this morning. Resident #62 (R62) In review of R62's Witness Statement dated 5/14/23, she indicated she received her medication on 5/13/23 at 9:00 PM.; but did not see the nurse the next morning on 5/14/23. In the same statement, R62 reported she had concerns about how she was treated the night of 5/13/23; she reported the nurse gave her 10 pills, which was a lot more than she usually took, and she never took 10 pills. R62 reported she took the 10 pills, two at a time. In review of R62's May 2023 MAR, the following oral medications were scheduled to be administered at 9:00 PM: Atorvastatin Calcium, Effexor, Trazadone, Carvedilol, Baclofen. In review of the Medication Administration Audit Report, R62 received her oral medications scheduled for 5/13/23 at 9:00 PM on 5/14/23 between 1:03 AM and 1:08 AM. There were no nurses' notes explaining rationale for late administration/documentation of medications or documentation of resident assessment on 5/13/23. In review of R62's May 2023 MAR, Lasix 10 mg was ordered to administer at 6:00 AM, with instructions to hold with systolic blood pressure was less than 110. There was no documentation of her blood pressure or that Lasix was given. In review of R62's Medication Incident report dated 5/13/23 at 9:00 PM, under incident description Patient claims that on 5/13/232 at 9 PM she received more pills than she was supposed to get, and that at 6 AM on 5/14/23 she did not receive any medication. Patient states that she was given 10 pills at bedtime and non at 6 AM on 5/13/23 7 PM to 7AM shift. The same report indicated R62 was oriented to person, place, situation and time. Nursing Home Administration (NHA) A was interviewed on 6/12/12 at 12:17 PM and stated she investigated abuse part and Nursing investigated medication part of the allegations on 5/14/23. NHA A stated she was also concerned that staff saw that something wasn't right with the nurse the night of 5/13/23 (7 PM to 7 AM shift), education was given. NHA A stated she would have sent the nurse in question for drug testing. 46954 Resident #10 (R10) On 6/06/23 at 11:29 AM R10 was observed laying back in her bed talking to her roommate. R10 reported that a few weeks ago, we had an agency nurse here that was odd. He only worked two nights. He was not clean, his clothes were wrinkled and stained, and he had very long fingernails . R10 then reported that he forgot my eyedrops but I wasn't about to say anything because I was afraid of those long fingernails, I didn't want him giving me the eye drops with those fingernails . R10's Minimum Data Set (MDS) assessment dated [DATE] indicated he had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 15 indicating she was cognitively contact. In review of R10's Witness Statement, dated 5/14/23, she indicated that she did not receive her eye drops. In response to the question Do you have any concerns about how you were treated last night?; R10's response was he was different. Review of the May Medication Administration Record (MAR) revealed that R10's 5/13/23 at 9:00 PM scheduled medication of Latanoprost Ophthalmic Solution 0.005 % (Latanoprost- an eyedrop used for the treatment of glaucoma) was signed out on the MAR indicating it was given but R10 reported that the eye drops were not given, nor, did she feel safe receiving them from the nurse. There were no nurses' notes explaining rationale for the missing medication or documentation of resident assessment on 5/13/23. Resident #103 (R103) On 6/06/23 at 11:29 AM R103 was observed seated in her wheelchair talking to her roommate. R10 reported that she had an issue with an agency nurse recently. R103 stated he tried to give Metamucil (fiber supplement) to me, I told him I don't take Metamucil, I take Miralax (laxative) in the morning. He told me to just take, it it's the same thing. My roommate takes Metamucil . R103's Minimum Data Set (MDS) assessment dated [DATE] indicated she had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 14 indicating she was cognitively contact. In review of R103's Witness Statement, dated 5/14/23, she indicated that she did not receive her Metamucil on 5/12/23 and that she did not receive her scheduled medications on 5/13/23. When asked, Do you have any concerns about how you were treated last night, R103 stated he was sloppy. His fingernails were long, and he looked like he was half there. Review of the May Medication Administration Record revealed R103 did not receive the following scheduled medications on 5/13/23: Pantoprazole (Protonix, a stomach acid reducer) Sodium Tablet Delayed Release 40 milligrams (MG). Glipizide (a medication that lowers blood sugar by causing the pancreas to produce insulin) Tablet 5 MG. Gabapentin (nerve pain medication) Capsule 100 MG. Novolog (Insulin Aspart-a rapid acting insulin) Solution 100 UNIT/ML There were no nurses' notes explaining rationale for the missing medication or documentation of resident assessment on 5/13/23. Resident #400-8 (R400-8) Per the facility facesheet R400-8 had resided at the facility since 5/31/23. Review of a Minimum Data Set (MDS) dated [DATE], revealed R400-8 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated moderate cognitive impairment. Review of a documented statement dated 5/14/2023, revealed R400-8 had stated that on 5/12/2023, Licensed Practical Nurse (LPN) Y had provided R400-D with her scheduled 9:00 PM medication. The statement also revealed that on 5/13/23, R400-8 reported that she had received her 6:00 AM medications. Review of the May Medication Administration Record revealed that R400-8 did not receive the following scheduled medications on 5/13/23: Biofreeze (pain reliving topical medication) 5% Apply to L knee topically every shift for pain. Review of the May Medication Administration Record revealed that R400-8 did not receive the following medications scheduled for 5/14/23 at 6:00 AM: Lasix Oral Tablet 20 milligrams (MG) (Furosemide-a diuretic that removes excess fluid from the body) Give 60 mg by mouth two times a day for CHF (Congestive Heart Failure, a medical condition that can lead to fluid retention). Acetaminophen Extra Strength Oral Tablet 500 MG (Tylenol, a pain reliever) Give 2 tablet by mouth every 8 hours for pain Baclofen Oral Tablet 10 MG (a muscle relaxant used for muscle spasms) Give 1 tablet by mouth every 6 hours for muscle spasms. There were no nurses' notes explaining rationale for the missing medication or documentation of resident assessment on 5/13/23 or 5/14/23. Resident #400-9 (R400-9): Per the facility facesheet R400-9 had resided at the facility since 5/28/23. Review of a Minimum Data Set (MDS) dated [DATE], revealed R400-9 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R400-9 was cognitively intact. Review of a documented statement dated 5/14/2023, revealed R400-9 had stated that on 5/12/2023, Licensed Practical Nurse (LPN) Y had provided R400-9 with his scheduled 9:00 PM medication. The statement also revealed that on 5/13/23, R400-9 reported that he had received his 6:00 AM medications. Review of the May Medication Administration Record revealed that R400-9 did not receive the following scheduled medications on 5/14/23: Levothyroxine Sodium (a medication to treat an unactive thyroid) tablet 20 milligrams (mg). Omeprazole (Prilosec- a medication that aids in the prevention of heartburn) Capsule Delayed Release 20 mg. Lasix (Furesomide- a diuretic that removed excess fluid from the body) Tablet 80 mg There were no nurses' notes explaining rationale for the missing medication or documentation of resident assessment on 5/13/23. 46955 Resident # 300-5 Review of the medical record reflected that Resident # 300-5 (R300-5) was admitted to the facility 9/13/19 with diagnoses including central cord syndrome, cramp and spasm, neuralgia and neuritis, and spastic hemiplegia. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/21/23 revealed that R300-5 had clear speech, was able to understand others and be understood by others and had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 15 (cognitively intact). In an observation and interview on 6/8/23 at 12:05 PM, R300-5 was observed sitting in his wheelchair in doorway of room and proceeded to self-propel wheelchair in room for interview. R300-5 denied remembering specific dates but stated that a few weeks back he had a bigger male nurse with long fingernails whom he described as acting strange. R300-5 stated that he liked sitting in his wheelchair in the doorway of his room and recalled that between approximately 7:00 and 10:00 PM, on that date, he observed the nurse walking back and forth in the hallway, running into walls, and acting like he was drunk or something. R300-5 stated that, from what he could recall, he had received some of his normal night medications, but not others, from that same nurse and that the nurse had administered them at weird times. Per R300-5, when his medications were not administered when scheduled his muscles stiffened and he had a harder time moving. R300-5 stated that he recalled reporting his concern to a staff member following the event but did not recall any additional staff follow-up or the completion of an assessment. Review of a facility form titled WITNESS STATEMENT, revealed that in an interview conducted by facility staff on 5/14/23 that R300-5 reported that he did not get his scheduled 5/13/23 9:00 PM medications and that he only received 1 capsule on 5/14/23 at 6:00 AM. On the same form, in response to the question Do you have any concerns about how you were treated last night?, R300-5 was indicated to have responded Yes. He was drunk. He was going into people's room, hiding behind the curtains. He just kept walking back and forth. Then he would walk away with med (medication) cart open . Review of R300-5's medical record reflected an active order for Baclofen 20 MG (milligrams) twice daily for muscle spasms with corresponding administration times of 12:00 AM and 6:00 AM. Review of R300-5's Medication Administration Record (MAR) dated 5/1/2023 through 5/31/2023 reflected that Licensed Practical Nurse (LPN) Y signed out the 5/14/23 12:00 AM dose as administered with review of the Medication Admin (Administration) Audit Report indicating an administration time of 5/13/23 at 9:53 PM, over 2 hours prior to the scheduled 12:00 AM administration time. Additionally, the same MAR dated 5/1/2023-5/31/2023 reflected that the 5/14/23 6:00 AM dose of Baclofen 20 MG was not administered, as ordered, as the corresponding administration box was noted to be blank. Review of R300-5's medical record reflected no documented nursing or physician assessment on 5/13/23 or 5/14/23. R300-5's Skilled Nursing Note dated 5/15/2023 at 7:05 PM (more than 36 hours after not receiving the scheduled 5/14/23 6:00 AM dose of baclofen) stated, resident alert x (times) 3. denies pain. here long term. extensive assist. incont. (incontinent) b&b (bowel and bladder). A Patient Safety Note dated 5/16/23 at 4:10 PM (approximately 2.5 days after not receiving the scheduled 5/14/23 6:00 AM dose of baclofen) stated, Late Entry .No side effects noted related to not receiving reported medication. Resident # R300-3 Review of the medical record reflected that Resident # 300-3 (R300-3) was originally admitted to facility 2/24/14 with multiple emergency room transfers, hospital admissions, and facility readmissions including the most recent 6/7/23 facility readmission with diagnoses including multiple sclerosis, hypothyroidism, irritable bowel syndrome, polyneuropathy, fibromyalgia, Anxiety, and Major Depressive Disorder. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/14/23 revealed that R300-3 had clear speech, was able to understand others and be understood by others and had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 15 (cognitively intact). In an observation and interview on 6/8/23 at 12:33 PM, R300-3 was observed lying in bed, on left side. R300-3 stated that she had just returned to the facility a short time ago, had been in the emergency room , and that nothing new was identified with treatment for her known urinary tract infection to continue. R300-3 stated that although she couldn't remember a specific date, she recalled a night shift nurse toward the middle of May when she had a very tall, very large, disheveled gentleman with very long fingernails. Per R300-3, he was grubby and I had to keep hounding him for my medications but still didn't get them all. R300-3 stated the nurse did not approach her with her routine night and morning medications, that he did bring her the one's that she had requested although she knew that she had not received them all, and that as he was disrespectful and grubby she did not want to keep asking for them. R300-3 reported that she kept track of her medications, had them all written out on notebook paper and knew them well, and thought that this irritated the nurse. R300-3 stated that a management nurse did question her regarding that specific nurse and that she had reported concerns regarding not receiving her medications but that no additional follow-up or assessments were complete. Review of a facility form titled WITNESS STATEMENT, revealed that in an interview conducted by facility staff on 5/14/23 that R300-3 reported that she did not get the correct medications 5/13/23 at 9:00 PM and received none of her scheduled medications on 5/14/23 at 6:00 AM. On the same form, in response to the question Do you have any concerns about how you were treated last night?, R300-3 was indicated to have responded Yes, I felt like I was being disrespected .The nurse was very strange. I had to tell him what meds (medications) to give me. His fingernails were very long. Review of R300-3's Medication Administration Record (MAR) dated 5/1/2023 through 5/31/2023 revealed the 5/13/2023 9:00 PM doses of Ditropan XL 15 MG ordered for overactive bladder, Latanoprost Ophthalmic 0.005 % (percent) ordered for glaucoma, Lipitor 20mg ordered for cholesterol, Mirtazapine 45 MG ordered for depression, Nitrofurantoin 100 MG ordered for Urinary Tract Infection, Restasis Ophthalmic Emulsion 0.05 % ordered for dry eyes; the 5/13/2023 10:00 PM doses of Hydroxyzine 25 MG ordered for anxiety, Miralax 17 GM ordered for constipation, Pyridium 100 MG ordered for bladder pain, Valium 10 MG and Valium 2 MG ordered for anxiety; and the 5/14/2023 6:00 AM doses of Cymbalta 60 MG ordered for depression, Linaclotide 290 MCG (micrograms) ordered for constipation, Mirabegron ER 50 MG ordered for overactive bladder, Motegrity 2mg ordered for CIC (Chronic Idiopathic Constipation), Synthroid 75 MCG ordered for hypothyroidism, Amitriptyline 25 MG ordered for depression, Omeprazole 20 MG ordered for heartburn, Restasis Ophthalmic Emulsion 0.05 % ordered for dry eyes, Topiramate 50 MG ordered for migraine headaches, Hydroxyzine 25 MG ordered for anxiety, Miralax 17 GM ordered for constipation, Pyridium 100 MG ordered for bladder pain, and Valium 10 MG and Valium 2 MG ordered for anxiety all to have not been administered, as ordered, as the corresponding medication administration boxes for all indicated medications were noted to be blank. Review of R300-3's Controlled Substances Record for both Diazepam (Valium) 2 MG and Diazepam 10 MG included no entry for the scheduled 5/13/23 10:00 PM dose nor the 5/14/23 6:00 AM dose further indicating that these medications were not administered, as ordered. Review of R300-3's medical record reflected no documented nursing or physician assessments on 5/13/23 or 5/14/23. A General Progress Note dated 5/15/2023 at 2:05 AM stated, Patient states she did not receive her medications on 5/14/23 at 6AM. MD (Medical Doctor) notified, no new orders received. Continuing to monitor vitals every shift. No nursing or physician assessment noted within the medical record to indicate R300-3's status after not receiving scheduled medications on both 5/13/23 and 5/14/23.

