Every finding on record at Optalis Health and Rehabilitation of Dearborn Heig

Based on interview, and record review, the facility failed to provide two-person assistance during care for one resident (R302) of three residents reviewed for falls, resulting in a fall from bed, being transferred to the hospital, and returning to the facility with five stitches on their forehead.Findings include: R302R302 was admitted into the facility on [DATE] with the diagnosis of cerebral infarction, vascular dementia, wedge compression fracture of the thoracic spine (T11-T12), Major Depression, anxiety, and adjustment disorder. R302's Brief Interview of Mental Status (BIMS) score dated 2/2/26, was 2/15 indicating severely impaired cognition. The 2/2/26 Minimum Data Set (MDS) section GG functions were uncoded. A Care Plan dated 12/20/2024 for Self-care deficit specified interventions requiring a 2-person assist with toileting at bed level and, with bed mobility.A nurse's notes authored by nurse JW dated 4/4/26 at 9:11 AM, documented: Writer was called to the resident's room by another nurse and observed the resident on the floor with CNA (Certified Nurse Aide) present. The nurse assessed the resident and noted an abrasion on the right side of the resident's forehead with a pool of blood on the floor. CNA was changing the resident when the resident rolled out of bed and fell on the floor.An Incident Report dated 4/7/26, reviewed, revealed: on 4/4/26, between 8:30 and 9:30 AM, (name of R302) was receiving ADL care (activities of daily living) from CNA (Certified Nursing Assistant) DG. During care, which included cleaning the resident and changing the bed linens, the resident fell to the side of the bed. Upon arrival of Nurse JW, (name of R302) was observed lying face down on the floor with active bleeding from the head. Nurse JW, along with additional staff, immediately assessed (name of R302). The EMS (emergency medical system), DON (Director of Nursing), Physician, and family were promptly notified CNA acknowledge (name of R302) is a two (2) person assist but stated they did not seek assistance because the staff was busy . CNA DG stated she was unfamiliar with the Happy Feet protocol (facilities fall prevention program) but reviewed R302's Kardex (resident care guide), which specifies 2-person assistance for bed mobility. (Name of R302) was transported to the nearby hospital for further evaluation and returned later the same day with five sutures to the head .Review of the hospital records dated 4/4/26 at 11:19 AM, the reason for visit was: Fall and Facial Laceration. Five sutures were placed in her forehead. CT Head Cervical Spine Without Contrast, ECG 12 Lead, Chest and Pelvic X-rays, and laboratory tests were obtained while at the hospital. The resident was returned to the facility with discharge instructions for the 5 sutures care and pain relief.On 4/30/26 at 11:45 AM, the Administrator was asked about the incident and stated, The CNA did not follow the care plan for R302 to have two (2) persons assist for bed mobility and transfers. Thus, causing the resident to fall because they should have 2-person assistance during care.Attempted to call CNA DG on 4/30/26 at 12:00 PM but did not return the call after a voice mail was left.The DON was interviewed on 4/29/26 at 3:30 PM and revealed the resident's fall was due to the CNA DG not waiting for another staff member to provide ADL care. (Name of R302) rolled out of bed while the CNA was providing incontinence care, without a second staff member present. The resident ended up being sent to the hospital and returned the same day with 5 stitches on their forehead.R302 was observed lying in bed in their room on 4/30/26 at 1:00 PM. The resident was nonverbal but was crying pointing at their forehead, where stitches were observed. R302's mouth was moving but unable to determine what was being said.The Administrator presented the corrective action plan regarding Resident 302's fall on 4/4/2026 when the care plan had not been followed during bed mobility with two persons assist. Past Non-Compliance (PNC) was identified during investigation of the deficient practice and was accepted by the survey team upon exit from the facility for this citation. The facility attained and maintained compliance for F689 with a compliance date on 4/7/2026.Element 1: On 4/4/2026, immediately after the fall, Resident 302 was assessed and transferred to a nearby hospital for further evaluation and treatment. R302 returned from the hospital on the same day with five (5) stitches on the head. A one-time review of R302 bed mobility and fall care plans were reviewed on 4/6/2026 by the interdisciplinary team to ensure they were appropriate and were updated as needed.Element 2: All residents have the potential to be affected. All residents reviewed for bed mobility as one time audit on 4/6/26. Like residents are defined as those requiring a two-person assist for bed mobility. Element 3: The Fall Management Policy was reviewed and determined to be appropriate. The Interdisciplinary Team and Nursing staff were re-educated on bed mobility and to follow the Happy Feet designation of residents requiring two (2) person assistance in bed mobility. Education completed on 4/6/26, for all nursing staff with the Topic: Safety and Fall Management Policy, follow Happy Feet designation requiring two (2) person assistance, care plans and Kardex's (care guides), with signed signatures of CNAs and nurses. A signed Performance Education for CNA DG acknowledging education was received on 4/6/26. Audits completed on 4/8/26, 4/13/26and 4/27/26. All audits will be reviewed with the QA committee. Date of compliance of the plan of correction: 4/7/2026.The State Surveyor verified the documentation provided by the facility and conducted interviews with facility staff regarding following care planned interventions and staff were knowledgeable about the facility policies. Other Residents were reviewed for falls and noncompliance was not identified with F-689.

This citation pertains to Intakes 2987085 and 2973371.Based on observation, interview, and record review, the facility failed to ensure call lights were accessible and answered timely for one resident (R304) of five reviewed and failed to provide an adaptive knife for one resident (R305) of five residents reviewed for residents rights.Findings include: R304On 4/29/26, at 4:00 PM, R304 was observed lying on their bed, eyes closed, sleeping in the room. The bed was noted to be in the lowest position. When Registered Nurse (RN)C approached the door of the room, the surveyor asked to see where R304's call light was and found the call light wrapped around the television tucked away and far from the residents reach. At this time, RN C was interviewed and confirmed R304's call light was not within their reach. R304 was admitted into the facility on March 13, 2026, with a diagnosis of displaced intertrochanteric fracture of the right femur, Type 2 diabetes mellitus, deaf, nonverbal, and with difficulty walking. According to the Minimum Data Set (MDS) assessment dated [DATE], R304 Brief Interview of Mental Status Score (BIMS) was zero, indicating severely impaired cognition having the ability to make themself understood, sometimes. The MDS documented R304 is dependent in toileting, showers, and activities of daily living and required maximum assistance with bed mobility and transfers.A review of R304's care plan dated 3/14/26, revealed the resident is at risk for falls due to a history of falls resulting in a recent fracture of the right femur with surgical repair. The care planned interventions included call lights within reach, orienting to surroundings, and using call lights. R305R305 was admitted into the facility on 3/20/2026, with the diagnosis of Rhabdomyolysis, major depressive disorder, anxiety disorder, and chronic inflammatory demyelinating polyneuritis in addition to other diagnoses. R305 Brief Interview for Mental Status (BIMS) Score dated March 26, 2026, was 15/15 indicating cognitively intact and ADL assistance from one staff member with meals. A current care plan revealed the resident was to have adaptive equipment for eating: weighted utensils, and a plated guard. R305 was observed eating in their room on 4/29/26 at 12:35 PM. When the surveyor asked about how the meals were, R305 stated, Most meals are good. But sometimes it's like a kid's meal. The resident stated the portions were too small and has been receiving double portions for almost a week now. While eating independently, R305 struggled with the adaptive fork and attempted to cut a chicken breast with it. R305 appeared frustrated, picked up the large chicken breast with a fork, and started nibbling it, leaving crumbs and honey glaze on their face. When asked where the knife was, the resident said, It did not come with it; they did not send one this time. Sometimes they do, and sometimes they don't. I am supposed to have a weighted spoon, fork, and knife. Observation of the lunch tray revealed only a weighted fork. No weighted knife or weighted spoon were noted. R305's Meal ticket documented: LUNCH, Wednesday, 4/29/26-Feeding Assistance devices: weighted fork, weighted knife, and weighted spoon. At 12:40 PM, R305 described their hands were very numb and sometimes felt like they were on fire and that's why I need the weighted spoons and fork. It helps.On 4/29/26 at 1:35 PM, Occupational Therapist (OT) K said sometimes (name of R305) experiences heavy weakness, and sometimes it is mild. Last month, their status was maximum assist with Activities of Daily Living (ADL) and rehab was working to strengthen and develop fine motor skills using the adaptive devices.On 4/30/26, at 3:00 PM, the Resident Council Minutes for March 2026 and April 2026 were reviewed and revealed:-March 17, 2026, at 2:30-3:30 PM, complaints noted: Call lights not answered in a timely manner, not accessible, and not within reach.-April 16, 2026, from 2:30-3:30 PM, there were repeated complaints about call lights being unreachable and long waits for them to be answered.On 4/30/26 at 1:00 PM, the Call Light Policy, Dignity and Adaptive Devices Policy were reviewed.

Based on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen. Findings include:On 02/04/2026 at 9:30 AM, the initial kitchen observation was conducted with the Dietary Manager. The following items were observed: The terminal end of the drain for the food prep area sink slanted down below the level of the floor drain and did not have a minimum one inch air gap; The inside frame of the microwave opening had visible rust along the bottom edge which extended a half or more from the inside rim; The center area of the microwave also had a quarter size area of rust; Each with a potential to contact food; The freezer had a box of burgers open to the air inside the cooler. These were removed by the Dietary Manager. The dietary manager reported the identified concerns would need to be rectified. A review of the facility policy titled, Food Storage dated 12/26/22 revealed, It is the policy of this facility to provide sufficient storage to keep foods safe, wholesome and appetizing .It is the responsibility of the Dietary staff and supervisors to ensure that food is stored, labeled and used within the recommended time guidelines to prevent food borne illness. A review of the facility policy titled, Air Gaps dated 05/01/25 revealed, an air gap is a critical safety measure used to prevent backflow and contamination of the potable water supply or food-handling equipment. It is defined as the unobstructed vertical space through the free atmosphere between the lowest opening of any pipe or faucet supplying water to a tank, plumbing fixture, or other device and the flood-level rim of the receptacle. gaps are strictly required for equipment used for the storage, preparation, and handling of food, such as: 1. Ice Machines: Since ice is classified as food, both the water supply and drain lines require air gaps. 2. Food Prep Sinks: These must discharge through an indirect waste pipe by means of an air gap. 3. Walk-in Refrigerators: Floor drains inside walk-ins must be indirectly connected via an air gap. 4. The air gap must be at least twice the diameter of the water supply inlet and cannot be less than 25 millimeters (1 inch).

Based on observation, interview, record review the facility failed to maintain clean and sanitary conditions in two resident rooms and two ice machines. Findings include: On 02/04/26 at 9:30 AM, the drain tube for the ice machine on the 300 unit was observed to have a circumferential buildup of a black gel/mildew like substance at the distal end where it entered the drain. The distal end of the ice machine drain was down below the rim level of the drain from the floor and without the minimal one-inch air gap. On 02/04/2026 at 10:33 AM and on 02/05/2026 at 9:35 AM, the tube feeding pole in room [ROOM NUMBER]B was observed with multiple dried areas of tube feeding liquid on the base and shaft and on the floor. The spots could not be easily scraped from the floor. On 02/04/2026 at 10:35 AM and on 02/05/2026 at 11:19 AM, in room [ROOM NUMBER]B the privacy curtain had three yellow half dollar sized stains and mixed in with multiple milk chocolate colored dry drip stains along the left edge and left center area of the curtain. The feet of the tube feeding pole had multiple polka dot like tan colored dried tube feeding on them. On 02/05/2026 at 4:14 PM, the dual drain tube from the back side of the ice machine off service hall/100 hall were below the level of the drain cup and without the minimal one inch air gap. The front tray was noted to be mounded with ice. On 02/06/2026 at 11:25 AM, the Interim facility Director of Nursing (DON) observed the tube feeding pole in room [ROOM NUMBER] and acknowledged the liquid tube feeding residue on the pole base and floor and reported the expectation was that the equipment and area should be kept clean and not be left to dry.On 02/06/2026 at 2:20 PM, the Maintenance Director acknowledged the identified observations for the airgaps and the needed repair of the drain lines and ice machine maintenance. A review of the facility policy titled, Homelike Environment review dated 02/03/26 revealed, Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible.A review of the facility policy titled, Air Gaps dated 05/01/25 revealed, an air gap is a critical safety measure used to prevent backflow and contamination of the potable water supply or food-handling equipment. It is defined as the unobstructed vertical space through the free atmosphere between the lowest opening of any pipe or faucet supplying water to a tank, plumbing fixture, or other device and the flood-level rim of the receptacle. gaps are strictly required for equipment used for the storage, preparation, and handling of food, such as: 1. Ice Machines: Since ice is classified as food, both the water supply and drain lines require air gaps. 2. Food Prep Sinks: These must discharge through an indirect waste pipe by means of an air gap. 3. Walk-in Refrigerators: Floor drains inside walk-ins must be indirectly connected via an air gap. 4. The air gap must be at least twice the diameter of the water supply inlet and cannot be less than 25 millimeters (1 inch).

Based on observation, interview, and record review the facility failed to ensure medication was not left at the bedside with a cognitively impaired resident for one resident (R118) of four reviewed for medication administration. Findings include: On 02/04/2026 at 10:18 AM, R118 was observed to have a bottle of Saline Nasal Spray on the overbed table. R118 stated they administer it to themself. On 02/05/2026 at 4:03 PM, R118 was observed to have a bottle of Saline Nasal Spray on the overbed table.On 02/06/2026 at 8:45 AM, R118 was observed to have a bottle of Saline Nasal Spray on the overbed table with the breakfast tray. A review of the record documented R118 to lack capacity to make medical decisions. No medication self-assessment was located in the medical record. On 02/06/2026 at 8:47 AM, Licensed Practical Nurse (LPN) G LPN reported they knew of only one resident with self-administration for medication. This was not R118.On 02/06/2026 at 8:58 AM, the Director of Nursing (DON) reported if a resident was granted self-administration of medication upon assessment, then they would have a lock box for them and if a resident was going to keep medication at the bedside, a self-administration assessment was needed. This included inhalers, over the counter medications and nasal sprays. A review of the record for R118 revealed R118 was admitted into the facility on [DATE]. Diagnoses included Dementia, Depression and High Blood Pressure. The active care plan documented an alteration in communication related to cognitive impairment and hard of hearing . A review of the Minimum Data Set (MDS) assessment dated [DATE] indicated a severely to moderately impaired cognition with a 6/15 Brief Interview for Mental Status score (BIMs) and the need for setup for meals. A review of the facility policy titled, Medication Self-Administration revised 02/03/26 revealed, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.A review of the facility policy titled, Medication Administration revised 02/03/26 revealed, Policy: To safely and accurately prepare and administer medication according to physician order, professional standards of practice, and resident needs . Medications administered are documented following administration .