Resident # 300-5 Review of the medical record reflected that Resident # 300-5 (R300-5) was admitted to the facility 9/13/19 with diagnoses including central cord syndrome, cramp and spasm, neuralgia and neuritis, and spastic hemiplegia. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/21/23 revealed that R300-5 had clear speech, was able to understand others and be understood by others and had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 15 (cognitively intact). In an observation and interview on 6/8/23 at 12:05 PM, R300-5 was observed sitting in his wheelchair in doorway of room and proceeded to self-propel wheelchair in room for interview. R300-5 denied remembering specific dates but stated that a few weeks back he had a bigger male nurse with long fingernails whom he described as acting strange. R300-5 stated that he liked sitting in his wheelchair in the doorway of his room and recalled that between approximately 7:00 and 10:00 PM, on that date, he observed the nurse walking back and forth in the hallway, running into walls, and acting like he was drunk or something. R300-5 stated that, from what he could recall, he had received some of his normal night medications, but not others, from that same nurse and that the nurse had administered them at weird times. Per R300-5, when his medications were not administered when scheduled his muscles stiffened and he had a harder time moving. R300-5 stated that he recalled reporting his concern to a staff member following the event but did not recall any additional staff follow-up or the completion of an assessment. Review of a facility form titled WITNESS STATEMENT, revealed that in an interview conducted by facility staff on 5/14/23 that R300-5 reported that he did not get his scheduled 5/13/23 9:00 PM medications and that he only received 1 capsule on 5/14/23 at 6:00 AM. On the same form, in response to the question Do you have any concerns about how you were treated last night?, R300-5 was indicated to have responded Yes. He was drunk. He was going into people's room, hiding behind the curtains. He just kept walking back and forth. Then he would walk away with med (medication) cart open . Review of R300-5's medical record reflected an active order for Baclofen 20 MG (milligrams) twice daily for muscle spasms with corresponding administration times of 12:00 AM and 6:00 AM. Review of R300-5's Medication Administration Record (MAR) dated 5/1/2023 through 5/31/2023 reflected that Licensed Practical Nurse (LPN) Y signed out the 5/14/23 12:00 AM dose as administered with review of the Medication Admin (Administration) Audit Report indicating an administration time of 5/13/23 at 9:53 PM, over 2 hours prior to the scheduled 12:00 AM administration time. Additionally, the same MAR dated 5/1/2023-5/31/2023 reflected that the 5/14/23 6:00 AM dose of Baclofen 20 MG was not administered, as ordered, as the corresponding administration box was noted to be blank. Review of R300-5's medical record reflected no documented nursing or physician assessment on 5/13/23 or 5/14/23. R300-5's Skilled Nursing Note dated 5/15/2023 at 7:05 PM (more than 36 hours after not receiving the scheduled 5/14/23 6:00 AM dose of baclofen) stated, resident alert x (times) 3. denies pain. here long term. extensive assist. incont. (incontinent) b&b (bowel and bladder). A Patient Safety Note dated 5/16/23 at 4:10 PM (approximately 2.5 days after not receiving the scheduled 5/14/23 6:00 AM dose of baclofen) stated, Late Entry .No side effects noted related to not receiving reported medication. Resident # R300-3 Review of the medical record reflected that Resident # 300-3 (R300-3) was originally admitted to facility 2/24/14 with multiple emergency room transfers, hospital admissions, and facility readmissions including the most recent 6/7/23 facility readmission with diagnoses including multiple sclerosis, hypothyroidism, irritable bowel syndrome, polyneuropathy, fibromyalgia, Anxiety, and Major Depressive Disorder. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/14/23 revealed that R300-3 had clear speech, was able to understand others and be understood by others and had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 15 (cognitively intact). In an observation and interview on 6/8/23 at 12:33 PM, R300-3 was observed lying in bed, on left side. R300-3 stated that she had just returned to the facility a short time ago, had been in the emergency room, and that nothing new was identified with treatment for her known urinary tract infection to continue. R300-3 stated that although she couldn't remember a specific date, she recalled a night shift nurse toward the middle of May when she had a very tall, very large, disheveled gentleman with very long fingernails. Per R300-3, he was grubby and I had to keep hounding him for my medications but still didn't get them all. R300-3 stated the nurse did not approach her with her routine night and morning medications, that he did bring her the one's that she had requested although she knew that she had not received them all, and that as he was disrespectful and grubby she did not want to keep asking for them. R300-3 reported that she kept track of her medications, had them all written out on notebook paper and knew them well, and thought that this irritated the nurse. R300-3 stated that a management nurse did question her regarding that specific nurse and that she had reported concerns regarding not receiving her medications but that no additional follow-up or assessments were complete. Review of a facility form titled WITNESS STATEMENT, revealed that in an interview conducted by facility staff on 5/14/23 that R300-3 reported that she did not get the correct medications 5/13/23 at 9:00 PM and received none of her scheduled medications on 5/14/23 at 6:00 AM. On the same form, in response to the question Do you have any concerns about how you were treated last night?, R300-3 was indicated to have responded Yes, I felt like I was being disrespected .The nurse was very strange. I had to tell him what meds (medications) to give me. His fingernails were very long. Review of R300-3's Medication Administration Record (MAR) dated 5/1/2023 through 5/31/2023 revealed the 5/13/2023 9:00 PM doses of Ditropan XL 15 MG ordered for overactive bladder, Latanoprost Ophthalmic 0.005 % (percent) ordered for glaucoma, Lipitor 20mg ordered for cholesterol, Mirtazapine 45 MG ordered for depression, Nitrofurantoin 100 MG ordered for Urinary Tract Infection, Restasis Ophthalmic Emulsion 0.05 % ordered for dry eyes; the 5/13/2023 10:00 PM doses of Hydroxyzine 25 MG ordered for anxiety, Miralax 17 GM ordered for constipation, Pyridium 100 MG ordered for bladder pain, Valium 10 MG and Valium 2 MG ordered for anxiety; and the 5/14/2023 6:00 AM doses of Cymbalta 60 MG ordered for depression, Linaclotide 290 MCG (micrograms) ordered for constipation, Mirabegron ER 50 MG ordered for overactive bladder, Motegrity 2mg ordered for CIC (Chronic Idiopathic Constipation), Synthroid 75 MCG ordered for hypothyroidism, Amitriptyline 25 MG ordered for depression, Omeprazole 20 MG ordered for heartburn, Restasis Ophthalmic Emulsion 0.05 % ordered for dry eyes, Topiramate 50 MG ordered for migraine headaches, Hydroxyzine 25 MG ordered for anxiety, Miralax 17 GM ordered for constipation, Pyridium 100 MG ordered for bladder pain, and Valium 10 MG and Valium 2 MG ordered for anxiety all to have not been administered, as ordered, as the corresponding medication administration boxes for all indicated medications were noted to be blank. Review of R300-3's Controlled Substances Record for both Diazepam (Valium) 2 MG and Diazepam 10 MG included no entry for the scheduled 5/13/23 10:00 PM dose nor the 5/14/23 6:00 AM dose further indicating that these medications were not administered, as ordered. Review of R300-3's medical record reflected no documented nursing or physician assessments on 5/13/23 or 5/14/23. A General Progress Note dated 5/15/2023 at 2:05 AM stated, Patient states she did not receive her medications on 5/14/23 at 6AM. MD (Medical Doctor) notified, no new orders received. Continuing to monitor vitals every shift. No nursing or physician assessment noted within the medical record to indicate R300-3's status after not receiving scheduled medications on both 5/13/23 and 5/14/23. Resident #10 (R10) On 6/06/23 at 11:29 AM R10 was observed laying back in her bed talking to her roommate. R10 reported that a few weeks ago, we had an agency nurse here that was odd. He only worked two nights. He was not clean, his clothes were wrinkled and stained, and he had very long fingernails . R10 then reported that he forgot my eyedrops but I wasn't about to say anything because I was afraid of those long fingernails, I didn't want him giving me the eye drops with those fingernails . R10's Minimum Data Set (MDS) assessment dated [DATE] indicated he had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 15 indicating she was cognitively contact. In review of R10's Witness Statement, dated 5/14/23, she indicated that she did not receive her eye drops. In response to the question Do you have any concerns about how you were treated last night?; R10's response was he was different. Review of the May Medication Administration Record (MAR) revealed that R10's 5/13/23 at 9:00 PM scheduled medication of Latanoprost Ophthalmic Solution 0.005 % (Latanoprost- an eyedrop used for the treatment of glaucoma) was signed out on the MAR indicating it was given but R10 reported that the eye drops were not given, nor, did she feel safe receiving them from the nurse. There were no nurses' notes explaining rationale for the missing medication or documentation of resident assessment on 5/13/23. Resident #103 (R103) On 6/06/23 at 11:29 AM R103 was observed seated in her wheelchair talking to her roommate. R10 reported that she had an issue with an agency nurse recently. R103 stated he tried to give Metamucil (fiber supplement) to me, I told him I don't take Metamucil, I take Miralax (laxative) in the morning. He told me to just take, it it's the same thing. My roommate takes Metamucil . R103's Minimum Data Set (MDS) assessment dated [DATE] indicated she had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 14 indicating she was cognitively contact. In review of R103's Witness Statement, dated 5/14/23, she indicated that she did not receive her Metamucil on 5/12/23 and that she did not receive her scheduled medications on 5/13/23. When asked, Do you have any concerns about how you were treated last night, R103 stated he was sloppy. His fingernails were long, and he looked like he was half there. Review of the May Medication Administration Record revealed R103 did not receive the following scheduled medications on 5/13/23: Pantoprazole (Protonix, a stomach acid reducer) Sodium Tablet Delayed Release 40 milligrams (MG). Glipizide (a medication that lowers blood sugar by causing the pancreas to produce insulin) Tablet 5 MG. Gabapentin (nerve pain medication) Capsule 100 MG. Novolog (Insulin Aspart-a rapid acting insulin) Solution 100 UNIT/ML There were no nurses' notes explaining rationale for the missing medication or documentation of resident assessment on 5/13/23. Resident #400-8 (R400-8) Per the facility facesheet R400-8 had resided at the facility since 5/31/23. Review of a Minimum Data Set (MDS) dated [DATE], revealed R400-8 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated moderate cognitive impairment. Review of a documented statement dated 5/14/2023, revealed R400-8 had stated that on 5/12/2023, Licensed Practical Nurse (LPN) Y had provided R400-D with her scheduled 9:00 PM medication. The statement also revealed that on 5/13/23, R400-8 reported that she had received her 6:00 AM medications. Review of the May Medication Administration Record revealed that R400-8 did not receive the following scheduled medications on 5/13/23: Biofreeze (pain reliving topical medication) 5% Apply to L knee topically every shift for pain. Review of the May Medication Administration Record revealed that R400-8 did not receive the following medications scheduled for 5/14/23 at 6:00 AM: Lasix Oral Tablet 20 milligrams (MG) (Furosemide-a diuretic that removes excess fluid from the body) Give 60 mg by mouth two times a day for CHF (Congestive Heart Failure, a medical condition that can lead to fluid retention). Acetaminophen Extra Strength Oral Tablet 500 MG (Tylenol, a pain reliever) Give 2 tablet by mouth every 8 hours for pain Baclofen Oral Tablet 10 MG (a muscle relaxant used for muscle spasms) Give 1 tablet by mouth every 6 hours for muscle spasms. There were no nurses' notes explaining rationale for the missing medication or documentation of resident assessment on 5/13/23 or 5/14/23. Resident #400-9 (R400-9): Per the facility facesheet R400-9 had resided at the facility since 5/28/23. Review of a Minimum Data Set (MDS) dated [DATE], revealed R400-9 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R400-9 was cognitively intact. Review of a documented statement dated 5/14/2023, revealed R400-9 had stated that on 5/12/2023, Licensed Practical Nurse (LPN) Y had provided R400-9 with his scheduled 9:00 PM medication. The statement also revealed that on 5/13/23, R400-9 reported that he had received his 6:00 AM medications. Review of the May Medication Administration Record revealed that R400-9 did not receive the following scheduled medications on 5/14/23: Levothyroxine Sodium (a medication to treat an unactive thyroid) tablet 20 milligrams (mg). Omeprazole (Prilosec- a medication that aids in the prevention of heartburn) Capsule Delayed Release 20 mg. Lasix (Furesomide- a diuretic that removed excess fluid from the body) Tablet 80 mg There were no nurses' notes explaining rationale for the missing medication or documentation of resident assessment on 5/13/23. Based on observation, interview and record review, the facility failed administer medications as ordered in 7 of 29 residents reviewed for allegations of abuse (Resident #10, #103, #300-3, #300-5, #400-7 & 400-9), resulting in and unmet needs and hospitalization (Resident #64). Findings include: Resident #64 (R64) In review of R64's May 2023's Medication Administration Record (MAR), an order instructed to administer Furosemide (Lasix) 40 milligram (mg) tablet (diuretic to treat fluid retention), 2 tablets by mouth daily at 6:00 AM for congestive heart failure. The same MAR indicated Furosemide was not signed as administered on 5/14/23 at 6:00 AM. The same MAR revealed Gabapentin 100 mg capsule, give 2 capsules at bedtime for neuropathy; was documented as given on 5/13/23; however, the medication was not signed out on the Controlled Substance Record on 5/13/23. R64's May 2023 MAR indicated Ultram 50 mg was administered at bedtime on 5/13/23, the medication was not signed out of the Controlled Substance Record. R64's Humulin 70/30 insulin, 5 units at bedtime was signed as administered on 5/13/23 at 9:00 PM. A Medication Administration Audit Report indicated the insulin was not actually signed at administered until the next day, on 5/14/23 at 3:51 AM. There were no nurses' notes explaining rationale for late administration/documentation of medications or documentation of resident assessment on 5/13/23. Progress Note dated 5/14/23 at 5:28 PM revealed R64 had a change in condition. Her blood pressure was 188/69, her temperature was 101 degrees Fahrenheit. R64 was wheezing. In review of Witness Statement, not dated, R64 was asked if she received her scheduled medication on 5/13/23 at 9:00 PM; R64 replied no, she got 3 pills and did not know what they were and no insulin. R64 reported on the same statement that she received her medications in the morning of 5/14/23. In review of R64's Medication incident report dated 5/13/23, there was no mention her Lasix was not signed out as administered or that her blood pressure wasn't documented on 5/14/23 at 6:00 AM. R64's Blood Pressure Summary indicated the following: 5/13/23 at 11:38 PM was 128/58, 5/14/23 at 2:09 PM as 162/54, 5/14/23 at 4:41 PM was 188/69. There was no documentation blood pressure measurement was obtained at 6:00 AM on 5/14/23. Physician order dated 5/14/23 at 5:21 PM indicated to send R64 to the emergency room STAT for shortness of breathe, wheeze and fever. Hospital Notes dated 5/14/23 indicated R64 received nebulizer treatments, 2 doses of Lasix 40 mg intravenously, and antibiotics while at the emergency department. The same notes indicated R64 had plus 2 pitting edema (fluid build-up in the body, when pressure applied to area indentation remained) in both legs to the knee. R64 was admitted to the hospital. Social Work note dated 5/31/23 at 8:29 AM revealed Social Work had completed a readmission interview and review. R64's Brief Interview for Mental Status Score (BIMS), a short performance-based cognitive screener, score was 15 (13-15 Cognitively intact). R64's Patient Health Questionaire-9 (PHQ-9, depression assessment) prior to hospitalization score was 1/27 (1-4, minimum depression) and current PHQ-9 score of 6/27 (5-9, Mild Depression). Resident #300-6 (R300-6) On 6/06/23 at 8:40 AM R300-6 was observed sitting in his room. R300-6 stated he did not like agency staff, he had a nurse that he didn't see the entire night and did not give him his medications. R300-6 stated he had to sign a paper to make sure that nurse did not come back to work at the facility. R300-6 Minimum Data Set (MDS) assessment dated [DATE] indicated he had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 13 (13-15 Cognitively Intact). In review of R300-6's Witness Statement, dated 5/14/23, he indicated he did not receive his scheduled medication on 5/13/23 at 9:00 PM or 5/14/23 at 6:00 AM, he did not receive anything at all the entire night; the nurse did not come in at all. In response to the question Do you have any concerns about how you were treated last night?; R300-6's response was none of my medications were given to me. I asked for Tylenol at 9 PM, and he did not give me anything. He never gave me my inhalers. I couldn't breath. They had to put my oxygen on this morning. Resident #62 (R62) In review of R62's Witness Statement dated 5/14/23, she indicated she received her medication on 5/13/23 at 9:00 PM.; but did not see the nurse the next morning on 5/14/23. In the same statement, R62 reported she had concerns about how she was treated the night of 5/13/23; she reported the nurse gave her 10 pills, which was a lot more than she usually took, and she never took 10 pills. R62 reported she took the 10 pills, two at a time. In review of R62's May 2023 MAR, the following oral medications were scheduled to be administered at 9:00 PM: Atorvastatin Calcium, Effexor, Trazadone, Carvedilol, Baclofen. In review of the Medication Administration Audit Report, R62 received her oral medications scheduled for 5/13/23 at 9:00 PM on 5/14/23 between 1:03 AM and 1:08 AM. There were no nurses' notes explaining rationale for late administration/documentation of medications or documentation of resident assessment on 5/13/23. In review of R62's May 2023 MAR, Lasix 10 mg was ordered to administer at 6:00 AM, with instructions to hold with systolic blood pressure was less than 110. There was no documentation of her blood pressure or that Lasix was given. In review of R62's Medication Incident report dated 5/13/23 at 9:00 PM, under incident description Patient claims that on 5/13/232 at 9 PM she received more pills than she was supposed to get, and that at 6 AM on 5/14/23 she did not receive any medication. Patient states that she was given 10 pills at bedtime and non at 6 AM on 5/13/23 7 PM to 7AM shift. The same report indicated R62 was oriented to person, place, situation and time. Nursing Home Administration (NHA) A was interviewed on 6/12/12 at 12:17 PM and stated she investigated abuse part and Nursing investigated medication part of the allegations on 5/14/23. NHA A stated she was also concerned that staff saw that something wasn't right with the nurse the night of 5/13/23 (7 PM to 7 AM shift), education was given. NHA A stated she would have sent the nurse in question for drug testing.

Based on observation, interview, and record review the facility failed to provide appropriate dementia treatment and services for three residents (Resident #12, Resident #34, and Resident #92) of three residents reviewed, resulting in harm (defined for a reasonable person) for one resident (Resident #12) by not providing treatment/services for dementia care and the potential for unmet care needs of two residents (Resident #34 and Resident #92) to meet the highest practicable physical, mental, and psychosocial well-being. Findings Included: Resident #12 (R12:) Review of the medical record revealed R12 was admitted to the facility 12/5/2020 with diagnoses that included congestive heart failure (CHF), hypertension, chronic respiratory failure, type 2 diabetes, atherosclerotic heart disease, occlusion (blockage) and stenosis (narrowing) of carotid artery, atrial fibrillation, vascular dementia, anxiety, psychotic disturbances, mood disturbance, insomnia, gout (buildup of uric acid in bone joints) , dysphagia (difficulty swallowing), and anemia (low blood count). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/09/2023, revealed R12 had a Brief Interview for Mental Status (BIMS) of 99 (unable to participate in assessment). During observation on 04/05/2023 at 08:00 a.m. R12 was observed setting on the side of her bed eating breakfast. She repeatedly was making grunting sounds and saying help. R12 did not respond to verbal stimulation. In an interview on 04/10/2023 at 10:34 a.m. Certified Nursing Aide (CNA) CC explained that R12 did have behaviors of grunting and saying help repeatedly. CNA CC explained that the behaviors had been getting worse. She also explained that she was not aware of any interventions that would help R12 during these behaviors. She explained that she only knew to place an alert in the point of care documentation that would notify the nurse, but she also explained that she does not chart the behavior everyday it occurs because she knew the nurses were aware of it. She explained that these R12's behaviors occurred every day. Review of the medical record revealed R12 had the problem statement cognitive loss as evidence by dx (diagnosis) of vascular dementia with behaviors. No identification of R12 recent behaviors or interventions to assist the resident. In an interview on 04/12/23 at 10:31 a.m. Social Worker (SW) J explained that she was aware of behaviors that had been observed for R12. SW J explained that she was made aware by alerts when residents have behaviors. She also explained that she was made aware by a progress note (04/04/2023) that R12 had been yelling. When asked if behavior of R12 were tracked she explained that behaviors are not tracked in the computer charting (point of care) by the staff. She explained that alerts are reviewed at a morning meeting each day. She further explained that she does not have charting in the progress notes demonstrating that alerts are reviewed and what if any action was taken. She explained that she tracks the behaviors of resident on a word document. SW J was asked to review the plan of care for R12. She confirmed that the new behaviors were not located in the plan of care and no new interventions were present for the new behaviors that had been exhibited. SW J explained that she should have placed those behaviors in the plan of care and included interventions to assist the staff in providing care to R12. SW J could not explain why the plan of care was not updated. SW J was asked if the facility had a Behavior Management Program Policy. SW J explained that three was a policy but she did not have access to it, she explained that the Nursing Home Administrator had it. SW J explained that she had not read the policy in over 6 years. She admitted that she had not read the policy since transferring to this building from another building in the company. When questioned SW J if she suggested any interventions to put in place for R12 she responded, I guess we can provide her with a psychiatric consult. Review of the Psychosocial Outcome Severity Guide provided by Center for Medicare/Medicaid Services (CMS) demonstrated that R12's untreated and continued behavior was defined as reasonable person concept meaning. The behaviors of repeated request for help and grunting noises would cause a reasonable distress. Resident #34 (R34): Review of the medical record revealed R34 was originally admitted to the facility 08/10/2022 and most recently readmitted [DATE] (following a recent hospital stay on 02/19/2023) with diagnoses that included chronic ischemic heart disease, congestive heart failure (CHF), atherosclerotic heart disease of coronary artery, Alzheimer's disease, chronic obstructive pulmonary disease (COPD), atrial fibrillation, gastro-esophageal reflux, hypercholesteremia, chronic viral hepatitis C, hypertension, anxiety, depression, and benign prostatic hyperplasia (prostate enlargement). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/28/2023, revealed R34 had a Brief Interview for Mental Status (BIMS) of 10 (moderately impaired cognition) out of 15. During observation and interview on 04/05/2023 at 09:43 a.m. R34 was observed laying on his bed. R34 explained that he recently had a short stay at the hospital sometime in February of this year and explained that he was happy to be back at the facility. During review of R34's medical record it was revealed that R34 had a care plan that stated, At risk for behavior symptoms r/t (related to) Alzheimer's disease/dementia. No specific types or behaviors that had been exhibited were list on R34's plan of care. In an interview on 04/12/2023 at 10:47 a.m. Social Worker J explained that R34 does exhibit certain behaviors such as walking around with his front wheel walker when he is anxious and can be verbally aggressive when the facility staff. Social Worker J could not explain why R34's behaviors had not been included on his plan of care or what why interventions had not been listed. SW J was asked to provide behavior tracking for R34's behaviors. She explained that there are not specific behaviors that are tracked for R34. SW J could not provide any documentation for behaviors that R34 had exhibited. SW J explained that she had spoken to R34 last week but did not write a progress note regarding that discussion. Resident #92 (R92): Review of the medical record revealed R92 was admitted to the facility 06/17/2019 with diagnoses that included pulmonary embolism, abnormal heart beat, cardiac murmurs (abnormal sound of blood in heart), fatigue, restless leg syndrome, pulmonary nodule (mass), dysphagia (difficulty swallowing), muscle wasting and atrophy, subdural hemorrhage (brain bleed), anxiety, psychotic disorder with delusions, psychotic disorder with hallucinations, polyosteioarthritis (joint pain and stiffness), diverticulosis (abnormal pouch in intestinal wall of the intestines), stage 2 kidney failure, neuropathy (nerve damage), Parkinson's disease, type 2 diabetes, insomnia, gastro-esophageal reflux, hyperlipidemia, and Lewy body dementia. ). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/05/2023, revealed R92 had a Brief Interview for Mental Status (BIMS) of 11 (moderately impaired cognition) out of 15. During observation and interview on 04/10/2023 at 08:29 a.m. R92 was observed sitting up in a chair was the side of her bed eating breakfast. R92 was unable to answer questions and just kept saying doing good. Review of the medical record revealed R92 had a plan of care that stated, Paranoia/Suspiciousness and hallucinations as evidenced by: she stated that she believes people are trying to force her to go to the hospital, someone is forcing her to have a brain procedure, related to: unknown cause, my be related to her reading books. A lot of her feeling things are reality to her. She sites from recent books she has read or when she is listening to her roommates TV shows. She will make comments about the person is coming after her from the show. This care plan problem statement was last updated 04/12/2023. The only intervention listed of for that problem was to administer medication per physician orders, which was last updated 04/12/2023. In an interview on 04/12/2023 at 10:54 a.m. Social Worker J explained that R92 had delusions that her dad was supposed to pick her up. SW J could not demonstrate that those delusions were in R92's plan of care. SW J explained interventions for those delusions were that R92 was easily redirectable, and that staff should take her back to the room and set and talked with her. SW J could not demonstrate that that any intervention was listed on R92's plan of care other than administer medication per physician orders. SW J could not provide any behavior tracking for R92. Review of the facility entitled document Behavioral Management Guidelines, with a date of 03/2022, demonstrated on page 4 of 8 stated: Behaviors are documented in the clinical record. Alerts can be entered POC. Mood/behavior progress notes document the evaluation of reported behaviors. The same document demonstrated on page 4 of 8 stated, The individuals comprehensive care plan addresses the behavior management program, the goal for the behavior management, individualized interventions to address the patients specific risk factors and the plan for reduction of risk related to behaviors.