Based on interview and record review the facility failed to ensure appropriate monitoring for lactulose (laxative medication) administered for elevated ammonia levels for one resident (R96) of four residents observed during the medication pass observation. Findings include: On 02/05/26 at 11:19 PM, an observation of a medication pass for R96 was conducted with Licensed Practical Nurse (LPN) I. It was noted by LPN I that the lactulose was not available for administration. The indication for the lactulose was documented as for an ammonia level. The record was reviewed with LPN I who confirmed the last level they found was from July of 2025. A review of the order revealed, Lactulose Oral Solution, Give 30 ml via PEG-Tube two times a day for Ammonia Level with an original order date of 01/20/25. A review of the record indicated the ammonia level was last drawn on 07/25/25. The level was 79 with a normal range of 31-169 indicated. The note on the lab dated 07/28/25 indicated no new orders were given.A review of the medication administration records (MARs) documented administration of the lactulose since July of 2025. The MAR for 2/2026 revealed, Senna Oral Tablet 8.6 MG (Sennosides) Give 2 tablet via PEG-Tube two times a day for constipation -Start Date- 10/31/2024 was also documented as given. The tasks for the last thirty days documented one or more daily bowel movements. An additional order for GlycoLax Powder (Polyethylene Glycol 3350) Give 17 gram via PEG-Tube every 8 hours as needed for constipation was noted with no administration documented in February 2026.A review of the progress note date 02/5/2026 at 2:56 PM by the Director of Nursing documented, Writer spoke with (nurse practitioner) NP (J) concerning Lactulose. NP ordered that lactulose be discontinued and ordered (labs/bloodwork) CBC, CMP, Ammonia, and Mag levels on next draw Friday 02/6/26.On 02/06/2026 at 2:35 PM, the lactulose medication and monitoring were reviewed with NP J. The NP reported originally R96 was put on lactulose for an elevated ammonia level and once on lactulose the ammonia level would be monitored weekly until in range. Once in range the level would be continued to be monitored and the lactulose tapered as needed. The NP did not indicate a follow up interval for monitoring and noted it would be continued based on the labs and on a case-by-case basis.A review of the facility policy titled, Laboratory Results with review dated 02/03/26, revealed, .the facility must provide or obtain laboratory services to meet the needs of the resident A review of the facility policy titled, Medication Administration with review dated 02/03/26, revealed, .Laboratory values are validated prior to the administration of laboratory dependent medications in accordance with the medical practitioner's orders

Based on observation, interview and record review, the facility failed to provide podiatry services to one resident (R4) of one reviewed for foot care. Findings include:On 02/06/2026 at 10:29 AM, R4 was observed lying in bed. R4's toenails on their left foot were observed as yellow, extremely elongated measuring the length of the nail bed and curling over. Attempts to ask the resident if they had seen a podiatrist however, due to their cognition, they were unable to respond. A review of R4's medical record revealed the resident was admitted into the facility on 2/21/25 with diagnoses which included Cerebral Infarction, Vascular Dementia, and Epilepsy. Further review revealed the resident had a severe cognitive impairment and required assistance with activities of daily living. On 02/06/2026 at 12:08 PM, all podiatry notes for R4 were requested from the facility however, the surveyor was provided with a list of residents scheduled to be seen on 2/18/26. On 02/06/2026 at 3:05 PM, an interview was completed with the Director of Nursing (DON) regarding R4 not being provided with podiatry services. The DON was unsure why the resident had not been seen. On 02/06/2026 at 3:34 PM, an interview was completed with Social Worker B regarding R4 not being seen by podiatry. She explained the resident's spouse had requested the resident be seen by the podiatrist and was placed on the list to be seen in October and December. Social Worker B explained that reminder emails were sent to the podiatry provider for R4 to be seen however, for unknown reasons the resident was not seen. Social Worker B also acknowledged that the podiatrist was in the building the day prior, 2/6/25 and R4 had not been seen. On 02/06/2026 at 2:19 PM, a policy regarding podiatry services was requested from the facility but was not received by the end of the survey.

Based on observation, interview and record review the facility failed to implement interventions for heel pressure sores for one resident (R80) of three reviewed for skin management. Findings include: On 02/04/2026 at 2:44 PM and at 4:45 PM, R80 was observed to be on their back in bed with the head of the bed up 45-60 degrees. R80 reported they had boots on in the morning, but they were taken off and not put back on. The boots were not observed to be in place. The low air loss mattress was active and set on alternating with a setting for the resident's weight of 450 pounds. R80 did not look to weigh 450 pounds. R80 was not observed to be out of bed during the hours of the survey on 02/04/26. On 02/05/2026 at 1:00 PM, R80 was observed to be on their back in bed with their heels on the bed and no device under the lower legs to elevate the heels off the bed surface. R80 reported no pain in heels this day but did have pain off and on. The heel boots were off and had been put on the windowsill toward the foot of the bed. The head of bed was up around 60-90 degrees for lunch and R80 reported they liked to sit up so they are more over plate of food. R80 reported it was kind of hard to move around and reported their tailbone was a little sore. R80 noted they had been out to the doctor and had the staples in their hip and leg out. At 2:20 PM and 4:09 PM R80 continued in bed as before. The curtain had been pulled to the waist area. R80 denied any refusal to wear the boots or be repositioned. On 02/06/2026 at 8:20 AM, 9:09 AM, 9:44 AM, and 10:10 AM, R80 was observed to be on their backside in bed with the head of the bed up around 45-60 degrees for breakfast. The heels rested on the bed surface and the dressing for the right heel wound was visible above the sock. The heel boots were on the windowsill in same area at the foot of the bed. At 9:44 AM Staff were seen to enter the room. At 10:10 AM R80 reported pain from their hip to their feet. The heel boots were on the windowsill. On 02/06/2026 at 10:19 AM, R80's heels were observed with the wound care nurse. Both heels had dry deep tissue injuries with the right one larger covering the entire planter surface of the heel. A wound consult note date 01/31/26 documented, Seeing patient regarding bilateral heel wounds .pressure induced dep tissue damage of right heel (3.6 centimeters [cm] x 2.8 cm); pressure induced dep tissue damage of left heel (2.5 cm x 3.0 cm) .heel lift boot while in bed . The wound nurse confirmed the heel boots along with the leg splint for the right leg should be on while in bed On 02/06/2026 at 9:45 AM, CNA D reported R80 to be non-weight bearing due to the heels, alert and oriented, cooperative in care and would make needs known. On 02/06/2026 at 12:19 PM, the Director of Nursing confirmed pressure injury interventions should be applied to improve wound healing. A review of the record for R80 revealed R80 was admitted into the facility on [DATE]. Diagnoses included Fracture of the right Femur and Deep Tissue injuries of the right and left heels. The care plan documented, Risk for pressure injury formation . encourage to reposition . encourage resident to float heels or wear heel boots . initiated 01/19/26 . The Minimum Data Set (MDS) assessment dated [DATE] documented intact moderately impaired cognition and the need for assistance with rolling left and right in bed and dependence on staff for transfers, to sit up and to stand. A physician order with revision date of 01/27/26 documented, Place bilateral heel protectors. A review of the facility policy titled, Skin and Wound Guidelines revised 02/04/26 revealed, Policy: To describe the process steps required for identification of residents at risk for the development of pressure injuries, identify prevention techniques and interventions to assist with the management of pressure injuries and skin alterations . The individualized comprehensive care plan addresses the resident's problem (i.e. at risk for skin breakdown or actual wound), the goal for prevention and/or treatment, and individualized interventions to address the resident's specific risk factors and the plan for reduction of risk . Pressure Injury: Localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical or other device. Can be present as intact skin or an open ulcer and may be painful. Injury occurs because of intense and or prolonged pressure or pressure in combination with shear and is classified by stage.

Based on observation, interview and record review, the facility failed to maintain appropriate grooming and skin care for one resident (R104), of four reviewed for Activities of Daily Living (ADLs). Findings include: On 02/04/2026 at 12:58 PM, R104 was observed lying in bed. The skin on their face was observed as white and scaly, with the residue covering the front of the resident's black t-shirt. On 02/05/26 at 9:24 AM, R104 was observed in bed finishing their breakfast. They were observed wearing the same black t-shirt they wore the previous day. They continued to have dry scaling skin on their face with the scaling residue covering the neck/chest area of their shirt. On 02/06/2026 at 10:25 AM, R104 was observed at bedside. The chest of their shirt was covered with dry skin residue. On 02/06/2026 at 10:39 AM, Licensed Practical Nurse, LPN E was interviewed and asked if they would expect residents with dry skin to have their skin moisturized/treated during daily care or only on shower days. LPN E reported dry skin should be treated daily on residents as needed. On 02/06/2026 at 10:46 AM, Certified Nursing Assistant, CNA F was interviewed and asked the protocol for providing skin care for residents with dry skin, and they reported they complete dry skin care as needed during daily grooming and hygiene care and not only after showers. On 02/06/2026 at 11:25 AM, the Director of Nursing (DON) observed R104 with the surveyor and acknowledged the dry skin residue on the resident's shirt. He reported the expectation is that the resident's shirt would be kept clean and free of debris, and their face and skin otherwise should be kept moisturized. A review of the facility's, Activities of Daily Living (ADLs) policy revealed the following, Appropriate care and services will be provided for residents who are unable to carry out ADL independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, grooming, and oral care) .

Based on observation, interview, and record review, the facility failed to apply a palm protector per physician order and plan of care for one resident (R96) of one reviewed for range of motion. Findings include:On 02/04/2026 at 10:35 AM, R96 was lying flat on their back asleep. An observation of R96's left hand was observed as contracted. There was no palm protector observed being worn by the resident or noted anywhere near the resident's bed.A review of R96's medical record revealed they were admitted into the facility on 3/16/23 with diagnoses which included Muscle Wasting and Atrophy, Cognitive Communication Deficit, and Diabetes. Further review revealed the resident was severely cognitively impaired and required one-person assist with activities of daily living (ADLs).Further review of R96's medical record revealed the following care plan, Focus: Resident has an ADL self-care performance deficit r/t (related to): Confusion, Impaired balance, Significant Mobility Impairments, reduced ROM LUE (left upper extremity) Date Initiated: 06/05/2024 .left hand palm protector to wear during day shift. Please remove at end of day shift to perform skin check. Date Initiated: 11/16/2024 .Further review of R96's medical record revealed the following active physician order dated 11/17/24, Orthosis/Splint to be applied to: during the day shift to apply left hand palm protector. Remove at the end of day shift. Please observe hand for any skin every day shift On in the Morning, Off in the Evening.On 02/05/2026 at 9:59 AM and 11:48 AM, no splint was observed on R96's left hand. On 02/06/2026 at 10:27 AM, 11:40 AM, and 1:11 PM, no splint was observed on R96's left hand. On 02/06/2026 at 1:59 PM, the Assistant Director of Therapy was interviewed regarding the need for R96's palm protector, and she explained when R96 was on their caseload, she would make attempts to stretch their hand with resistance and identified the resident would benefit from a palm protector. On 02/06/2026 at 3:06 PM, the Director of Nursing (DON) was asked about the resident not wearing their palm protector and explained they were still looking into it as they thought the resident was utilizing the palm protector on a trial basis. A review of the facility's Restorative Nursing Program policy revealed the following, .Residents will receive restorative nursing care as needed to help promote optimal safety and independence .Residents will receive services when they are assessed to have a need for a restorative nursing program. These services may include: Active, active-assisted, or passive range of motion, Splint or brace assistance .

Based on observation, interview, and record review the facility failed to update the care plan related to meal assistance for one sampled resident (R6) of three reviewed for care plans revisions. Findings include:On 2/04/2026 at 12:48 PM, R6 was observed eating lunch in their room without assistance. Observed on R6's plate was chicken tenders, macaroni and cheese, broccoli, and chocolate dessert.On 2/05/2026 at 1:05 PM, R6 was asked what they had for lunch. R6 reported they ate in their room and had chopped up chicken, two soups, and a banana. R6 stated, It was delicious. On 2/06/2026 at 12:53 PM, R6 was observed in their room feeding themselves their lunch.A review of R6's medical record noted R6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Nontraumatic acute subdural hemorrhage and Severe-protein-calorie malnutrition. R6's Minimum Data Set (MDS) assessment noted R6 with an impaired cognition and required setup or clean up assistance for eating.A review of R6's orders noted, Order: Regular diet Soft Bite Size texture, Thin consistency, at risk for hot liquid spill: total assistance when served hot liquids. Assistance recommended with all meals. Dated: 12/15/25 - Indefinite.A review of R6's care plan noted, Focus: Risk for aspiration related to diagnosis of Dysphagia, severe cognitive impairment. Date Initiated: 07/15/2025. Goal: Will have no food or fluid aspirated through next review date. Date Initiated: 07/15/2025. Interventions: Assistance recommended with all meals, 1:1 assist with feeding. Date Initiated: 07/15/2025. Monitor for choking, coughing, any food or fluid being pocketed in mouth s/p (status post) each meal. Alert nurse of any unusual findings. Date Initiated: 07/15/2025. Position resident upright during all meals, and upright for 30 minutes after each meal. Date Initiated: 07/15/2025.A review of the physician's progress note revealed, 1/19/26 Physician Team Progress note: Active Medical Problems . Dysphagia requiring texture-modified diet. 4. Protein-Calorie Malnutrition. Continue texture-modified diet. Continue Magic Cup BID (two times a day) and Pro-Heal supplementation. Monitor weights and intake. 5. Dysphagia Maintain aspiration precautions. Continue assisted feeding and diet consistency .On 2/06/2026 at 2:51 PM, the Dietician (RD) was asked about R6's care plan that noted R6 to be a one to one with meals. The RD explained R6 needed one to one assistance when R6 was first admitted , R6 currently only needs help with setting up the meal and encouragement. On 2/06/2026 at 3:12 PM, the Director of Nursing (DON) was asked about R6's care plan meal assistance as one to one with meals. The DON reported R6 was confused when admitted but has improved. The DON indicated R6's care plan should have been updated because R6 is able to feed themselves. A review of the facility's policy titled Care Plan-Comprehensive Revision dated 8/25/23. POLICY OVERVIEW: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. GENERAL GUIDELINES: . Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan: o When there has been a significant change in the resident's condition. o When the desired outcome is not met. o When the resident has been readmitted to the facility from a hospital stay. At least quarterly, in conjunction with the required quarterly MDS assessment .