This citation pertains to intake: MI00135091 Based on record review and interview the facility failed to prevent the development of a pressure ulcer for one resident (#11) of three residents reviewed for the development of pressure ulcers resulting in the development of a stage 3 pressure ulcer (pressure ulcer involving full-thickness tissue loss) and resulting in a decreased quality of life. Findings Include: Resident #11 (R11) Review of the medical record revealed R11 was admitted originally admitted to the facility 08/14/2022 and most recently readmitted [DATE] with diagnoses that included type 2 diabetes, major depression, adjustment disorder, anxiety, depression, insomnia, cerebral vascular disease (disease affecting blood flow to the brain), obstructive sleep apnea, gastro-esophageal reflux, spinal stenosis, dementia, osteo-arthritis, mood effective disorder, hyperlipidemia (high lipid levels in blood), and delusional disorder. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/22/22022 demonstrated R11 had a Brief Interview for Mental Status (BIMS) of 99 (not able to score) out of 15. R11 was discharged back to the community 01/13/2023. Review of the medical record revealed R11 had been discharged for an acute care illness on 11/18/2022, she then returned to the facility 12/02/2022. R11 admission assessment, completed 12/03/2022) demonstrated the only skin issue was listed as dry flaky skin all over. R11's MDS, with an ARD of 2/09/2022, demonstrated no pressure ulcers. Review of the medical record revealed R11 had a Significant Change MDS with an ARD of 12/22/2022, that demonstrated (in section M) that she had a one stage 3 pressure ulcer. Review of R11's plan of care demonstrated the problem statement Resident has pressure ulcer stage 3 related to incontinence, impaired mobility with a date initiated of 15/15/2023. Review of R11's clinical progress notes were reviewed. No progress note was present before 12/15/2022 that addressed that R11 had any pressure ulcers. R11's record demonstrated a clinical progress note, entered 12/15/2022, that stated, Resident has stage 3 pressure ulcer to coccyx, resident is incontinent bowel and bladder. Resident offered to et out of bed daily. Resident chooses to stay in bed. Resident educated on important of turning, and repositioning. Family aware . Treatment orders initiated. Dailey body audit. Work order in place for air mattress. Wound imaged for weekly tracking . The first Skin & Wound Evaluation 5.0, completed on 12/15/2022 demonstrated that R11 had an in house acquired stage 3 pressure ulcer on her coccyx. The stage 3 pressure ulcer measured 9.6 cm2 (centimeters squared) in area, 5.3 cm (centimeters) in length, 4.1cm in width, and a depth that was documented as NA (nonapplicable). The wound bed was documented as containing 0% slough, exude, or eschar. Review of R11's physician orders revealed Magic Butt Cream, apply to left buttocks topically everyday and night shift for scabbed area opening started on 12/10/2022. No clinical progress note, or wound assessment was located in R11's medical record explaining the necessity for the above physician treatment order. In an interview on 03/27/2023 at 04:00 p.m. Nurse Manager F explained that facility skin audits are conducted by certified nursing aides (CNA) which are conducted during showers or bathing of residents and recorded on the facility CNA Skin Worksheet. She explained that those documents are not kept in the medical records but are maintained by the Nurse Managers of the units. She explained if the Licensed nursing staff identified or was made aware of a resident skin issue the Licensed nursing staff would complete a Nursing Body Audit Assessment. She also explained that these documents are not in the medical record but are maintained by the Nurse Managers. Review of CNA Skin Worksheet (provided by the facility), with a completion date of 12/14/2022 revealed that R11 did not have any documented skin concerns. Review of Nursing Body Audit Assessment (provided by the facility), with a completion date of 12/11/2022 demonstrated that R11 had a scabbed open area (handwritten on the document) to the inner right buttock. Review of the Nursing Body Audit Assessment (provided by the facility), with a completion dare of 12/12/22 demonstrated R11 had a red coccyx area (handwritten on the document). Review of the Nursing Body Audit Assessment (provided by the facility) with a completion date of 12/14/2022 demonstrated R11 had a open coccyx area (handwritten on the document). In an interview on 03/28/2023 at 08:56 a.m. Director of Nursing (DON) B explained that the facility completes skin assessments daily by licensed nursing staff and during care that is performed by the CNA's. DON B explained that she had been aware of R11's stage 3 pressure ulcer but could not explain why that staff had not identified a wound prior to this level of wound progression. DON B agreed that lack of identification of R11's pressure ulcer was concerning, and a skin issue of lesser stage should have been identified previously to the identification of a stage 3 pressure ulcer.

This citation refers to Intake #'s: M 014 & M 7531. This citation has two deficient practices. Deficient Practice #1 Based on interview and record review the Facility failed to ensure safety measures were developed and followed for one (#717) with a known history of falls and poor safety awareness out of three resident's reviewed for falls, resulting in R #717 sustaining a [MEDICAL CONDITION] clavicle, multiple rib fractures, compression fractures to the [MEDICATION NAME] area at T5 and T12, prolonged pain and a hospital stay. Findings include: A complaint was made to the State Agency alleging that R#717 had an unwitnessed fall which resulted in multiple fractured ribs and a delay in emergency room treatment. A review of Resident #717's clinical record documented that the Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R#717's Minimum Data Set ((MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score was 0/15 (severely cognitively impaired) and required extensive two person assist for all transfers. A review of R#717's care plan documented, in part, the following: At risk for falls due to impaired balance/poor coordination (date initiated 6/16/17) .Interventions: Bed in low position (6/16/17), Encourage and assist with non skid socks while in bed (6/15/17), Encourage resident to be in common areas when in wheelchair (7/6/17), encourage to transfer and change positions slowly (6/16/17), Frequent visual checks of resident (7/4/17) . Continued review of the review of R#717's progress notes and clinical record documented, in part, the following: Progress note 12/25/17: Resident alert and orient <sic> x1. Resident was trying to get into bed and the aide found the resident sitting on the floor. The resident complained of left shoulder pain and the Dr. ordered a X-ray to R/O (rule out) fracture. Resident also has a small skin tear to the left arm . 12/25/17 (Medication Administration Record [REDACTED]. 12/26/17: (MAR) 5:36 AM (Pain 7/10), 10:34 AM (Pain 6/10), 2:35 PM (Pain 6/10) 12/28/17 (MAR) 10:42 (Pain 7/10) 12/28/17(3:59 AM): .patient calling out for assistance patient did c/o (complain of) left shoulder pain . 12/29/17 (11:30 AM) : .Pt c/o pain to left chest area s/p (status [REDACTED].X-ray completed . no fracture .Pt continues to c/o pain to left chest region. 12/29/17 (4:25 PM): Mobile x-ray service attempted to perform ordered x-rays .Pt yelling out in pain stating he is unable to move his left arm .unable to tolerate x-ray .then sent PT to ER (emergency room ) . 12/31/17: Pt returned from (name redacted) Hospital .temp 101.2 hospice nurse here.pt has dx (diagnosis) of closed fx (fracture) of clavicle, multiple rib fx's, and T5 and T12 compression fractures . 1/2/18: .Pt pronounced dead at 5:55 PM . A Hospital (name redacted) ED (emergency department) note dated 12/30/17 documented, in part, R#717 .presents from (name redacted) with complaints of left shoulder pain. By report he had a fall 4 days ago onto his left side and has been complaining of left shoulder pain since that time .he has been pointing to his left shoulder and saying ouchie. He seems reluctant to use that arm. R#717 is alert and oriented X1 at baseline and has severe dementia, so history is limited. Physical exam is also limited due to patients limited ability to follow commands . On 12/20/18 at approximately 2:00 PM an interview and record review was conducted with the Administrator. The following progress notes and Incident Investigations (I & A's) related to falls were reviewed with the Administrator: 6/16/17: .Pt in prone position on floor by foot of bed .quarter size abrasion to back of head . 6/23/17: Fall .laying on L(left) side on floor .1 CM diameter skin tear . 7/4/17: .Pt lying on R(right) side of floor next to closet red area back of head and forehead .pt left via .stretcher . 7/6/17: .2:30 pt call light on .pt knees by bedside .Dr .called . 7/7/17: .reviewed R#717 observed on floor on 7/4/17 .7/6/17 .new interventions are frequent visual checks and encourage resident to be in common areas when in w/c (wheelchair) . 7/26/17: .Pt fell out of bed .small skin tear on L outer elbow . 8/20/17: Pt found on floor .pt fell out of w/c in pt. room trying to go to the bathroom .2 skin tears on R elbow . 9/12/17: Pt is sitting on floor .open skin tear on elbow .pt unable to transfer due to severe pain .pt was transferred to Hospital . 11/5/17: Pt .trying to get out of bed throughout the night. Pt watching tv near nursing station. Pt is being monitored and kept close. 11/7/17: .review of fall from 11/7/17 .Pt. trying to transfer himself from wheelchair to his bed and fell to the floor on both knees .Intervention: Nursing staff to ask patient if he would like to go to bed by 8 PM . 12/5/17: .review of fall from 12/5/17 .pt was transferring without assistance from his bed to his wheelchair and fell to the floor .patient reported he needed to use the restroom .pt had a skin tear to left elbow .Interventions: more frequent visual checks. 12/15/17: .Pt. is seen because he sustained a fall. He is now having pain in his left lower extremity .there is swelling and tenderness over the knee. 12/23/17: .multiple attempts to get OOB (out of bed) per self, patient in lobby on unit to be observed for safety . 12/25/17: I & A (Incident and Accident): Date of Incident 12/25/17 2:30 PM .Description of Incident: Resident was in a wheelchair trying to get into the bed being non compliant. Aide passed by the room and saw the resident on the floor kneeling on both knees on the side of the bed. The CNAs (certified nursing assistant) helped assist the resident from the floor back to bed. Describe cause of the incident .Resident was trying to get into bed by self .Corrective Action .Assist resident back to the chair, took resident back in the hallway and educated resident to make sure he gets help or have someone help him getting back in to the bed .Extent of injuries .Resident has a skin tare on left arm and states shoulder hurts . Following the review of R#717's clinical record on 12/20/18, including notes pertaining to falls, the Administrator was queried as to the fall interventions in place to protect the resident prior to 12/25/17. The Administrator reviewed the care plan and reported that interventions included keeping the resident's bed in a low position, assisting with non-skid socks, encouraging resident to be in common area when in wheelchair, frequent visual checks and asking staff to put resident to bed by 8:00 PM and never leaving the resident alone in the bathroom. When queried as to why R#717 was left alone in his room in a wheelchair on 12/25/17 at approximately 2:30 PM, as the careplan and further interventions indicated the resident not be be alone in the room in a wheelchair, the Administrator did not provide a response. When further queried as to any further investigation documentation pertaining to the incident on 12/25/17, that may include statements from staff, the Administrator reported that there was no further investigation documentation and noted that there was some facility concerns pertaining to falls in the past that have been addressed. During a continued interview the Administrator was queried as to why R#717 was not sent to the Hospital until 12/29/17 at approximately 4:25 PM, the Administrator reported that an initial x-ray revealed no-fracture to the shoulder on 12/25/17 and therefore the resident was not sent out on that date. When queried as to whether R#717 was seen by a physician following the incident on 12/25/17 and prior to being transferred to the hospital on [DATE], the Administrator stated, No. When asked why R#717 was not sent to the hospital until 12/29/17, the Administrator stated, When R#717 had continued pain and trouble with a second x-ray we sent him out. On 12/20/18 at approximately 3:30PM a review of the Facility's Policy titled, Falls Practice Guide (issue date 12/2011) was reviewed and documented, in part, the following: Purpose: The purpose of the Falls Practice Guide is to describe the process steps for identification of patient fall risk factors and interventions and systems that may be used to manage falls. Fall management focuses on minimizing fall risk factors .Initial Evaluation: upon admission .complete .a patients history of actual falls and the on-going risk for falls .Initial Plan of Care: if upon completion of the (name redacted) the patient is found to be at risk for falls or has a history of falls .an initial plan of care is developed and .interventions are initiated .Comprehensive Care Plan: .for a patient with a history of falls, the goal may focus on limiting injuries from the falls .the approaches for fall interventions are clear, specific and individualized for the patients needs .Ongoing Management Strategies: On the basis of the information obtained .the next step is to implement an organized approach for the management of the patients falls or fall risk factors . Deficient Practice #2 Based on interview and record review the Facility failed to ensure a proper two person transfer for one (#713) of three resident's reviewed for falls/accidents, resulting in the R#713 being transferred by only one staff member causing pain during the transfer and customer service concerns. Findings include: The Facility reported to the State Agency that R#713 alleged that a CNA (certified nursing assistant) was mean to her by giving her attitude and putting her knee into R#713's surgical incision. A review of R#713's clinical record documented that the Resident was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R#717's MDS dated [DATE] documented that R#713 had a BIMS score of 14/15 (cognitively intact) and required a two person assist for all bed mobility and transfers. Continued review of R#713's ADL (activities of daily living) care plan documented, in part, the following: ADL self care deficit as evidenced by decreased mobility related to left hip hemi arthroplasty (date initiated 8/8/18) .Transfers Ext (extensive) 2 (date initiated 8/8/18) .2 caregivers at all times for care (date initiated 8/14/18). A review of an I & A record dated 8/9/18 detailed, in part, the following: Summary of Incident (unsigned/undated): On 8/10/18 resident #713 stated that an aide was mean to her by giving her attitude and that she put her knee into her surgical incision during transfer .the Facility was unable to substantiate any abuse allegation but rather a customer service concern. Out of an abudance of caution the aide will receive customer service training before working at our facility in the future. Statement by R#713: At about 10 PM last night I wanted to get in bed. I put my call light on and needed to be transferred from w/c to bed. I can't describe her. I don't remember what she looked like. Her attitude was so awful that I didn't even look her in the face. She was transferring me and her knee was going right into my surgical site and it hurt. I don't even know if it was there. She never asked me if she was hurting (me) or anything. She never apologized or anything .I don't want her to care for me anymore . Statement by R#713's roommate: Were you in room Sunday night when CNA was putting roommate to bed? Around 10:00 PM, I heard CNA helping my roommate to bed .I heard my roommate yelling you are hurting my sore . On 12/20/18 at approximately 9:20 AM an interview and record review was conducted with the Administrator/Abuse coordinator regarding the incident that occurred on 8/9/18. The Administrator was queried as to the investigation involving R#713 and CNA K. The Administrator reported that after an investigation, the Facility determined that R#713 was not abused by CNA K. The Administrator stated, We determined that CNA K provided poor customer service to R#713. She was an Agency CNA and was suspended and asked not to return to the Facility. When further as to whether the Facility was aware that CNA K transferred R#713 without assistance, the Administrator reported that R#713 was a two person assist and should have been transferred with two people. When asked whether transferring R#713 without assistance may have caused CNA K to push on the resident's surgical site, the Administrator did not provide an answer. On 12/20/18 at approximately 3:45 PM a review of the Facility's Policy titled, Transfer: Bed-Chair/Wheel-Chair (dated 1/2011). Purpose: To move safely from bed to chair or wheelchair back again .