Based on observation, interview, and record review the facility failed to ensure a call light was in reach for one dependent resident (R129) of three reviewed for falls. Findings include: On 02/04/2026 at 2:55 PM and 4:39 PM, R129 was observed to be on their back in bed, dressed in a hospital style gown, with the head of the bed up, and the tray table to left side of bed. The call light was not in reach and looped over the headboard of the bed. The gown was hanging down off the bare right shoulder. A review of R129's record revealed a fall onto the knees on 02/03/26. On 02/05/2026 at 8:33 AM, R129 was observed with active arm and leg movements while on their back in bed without nonslip socks on. Breakfast had been eaten. The blanket and sheets were soiled with stool and items from breakfast. The water cup was dated 2/4. The call light was behind the head of the bed, looped partially over the headboard and down between the nightstand and the bed. The call button portion was on the nightstand. At 8:42 AM staff entered the room to change the resident after the breakfast tray was brought out by the Administrator. The call light remained on the nightstand after care was completed. At 02/05/2026 at 10:49 AM, R129 was observed to be placed from the bed into a wheelchair by the aide. On 02/05/2026 at 1:15 PM, R129 was observed to be seated in the wheelchair at the nurse's station. R129 was awake with their feet on the footrests. R129 was dressed in a hospital style gown and intermittently looked around and then fell back to sleep with the head down, eyes closed and mouth slightly open; At 2:18 PM, R129 continued in the wheelchair in the same spot, with a blanket over the legs and feet; At 4:07 PM, R129 was seated in the wheelchair at nurse station in the same spot, positioned higher up in the wheelchair with the feet on the footrests. R129 looked asleep with eyes closed, head tilted down toward left shoulder and the mouth open slightly. A blanket was over the right shoulder. On 02/06/2026 at 8:18 AM, R129 was observed to be supine in bed, the head of the bead up around 45 degrees and feeding themself breakfast. The call light was behind the head of the bed, and the button portion was on the floor. The breakfast tray was on the over bed table. R129 said hello on query but did not elaborate or provide answers to questions. At 8:49 AM, R129 continued in bed as before; At 9:08 AM, R129 continued eating breakfast while supine in bed and in a similar position as before. The call light button was behind the head of the bed on the floor. On 02/06/2026 at 9:23 AM, Certified Nursing Assistant (CNA) C reported R129 was noted to have confusion but was redirectable. On 02/06/2026 at 9:45 AM, CNA D reported R129 needed help to get dressed, was able to feed themself, was able to use the call light, could talk enough to make needs known but was forgetful as with thinking they can do things like stand on their own. CNA D also reported R129 was a fall risk and not very steady on their feet, so staff still needed to check on R129. CNA D recalled only one fall for R129. On 02/06/2026 at 12:19 PM, the Director of Nursing was asked about resident care and the need for a call light in reach and reported call lights are to be in reach for all residents in order to meet the needs of the resident and should be checked by staff upon entering a room. A review of the record for R129 revealed R129 was admitted into the facility on [DATE]. Diagnoses included History of Falling, Muscle Wasting, Heart Failure and Overactive Bladder. A review of the active care plan documented, At risk for falls secondary to generalized weakness, impaired balance, worsening dementia, waxing and waning status, pain, exertional dyspnea, impaired judgement, reduced recognition of routines, history of repeated falls, incontinence, impaired vision, impaired safety awareness, osteoarthritis, cervical spondylosis Date Initiated: 01/22/2026 . Call light within reach . The Minimum Data Set assessment dated [DATE] documented severe cognitive impairment and the need for assistance to transfer from bed to chair, to stand from a sitting position and personal hygiene. A review of the facility policy titled, Care Plan - Comprehensive and Revision last revised 02/02/26 revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

This citation pertains to intake 2715408. Based on interview and record review the facility failed to draw ordered labs for two sampled residents (R128, R6) of three reviewed for laboratory services. Findings include: R128A review of the intake noted, Lab levels were not being monitored appropriately . The ammonia level was ordered on 12/22 (25) or 12/23 (25) and never resulted according to the PM (evening) supervisor. A review of R128's physician orders noted, an order dated 12/22/25 to collect labs for CMP (comprehensive metabolic panel), MAG (magnesium), Phos (phosphorus), and Ammonia level. A review of R128's medical record progress note revealed, 1/6/2026 00:00 (12:00 AM) Nursing: Writer reorder labs to done on 1/7/2026 CBC, CMP, MAG, Phos, and Ammonia level. A review of R128's physician orders reflected the above reorder of labs. Further review noted R128 was admitted to the facility on [DATE] with diagnosis of Cirrhosis of the liver. R128's Minimum Data Set (MDS) assessment noted R128 with an intact cognition and required staff to assist with activities of daily living. R128's medical record noted, R128 was transferred to the hospital on 1/6/26 due to a mental status. On 2/06/2026 at 11:02 AM, Unit Manager (UM A) was asked the reason the labs were reordered, UM A reported the labs were never completed when they were first ordered on 12/22/25. UM A continued and reported that labs were reordered on 1/6/26 but not completed due to the resident transferring to the hospital. A review of R128's progress note revealed, 1/6/2026 15:23 (3:23 PM) Nursing Progress Note: Resident displaying increased lethargy. Writer contacted provider. Order given to increase Lactulose 3 times daily and collect labs . Provider then arrived and stated he wanted the resident sent to out (to the hospital due to) the increased lethargy and lactulose (used to prevent and treat hepatic encephalopathy, a condition caused by liver failure that leads to increased ammonia levels in the blood) will not have an immediate effectiveness. On 2/06/2026 at 12:18 PM, the Director of Nursing (DON), was asked the explanation why the lab was not completed after the first order dated 12/22/25. The DON explained the process was not done correctly. The order was never placed into the lab book for it to be completed, without it being placed in the book the tech would not know there was an order. The DON was asked how R128's ammonia was being monitored, and reported ammonia is monitored via labs. R6R6 was admitted to the facility on [DATE] with diagnoses that included: vascular dementia, schizoaffective disorder and bipolar disease. Review of the resident's Minimum Data Set (MDS) noted the R6 had a Brief Interview for Mental Status (BIMS) score of 3/15 (severely cognitively impaired).Continued review of R6's clinical record revealed the following: 11/26/25: Consultant Pharmacist Recommendation to Prescriber : .(R6) MRR (Medication Regimen Review) Date 11/26/25.Please consider scheduling the following labs for clinical monitoring on the next convenient lab day: valproic acid level.Physician/Prescription Response.Agree.date: 12/3/25.1/31/26: Consultant Pharmacist Recommendation to Nursing: .(R6) MRR Date: 1/31/2026.This recommendation from 11/26/25 was reported to order a valproic acid level however I don't see a valproic acid level order or result in pcc (electronic record system).Order to be drawn 2/4/26.Laboratory Results: .Collection Date: 2/4/26.Reported Date 2/5/26.Results.VALPROIC ACID.Result: 8.57.Ref. Range (50.0-100.0).Flag: L (low).Status: Final.On 2/5/26 at approximately 1:25 PM an interview and record review were conducted with the Director of Nursing (DON). The DON was queried as to the facility policy regarding MRR recommendations. The DON noted that the pharmacy recommendations are completed monthly. If there are concerns, they are sent to the physician for a response. The DON was asked about the delay in obtaining R6's labs for Valproic acid as the physician had agreed with the pharmacy recommendation on 12/3/25. The DON reported that the recommendation should have been addressed earlier and will follow-up with the 2/4/26 laboratory results. A review of the facility's policy titled laboratory results dated [DATE], revealed, POLICY OVERVIEW: The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. GENERAL GUIDELINES: The facility must provide or obtain laboratory services to meet the needs of its residents. The facility will assist the resident in making transportation arrangements to and from the laboratory if necessary. Labs not drawn as ordered are reported to the attending physician for further direction. STAT lab results are received according to timeframes established in the contract. Laboratory results will be dated and contain the name and address of the testing laboratory. PROCEDURE: The physician will identify and order laboratory testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The laboratory or other testing source will report test results to the facility. The laboratory will notify the facility of critical or panic laboratory results .