This citation pertains to intake #MI 779 Based on observation, interview and record review the facility failed to ensure one resident (R#901) of three residents reviewed for accidents, had their wheelchair pedeals placed in a locked position prior to transport resulting in R#901 being sent to the hospital and sustaining a fracture of their right femur. Findings include: On 9/18/18 at approximately 9:06 a.m., R#901 was observed in their room lying in their bed. R#901 was observed to have a leg immobilizer on their right leg. On 9/18/18 the medical record for R#901 was reviewed and revealed the following: R#901 was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. R#901 had [DIAGNOSES REDACTED]. R#901's MDS (minimum data set) with an ARD (assessment reference date) of 7/10/18 revealed R#901 needed extensive assistance from facility staff with bed mobility, transfers, dressing, personal hygiene and bathing. R#901's BIMS score (brief interview of mental status) was 15 indicating intact cognation. A nurses note dated 9/2/18 revealed the following: Pt (patient) sent to ER (emergency room ) at (name of local hospital) for knee pain. Called to ER nurse they did right knee x-ray and results were negative. States pt is still in severe pain so unsure if pt will be admitted . A nurses note dated 9/3/18 revealed the following: Pt alert and orientated times three (knows who they are, where they are and the time). Patient returned from hospital at 0715 (military time) and immediately was c/o (complaining of) severe pain to right knee. Patients nurse from hospital called to request patient return as they found a fracture in her right knee. She was taken back via (name of ambulance company) and returned at 1645 still in a lot of pain and her PRN (as needed) med was administered for that at 1800 as well . A hospital X-ray dated 9/3/18 revealed the following: 1. Acute nondisplaced fracture traversing from the posterior femoral distal shaft just superior to the medial femoral condyle and likely extending through the anterior femoral condyle . A hospital CT scan (computed tomography) dated 9/3/18 revealed the following: Attending addend; CT imaging report noted fracture right distal femoral condyle fracture and impaction fracture to tibial plateau. Initial stabilization and splinting provided. A hospital HPI (History of present illness) by the Emergency Department Physician dated 9/3/18 revealed the following: This is a (age of R#901) year old female with a past medical history of [REDACTED]. She was initially seen here in the Emergency Department yesterday after being pushed in a wheelchair and having her right foot get caught underneath the right foot rest. Her leg was twisted and she had acute onset of pain of her right knee at the time. She had an x-ray that was performed, did not appreciate any significant fractures or other injuries. On radiology review by the attending physician, a new fracture was noted. Because of this, she was referred back to the Emergency Department for reevaluation. Currently, she acknowledges 10/10 pain of her right knee. On 9/18/18 a facility investigation regarding R#901's injury on 9/2/18 was reviewed and revealed the following: Incident Report dated 9/2/18-Description of Incident: Patient was being propelled in w/c (wheelchair), foot rest swung open, and patient' R (right) foot went under w/c. Describe cause of incident, if known: foot rest swung open. A witness statement from staff member A dated 9/11/18 revealed the following: On 9/2/18 around 1:45 pm I was in the Huron Dining Room. (R#901) was sitting at the dining room table and was going to go to the church services. So I looked down and she had her wheelchair pedals on so I talked to (R#901) and let her know I was going to pull back her wheelchair from the table and take her to the church services. After I pulled her wheelchair back and started to turn the chair and start a forward motion with the chair, her right wheelchair foot pedal swung outward and her right leg fell off the pedal. Her knee bent to almost a 90 degree angle and she said 'ouch'. I immediately stopped and I told her to wait just a minute and I got the nurse to come evaluate her. The foot pedal seemed to be locked in place at the time that I as assisting her. A witness statement from R#901 dated 9/11/18 revealed the following: I was in a church group here. (Staff member A) was moving me to be with everyone else. While she was moving me the w/c pedal popped out, my leg fell . My leg went backwards, she stopped right away. I heard a creek. They got the nurse and they took me to the hospital. On 9/18/18 at approximately 10:43 a.m., staff member A was interviewed via phone regarding the incident for R#901 on 9/2/18. Staff member A was queried how they ensured R#901's wheelchair pedals were locked in place for safe transport and they indicated that the wheelchair pedals looked aligned. Staff member A was queried if they had physically inspected the wheelchair pedals to ensure they were in a locked position before transporting R#901 and they said they had not. On 9/19/18 at approximately 2:41 p.m., the Director of Nursing (DON) was queried if it was their expectation that the facility staff safely transport residents in their wheelchairs and they indicated that it was. The DON was queried how to ensure a residents wheelchair pedals are safely locked in position for transport and they stated, you got to grab them and make sure you can't move them and that their locked. The DON was queried if a visual inspection of wheelchair pedals ensures a safe transport and that wheelchair pedals are locked in position and they said no. On 9/18/18 a policy regarding transporting residents in wheelchairs was requested. A facility document titled Transfer: Bed-Chair/Wheelchair with a date of 01/2011 was provided and reviewed. It did not indicate how to ensure wheelchair pedals were locked for safe transport of residents.

Based on observation, interview, and record review the facility failed to ensure that one resident (R#28) who was assessed as an at-risk smoker and who had a history of [REDACTED].-smoking status when the resident was observed by staff on 7/16/18, 7/19/18, and 8/7/18 smoking inside of his room for one of one residents reviewed for smoking, potentially affecting all 167 residents who reside at the facility, resulting in the potential for serious injury, harm, or death [MEDICAL CONDITION] fire. This resulted in an immediate jeopardy to the health and safety of all residents residing in the facility. Findings include: This immediate jeopardy was identified on 8/21/18 at 1:30 p.m. The Administrator was notified on 8/21/18 at 2:18PM and a plan of removal was requested to remove the immediacy. The immediacy was removed on 8/21/18 based on the facility's implementation of an acceptable plan of removal as verified on site by the survey team. The start date of the immediate jeopardy was identified as 7/16/18. Although the immediacy was removed, the facility's deficient practice was not corrected and remained an isolated incident that is not Immediate Jeopardy. On 8/20/18 at 8:56AM R#28 was observed lying in bed in their room and was queried in regard to their stay at the facility. At this time R#28 stated, I don't trust the staff . I had a feeling they were going to take me around the corner and beat me up they are trespassing on my behalf I feel threatened. R#28 explained that he felt staff were going to mutilate him, explained that he felt threatened, and then explained that most of the staff members were doing their job. On 8/21/18 at 12:35 PM the clinical record for R#28 was reviewed and revealed the resident had been admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of the resident's quarterly minimum data set (MDS) assessment dated [DATE] the resident scored 4 out of 15 on a brief interview for mental status exam, which indicated the resident was severely cognitively impaired. Continued review of the clinical record for R#28 revealed the following: Per a Physician's Evaluation of Resident's Capacity To Make Health Care Decisions form dated 4/4/18 for R#28, the following statements were checked as applicable for the resident: does not have the capacity to make medical decisions, does not have the capacity to make financial/legal decisions. Per a progress note dated 6/25/2018 at 6:23PM the following was documented: General Progress Note Text: Writer put away lighter retrieved from resident's person. Resident became upset Review of a Long Term Care Nursing Facility Admission History & Physical completed by the physician dated 7/12/18 for R#28 revealed, in part, the following: (R#28) is seen for evaluation for admission for LTC (long term care) following recent hospitalization . Per the Medical Plan of Care section of the form the following was documented: Tobacco abuse counseling Assessment & Plan: Patient is on the fence about being ready to quit despite having reduced his smoking considerably between the hospital inpatient and our SNF (skilled nursing facility) stay. He does agree that he will not try to smoke on the campus, and requests reinstatement of his courtyard LOA (leave of absence). I was clear that if he violates the smoking policy again he will lose his privileges to do so moving forward. Review of a Skilled Nursing Facility Progress Note completed by the Nurse Practitioner dated 7/17/18 revealed, in part, the following: .The patient states he did smoke several cigarettes yesterday and was caught by nursing staff. He reports he continues to try to be good. Per the Assessment and Plan section of the evaluation the following was documented: .3. Tobacco use. The patient continues to somehow obtain cigarettes and smoke his cigarettes somewhere in campus. Smoking cessation counseling was provided to the patient and this will be continued to offered the patient on a regular basis. (Facility Name) policy is strict on allowing patient is to smoke on campus. Per a progress note dated 7/19/2018 at 2:26PM the following was documented: Skilled Nursing Note Text: Nurse aid in the hall-way repeatedly smelling cigarette from room (room number); proceed to the and it was the patient in (room number) smoking (Resident # 28). When asked if he was smoking and began saying I will not smoke again; sorry. The cigar was taken from him and put in cart. Called patient responsible party (Name redacted) and left message with her secretary. MD (Name redacted) was called also. Educated patient about the important of not smoking in his room or hall; patient verbally understanding. Patient is now in his room. Continue to monitor. Review of a Long Term Care Nursing Facility Urgent Visit Progress Note dated 8/6/18 for R#28 revealed, in part, the following: PHYSICAL EXAMINATION Gen: Patient is seen lying in bed in no acute distress. Alert and mostly appropriate in conversation and oriented x3 (person, place, time), however he doesn't appreciate the significance of his illness, needs for recovery and is contemplative in regards to being ready to quit smoking Review of Incident/Accident reports for Resident # 28 revealed, in part, the following: 7/16/18 at 4:13PM Description of Incident: Writer informed by staff that resident was smoking in room. Writer asked resident about paraphernalia. resident states I flushed it down the toilet because I knew you were gonna take it. Writer and other Nurse searched room and were unable to find any items that did not belong. Per the Incident Cause section of the form the following was documented: resident had a visitor shortly before smoking in room. Corrective action for the incident documented the following: writer was unable to locate any cigarettes or lighters. resident was educated on the importance of maintaining safety for himself and others. 7/19/18 at 1:50PM: Description of Incident: Observed patient smoking in his bath room. Per the Incident Cause section of the form the following was documented: Observed Patient was smoking in his bath room. Per the corrective action section of the form it was documented, Educated patient about the danger of smoking in room/bathroom or in the facility. 8/7/18 at 5:00pm: Description of Incident: Staff smelled smoke and walked into patient's room to find patient smoking in bathroom. Patient stated that he knows that he should not have been smoking. He stated that he bummed a cigarette but cannot remember from what patient. He had a book of matches that he was willing to give to staff. Per the Incident Cause section of the form the following was documented: Patient has been offered smoking cessation but has declined in the past. Nurse reoffered, and patient accepted. Corrective action for the incident documented the following: Patient was re-educated on the non-smoking policy of the building and was offered a smoking cessation in which he accepted. On 8/21/18 at 12:52 PM review of a Smoking Facility-Smoking Evaluation form signed on 5/8/18 for R#28 documented the following: Per the Cognitive function section of the evaluation the following questions were all answered No: Short term memory is ok; recall after 5 minutes, Long term memory is OK: recall of long past events, Adequate memory/recall ability: recall of activities over last 7 days, Able to make decisions regarding tasks of daily life (e.g., decisions are consistent and reasonable). Per the Determination section of the evaluation, R#28 was identified as being an at risk smoker, and a box on the form was checked which indicated the resident required family, friend or staff for physical support or supervision to smoke. Per the comments section of the evaluation the following was documented: Pt. (patient) educated that we are a non-smoking facility. On 8/21/18 at 1:22 PM care plans for R#28 were reviewed and did not reveal a care plan to address R#28's smoking behaviors. On 8/22/18 at 11:59 AM Review of a Center Supplement packet included in the facility's Patient Information Handbook documented the following: January (YEAR) Center Supplement: Smoke-Free Campus If you are a NON-smoking campus, include this information in your Center Supplement: SMOKE-FREE CAMPUS For everyone's health, the Center is a smoke free environment, both indoors and outdoors. Because we have a smoke-free campus, no patients are allowed to have any smoking materials, including, but not limited to, lighters, matches, cigarettes, e-cigarettes, pipes, and cigars, on the campus. If you are interested in receiving help to stop smoking, please contact Center staff. On 8/22/18 at 12:06 PM the facility's Director of Nursing (DON) was queried in regard to her knowledge of R#28's smoking and responded that she was aware of the incident dated 8/7/18. When queried as to whether she was aware of previous incidents of the resident smoking in the building or on the facility's campus, the DON could not recall specific details regarding prior incidents. The DON was queried in regard to the process for newly admitted residents regarding smoking. Per the DON, the resident would be queried in regard to their smoking history, smoking cessation would be offered, and the resident would be informed that the facility was a smoke free facility. Per the DON nicotine patches had been attempted for the resident, and the resident would say that they would not smoke again. Per the DON R#28 apologized after the incident. On 8/22/18 at 2:46 PM the facility's Administrator was queried in regard to her knowledge of R#28's smoking and responded that she knew of two instances of the resident smoking. Per the Administrator, following the first incident of the resident smoking the resident's room was searched, paraphernalia was confiscated, education was provided to the resident, the physician and guardian were contacted, and the resident was offered smoking cessation. When queried as to whether R#28 was receptive to the education, the Administrator responded the resident was receptive, as the resident would come to her and say (R#28) would not smoke again. Per the Administrator the second time the resident was found smoking the same interventions as the first incident were implemented, and as the facility was unable to determine how the resident was getting the paraphernalia the resident was unable to have visitors in the resident room (with the exception of the resident's guardian) unless the Administrator had been made aware so the situation could be monitored. Per the Administrator they were out of the facility at the time of the next occurrence of R#28 smoking. Review of a facility policy titled Smoking Guidelines revised 7/2017 documented, in part, the following: Any non-compliance with the smoking guidelines is addressed with the patient and family members as the non-compliant activities occur. Additional education is provided as needed and the plan of care is updated to reflect the patient's current needs. The facility submitted the following plan of removal: Date: 8/21/2018 This serves as (Facility Name Redacted) response to the immediate jeopardy notification that the center received (MONTH) 21, (YEAR). The facility Quality Assessment and Assurance committee met on 8/21/2018 to resolve the alleged failure of the facility to ensure that one resident maintained compliance with the facility's non-smoking status. As a result the following plan of correction has been developed. Element 1 Identified resident (#28) was placed on one on one supervision. Resident has been assessed with [REDACTED]. The resident's physician and guardian were re-notified and understand the non-smoking policy. Element 2 On 8/21/2018 the interdisciplinary team reviewed 160 of 160 resident's clinical records to determine if they were at risk for non-compliance with the centers non-smoking policy these residents will have an assessment to ensure they had no negative outcome. The interdisciplinary team identified 3 of 167 residents who are at risk for smoking. The interdisciplinary team reviewed and revised like residents care plans and Kardex's as indicated. These 3 residents have smoking assessments in place and have been provided the smoke-free property notice. Newly admitted residents will continue to be evaluated for at-risk for smoking. Interdisciplinary team will review new admissions for at risk for smoking and update their care plans as indicated. Element 3 On 8/21/2018 Administrator began re-education on the facility's non-smoking policy to identified residents and staff. The education includes immediate appropriate interventions based on comprehensive assessment of the resident to ensure safety of the residents in the center. On 8/21/2018 staff currently working will be educated before the end of their shift and oncoming shift employees will be educated prior to the start of their shift until 100% of staff are educated. On 8/21/2018 as of 8pm 64 facility staff have been educated. Element 4 Unit Managers/designee will complete random observations of the identified residents to maintain the center's smoke free environment. Concerns identified will be addressed immediately. Results of the audits will be provided to the DON/designee weekly for additional follow-up as needed. The DON will provide a summary of the audits to the Administrator and the QA&A committee monthly for analysis and development of a QA action plan as needed until further directed by the QA committee.

This is a citation pertains to intake MI 228 Based on interview and record review the facility failed to provide ADL care based on the resident's accessed need of two person assist for ADL care for 1 (#701) resident of 2 residents reviewed for falls of the total sample of 4 residents, resulting in a right subtrochanteric (hip) fracture when a fall occurred during incontinence care with only one CNA (certified nursing assistant), provided care. Findings include: Resident #701 On 1/4/18 at 10:14 AM, a review of the facility investigation revealed an incident of a fall resulting in a right [MEDICAL CONDITION], that occurred on 12/16/17 at approximately 4:30 PM. Per interview by facility staff with CNA B during the facility investigation, she stated, I was changing her brief when she rolled off the bed onto the floor. Staff observed resident #701 lying on her right side or straight on the pillow between the two residents beds. When asked if the plan of care was followed and does CNA B think she was wrong? CNA B responded I don't know, I didn't go through her tasks. I don't know what it says about the patient. Upon further review of the facility investigation of resident #701 revealed, CNA B was changing the resident's brief, she turned the resident away from her (during incontinence care), the resident had a leg spasm or jerk then fell out of the bed. The facility Administration staff stated in the investigation, I explained the correct way to do it as, we had a similar incident last week that I heard about but I wasn't here with the resident and one CNA changing her. On 1/4/18 at 11:34 AM, the clinical record for resident #701 revealed an admission date of [DATE] and readmitted [DATE]. [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment dated , 12/ 18/17, indicated a BIMS (brief interview of mental status) score of 0. A score of 0 to 7 indicates a resident is severe cognitive impairment. Requires extensive two person assistance with ADL care (activities of daily living), bed mobility, transfer, hygiene, bowel and bladder needs. On 1/4/18 at 12:48 PM, The Director of Nursing was queried about the fall involving resident #701, she stated, On 12/16/17 at approximately 4:30 PM, the CNA was changing of the resident with bilateral leg contractures when the resident jerked and rolled off the bed onto the floor due to a leg spasm. The physician examined the resident the next day on 12/17/17, he noted there were no facial grimacing from pain following his physical examination of resident #701. The next day, resident #701 was sent to the hospital on [DATE], due to abnormal labs, they did a CT scan of her hip, that's when the [MEDICAL CONDITION] hip was discovered, she return to the facility on [DATE]. On 1/4/18 at 2:23 PM, resident #701 was observed lying in bed on her back awake, alert to name. Resident has impaired language stated, Hello and Hungry two words were used repetitively due to the cognitive deficit. On 1/4/18 at 2:27 PM, a review of the Physical Therapy evaluation and Plan of Treatment dated, 12/18/17, revealed resident #701 was alert, disorientated, confused and an unreliable informant due to cognition. Resident requires total care, total dependence without attempts to initiate for bed mobility and transfers. Resident #701 is non-ambulatory (unable to walk) and depends on staff for all levels of mobility. On 1/4/18 at 2:50 PM, Nurse C was asked if she was aware of the fall that occurred on 12/16/17 involving resident #701. Stating, Yes, I'm the nurse who sent her to the hospital because she was acting different from her norm. I could tell something was wrong with her, but she's aphasic, so she couldn't tell me what was wrong. She (resident #701) has [MEDICAL CONDITION] and kept saying that she was hungry which was unusual for her at that time, she wasn't saying the word hungry before the fall. I contacted the doctor, told him my concerns and he ordered labs. The results came back abnormal with Leukocytosis, Fever and [MEDICAL CONDITION] I sent her to the hospital that day, they performed a CT scan on her hip and that's when we were made aware of the [MEDICAL CONDITION]. On 1/4/18 at 3:05 PM, CNA B was queried via telephone regarding the fall involving resident #701 on 12/16/17. She stated, I was changing her, when I turned her away from me, she had a leg spasm or jerk and fell out of the bed. CNA B was asked if resident #701 required two person assistance with care? Stating, We usually use two people for transfers, but not really for brief changes. CNA B was asked if the plan of care was followed for resident #701's during care? Stating, I think so, don't think I did anything wrong. On 1/4/18 at 3:53 PM, the Director of Nursing (DON) was asked if resident # 701 required extensive assistance with incontinence care? Stating, Yes, she required two person assistance with ADL and incontinence care, she's total care. Her (resident #701) care needs were on the CNA Kardex (resident care guide for certified nursing assistance) for two person assist with ADL care. I educated CNA on bed mobility, the CNA should have had another CNA with her, but she was by herself. The DON was asked if the CNA provided appropriate care for the resident at that time? she stated, The CNA didn't know how to provide the appropriate care for the resident. The resident can't turn and reposition herself without staff assistance. On 1/4/18 at 4:15 PM, the facility policy titled, Incontinence Care, revised on 8/2014, stated, If a patient is unable to maintain his position, assist to the side lying position by turning towards caregiver, unless more than one caregiver present. After turning patient toward caregiver, assure patient is positioned in the center of the bed before moving to the opposite side of the bed to provide care.

REFER TO INTAKE # MI 338 BASED ON OBSERVATION, INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE THE NECESSARY SERVICES TO ATTAIN AND MAINTAIN THE HIGHEST PRACTICABLE, PHYSICAL, MENTAL AND PSYCHOSOCIAL WELL-BEING, IN ACCORDANCE TO COMPREHENSIVE ASSESSMENT AND PLAN OF CARE FOR CARE OF POST SURGICAL INCISION SITE IN 2 OF 5 SAMPLED RESIDENTS RESULTING IN [MEDICAL CONDITION] AROUND THE SURGICAL INCISION SITE (RESIDENT #103) AND MILD SWELLING AND REDNESS OF THE SURGICAL SITE (RESIDENT #105). FINDINGS INCLUDE: RESIDENT #103: RESIDENT WAS [AGE] years OLD ALERT AND ORIENTED WHO HAD HISTORY OF A [MEDICAL CONDITION] SECONDARY TO A FALL. RESIDENT #103 UNDERWENT RIGHT HIP CEMENTED HEMIARTHROPLASTY ON 12/27/11. RESIDENT #103 WAS admitted to the facility on [DATE], FOR SHORT TERM REHABILITATION WITH A GOAL OF RETURNING HOME AFTER COMPLETING REHABILITATION. RECORD REVIEW REVEALED AN ADMISSION SKIN assessment dated [DATE], WHICH DID NOT INDICATE THE PRESENCE OF A SURGICAL SITE OR THE PRESENCE OF STAPLES ON THE RIGHT HIP. THERE WAS NO WOUND ASSESSMENT FOUND ON THE ADMISSION SKIN ASSESSMENT FORM OR IN THE ADMISSION NURSE'S NOTES. A CARE PLAN FOR RIGHT HIP INCISION ON ADMISSION, DATED 1/2/12, DID NOT INDICATE ANY EVIDENCE OF STAPLES PRESENT ON THE RIGHT HIP INCISION SITE AND NO SPECIFIC POST SURGICAL CARE: STAPLE CARE WAS NOTED. PHYSICIAN'S HISTORY AND PHYSICAL DATED 1/3/12 AND PROGRESS NOTES DATED 1/5/12 DID NOT NOTE STAPLES IN THE INCISION SITE. THERE WAS NO INITIAL SKIN ALTERATION SHEET FOUND FOR RESIDENT #103 PER FACILITY PROTOCOL ON ALTERATION IN SKIN INTEGRITY. MARS (MEDICATION ADMINISTRATION RECORD) AND TARS (TREATMENT ADMINISTRATION RECORD) DID NOT HAVE ANY DOCUMENTATION OF STAPLES PRESENT ON THE POSTSURGICAL WOUND. CONTROLLED SUBSTANCE PROOF OF USE RECORD DATED FROM 12/31/11 THROUGH 1/6/12 SHOWED THAT RESIDENT #103 HAD REQUESTED MEDICATION FOR PAIN RELIEF. NURSES' NOTES DATED 12/30/12 THROUGH 1/6/12 AND THE DISCHARGE NURSE'S NOTE, DATED 1/6/12, DID NOT INCLUDE INFORMATION INDICATING THAT RESIDENT #103 HAD STAPLES ON THE POSTSURGICAL SITE (RIGHT HIP). IT WAS NOTED ON 1/3/12 THAT THERE WAS SLIGHT DRAINAGE ON RIGHT HIP SURGICAL INCISION DUE TO TAPE BURNS. THERE WERE NO MEASUREMENTS OR ANY DESCRIPTION OF THE SKIN ALTERATION AT THE INCISION SITE AFTER 1/3/12. A SKIN WORKSHEET DATED 1/2/12 NOTED REDDENED AREA RIGHT HIP INCISION. A SECOND SKIN ALTERATION WORK SHEET , DATED 1/5/12, NOTED SURGICAL SITE AS ABNORMAL (BROKEN, BRUISED, REDDENED AREA). NO FURTHER ACTION WAS DOCUMENTED IN THE CARE PLAN, TAR OR THE NURSE'S NOTES RELATED TO THESE OBSERVATIONS. STAPLES IN THE INCISION WAS NEVER NOTED. FACILITY'S DISCHARGE/ACUTE CARE TRANSFER SHEET DATED 1/6/12, DOCUMENTED THAT RESIDENT #103 WAS TRANSFERRED TO THE HOSPITAL PER THE FAMILY'S REQUEST. NO WOUND TREATMENT/SPECIAL TREATMENTS WERE INDICATED IN THE FORM. THE POST SURGICAL WOUND WAS NOT NOTED. HOSPITAL RECORDS DATED 1/6/12 TO 1/9/12, REVEALED RESIDENT #103 WAS admitted for treatment of [REDACTED]. ACCORDING TO THE emergency room CONSULTATION /PHYSICAL EXAMINATION, "RESIDENT (#103) HAD SOME DRAINAGE FROM THE HIP AND ORTHOPEDIC SERVICE WAS CONSULTED FOR FURTHER EVALUATION AND TREATMENT." emergency room laboratory results dated [DATE] SHOWED ELEVATED WBC (WHITE BLOOD CELLS) WHICH INDICATED INFECTION. PHYSICAL EXAMINATION FINDINGS NOTED: "THERE IS ANTERIORLY LOCATED 2 WHAT APPEAR TO BE TAPE BLISTERS THAT ARE RESPONSIBLE FOR THE DRAINAGE THE PATIENT IS EXPERIENCING. THERE IS SOME [DIAGNOSES REDACTED] AROUND THE STAPLES WHICH ARE IN PLACE, NOW 11 DAYS, WHICH NEEDS TO BE REMOVED IN DAY 14. NOTED LABORATORY RESULTS SHOWED HIGH LEVELS OF WBC IN URINE WHICH INDICATED AN INFECTION." PLAN WAS IV (INTRAVENOUS)[MEDICATION NAME] UTI. "THIS WILL ALSO HELP HER SKIN [MEDICAL CONDITION]." THE DON (DIRECTOR OF NURSING) ON 1/30/12 AT 3:15 PM, STATED THAT NO DOCUMENTATION WAS FOUND UPON ADMISSION RELATED TO THE POSTSURGICAL WOUND ASSESSMENT. THERE WAS NO ASSESSMENT DONE INITIALLY. POSTSURGICAL STAPLES WERE NOT NOTED AND DOCUMENTED ANYWHERE UPON ADMISSION, DURING DAILY TREATMENT AND UPON DISCHARGE. TAR (TREATMENT ADMINISTRATION RECORD) DID NOT HAVE EVIDENCE THAT STAPLES WERE PRESENT AND IF IT WAS ASSESSED, MONITORED AND TREATED DAILY. THE PHYSICIAN EXAMINED RESIDENT #103 FOR RIGHT HIP PAIN ON 1/5/12 BUT THERE WAS NO MENTION OF STAPLES OR OTHER [MEDICAL CONDITION] SURROUNDING THE INCISION SITE. RESIDENT #105: RESIDENT # 105 WAS [AGE] years OLD ALERT, ORIENTED, AND ABLE TO FULLY COMMUNICATE HER NEEDS. SHE WAS admitted on [DATE], AFTER SUSTAINING A RIGHT FEMORAL FRACTURE THAT REQUIRED PERCUTANEOUS PINNING. RESIDENT #105 WAS discharged FROM THE hospital on [DATE] WITH STAPLES AT THE SURGICAL SITE. RESIDENT WAS TO UNDERGO SUB-ACUTE OCCUPATIONAL AND PHYSICAL THERAPY WITH THE GOAL TO RETURN HOME AFTER REHABILITATION. CLINICAL RECORD REVIEW REVEALED AN ADMISSION SKIN assessment dated [DATE]. THIS DOCUMENT DID NOT SPECIFY THAT THE RESIDENT HAD A POST SURGICAL INCISION SITE ON THE RIGHT HIP. THERE WAS NO WOUND ASSESSMENT FOUND IN THE ADMISSION SKIN ASSESSMENT FORM. HOWEVER, ON THE NURSES NOTES DATED 1/18/12, IT DESCRIBED THAT THERE WERE 8 STAPLES FOUND IN THE INCISION AREA WITH NO SIGNS OF INFECTION. THE CARE PLAN FOR RIGHT HIP INCISION WAS NOT INITIATED UNTIL 1/25/2012 (8 DAYS AFTER admitted ). THE SKIN ALTERATION RECORD WAS NOT DONE UPON INITIAL ADMISSION (1/18/12) BUT WAS PERFORMED ON 1/29/12 (12 DAYS AFTER RESIDENT #105 WAS admitted ). THERE WAS NO EVIDENCE IN THE CLINICAL RECORD THAT THE RESIDENT WAS ASSESSED, TREATED AND MONITORED FOR POST SURGICAL STAPLE CARE. STAPLE CARE WAS NOTED IN THE TAR DATED 1/18/12 THROUGH 1/30/12. THE CARE PLAN DID NOT HAVE DOCUMENTATION RELATED TO STAPLES BEING INTACT OR HAVING BEEN REMOVED. UPON WOUND OBSERVATION CONDUCTED ON 1/30/12 AT 3:00 PM, RESIDENT #105 DID NOT HAVE STAPLES ON HER INCISION SITE. RESIDENT #105 STATED THAT SHE DID NOT HAVE A DRESSING CHANGED TODAY (1/30/12) AND SHE WAS UNSURE IF SHE RECEIVED WOUND TREATMENT THE DAY BEFORE. SURVEYOR OBSERVED 3 STERISTRIPS (STERILE STRIP TAPE) COVERING THE WOUND INCISION BUT ONE STRIP WAS COMING OFF EXPOSING THE LOWER 1/3 OF THE INCISION. IT WAS DRY BUT APPEARED DISCOLORED AND SLIGHTLY SWOLLEN SURROUNDING THE INCISION. RESIDENT #105 MENTIONED THAT THE DOCTOR REMOVED THE STAPLES BUT CAN NOT RECALL WHEN AND WHERE. RESIDENT COMPLAINED OF PERSISTENT MILD PAIN AND SWELLING AND WAS VERY CONCERNED ABOUT BRUISING. THERE WAS NO DOCUMENTATION FOUND ON THE TAR, NURSE'S NOTES OR PHYSICIAN'S PROGRESS NOTES WHEN STAPLES WERE REMOVED. THERE WAS NO DOCUMENTED EVIDENCE TO SHOW THAT THE SURGICAL STAPLES WERE INITIALLY ASSESSED AND MONITORED AND NO EVIDENCE THAT STAPLES WERE REMOVED AND REPLACED WITH STERILE STRIP TAPE. THE DON AGREED ON 1/31/12 AT 3:15 PM, THAT THE CARE PLAN DID NOT INCLUDE STAPLE CARE. THERE WAS NO DOCUMENTATION THAT THE WOUND HAD STAPLES IN THE ADMISSION ASSESSMENT OR IN THE TAR. THE SKIN ALTERATION RECORD WAS NOT DONE UPON INITIAL ADMISSION BUT WAS PERFORMED ON 1/29/12 (12 DAYS AFTER RESIDENT #105 WAS admitted ). THE CARE PLAN AND TAR DID NOT REFLECT PRESENCE OF STAPLES AND WHEN THEY WERE REMOVED OR DISCONTINUED. ( )

BASED ON INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO SUPERVISE AND ENSURE CORRECTIVE SAFETY MEASURES WERE MAINTAINED FOR ONE (#804) OF EIGHT SAMPLED RESIDENTS REVIEWED FOR FALLS, FROM A TOTAL SAMPLE OF 24, RESULTING IN RESIDENT #816 SITTING ON HER ROOMMATE'S (#804) LAP AND A FEMUR FRACTURE. FINDINGS INCLUDE: ON 4/7/11 AT 8:43 A.M., RESIDENT #804 WAS INTERVIEWED, THE RESIDENT STATED, "BEFORE THE INCIDENT WHEN MY ROOMMATE SAT ON MY LEG (WHICH OCCURRED ON 2/17/11 AT APPROXIMATELY 6:30 A.M., I HAD REPEATEDLY COMPLAINED ABOUT HER. SHE WAS ALWAYS ROAMING IN THE ROOM, GOING THROUGH MY THINGS. I HAVE ALSO SEEN HER GOING IN OTHER RESIDENT ROOMS ...SHE HAD AN ALARM THAT IS ALWAYS SOUNDING, SOMETIMES THEY DIDN'T RESPOND TO IT FOR LONG PERIODS OF TIME AND SHE WOULD TAKE IT OFF." "ON THE MORNING THAT MY ROOM MATE (#816) SAT ON MY LEG I WAS SLEEPING. IT WAS ABOUT 6:20 A.M., I ASKED HER AND TRIED TO GET HER OFF MY RIGHT LEG, I COULD NOT. MY RIGHT LEG WAS HURTING, I COULDN'T GET HER OFF. I PUSHED THE CALL LIGHT AND YELLED, IT WAS 20 MINUTES BEFORE THEY CAME. WHEN THE CNA (CERTIFIED NURSING ASSISTANTS) CAME INTO THE ROOM, THEY STARTED GIGGLING, THEN THEY LIFTED HER OFF MY LEG AND ESCORTED HER (RESIDENT #816) OUT OF THE ROOM. I HAD EXCRUCIATING PAIN IN MY RIGHT LEG DURING AND FOLLOWING THE INCIDENT." ON 4/7/11 AT 11:40 A.M., REVIEW OF RESIDENT #804'S MEDICAL RECORD FACE SHEET REVEALED THE RESIDENT WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #804 WAS readmitted INto the facility on [DATE] WITH THE ADDITIONAL [DIAGNOSES REDACTED]. REVIEW OF RESIDENT #804'S MINIMUM DATA SET (MDS), dated [DATE] AND 3/2/11, INDICATED THE RESIDENT HAD NO COGNITIVE DEFICITS. THE MDS ALSO INDICATED THAT RESIDENT #804 REQUIRED EXTENSIVE ASSISTANCE WITH TRANSFER, DRESSING, HYGIENE AND MOBILITY. REVIEW OF THE history and physical examination RESIDENT (#804) WAS admitted TO THE FACILITY FOLLOWING AN INFECTED HIP PROSTHESIS POST EXPLANT (REMOVAL OF HIP PROSTHESIS) WITH THE PLACEMENT OF AN ANTIBIOTIC SPACER ...SHE IS NOT TO PUT WEIGHT DOWN ON THE RIGHT LEG." REVIEW OF RESIDENT #804'S NURSES NOTES DATED 2/17/11 AT 10:45 P.M., LATE ENTRY,DOCUMENTED, " AT APPROXIMATELY 6:50 A.M., CNA CAME TO NURSES STATION AND STATED HER (#804) ROOMMATE (#816) HAD GOTTEN OUT OF BED AND BEING CONFUSED AT TIMES AND WANDERED OVER TO HER BED AND SAT ON HER RIGHT LEG AND SHE WAS IN EXCRUCIATING PAIN. CNA STATED ROOMMATES (#816) ALARM WAS ON BUT WAS MUFFLED BY THE DOOR BEING CLOSED AT THE REQUEST OF THE RESIDENT (#804) ... THE PHYSICIAN WAS NOTIFIED ...X-RAYS OF THE RIGHT HIP WERE ORDERED. " REVIEW OF THE X-RAY RESULTS DATED 2/17/11 AT 10:13 A.M., REVEALED, " TWO VIEWS OF THE RIGHT HIP REVEALED A MODIFIED HIP PROSTHESIS IN PLACE, BUT IT IS DISLOCATED OUT OF THE ACETABULUM. THERE IS A DISPLACED FRACTURE OF THE GREATER TROCHANTER AND PROXIMAL LATERAL SHAFT OF THE FEMUR THAT IS PROBABLY RECENT." BASED ON THE X-RAY RESULTS THE PHYSICIAN ORDERED THAT RESIDENT #804 BE TRANSFERRED TO THE HOSPITAL FOR FURTHER DIAGNOSTIC STUDIES AND EVALUATION. ON 4/8/11 AT 9:05 A.M., IN THE PRESENCE OF THE DIRECTOR OF NURSING (DON), NURSE (N) WAS INTERVIEWED REGARDING THE INCIDENT ON 2/17/11. NURSE (N) STATED THE CNA (O) SAID THAT RESIDENT (#804) WANTED TO SEE THE NURSE. HER ROOMMATE HAD GOTTEN OUT OF BED AND SAT ON HER RIGHT LEG. SHE WAS IN EXCRUCIATING PAIN. THE CNA STATED THAT RESIDENT'S (#816) ALARM WAS SOUNDING, IT WAS MUFFLED BECAUSE THE DOOR TO THE ROOM WAS CLOSED. NURSE (N) SAID SHE WENT TO THE RESIDENT'S ROOM AND THE RESIDENT REPEATED THE SAME EVENTS. NURSE (N) SAID RESIDENT (#804) WAS ALSO UPSET BECAUSE THE CNA WAS GIGGLING WHEN SHE SAW WHAT WAS HAPPENING. NURSE (N) SAID SHE APOLOGIZED TO THE RESIDENT. AT 9:32 A.M., IN THE PRESENCE OF THE DON, CNA (O) WAS INTERVIEWED REGARDING THE INCIDENT ON 2/17/11. CNA (O) STATED, "I RESPONDED TO THE CALL LIGHT, WHEN I ARRIVED IN THE ROOM, RESIDENT (#816) WAS SITTING ON RESIDENT'S (#804) RIGHT LEG. RESIDENT (#816) DID NOT HAVE AN ALARM ON. SHE FREQUENTLY REMOVED THE ALARM. I DON'T THINK THE ALARM WAS WORKING. IT MAY HAVE NEEDED BATTERIES. IT WAS IN THE DRAW. THE DOOR TO THE ROOM WAS NOT CLOSED. WE WOULD NEVER ALLOW A DOOR TO BE CLOSED BECAUSE RESIDENT (#816) IS A HIGH SAFETY RISK." WHEN ASKED HAD SHE GIGGLED OR LAUGHED WHEN SHE SAW WHAT HAPPENED. CNA (O) SAID NO, THERE WAS NO LAUGHING. AT 9:45 A..M., IN THE PRESENCE OF THE DON, CNA (P) WAS INTERVIEWED BY TELEPHONE REGARDING THE INCIDENT ON 2/17/11. CNA (P) STATED, "I DON'T REMEMBER VERY MUCH, IT WAS SO LONG AGO. I REMEMBER RESIDENT (#816) WAS SITTING ON RESIDENT (#804) LEG. WE REMOVED HER (#816) FROM THE ROOM, I REMEMBER HER SAYING THE AMBULANCE DRIVERS HAD HANDLED HER ROUGHLY. " WHEN ASKED HAD SHE GIGGLED OR LAUGHED WHEN SHE SAW WHAT HAPPENED. CNA (P) SAID NO, WE DID NOT LAUGH. AT 11:30 A.M., DR. (S) WAS QUERIED REGARDING RESIDENT #804'S INJURY ON 2/17/11. DR (S) WAS INFORMED THAT RESIDENT #804 FELT PAIN WHEN RESIDENT #816 SAT ON HER RIGHT LEG SHE INJURED IT. DR.