Based on interview, observation and record review the facility failed to ensure residents received a clear understanding of the facility's Binding Arbitration agreement for three (R20, R25 and R74) out of 36 residents reviewed for Binding Arbitration. Findings include: A review of the facility document titled, Arbitration Agreement documented, in part: .This Agreement is an addendum to the admission agreement between the parties.In further consideration for this Agreement, the parties acknowledge they will receive mutual benefits from resolution of any dispute/controversy through efficient arbitration.This is a voluntary Agreement between the Parties to have all disputes resolved through binding arbitration.In the event of any dispute or controversy between the Parties, including those arising out of the diagnosis, treatment, or care of the Resident by the Facility, the dispute or controversy shall be submitted to binding arbitration.The Arbitrator Has Sole Jurisdiction. The arbitrators will be the only ones with the authority and jurisdiction to resolve all party disputes, including wrongful death.Waiver of Judge, [NAME] and Trial, No appeal. By signing this arbitration agreement, you are waiving the right to have all disputes decided by judge, jury or by trial. The arbitrator's decision is final and binding. The facility provided a list of 36 residents that currently resided in the facility who had entered Binding Arbitration. A sample of residents who entered into the facility's Binding Arbitration agreement were interviewed as follows: R25On 2/5/26 at approximately 1:19 PM, R 25 was observed lying in bed. R25 was asked if they remembered signing and agreeing to Binding Arbitration. R25 reported they did not recall signing the document and was not familiar with what Binding Arbitration meant. When told the facility agreement they signed would not allow them to resolve any disputes against the facility via a judge, jury or trial, R25 noted that if that was told to them, they never would have agreed to it. A review of R25's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: COPD (chronic obstructive pulmonary disease), type II diabetes and heart failure. A review of R25's Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 10/15 (moderately impaired cognition). R74On 2/5/26 at approximately 1:25 PM, R74 was observed in their room. R74 was asked if they remembered signing and agreeing to Binding Arbitration. They reported that they did not recall signing it. When told the facility agreement they signed, they would not allow them to resolve any disputes against the facility via a judge, jury or trial, R25 noted that they most likely would not have agreed to it. A review of R74's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: muscle wasting, type II diabetes and unspecified dementia A review of R25's Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 (cognitively intact cognition). R20On 2/5/26 at approximately 2:40 PM, R20 attended the resident council meeting. The group attendees were asked if they had entered into a Binding Arbitration agreement and understood the explanation details expressed by the facility as noted in the agreement. R20 reported they did not recall entering into that agreement. A review of R20's clinical record revealed the resident was admitted to the facility on [DATE].A review of R20s Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 (cognitively intact cognition). On 2/5/26 at approximately 1:53 PM, the Administrator was asked about the facility Binding Arbitration agreement and the residents who agreed to it. The Administrator reported they were not that familiar with the agreement and suggested that the Surveyor speak with the Admissions Director (AD)K. On 2/5/26 at approximately 1:55 PM, an interview was conducted with AD K. AD K reported they started their position at the facility in November 2025. When was queried as to how they explain the Binding Arbitration agreement, AD K reported that when residents are admitted to the facility, they will drop off the admission packet to the resident's room to have the resident/resident's representative to review. AD K noted that the packet contains several documents including the Binding Arbitration agreement. Soon after the admission they will meet with the resident and review the documents included in the packet and have them sign the needed documents. When asked how they explain Binding Arbitration to the residents they reported they will give a simple explanation that notes arbitration is like a dispute with siblings when they were young and their parent(s) told them they needed to sit at the table until they worked things out. AD K was asked if they ensure residents are aware that Binding Arbitration limits their right to resolve a dispute via Judge/Jury and Trial. They reported that they never thought of explaining the agreement that way.

This citation pertains to Intake MI00151482. Based on interview and record review, the facility failed to provide Occupational Therapy (OT) and Physical Therapy (PT) as ordered, for one resident (R701) out of one reviewed for therapy services. Findings include: A review of a complaint called into the State Agency noted the following, Complainant states the resident didn't receive Physical Therapy. A review of the medical record revealed that R701 admitted into the facility on [DATE] with the following medical diagnoses, Dysphagia and Muscle Wasting. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score 13/15 indicating an intact cognition. R701 also required staff assistance with bed mobility and transfers. Further review of PT/OT encounters noted R701 certification period were from 3/13/2025-4/11/2025. PT/OT encounters revealed R701 missed OT on the following days 3/14/2025 and 3/15/2025 and PT on the following days 3/17/2025, 3/19/2025, and 3/21/2025. R701 was then transferred to the hospital on 3/23/2025 and did not return to facility. On 4/1/2025 at 10:57 AM, an interview was conducted with the Director of Rehabilitation (DOR). The DOR reported they have a therapist in the facility Monday through Friday and part time and as needed staff on the weekends to make up sessions. The DOR reported R701 was scheduled for PT/OT five days a week and did miss a couple of therapy days, and then they were sent out to the hospital. A therapy agreement with the facility titled, Therapy Services noted the following, 2.3. Supplier shall render the Therapy Services to inpatients and/or outpatients of Facility only in accordance with, and upon the written orders of, the patients attending physician. Supplier shall consult with the patient's attending physician in the development of a written plan of care for each patient receiving the Therapy Services.

This citation pertains to Intake MI00149394. Based on observation, interview, and record review, the facility failed to fill water cups with ice in a sanitary manner. This deficient practice had the potential to affect all 104 residents that drink water in the facility. Findings include: On 2/11/25 at 4:39 PM, Certified Nursing Assistant A (CNA A) was observed to fill empty water cups with ice from a bag. CNA A used another empty cup to first scoop ice out of the bag, and then started to use their bare hand to scoop ice into empty cups. A few empty cups were observed to fall to the floor and subsequently, the CNA was observed to pick the cups up from the floor, filled them with ice, and then with water. CNA A was asked if they were going to use the cups that had fell on the floor to provide water to the residents, to which the CNA did not respond. On 2/11/25 at 5:17 PM, the Nursing Home Administrator (NHA) was asked the procedure for scooping ice from a bag. The NHA stated the bagged ice is to go into a cooler and a scoop is to be used. The NHA was asked for a policy and procedure for using store bought ice to fill the cups. The NHA explained there is no written policy for using the bagged ice.

This citation pertains to Intake: MI00149497. Based on observation, interview, and record review, the facility failed to follow physician orders for elastic bandage leg wraps for one sampled resident (R902) of three review for resident care and treatments. Findings include: On 2/11/25 at 2:30 PM, R902 was observed sitting up in bed and was asked if they had concerns with their care. R902 said at their last care conference they reported three concerns, brief size, not being changed timely, and legs not being wrapped. R902 explained the elastic bandages/wraps were delivered on Sunday 2/9/25 and has not been put on their legs as of yet. R902's legs were observed to be without the elastic bandage wraps on. Observation was made of four rolls of elastic bandage wraps observed in R902's window seal unopened. A review of R902's medical record revealed, R902 was admitted to the facility on [DATE] with diagnosis of Acute on Chronic Diastolic (Congestive) Heart Failure. Further review of R902's Minimum Data Set (MDS) assessment noted, R902 with an intact cognition and dependent on staff to complete activities of daily living. A review of R902's February (2025) Treatment Administration Record (TAR) noted, Order: Wrap legs up to groin with (name of elastic wrap) wrap daily, remove @HS (bedtime) one time a day for wrap legs. Start Date: 2/4/25. End date: Indefinite. Specific time(s) 0900 (9:00 AM). The order was noted to be documented as completed on February 4th through 9th. A review of R902's care plan noted, Focus: At risk for pain and has pain related to: lymph-edema and lip edema to BLE (Bilateral Lower Extremities) Date Initiated: 01/31/2025. Goal: Pain or analgesia will not affect participation in activities of choice or daily routine Date Initiated: 01/31/2025. Interventions: Adjust times of ADL (activities of daily living) and treatment activities so that occur after analgesia benefits have been achieved (i.e., therapy, wound dressing change, etc.) Date Initiated: 01/31/2025. Therapy evaluation and treatment per orders Date Initiated: 01/31/2025. On 2/11/25 at 2:56 PM, the Assistant Director of Nursing (ADON) was asked about R902's order for legs to be wrap. The ADON explained, they reviewed the order and noted the order had been documented as completed, but not provided to the resident. The ADON was asked the expectation of following physician's orders and explained, the order is to be followed and documented correctly. A review of the facility's policy titled, Medication Administration dated 8/7/23, noted POLICY OVERVIEW: To safely and accurately prepare and administer medication according to physician order, professional standards of practice, and resident needs . DOCUMENTATION: Medications administered are documented following administration. Administration of PRN medications include the justification and response to administration. The licensed nurse is responsible for validating documentation is completed for any medication administered during the shift .