(S) STATED, " SHE'S PROBABLY RIGHT." ON 4/7/11 AT 11:40 A.M., REVIEW OF RESIDENT #816'S MEDICAL RECORD FACE SHEET REVEALED THE RESIDENT WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF RESIDENT #816'S MINIMUM DATA SET (MDS), dated [DATE], INDICATED THE RESIDENT'S COGNITION WAS SEVERELY IMPAIRED. THE MDS ALSO INDICATED THAT RESIDENT #816 REQUIRED EXTENSIVE ASSISTANCE WITH TRANSFER, DRESSING, HYGIENE AND MOBILITY. REVIEW OF RESIDENT #816'S NURSES NOTES REVEALED THE FOLLOWING; ON 2/5/11, "CONFUSION ...MULTIPLE ATTEMPTS TO GET UP AND OUT OF BED." THERE WAS NO DOCUMENTED EVIDENCE THAT THE RESIDENT'S CARE PLAN WAS RE-ASSESSED FOR ADDITIONAL MEASURES TO PREVENT ACCIDENTS. ON 2/6/11, "SEVERAL ATTEMPTS TO GET OUT OF BED." THERE WAS NO DOCUMENTED EVIDENCE THAT THE RESIDENT'S CARE PLAN WAS RE-ASSESSED FOR ADDITIONAL MEASURES TO PREVENT ACCIDENTS. ON 2/7/11, "CONFUSED, NEEDS MUCH REDIRECTION REGARDING SAFETY. GETS OUT OF BED OVER BOLSTERS, AMBULATES IN ROOM, WANDERS INTO OTHER RESIDENTS ROOMS." THERE WAS NO DOCUMENTED EVIDENCE THAT THE RESIDENT'S CARE PLAN WAS RE-ASSESSED FOR ADDITIONAL MEASURES TO PREVENT ACCIDENTS. ON 2/8/11, "RESIDENT IS NON-COMPLIANT WITH SAFETY DEVICES." THERE WAS NO DOCUMENTED EVIDENCE THAT THE RESIDENT ' S CARE PLAN WAS UPDATED WITH ADDITIONAL MEASURES TO PREVENT ACCIDENTS. ON 2/12/11, "NON COMPLIANT WITH SAFETY DEVICES." THERE WAS NO DOCUMENTED EVIDENCE THAT THE RESIDENT ' S CARE PLAN WAS UPDATED WITH ADDITIONAL MEASURES TO PREVENT ACCIDENTS. REVIEW OF RESIDENT #816'S FALLS CARE PLAN DATED 2/4/11 DOCUMENTED, "RESIDENT HAS IMPAIRED BALANCE/POOR COORDINATION, UNSTEADY GAIT, NON-COMPLIANCE WITH MOBILITY AIDE USE, POOR SAFETY AWARENESS AND A HISTORY OF FALLS. INTERVENTIONS INCLUDED: 1. ENSURE THAT ALARM DEVICE. MOTION MAT IS IN PLACE WHEN IN BED AND WHEELCHAIR. 2. REINFORCE THE NEED TO CALL FOR ASSISTANCE. 3. PROVIDE ASSISTANCE WITH TRANSFER AND AMBULATE AS NEEDED. 4. ASSESS FOR FALL RISK UPON ADMISSION AND REASSESS AS NEEDED. THE DON OFFERED NO EXPLANATION REGARDING WHY RESIDENT #804'S COMPLAINTS ABOUT HER ROOMMATE WERE NOT ADDRESSED; WHY RESIDENT #816'S ALARMS WERE NOT WORKING, AND NO EXPLANATION WHY THE ALARMS WERE NOT ATTACHED TO THE RESIDENT TO ALERT STAFF OF HER UNSUPERVISED TRANSFER. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ASSESS, MONITOR AND PROVIDE PAIN MEDICATION FOR TWO (#'S 804 AND 811) OF A TOTAL 24 SAMPLED RESIDENTS COMPLAINING OF EXCRUCIATING PAIN, RESULTING IN UNNECESSARY, PROLONGED PAIN; FAILED TO FOLLOW FLUID RESTRICTION ORDERS FOR ONE (#803) OF TWO SAMPLED RESIDENT REVIEWED WHO WERE RECEIVING [MEDICAL TREATMENT]; AND FAILED TO FOLLOW PHYSICIAN ORDERS [REDACTED]. FINDINGS INCLUDE: ON 4/7/11 AT 2:45 P.M., AN OBSERVATION OF WOUND VAC DRESSING CHANGE FOR RESIDENT #811, REVEALED THE RESIDENT MOANING, GROANING AND MAKING FACIAL GRIMACES DURING THE PROCEDURE. WHEN QUERIED THE RESIDENT STATED HE WAS IN PAIN. NURSE "J" CONTINUED WITH THE TREATMENT. NURSE "K" WHO WAS ASSISTING HER ASKED RESIDENT #811 IF HE WOULD LIKE TO HOLD HER HAND. NURSE "J" STATED, "I'M ALMOST FINISHED." THEN NURSE "J" WAS READJUSTING THE CELLOPHANE ADHESIVE WHICH PULLED RESIDENT #809'S PUBIC HAIRS AND THE RESIDENT LET OUT A LOUD MOAN. WHEN QUERIED REGARDING PAIN MEDICATION, NURSE "J" STATED, RESIDENT #811 RECEIVED A SCHEDULED DOSE OF [MEDICATION NAME] (PAIN) AT APPROXIMATELY 9:00 A.M. ON 4/8/11 AT 8:45 A.M., RESIDENT #811 WAS INTERVIEWED REGARDING THE WOUND VAC DRESSING CHANGE THAT OCCURRED ON 4/7/11 AT 2:45 P.M., THE RESIDENT STATED, (IN A LOUD FIRM TONE) "IT HURTS LIKE HELL. THEY HAVE DONE THAT PROCEDURE BEFORE AND IT'S VERY PAINFUL." ON 4/8/11 AT 9:00 A.M., NURSE "K" WAS INTERVIEWED AND STATED," IT WAS TOO COSTLY TO STOP THE PROCEDURE AND DISCARD THE EQUIPMENT." NURSE "J" STATED, "I THOUGHT IT WAS INAPPROPRIATE NOT TO FINISH THE TREATMENT THAT'S WHY I CONTINUED EVEN THOUGH I WAS AWARE THE RESIDENT WAS HAVING PAIN. RESIDENT #811 HAS A AS NEEDED PAIN MEDICATION ORDER." ON 4/8/11 AT 10:00 A.M., RECORD REVIEW REVEALED THAT RESIDENT #811 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] INDICATED RESIDENT #811 COGNITION WAS MODIFIED INDEPENDENCE AND REQUIRED EXTENSIVE ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING. THE MDS ALSO INDICATED RESIDENT #811 HAD OCCASIONAL PAIN ON A SCALE OF 0 (LEAST) AND 10 (HIGHEST) HIS PAIN WAS A SEVEN. REVIEW OF THE physician's orders [REDACTED]. " REVIEW OF THE NURSE'S NOTES AND THE APRIL'S Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"AS NEEDED" PAIN MEDICATION ON 4/7/11. REVIEW OF A CARE PLAN DATED 1/19/11 ENTITLED, " PAIN IN BILATERAL LOWER EXTREMITIES , FEET AND GROIN AREA " DOCUMENTED, ADMINISTER PAIN MEDICATION AS PER physician's orders [REDACTED]. ON 4/8/11 AT 1:00 P.M., DURING AN INTERVIEW THE DIRECTOR OF NURSING STATED, THE NURSES WERE NERVOUS. THE "AS NEEDED" PAIN MEDICATION SHOULD HAVE BEEN GIVEN." REVIEW OF THE FACILITY'S UNDATED POLICY ENTITLED, " PAIN PRACTICE GUIDE, DIRECTED THE NURSE TO EVALUATE PATIENT PAIN BY: "LISTEN TO WHAT THE PATIENT SAYS; ANTICIPATE PAIN; AND PREVENT PAIN FROM OCCURRING. " ( ) ON 4/7/11 AT 8:43 A.M., RESIDENT #804 WAS INTERVIEWED AND REPORTED ONE MORNING HER ROOM MATE (RESIDENT #816) SAT ON HER LEG WHILE SHE WAS SLEEPING AND SHE COULD NOT GET RESIDENT 816 TO MOVE. THE RESIDENT EXPLAINED HER RIGHT LEG WAS HURT AND SHE PUSHED THE CALL LIGHT AND YELLED. THE RESIDENT REPORTED IT WAS 20 MINUTES BEFORE HELP ARRIVED AND REMOVED THE RESIDENT FROM HER LAP. RESIDENT #804 STATED, "I HAD EXCRUCIATING PAIN IN MY RIGHT LEG DURING AND FOLLOWING THE INCIDENT AND I ASKED TO SPEAK WITH THE NURSE. WHEN THE NURSE CAME IN, I TOLD HER I WAS HAVING EXCRUCIATING PAIN IN MY RIGHT LEG, AND SHE SAID, "IT'S NOT TIME FOR YOUR PAIN MEDICINE." I TOLD THE NURSE THAT MY ROOMMATE HAD HURT MY LEG. SHE STILL DID NOTHING TO HELP ME. " ON 4/7/11 AT 11:40 A.M., REVIEW OF RESIDENT #804'S MEDICAL RECORD FACE SHEET REVEALED THE RESIDENT WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #804 WAS readmitted INto the facility on [DATE] WITH THE ADDITIONAL [DIAGNOSES REDACTED]. REVIEW OF RESIDENT #804 ' S MINIMUM DATA SET (MDS), dated [DATE] AND 3/2/11 INDICATED THE RESIDENT'S COGNITION WAS INTACT. THE MDS ALSO INDICATED THAT RESIDENT #804 REQUIRED EXTENSIVE ASSISTANCE WITH TRANSFER, DRESSING, HYGIENE AND MOBILITY. REVIEW OF THE history and physical examination RESIDENT (#804) WAS admitted TO THE FACILITY FOLLOWING AN INFECTED HIP PROSTHESIS POST EXPLANT (REMOVAL OF HIP PROSTHESIS) WITH THE PLACEMENT OF AN ANTIBIOTIC SPACER ...SHE IS NOT TO PUT WEIGHT DOWN ON THE RIGHT LEG. " REVIEW OF RESIDENT #804 ' S NURSES NOTES DATED 2/17/11 AT 10:45 P.M., LATE ENTRY,DOCUMENTED, "AT APPROXIMATELY 6:50 A.M., CNA CAME TO NURSES STATION AND STATED HER (#804) ROOM MATE (#816) HAD GOTTEN OUT OF BED AND BEING CONFUSED AT TIMES AND WANDERED OVER TO HER BED AND SAT ON HER RIGHT LEG AND SHE WAS IN EXCRUCIATING PAIN. CNA STATED ROOMMATES ALARM WAS ON BUT WAS MUFFLED BY THE DOOR BEING CLOSED AT THE REQUEST OF THE RESIDENT (#804) ... WHEN I ENTERED THE ROOM, SHE REPEATED THE SAME STORY. THE PHYSICIAN WAS NOTIFIED ...X-RAYS OF THE RIGHT HIP WERE ORDERED. " THERE WAS NO DOCUMENTED EVIDENCE THE NURSE ASSESSED THE RESIDENT FOR INJURIES OR PERFORMED A SKIN ASSESSMENT. THERE WAS NO DOCUMENTED EVIDENCE THE NURSE CONDUCTED A PAIN ASSESSMENT FOLLOWING THE INJURY. REVIEW OF THE X-RAY RESULTS DATED 2/17/11 AT 10:13 A.M., DOCUMENTED, " TWO VIEWS OF THE RIGHT HIP REVEALED A MODIFIED HIP PROSTHESIS IN PLACE, BUT IT IS DISLOCATED OUT OF THE ACETABULUM. THERE IS A DISPLACED [MEDICAL CONDITION] TROCHANTER AND PROXIMAL LATERAL SHAFT OF THE FEMUR THAT IS PROBABLY RECENT. " BASED ON THE X-RAY RESULTS THE PHYSICIAN ORDERED THAT RESIDENT #804 BE TRANSFERRED TO THE HOSPITAL FOR FURTHER DIAGNOSTIC STUDIES AND EVALUATION. ON 4/8/11 AT 9:05 A.M., NURSE (N) WAS INTERVIEWED REGARDING THE INCIDENT ON 2/17/11. NURSE (N) STATED THE CNA SAID THE RESIDENT (#804) WANTED TO SEE THE NURSE. HER ROOMMATE HAD GOTTEN OUT OF BED AND SAT ON HER RIGHT LEG. SHE WAS IN EXCRUCIATING PAIN. I TOLD HER I HAD RECENTLY GIVEN HER PAIN MEDICATION. SHE WAS NOT DUE FOR MORE PAIN MEDICATIONS. " NURSE (N) SAID SHE HAD REVIEWED THE MEDICAL RECORD AND RESIDENT (#804'S) "AS NEEDED" MEDICATION HAD BEEN DISCONTINUED ON 2/9/11. NURSE (N) REVIEWED THE RECORD AND WAS UNABLE TO FIND A physician's order [REDACTED]. NURSE (N) WAS ASKED HAD SHE CONDUCTED A PAIN ASSESSMENT ON RESIDENT #804 FOLLOWING THE INJURY ON 2/17/11. NURSE (N) STATED, I REMEMBER HER SAYING THE PAIN WAS AT A LEVEL 10 (THE HIGHEST PAIN LEVEL). THE DON WAS QUERIED AND STATED, " A PAIN ASSESSMENT SHOULD HAVE BEEN DOCUMENTED AND INJURY ASSESSMENT COMPLETED. " ( ) ON 4/5/11 AT 9:30 A.M., DURING THE INITIAL TOUR WITH UNIT MANAGER (T), RESIDENT #803 WAS OBSERVED SITTING ON THE SIDE OF THE BED. THE RESIDENT HAD A 16 OUNCE CUP OF WATER SITTING ON THE BED SIDE STAND. THE RESIDENT DRANK FROM THE CUP AND SAID I NEED MORE WATER. ON 4/05/11 AT 1:20 P.M., RESIDENT #803 WAS OBSERVED DRINKING WATER FROM A 16 OUNCE CUP. THE RESIDENT WAS ASKED WHETHER SHE HAD BEEN INSTRUCTED REGARDING ANY FLUID RESTRICTIONS AND STATED, "NO, NO ONE HAS SAID ANY THING TO ME. THEY BRING ME FRESH WATER ALL DAY. I DRINK WAS MUCH AS I WANT." ON 4/05/11 AT 2:20 P.M., REVIEW OF RESIDENT #803 ' S MEDICAL RECORD FACE SHEET REVEALED THE RESIDENT WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #803 RECEIVED [MEDICAL TREATMENT] SERVICES. REVIEW OF RESIDENT #803 ' S NURSES NOTES DATED 4/3/11 DOCUMENTED, "THE RESIDENT IS ALERT AND ORIENTED TO TIME PLACE AND PERSON." REVIEW OF RESIDENT #803 NEW ADMISSION DIET ORDER DATED 3/31/11 DOCUMENTED, " DIET ORDERS; LOW CALORIE/LOW SODIUM, NO ADDED SALT, FLUID RESTRICTION 2000 MILLILITERS (ML) / DAY. " THERE WAS NO DOCUMENTED EVIDENCE THAT; 1. THE RESIDENT HAD BEEN EDUCATED ON FLUID RESTRICTIONS. 2. THE DIETETICS PROFESSIONALS HAD COORDINATED WITH NURSING AND DINING SERVICES. 3. A BEVERAGE PLAN WORKSHEET WAS DEVELOPED. 4. WHETHER "WATER AT THE BESIDE" WAS CONSIDERED IN THE PLANNING THE FLUID RESTRICTIONS. 