Based on observation, interview, and record review, the facility failed to ensure one Resident (R132) of one resident reviewed for accidents was served hot beverages in a stable, handled, thermal cup and provided proper meal set-up. This deficient practice resulted in an Immediate Jeopardy, when R132 sustained a second-degree burn (a burn affecting the skin layers, causing redness, pain, swelling, and blisters), and developed increased pain. Findings include: The Immediate Jeopardy was identified on 10/23/24, at 12:00 p.m., when R132 spilled hot scalding water for tea on themself, resulting in a second-degree burn and the likelihood of other residents affected due to lack of assessment and monitoring practices which could lead to serious harm, injury, impairment, or death. The Administrator was notified of the Immediate Jeopardy (IJ) on 11/21/24 at 11:30 a.m The Immediate Jeopardy began on 10/23/24. A plan to remove the immediacy was requested. The IJ was removed on 11/21/24, based on the facility's implementation of the plan of removal as verified by the Survey team on site. Although the IJ was removed, the facility's deficient practice was not corrected and remained isolated with actual harm. On 10/23/24 at approximately 12:00 p.m., R132 sustained a second-degree burn on their abdomen after spilling a cup of hot water on themselves during the lunch meal, which leaked through their blanket, shirt, and onto their skin. On 11/20/24 at 11:59 a.m., an observation revealed R132's hot water was served in a foam cup and was temped on their lunch tray at 164 degrees Fahrenheit, which placed R132 at risk for additional burns due to above scalding temperature. On 11/20/24 at 1:00 p.m., an observation revealed the hot water was temped at 184.6 degrees from the kitchen hot water dispenser for beverages. On 11/19/24 at 11:05 a.m., R132 reported they were burned when they spilled hot tea on themselves. R132 stated, It was in a (name of) foam cup and was not very stable. Sometimes they serve it in a mug. R132 reported they had pain 7/10 on their abdomen during the interview, and stated it was painful when the nurses changed their bandage. R132 explained the incident happened a few weeks ago at the facility. R132 stated, I keep the cup away from me, and make sure I pick it up with both hands. R132 confirmed they were afraid of spilling hot water on themselves, because 90% of the time it is (served in) a foam cup and lid. On 11/19/24 at approximately 12:25 p.m., the surveyors observed R132 in their room seated in a manual wheelchair with their cup of hot water for tea in front of them, in a foam cup with no lid. The surveyors observed the tray was not set up for R132, and the hot water temped at 124.4 degrees Fahrenheit. Review of R132's, Skin and Wound Evaluation, dated 10/23/24 at 1:15 p.m., revealed a new second-degree burn injury on the left lower quadrant of the abdomen, which was designated as in-house acquired. The measurements were 56.7 cm (centimeters) squared (area), 7.7 cm length, 10.7 cm width, and 0.2 cm depth. The wound was observed as a large pink wound, with slight blistering along the wound edges. Review of R132's, Skin and Wound Evaluation, dated 11/19/24, showed the burn wound measurements were 17.2 area in cm squared, 3.2 cm length, 6.4 cm width, and .3 cm depth. The wound was designated as slow to heal. The wound was observed as a medium-size healing blister, with scabbing and yellow blistering in the center of the wound. Review of R132's progress note, dated 10/23/24 at 12:30 p.m., by Licensed Practical Nurse (LPN) K, confirmed the description of the wound. The note revealed R132 reported they were attempting to place their tea bag after removing the cup lid and spilled hot water onto their blanket, shirt, and onto their skin .The noted further described petroleum jelly and burn cream were ordered to treat the wound. Review of R132's progress note, dated 10/23/24, by the wound care nurse, LPN L, revealed R132 spilled hot liquid on their abdomen when in bed, sustaining a burn injury which they described as on the mid-lower abdomen, pink in color with minimal serous (clear yellow) drainage. The note revealed they applied one layer of petroleum jelly and covered the wound with an ABD (wound protective) pad. Review of R132's facility investigation report, dated 10/23/24, revealed the facility interviewed Certified Nurse Assistant (CNA) U, who stated they were passing lunch meal trays and gave R132 their tray and hot tea. When CNA U returned to pick up R132's tray, R132 stated, Oh my G**, the hot water spilled on my belly . Review of R132's pain log revealed increased pain after the burn injury as follows: 10/23/24 at 12:00 p.m.: 5/10 pain (with 10 the highest possible pain) 10/23/24 at 12:40 p.m.: 7/10 10/23/24 at 6:25 p.m.: 0/10 10/23/24 at 8:00 p.m.: 2/10 Review of R132's Minimum Data Set (MDS) assessment, dated 10/17/24, revealed R132 was admitted to the facility on [DATE], with diagnoses including coronary artery disease, kidney disease, muscle wasting and atrophy, and repeated falls. R132 required set-up with eating, and maximal assistance with bed mobility and transfers. The Brief Interview for Mental Status (MDS) assessment score was 13/15, which showed R132 was cognitively intact. Review of the 10/23/24 food and beverage temperature log, showed the coffee temperature at breakfast was 191 degrees. There was no temperature designation on the log for a hot beverage at lunch or dinner. The log showed no category for hot beverages, only for coffee at breakfast. On 11/20/24 at 11:59 a.m., R132 was observed seated in their wheelchair in their room. Their lunch tray was delivered and set on R132's bedside table by the Activity Director, Staff G. R132's hot water for their tea was observed in a foam lidded cup. R132's hot water temped at 164 degrees using a digital food thermometer with Staff G confirmed they observed the same temperature. On 11/20/24 beginning at 12:00 p.m., LPN K, LPN O, and Registered Dietician (RD) J were asked to observe R132's hot water in the foam cup, and the temperatures, as follows: 12:03 p.m.: 158.5 degrees 12:05 p.m.: 152 degrees 12:08 p.m.: 148 degrees On 11/20/24 at 12:08 p.m., RD J was asked about R132's hot water being served at 164 degrees. RD J responded the safe temperature for hot liquids was 130 to 160 degrees, which they reported was their facility policy/process. On 11/20/24 at approximately 12:29 p.m., the Unit manager, Licensed Practical Nurse (LPN) O, was asked about any changes they had implemented since R132's abdominal burn from hot water on 10/23/24. LPN O responded, .Staff deliver (R132's) tray and do the set-up and the tea bag. Surveyor asked about R132 being observed with Styrofoam cup with hot water. LPN O stated, They (kitchen staff) typically use the brown (thermal) cups with lids for (hot) liquids .They (kitchen staff) are supposed to temp it before it leaves the kitchen, and it (the cup) sits there (in the kitchen). On 11/20/24 at approximately 12:35 p.m., LPN K confirmed they were the nurse assigned to R132 when the burn injury occurred on 10/23/24. LPN K stated, When it was reported, it was like three different areas and now it is one large area. The doctor was here when it happened and ordered Petroleum jelly. (R132) was in 6-7/10 pain. They reported they administered Over-the-Counter pain medication, which relieved R132's pain. On 11/20/24 at 12:55 p.m., RD J was interviewed with the Assistant Dietary Manager, DM B. DM B explained the hot beverages were obtained from the hot water dispenser in the kitchen, and cooled down for 15 minutes before being served, which RD J confirmed. RD J reported residents were typically assessed for hot liquid safety by Occupational Therapy staff. Both were asked why R132's hot liquid for tea was temped at 164 degrees on their tray, and neither could explain how this occurred. There was nothing about this process in writing upon Surveyor request. On 11/20/24 at approximately 1:00 p.m , RD J stated R132's Occupational Therapist indicated R132 was safe to handle hot liquids prior and after the burn injury. RD J and DM B both reported they were not instructed to do anything different in terms of providing hot beverage service to R132 after the incident. Both conveyed they usually served hot beverages in plastic, thermal