5. THE FLUID INTAKE WAS ASSESSED BY THE INTERDISPLINARY TEAM. 6. INTAKE AND OUTPUT OF FLUIDS WERE BEING MONITORED. ON 4/05/11 AT 2:40 P.M., UNIT NURSE (U) WAS QUERIED AND STATED, "I DIDN'T KNOW SHE WAS ON FLUID RESTRICTIONS. I NEED TO CHECK." A REVIEW OF ALL OF THE DIETARY MEAL TICKETS OF [MEDICAL TREATMENT] RESIDENTS WAS COMPLETED. THE DIETARY MEAL TICKET FOR RESIDENT #803 WAS NOT INCLUDED. AT 3:00 P.M., REGISTERED DIETITIANS (Q) AND (R) WERE QUERIED REGARDING RESIDENT #803'S DIET ORDERS FOR FLUID RESTRICTIONS. BOTH RD'S SAID THEY WERE NOT AWARE THAT RESIDENT #803 WAS ON [MEDICAL TREATMENT]. THEY SAID THE DIET ORDERS HAD NOT BEEN TRANSCRIBED IN A MANNER THAT WOULD ALERT DIETARY SERVICES. "THAT IS WHY SHE WAS MISSED." ( ) BASED ON OBSERVATION, RECORD REVIEW, AND INTERVIEW, THE FACILITY FAILED TO IMPLEMENT AND FOLLOW DOCTOR'S ORDERS AS WRITTEN IN THE PLAN OF CARE FOR 2 (#' 805 AND 808) OF 24 SAMPLED RESIDENTS, RESULTING IN THE POTENTIAL FOR UNMET CARE NEEDS. FINDINGS INCLUDE: ON 4/7/11 AT 9:05 A.M., 11:45 A.M., AND 2:30 P.M., 3:50 P.M., DURING AN OBSERVATION IN THE ARBOR DINING ROOM, RESIDENT #808 WAS OBSERVED WEARING A SEATBELT AND NON-SLIP SOCKS ON HER FEET. ON 4/8/11 9:40 A.M., IN THE ARBOR DINING ROOM RESIDENT #808 WAS OBSERVED BEING FED BY STAFF. THE RESIDENT WAS WEARING A SEATBELT AND NON-SLIP SOCKS. REVIEW OF THE PHYSICIAN ORDER'S DATED 3/24/11, DOCUMENTED RESIDENT #808 WAS ORDERED THE FOLLOWING: "... FOAM BOOTS TO BILATERAL LOWER EXTREMITIES APPLIED AT ALL TIMES, SEATBELT TO WHEEL CHAIR, CHECK PLACEMENT." ON 4/7/11 AT 3:30 P.M.,REVIEW OF THE COMPREHENSIVE CARE PLAN DOCUMENTED THE APPLICATION OF THE AFOREMENTIONED INTERVENTIONS, PRESCRIBED ON 3/24/11. ON 4/8/11 AT 11:40 A.M., DURING INTERVIEW WITH STAFF" M" CONCERNING THE APPLICATION OF THE FOAM BOOTS, THE NURSE AIDE REPORTED RESIDENT #808 HAD BEEN A LONG TERM RESIDENT AND STAFF WHO WORKED ON THE UNIT WERE AWARE THAT THE RESIDENT HAD ORDERS FOR FOAM BOOTS. " ON 4/8/11 AT 11:45 A.M., THE UNIT MANAGER REPORTED SHE WAS NOT SURE HOW STAFF FORGOT TO APPLY THE RESIDENT'S FOAM BOOTS, AND SHE ACKNOWLEDGED THE RESIDENT SHOULD BEEN WEARING THEM. ON 4/7/11 AT AT 9:35 A.M., REVIEW OF THE ADMISSION FACE SHEET DOCUMENTED RESIDENT #808 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET ((MDS) dated [DATE], DOCUMENTED RESIDENT #808 HAD LONG AND SHORT TERM MEMORY PROBLEMS AND HAD SEVERELY IMPAIRED COGNITIVE SKILLS FOR DECISION MAKING. THE MDS FURTHER INDICATED RESIDENT #808 WAS RECEIVED ENTERAL FEEDING AND WAS TOTALLY DEPENDENT ON THE STAFF FOR ALL ACTIVITIES OF DAILY LIVING. ( ) ON 4/6/11 AT 9:25 A.M. AND 10:15 A.M., RESIDENT #805 WAS OBSERVED SITTING IN WHEEL CHAIR WITH BOTH LEGS DANGLING AND FEET ON FLOOR. ON 4/6/11 AT 3:20 P.M., RESIDENT #805 WAS OBSERVED LYING IN BED AND HER LEGS WERE NOT ELEVATED. ON 4/7/11 AT 11:10 A.M., RESIDENT #805 OBSERVED SITTING ON SIDE OF BED WITH BOTH LEGS HANGING OVER THE SIDE OF THE BED WITH FEET RESTING ON FLOOR. BILATERAL [MEDICAL CONDITION] WAS NOTED TO BOTH LOWER LEGS AND ANKLES. THERE WERE FLUID FILLED BLISTERS ON DORSAL SIDE OF THE LEFT FOOT ABOVE 3RD AND 4 TH TOES. ON 4/8/11 AT 9:15 A.M., RESIDENT #805 WAS SITTING ON SIDE OF THE BED WITH FEET HANGING OVER THE SIDE AND WITH FEET RESTING ON THE FLOOR. ON 4/5/11 AT 10:15 A.M., REVIEW OF PHYSICIANS ORDERS DATED 4/5/11 DIRECTED STAFF TO "ELEVATE" BILATERAL LOWER EXTREMITIES WHILE AT REST AND MONITOR [MEDICAL CONDITION] IN BILATERAL LOWER EXTREMITIES EVERY SHIFT. THERE WAS NO EVIDENCE THIS WAS DONE. ( , )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO CONSISTENTLY ASSESS AND PROVIDE INTERVENTIONS TO PREVENT THE DEVELOPMENT OF A PRESSURE ULCER FOR ONE RESIDENT (#809); AND FAILED TO PROVIDE APPROPRIATE SERVICES AND TREATMENT TO PROMOTE HEALING OF AN EXISTING PRESSURE ULCER FOR ANOTHER RESIDENT (#806), OUT OF NINE SAMPLED RESIDENTS IDENTIFIED WITH PRESSURE ULCERS IN A TOTAL SAMPLE OF 24 RESIDENTS, RESULTING IN THE DEVELOPMENT OF A FACILITY ACQUIRED PRESSURE ULCER FOR RESIDENT (#809) AND THE DETERIORATION OF A PRESSURE ULCER AFTER RE-ADMISSION FOR RESIDENT (#806). FINDINGS INCLUDE: ON 4/6/11 AT 10:50 A.M., A WOUND CARE OBSERVATION FOR RESIDENT #809 REVEALED, NURSE "H" REMOVING FROM THE RIGHT HEEL AN OLD DRESSING WITH SCANTY AMOUNTS OF PALE YELLOW DRAINAGE. THE RIGHT HEEL HAD ESCHAR (DARK BLACKEN AREA) UNSTAGEABLE PRESSURE SORE. THE AREA WAS MEASURED 2.5 CENTIMETERS (CM) IN LENGTH BY 2.6 CM IN WIDTH. WHEN QUERIED RESIDENT #809 STATED, "I GOT THE SORE HERE. THE NURSE TOLD ME IT WAS FROM SHEARING AGAINST THE SHEETS. AFTER THE SORE DEVELOPED THEY STARTED PUTTING A PILLOW UNDER MY LEGS SO MY HEELS WOULD NOT TOUCH THE BED SHEETS. NO, THEY DID NOT TURN AND POSITION ME EVERY TWO HOURS." ON 4/6/11 AT 11:30 A.M., RECORD REVIEW REVEALED RESIDENT #809 WAS admitted INTO THE FACILITY WITH [DIAGNOSES REDACTED]. THE ADMISSION NURSING BODY ASSESSMENT, DATED 1/21/11, INDICATED RESIDENT #809 HAD NO PRESSURE SORES. THE Minimum Data Set, dated dated ,[DATE] /11, INDICATED, RESIDENT #809 WAS INDEPENDENT IN DECISION MAKING AND REQUIRED EXTENSIVE ASSISTANCE WITH BED MOBILITY, TOILETING AND LIMITED RANGE OF MOTION ON THE RIGHT LOWER EXTREMITY. REVIEW OF RESIDENT # 809 BRADEN SCALE ( A SCALE FOR PREDICTING PRESSURE RISK), DATED 1/28/1, REVEALED A SCORE OF 17; ON 2/4/11 A SCORE OF 17; ON 2/11/11 A SCORE 18; AND, ON 3/31/11 A SCORE OF 20; THE SCALE SUGGESTED A TOTAL SCORE OF 12 OR LESS REPRESENT "HIGH RISK" FOR PRESSURE SORE DEVELOPMENT. REVIEW OF THE FACILITY'S SKIN WORKSHEETS REVEALED THE FOLLOWING: 1. ON 2/2/11 DOCUMENTED, RESIDENT #809, " RIGHT HEEL HURTING HIM." 2. ON 2/12/11, SHOWER GIVEN, NO DOCUMENTATION REGARDING RIGHT HEEL. 3. ON 2/16/11; ON 2/23/11; ON 3/1/11 AND 3/25/11 DOCUMENTED RESIDENT #809 REFUSED HIS SHOWER. THE DAILY BODY AUDITS WERE SIGNED OFF, HOWEVER, THERE WAS NO DOCUMENTATION REGARDING THE RIGHT HEEL PRESSURE SORE. 4. ON 3/9/11, RIGHT HEEL BLACK AREA. 5. ON 3/22/11, SORE LEFT AND RIGHT HEEL. REVIEW OF THE PHYSICIAN'S PROGRESS NOTES FROM 2/2/11 TO 3/31/11 REVEALED NO DOCUMENTATION OF ASSESSMENT OR EVALUATION REGARDING RESIDENT #809'S PRESSURE SORE. REVIEW OF THE physician's orders [REDACTED]." THERE WAS NO OTHER DOCUMENTED TREATMENT. REVIEW OF THE NURSE'S NOTES REVEALED: 1. ON 2/2/11 AT 2:40 P.M., TURNED AND REPOSITIONED EVERY TWO HOURS. NO DOCUMENTATION REGARDING RIGHT HEEL HURTING. (THE SHOWER SHEET, DATED 2/2/11, INDICATED THE RESIDENT COMPLAINED OF PAIN OF THE RIGHT HEEL). 2. ON 2/19/11 AT 11:00 P.M., HEELS OFF BED. REVIEW OF A FACILITY FORM DATED 3/11/11 ENTITLED, " PRESSURE ULCER" (OFF CYCLE) UNDER EXTRINSIC RISK FACTORS DOCUMENTED, " REQUIRES STAFF ASSISTANCE TO MOVE." REVIEW OF THE RESIDENT'S CARE PLANS REVEALED NO DOCUMENTED EVIDENCE OF WRITTEN PRESSURE ULCER CARE PLANS UNTIL 3/11/10 (AFTER THE DEVELOPMENT OF THE PRESSURE SORE). REVIEW OF THE FACILITY'S POLICY ENTITLED "SKIN PRACTICE GUIDE REVEALED: "IF A PATIENT IS AT LOW OR MODERATE RISK AND MAJOR RISK FACTORS ARE PRESENT FOR EXAMPLE, ADVANCED AGE OR POOR DIETARY INTAKE, ADVANCE TO THE NEXT LEVEL. PATIENTS WHO DEVELOPED NEW ALTERATIONS ARE IDEALLY EVALUATED BY A QUALIFIED HEALTH PERSON WITHIN 24 HOURS, OR AS SOON AFTER SKIN ALTERCATION IDENTIFICATION. THE NURSE ASSISTANTS PERFORM PATIENT SKIN OBSERVATION DAILY WITH CARE. THE WORKSHEET IS COMPLETED BY THE NURSING ASSISTANT AT LEAST TWICE A WEEK " ON 4/7/11 AT 11:00 A.M., DURING AN INTERVIEW NURSE "C" (UNIT MANAGER) STATED, RESIDENT #809 DEVELOPED THE PRESSURE SORE AT THE FACILITY. THE RESIDENT WAS NOT FOLLOWED BY THE WOUND CARE TEAM." ( ) ON 4/5/11 AT 11:15 A.M., 1:35 P.M. AND 4:15 P.M., RESIDENT #806 WAS OBSERVED IN BED LYING IN BED ON HIS BACK. ON 4/6/11 AT 9:40 A.M., WOUND CARE WAS OBSERVED FOR RESIDENT #806. STAFF NURSE "E", WITH ASSISTANCE FROM CNA "M", TURNED THE RESIDENT TO HIS SIDE AND REMOVED THE DRESSING FROM THE RESIDENT'S SACRAL COCCYX AREA, REVEALING A STAGE 4 PRESSURE ULCER. THE WOUND WAS GRANULATING AND HAD A DEEP PINK BASE WITH NO VISIBLE DRAINAGE OR ODOR. A WOUND CONSULT NOTE, DATED 4/5/11, NOTED THAT THE PRESSURE ULCER MEASURED 1.5 CM IN LENGTH BY 1.0 CM IN WIDTH BY 0.2 CM IN DEPTH. STAFF NURSE "E" CLEANSED THE WOUND WITH NORMAL SALINE, APPLIED [MEDICATION NAME] AND COVERED THE WOUND WITH A DRY DRESSING. ON 4/6/11 AT 12:10 P.M., RESIDENT #806 WAS OBSERVED LYING ON HIS BACK. ON 4/6/11 AT 2:05 P.M., CNA "M" WAS INTERVIEWED REGARDING THE LAST TIME RESIDENT #806'S BRIEF HAD BEEN CHANGED. CNA "M" STATED THAT SHE HADN'T BEEN BACK TO CHANGE THE RESIDENT'S BRIEF SINCE MORNING, PRIOR TO WOUND CARE. ON 4/6/11 AT 3:20 P.M., AND AGAIN ON 4/7/11 AT 9:15 A.M. 11:30 A.M. AND 3:45 P.M., RESIDENT #806 WAS OBSERVED LYING IN BED ON HIS BACK. ACCORDING TO A REVIEW OF THE ADMISSION FACE SHEET, ON 4/5/11 AT 4:45 P.M., RESIDENT #806 WAS ORIGINALLY admitted TO THE FACILITY IN 2004 AND RE-admitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS), dated [DATE], REVEALED THAT RESIDENT #806 WAS MODERATELY COGNITIVELY IMPAIRED, REQUIRED EXTENSIVE ASSISTANCE WITH TRANSFERS AND DRESSING, AND TOTAL ASSISTANCE FROM STAFF WITH BATHING AND HYGIENE. THE MDS ALSO INDICATED THAT THE RESIDENT DID NOT WALK AND WAS INCONTINENT. A NURSING ADMISSION EVALUATION, DATED 8/19/10, NOTED THAT THE RESIDENT HAD A "13" BRADEN SCORE, INDICATING MODERATE RISK FOR SKIN BREAKDOWN AND A "REDDENED" AREA ON THE "COCCYX" THAT MEASURED 3.0 CENTIMETERS (CM) IN LENGTH BY 1.5 CM IN WIDTH BY 0.5 CM DEEP. THE ONLY OTHER SKIN ABNORMALITIES NOTED ON THE 8/19/10 NURSING ADMISSION EVALUATION WERE THE SURGICAL INCISION, "ROUND HOLES" FROM AN INTRAVENOUS SITE, AND A LEFT SHOULDER TATTOO. NURSING NOTES, DATED 8/19/10, DESCRIBED THE "REDDENED AREA" AS A "STG (STAGE) 2 ULCER TO SACRUM". THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"CALMO ([MEDICATION NAME] - A MOISTURE BARRIER) Q (EVERY) SHIFT" AND FOR STAFF TO CONDUCT A "DAILY BODY AUDIT". ON 8/24/10, THE TREATMENT ORDER WAS CHANGED TO "ALLEVYN (A FOAM DRESSING USED AS A BARRIER AND FOR DRAINING WOUNDS) TO SACRAL WOUND CHANGE Q (EVERY) 3 DAYS AND PRN (AS NEEDED). A NURSING CARE PLAN WAS INITIATED, ON 8/26/10 - A WEEK AFTER RE-ADMISSION, WITH A FOCUS OF "HIP REPAIR AND STAGE 3 ON BUTTOCKS RELATED TO HIP REPAIR, VASCULAR ULCER ON L (LEFT HEEL) R/T (RELATED TO) PERFUSION." INTERVENTIONS INCLUDED "ADMINISTER TREATMENT PER PHYSICIAN ORDERS", "ENCOURAGE AND ASSIST AS NEEDED TO TURN AND REPOSITION FREQUENTLY", "EVALUATE AND RECORD WOUND STATUS PER FACILITY GUIDELINES UNTIL HEALED" AND "REASSESS SKIN RISKS PER PROTOCOL." ANOTHER CARE PLAN, ENTITLED "AT RISK FOR SKIN INTEGRITY RELATED TO [MEDICAL CONDITION] REPAIR, DECREASED MOBILITY" WAS ALSO INITIATED ON 8/26/10 WITH ADDITIONAL INTERVENTIONS THAT INCLUDED "MONITOR SKIN CONDITION WITH ADL (ACTIVITY OF DAILY LIVING) CARE", "REPORT ABNORMALITIES" AND "CHECK FOR INCONTINENCE FREQUENTLY." A REVIEW OF THE NURSING NOTES, DATED 8/20/10 THROUGH 9/4/10, DOCUMENTED INFORMATION ON THE STATUS OF THE RESIDENT'S HIP INCISION. HOWEVER, THERE WAS NO INFORMATION IN THE NURSING NOTES, OR ANY OTHER DOCUMENTATION PROVIDED BY THE FACILITY, REGARDING THE CONDITION OF THE RESIDENT'S SACRO-COCCYX PRESSURE ULCER, IDENTIFIED ON RE-ADMISSION. NOR, WAS THERE ANY INFORMATION ABOUT ANY OTHER SKIN IMPAIRMENT UNTIL 9/4/10, TWO WEEKS AFTER RE-ADMISSION TO THE FACILITY. NURSING NOTES, DATED 9/4/10 AT 7:00 P.M., REVEALED THAT RESIDENT #806 HAD DEVELOPED ANOTHER PRESSURE ULCER THAT WAS FIRST DESCRIBED IN THE NURSING NOTES AS A "BLACK CAP TO LEFT HEEL ....LEFT HEEL SOFT/MUSHY." A PHYSICIAN ORDER [REDACTED]. THE NEXT DOCUMENTATION REGARDING THE STATUS OF THE RESIDENT'S SACRAL COCCYX PRESSURE ULCER SINCE RE-ADMISSION ON 8/19/10 WAS IN THE NURSING NOTES, DATED 9/5/10. THE NURSING NOTES REVEALED THAT THE RESIDENT'S COCCYX PRESSURE ULCER HAD DETERIORATED AND NOW MEASURED "7 X 5.3 CM TUNNELING 4 CM AT 1:00 P.M. (LOCATION) WOUND 1 CM DEEP LEFT HEEL OPEN." NEW PHYSICIAN ORDERS [REDACTED]. A WOUND CONSULTATION ASSESSMENT RECORD, DATED 9/7/10, NOTED THAT THE RESIDENT'S PRESSURE ULCER WAS NOW A STAGE FOUR ( FULL THICKNESS TISSUE LOSS WITH EXPOSED BONE, TENDON OR MUSCLE) WITH NECROSIS (DEAD TISSUE). THE LEFT HEEL WOUND WAS DESCRIBED AS A "BLACK, FULL THICKNESS, VASCULAR" WOUND, MEASURING "2 CM BY 1.1 CM". THE WOUND CONSULT RECORD ALSO NOTED THAT THE RESIDENT'S [MEDICATION NAME] ON 9/4 WAS 4.0 (REFERENCE RANGE 3.5 - 4.9) AND TOTAL PROTEIN LEVEL WAS 7.1 (6.0-8.3). TREATMENT TO THE PRESSURE ULCER WAS CHANGED TO SANTYL (AN ENZYMATIC OINTMENT USED TO REMOVE DEAD TISSUE FROM WOUNDS), AND AN ORDER WAS WRITTEN FOR A "LOW AIR LOSS MATTRESS, CUSHION FOR WHEELCHAIR, POSEY BOOTS, AND LIMIT TIME UP IN WHEELCHAIR TO 2 HOURS EACH SITTING." THE FACILITY'S "SKIN PRACTICE GUIDE", DATED 7/2008, NOTED THAT A "PUSH" TOOL SHOULD BE INITIATED FOR ALL RESIDENTS IDENTIFIED WITH A PRESSURE ULCER (A TOOL DEVELOPED FOR MEASURING PRESSURE ULCER STATUS OVER TIME). THE PUSH TOOL FOR THE PRESSURE ULCER ON THE RESIDENT'S SACRO-COCCYX WAS REQUESTED AND NOT PROVIDED PRIOR TO SURVEY EXIT. THE PRACTICE GUIDELINES ALSO INDICATE THAT "A LICENSED NURSE PROVIDES WOUND TREATMENTS.... DOCUMENTS COMPLETION OF TREATMENTS ON THE TREATMENT ADMINISTRATION RECORD", AND THAT "DAILY OBSERVATION AND EVALUATION OF THE WOUND INCLUDES STATUS OF THE DRESSING INCLUDING SURROUNDING SKIN." HOWEVER, THERE WAS NO DOCUMENTATION ABOUT THE CONDITION OR STATUS OF THE RESIDENT'S SACRO-COCCYX PRESSURE ULCER, THE DRESSING AND/OR THE SURROUNDING SKIN FROM THE INITIAL ADMISSION ASSESSMENT ON 8/19/10 UNTIL 9/5/10. IN ADDITION, THERE WAS NO INFORMATION IN THE physician progress notes [REDACTED]. ( )

THIS CITATION PERTAINS TO INTAKE; MI 184. BASED ON INTERVIEWS AND RECORDS REVIEW THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT FALLS IN 1 OF 5 RESIDENTS ( #103), RESULTING IN RESIDENT # 103'S KNEE SURGERY INCISION BURSTING OPEN, DEVELOPING CELLULITIS AND SUBSEQUENT INFECTION AFTER SUSTAINING A FALL IN THE BATHROOM . FINDINGS INCLUDE: ACCORDING TO THE FACILITY'S INVESTIGATION REPORT OF THE FALL ON 10/7/10, RESIDENT # 103 WAS FOUND ON THE BATHROOM FLOOR ON 10/7/10 AT APPROXIMATELY 9:30 P.M. RESIDENT # 103 HAD BEEN ASSISTED TO THE BATHROOM BY A CERTIFIED NURSE ASSISTANT (CNA) AND THEN LEFT ATTENDED WHILE THE CNA OBTAINED A BRIEF. A RECORD REVIEW REVEALED THAT RESIDENT # 103 WAS A [AGE] year OLD FEMALE WHO admitted to the facility on [DATE] AT APPROXIMATELY 4:00 P.M AFTER HAVING LEFT KNEE SURGERY. RESIDENT # 103 WAS THE FACILITY'S FALL MANAGEMENT PROGRAM UPDATED ON 11/9/09 INDICATES THAT RESIDENTS MAY BE AT RISK FOR FALLS DUE TO MEDICATIONS, RECENT SURGERY, AND GENERAL WEAKNESS, ETC. RESIDENTS admitted AT RISK FOR FALL NEED TO HAVE IMMEDIATE INTERVENTIONS IMPLEMENTED. RESIDENTS WHO ARE AT RISK FOR FALLS SHOULD NOT BE LEFT ALONE IN THE BATHROOM. ACCORDING TO THE emergency room PHYSICIAN'S NOTES DATED 10/8/10 , AT 1:25 A.M., RESIDENT # 103 WAS readmitted TO THE HOSPITAL AFTER SUSTAINING A FALL IN THE BATHROOM AT THE EXTENDED CARE FACILITY. RESIDENT # 103 SAID SHE WAS LEFT ALONE IN THE BATHROOM AND HER KNEE GAVE WAY WHEN SHE STARTED TO FEEL DIZZY. AN ASSESSMENT REVEALED THE SURGICAL WOUND HAD SPREAD OPEN 3 - 4 MILLIMETERS WITH MILD REDNESS AND SWELLING AT THE SITE. THERE IS CONCERN FOR CELLULITIS. ON 10/20/10 AT 11:00 A.M., RESIDENT # 103 SAID THAT PRIOR TO BEING TRANSFERRED OUT OF THE HOSPITAL TO THE FACILITY SHE TOOK AND ADDITIONAL PERCOCET TO CONTROL HER PAIN. WHEN SHE ARRIVED AT THE FACILITY SHE FELT VERY DROWSY AND fell ASLEEP FOR SEVERAL HOURS. THE NURSE WOKE HER UP AT APPROXIMATELY 9:00 P.M, AND ASKED IF SHE WANTED TO EAT ANY OF HER DINNER TRAY WHEN RESIDENT # 103 REALIZED SHE NEEDED TO GO TO THE BATHROOM. SHE ASKED THE NURSE TO ASSIST HER, BUT THE NURSE PUSHED HER CALL LIGHT AND TOLD HER A NURSE ASSISTANT WOULD BE THERE TO HELP HER. THE NURSE ASSISTANT ASSISTED HER TO THE BATHROOM AND THEN LEFT HER ALONE WHILE SHE WENT TO GET HER AN ADULT BRIEF. THAT BRIEF WAS NOT THE CORRECT SIZE AND THE NURSE ASSISTANT LEFT HER IN THE BATHROOM A SECOND TIME. RESIDENT # 103 SAID SHE WAS STANDING AT THE SINK WAITING FOR THE CNA TO RETURN AND SHE FELT DIZZY AND fell TO THE GROUND, BREAKING OPEN HER SURGICAL INCISION. RESIDENT # 103 SAID THE NURSE ASSISTANT SHOULD NOT HAVE LEFT HER IN THE BATHROOM ALONE, BECAUSE IT WAS HER FIRST TIME GETTING UP AND WAS ON A STRONG PAIN MEDICATION. ON 10/20/10 AT 2;00 P.M., LICENSED PRACTICAL NURSE ( LPN) # 5 SAID THAT RESIDENT # 103 HAD BEEN ASLEEP SINCE HER INITIAL ASSESSMENT AND HAD NOT EATEN ANY OF HER DINNER TRAY. AT APPROXIMATELY 9:00 P.M., DURING MY MEDICATION PASS, I WOKE HER UP TO ASSESS HER AND SEE IF SHE WANTED TO EAT ANYTHING BEFORE HER DINNER TRAY WAS REMOVED. RESIDENT # 103 REQUESTED TO GO TO THE BATHROOM. LPN # 5 SAID HE INSTRUCTED RESIDENT # 103 NOT TO GET UP BY HERSELF AND PRESSED THE CALL LIGHT FOR HER. LPN # 5 SAID HER PROCEEDED WITH HIS MEDICATION PASS WHEN CERTIFIED NURSE ASSISTANT (CNA) # 11 CAME INTO THE ROOM. LPN # 5 SAID THAT RESIDENT # 103 WAS NOT IDENTIFIED AS A FALL RISK AT THAT TIME ACCORDING TO HER PAPERWORK, BUT THAT NEWLY admitted RESIDENTS ARE CONSIDERED A FALL RISK UNTIL DETERMINED OTHERWISE. ON 10/20/10 AT 2:20 P.M., CNA # 11 SAID THAT SHE ANSWERED RESIDENT # 103 ' S CALL LIGHT, BUT THE RESIDENT ' S ROOMMATE IMMEDIATELY REQUESTED ASSISTANCE WITH HER BEDDING. RESIDENT # 103 THEN ATTEMPTED TO GET OUT OF BED HERSELF AND WAS USING HER WALKER. CNA # 11 SAID THAT SHE IMMEDIATELY ASSISTED RESIDENT # 103 TO THE BATHROOM AND THEN LEFT TO GO OBTAIN SOME ADULT BRIEFS. THE BRIEF WAS NOT THE CORRECT SIZE AND CNA # 11 SAID SHE LEFT RESIDENT # 103 ALONE IN THE BATHROOM A SECOND TIME. CNA # 11 SAID SHE DID NOT RECALL IF SHE INSTRUCTED RESIDENT # 103 TO WAIT FOR HER TO RETURN TO THE BATHROOM, OR IF SHE INSTRUCTED HER ' NOT TO GET UP ' . CNA # 11 SAID WHEN SHE RETURNED TO THE BATHROOM, RESIDENT # 103 WAS LAYING ON THE FLOOR BLEEDING FROM HER KNEE INCISION. CNA # 11 SAID SHE WAS NOT TOLD WHETHER RESIDENT # 103 WAS A FALL RISK OR NOT. CNA # 11 SAID THAT RESIDENTS WHO ARE FALL RISKS WOULD NOT BE LEFT ALONE IN THE BATHROOM. ( )

THIS CITATION PERTAINS TO INTAKE: MI 995. BASED ON INTERVIEWS AND RECORDS REVIEW THE FACILITY FAILED TO PROVIDE THE PROPER CARE AND treatment of [REDACTED].# 101) RESULTING IN RESIDENT # 101'S RESPIRATORY STATUS BEING SIGNIFICANTLY COMPROMISED WHEN THE INNER CANNULA OF HER 'JACKSON SIZE # 6' [MEDICAL CONDITION] WAS MISSING AND HAD TO BE REPLACED WITH A 'SHILEY SIZE #4' [MEDICAL CONDITION] CAUSING INCREASED RESISTANCE TO BREATHE, ANXIETY AND EVENTUAL RESPIRATORY DISTRESS AND ASPIRATION (INHALATION OF FOREIGN MATERIAL INTO LUNG) . SUBSEQUENTLY, RESIDENT # 101 WAS diagnosed with [REDACTED]. FINDINGS INCLUDE: A CLOSED RECORD REVIEW WAS CONDUCTED AND REVEALED THAT RESIDENT #101 WAS A [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE] WITH MULTIPLE [DIAGNOSES REDACTED]. ACCORDING TO THE FACILITY TRANSFER RECORDS, RESIDENT # 101 WAS SENT TO THE emergency room (ER) ON 9/24/10 AT 1:00 A.M., FOR RESPIRATORY DISTRESS AND RETURNED TO THE FACILITY AT APPROXIMATELY 6:00 A.M. THAT SAME DAY. ON 9/25/10 AT 2:30 P.M, RESIDENT # 101 WAS SENT BACK TO THE ER FOR RESPIRATORY DISTRESS AND INCREASED SECRETIONS. THE ADMISSION WORK SHEET DATED 9/20/10 DOCUMENTS THAT RESIDENT # 101 HAS A 'JACKSON SIZE #6' [MEDICAL CONDITION]. THE RESPIRATORY THERAPIST (RT) NOTES DATED 9/21/10 DOCUMENTS THAT RESIDENT # 101 HAS A 'JACKSON SIZE #6' [MEDICAL CONDITION]. ON 9/23/10 (NO TIME), THE RT NOTES DOCUMENT THAT RESIDENT # 101 WAS FOUND TO HAVE HER INNER CANNULA MISSING FROM HER 'JACKSON SIZE # 5' [MEDICAL CONDITION] AND THE [MEDICAL CONDITION] WAS CHANGED TO A 'SHILEY SIZE # 4' [MEDICAL CONDITION]. ACCORDING TO THE RESPIRATORY CARE MEDICAL JOURNAL TITLED '[MEDICAL CONDITION] AND RELATED APPLIANCES', April 2005, VOL 50, NO. 4, PAGES 497-499; THE 'JACKSON ' [MEDICAL CONDITION] ONLY COMES IN EVEN SIZES (THERE IS NO SIZE #5). THE 'JACKSON SIZE # 6' [MEDICAL CONDITION] HAS AN INNER DIAMETER (ID) OF 6.4 MILLIMETERS (MM). THE 'SHILEY SIZE # 4' [MEDICAL CONDITION] HAS AN ID OF 5.0 MM. IF THE ID IS TOO SMALL, IT WILL INCREASE THE RESISTANCE THROUGH THE TUBE AND MAKE AIRWAY CLEARANCE MORE DIFFICULT. MULLINS ET AL4 ESTIMATED THE RESISTANCE THROUGH A 'SHILEY SIZE # 6' [MEDICAL CONDITION] = 3.96 H2O/L/s. THE RESISTANCE THROUGH A 'SHILEY SIZE #4' [MEDICAL CONDITION] = 11.47 H2O/L/s. (THE RESISTANCE FOR RESIDENT # 101 TO BREATH WAS INCREASED 2.89 MORE TIMES WHEN HER [MEDICAL CONDITION] WAS CHANGED TO THE 'SHILEY SIZE # 4' WITH THE SMALLER ID). ON 10/20/10 AT 1:00 P.M., THE RT SAID ON 9/23/10, WHILE [MEDICAL CONDITION] TO RESIDENT # 101, IT WAS NOTICED THAT THE INNER CANNULA PART OF HER JACKSON [MEDICAL CONDITION] WAS MISSING. THE INNER CANNULA IS A SMALLER TUBE THAT SLIDES INTO THE LARGER CANNULA OF THE TRACH. THE INNER CANNULA IF A 'JACKSON'[MEDICAL CONDITION] IS REMOVED DAILY, CLEANED AND REPLACED BACK INTO THE LARGER TUBE OF THE [MEDICAL CONDITION] AS PART OF [MEDICAL CONDITION] CARE. THE RT SAID THE FACILITY DID NOT HAVE A JACKSON TYPE [MEDICAL CONDITION] AVAILABLE AND REPLACED THE ENTIRE [MEDICAL CONDITION] WITH A SMALLER 'SHILEY SIZE # 4 [MEDICAL CONDITION]. THE RT SAID SHE SELECTED A SMALLER SIZED [MEDICAL CONDITION] BECAUSE SHE DID NOT WANT TO CAUSE TRAUMA WHEN SHE RE-INSERTED THE [MEDICAL CONDITION] BACK INTO THE STOMA (OPENING). THE RT SAID SHE DID NOT KNOW WHAT HAD HAPPENED TO THE INNER CANNULA OF THE JACKSON [MEDICAL CONDITION], IT WAS PRESENT THE DAY BEFORE [MEDICAL CONDITION] WAS COMPLETED. THE RT SAID THAT THE FACILITY STAFF MAY HAVE THROWN IT OUT, THINKING IT WAS A DISPOSABLE PIECE. THE RT SAID THE MISSING PIECE WAS NOT REPORTED TO HER BY THE NURSING STAFF, IT WAS DISCOVERED DURING HER DAILY RESPIRATORY ASSESSMENT AND THAT RESIDENT # 101 WAS NOT IN ANY RESPIRATORY DISTRESS DURING THIS TIME. THE RT SAID THAT THE FACILITY'S POLICY IT TO PLACE AN ADDITIONAL [MEDICAL CONDITION] IS AT THE RESIDENT'S BEDSIDE IN CASE OF EMERGENCY. RESIDENT # 101 DID HAVE AN ADDITIONAL [MEDICAL CONDITION] AT HER BEDSIDE, BUT IT WAS NOT A 'JACKSON' [MEDICAL CONDITION], IT WAS A 'SHILEY' [MEDICAL CONDITION]. ON 10/20/10 AT 1:30 P.M., THE DIRECTOR OF NURSING (DON) SAID THAT THE FACILITY'S POLICY IS TO HAVE AN ADDITIONAL [MEDICAL CONDITION] AT THE RESIDENT'S BEDSIDE IN CASE OF EMERGENCY. THE DON REVIEWED THE ADMISSION FORM DATED 9/20/10 ( 1 DAY PRIOR TO RESIDENT' # 101'S ADMISSION TO THE FACILITY) AND COULD NOT OFFER AN EXPLANATION AS TO WHY A 'JACKSON SIZE # 6' [MEDICAL CONDITION] WAS NOT ORDERED FROM CENTRAL SUPPLY AND PLACED AT RESIDENT # 101'S BEDSIDE AT THE TIME OF ADMISSION. A REVIEW OF THE NURSE'S NOTES FROM 9/23/10 THROUGH 9/25/10 REVEALED THAT RESIDENT # 101 WAS SENT OUT TO THE hospital on [DATE] AT 1:00 A.M., FOR INCREASED RESPIRATORY DISTRESS AND LOW OXYGENATION LEVELS. ON 9/25/10 (NO TIME) RESIDENT # 101 WAS HAVING INCREASED RESPIRATORY SECRETIONS, LOW OXYGENATION LEVELS AND GENERAL DIFFICULTY IN BREATHING. RESIDENT # 101'S [MEDICAL CONDITION] WAS SUCTIONED FOR GROUND TURKEY AND GREEN BEANS AFTER EATING LUNCH. THE RESIDENT WAS DETERMINED TO HAVE ASPIRATED HER LUNCH (INHALED FOREIGN MATERIAL INTO THE LUNGS) ANS SENT OUT TO THE ER. ON 10/21/10 AT 1:30 P.M., LICENSED PRACTICAL NURSE (LPN) # 15 SAID THAT ON 9/25/10 RESIDENT # 101 WAS HAVING INCREASED SECRETIONS AND DIFFICULTY BREATHING ALL MORNING. LPN # 15 SAID SHE SUCTIONED RESIDENT # 101 APPROXIMATELY 15 TIMES AND PERFORMED [MEDICAL CONDITION] CARE APPROXIMATELY 8 TIMES BETWEEN 7:00 A.M AND 1:00 P.M. BUT RESIDENT # 101 CONTINUED TO HAVE LOW OXYGENATION LEVELS AND DIFFICULTY BREATHING. LPN # 15 SAID THAT DURING LUNCH TIME RESIDENT # 101 WAS SUCTIONED FOR GROUND TURKEY AND GREEN BEANS OUT OF HER [MEDICAL CONDITION] AND WAS THEN TRANSFERRED TO THE ER. ON 10/21/10 AT 3:30 P.M., THE PHYSICIAN SAID SHE WAS AWARE THAT RESIDENT' # 101'S [MEDICAL CONDITION] HAD BEEN CHANGED FROM A 'JACKSON' TO A 'SHILEY' BUT WAS UNAWARE IT WAS SUCH A SMALLER SIZE. THE PHYSICIAN SAID THAT COULD HAVE RESULTED IN INCREASED RESPIRATORY DISTRESS AND INABILITY TO CLEAR THE SECRETIONS. ACCORDING TO THE HOSPITAL LABORATORY REPORTS DATED 9/27/10, A RESPIRATORY SECRETION SAMPLED ON 9/24/10 WAS POSITIVE [MEDICAL CONDITION]. ( )