mugs with handles, however stated they had been running out of the stable thermal mugs. When asked why, DM B explained, We order them, and they just run out. Both indicated all the residents were supposed to receive thermal mugs with lids unless otherwise designated. RD J and DM B were asked how R132's hot water had temped at 164 degrees in their room on their tray in a foam lidded cup at lunch on 11/20/24. Neither could not explain how this occurred, as their process was for kitchen staff to cool down the hot water before it left the kitchen. On 11/20/24 at 1:05 p.m., Surveyor and DM B jointly temped the hot water in a foam cup coming out of the hot water dispenser in the kitchen. Surveyor obtained the temperature at 184.6 degrees with a food and beverage digital thermometer, and DM B obtained the temperature at 186 degrees, with their kitchen digital thermometer. On 11/20/24 at 1:10 p.m., Staff I, the day shift cook, was asked about serving hot liquids to facility residents. Staff I indicated they obtained the hot water from the hot water dispenser and then cooled it down. Staff I stated, We (kitchen staff) give it to them (residents) at 140 to 150 degrees. Surveyor asked about the temperature of 164 degrees taken in R132's room at lunch on their tray, and how this occurred. Staff I stated, It's too hot, that's a risk for a burn. On 11/20/24 at 1:23 p.m., DM B was asked about the temperature logs not showing a hot liquids temperature column prior to the incident. DM B explained they did not have the hot temperatures recorded on the old logs, as they only temped the coffee at breakfast prior to R132's burn incident. DM B stated, Our protocol wasn't tempting hot tea. DM B clarified the maximal temperature for serving hot liquids was 160 degrees. DM B was asked about the 191-degree temperature of the coffee logged on 10/23/24, the date R132 received their burn injury. DM B responded, That would have been pretty hot if we took this out (of the kitchen). That's scalding (temperature) hot right there. We should have never put it out (given to residents) at 191 degrees. Review of R132's tray ticket from 10/23/24 and 11/20/24 revealed no designation of a container for beverages, such as a thermal lidded cup with a handle. On 11/20/24 at 3:44 p.m., the Rehabilitation Director, Occupational Therapist (OT) R, was asked if R132 was determined to be safe with hot liquids, and for a copy of any assessments. OT R reported R132 was assessed to be safe with hot liquids during the initial OT evaluation by OT F on 10/08/24, and after the incident by Certified Occupational Therapist Assistant (COTA) H on 10/24/24. OT R reported the hot liquid assessment was a part of the therapy evaluations, and documentation. On 11/20/24 at 3:53 p.m., Certified Occupational Therapist Assistant, (COTA) H, was asked how R132 was determined to be safe with hot liquids after the burn injury on 10/23/24. COTA H reported they assessed R132 by having them set-up and drink their hot tea from a foam cup at their bedside. When asked about R132's functional status, COTA H reported although R132 set-up the tea adequately, they had postural concerns, as they slid down, or sometimes slumped forward, as they tired easily, had mild coordination problems, and fair safety. COTA H stated, .I prefer the mugs because of the handle and because the handle is good security (to prevent spillage). COTA H was asked if they reviewed the results of R132's hot liquid assessment with a supervising occupational therapist, and COTA H responded, No. Review of R132's progress note, dated 10/24/24, by COTA H, revealed they passed R132 on the second hot liquid assessment in a narrative notation and worked on sitting balance exercises and seating and positioning during self-feeding, showing postural concerns which may have impacted R132's safety and performance with self-feeding. Review of R132's physician note, dated 10/21/24 at 8:25 a.m. (prior to the burn incident), revealed R132 had muscle weakness, with 3/5 strength (fair muscle strength) in both arms and legs, and debility. Review of R132's physician note, dated 10/23/24 at 12:56 p.m. (after the burn incident), revealed R132 continued to have muscle weakness, with 3/5 strength in their arms and legs, and debility. Review of R132's Occupational Therapy and Physical Therapy records showed R132 was receiving therapy services from 10/08/24 through 11/20/24, prior, during, and after the burn incident. Review of R132's Occupational Therapy evaluation, dated 10/08/24, revealed R132 had decreased muscle strength in their arms, fair sitting balance, and muscle atrophy. On 11/21/24 at 9:53 a.m., R132's OT, OT F, was asked about the hot liquid evaluation process. OT F reported they simulated the task with residents as the assessment was documented in their evaluations. OT F confirmed they cleared R132 as safe with hot liquids on the OT evaluation on 10/08/24. OT F was asked if COTA H reviewed the assessment results with them or supervising therapists from 10/24/24. OT F responded, No. OT F reported R132 had some coordination problems. OT F explained R132 may have had limitations in reaching and grasping due to frequent infections, which caused slightly decreased coordination, increased weakness and decreased energy (activity tolerance). OT F acknowledged they or another OT did not reassess R132's feeding ability after the spill and burn from hot liquids on 10/23/24. OT F confirmed R132 would be safer with a stable mug with a handle and lid. OT F explained when a resident had breakfast in bed, they were concerned about safe positioning, and reported decreased postural control in bed could have played a role in R132's burn injury. On 11/21/24 at 12:22 p.m., R132's Power of Attorney, (POA) J, was asked about R132's care. POA J stated R132 was burned because the water (for tea) was so hot, and it was just in a foam cup instead of a mug. Maybe they (staff) can't control how hot the water comes out, and it should have been (served) in a mug. POA J explained R132 had neuropathy in their hands, which caused weakness. On 11/24/24 at 2:18 p.m., the NHA was asked about the concerns related to the Immediate Jeopardy. The NHA explained their former certified dietary manager had been on a leave since June 2024, and there had been a gap in kitchen supervisory staffing and training challenges due to limited availability of managerial oversight, as they had only recently moved DM B into the kitchen manager position. The NHA acknowledged a system failure, reporting they had become aware there was a breakdown in the temperature logging process, as this was a newer process, serving hot liquids in the kitchen. The NHA clarified until recently the kitchen had only made and served coffee and hot water for tea or cocoa per resident request from carafes and had only recently began providing coffee or hot water from the coffee and hot water dispenser. The NHA confirmed they were not aware of the shortage of mugs, although they understood the concern was missing lids. Review of the policy, Hot Beverages Temperature Limits, issued 11/03/24, revealed, Policy: Coffee machines will be set at 180 - 190 degrees Fahrenheit. This is industry standards for palatability. Goals for test trays will be to have coffee above 140 during tray line. There are no current regulations that specify temperatures appropriate for the consumption of hot beverages. Procedure: 1. Hot beverage temperatures will be monitored daily with tray line temperatures . There was no reference regarding above 140 degrees (or even as low as 120 degrees) may be scalding temperature for vulnerable adults in the facility. Review of the policy, Hot Liquid Assessment, issued 11/19/2018, revealed, It is the policy of the facility to assess residents for safe consumption of hot liquids .The Registered Dietician will observe all residents for safe handling of hot liquids upon admission and quarterly thereafter. Criteria for the Registered Dietician to consider include: Tremors, weakness .The Occupational Therapist (OT) will be responsible for determining if the resident continues to require a supervised dining setting due to hot liquid risk and if any additional interventions should be used to minimize risk of burns. Dietary will provide cups with sipping lids for all hot liquids during meal times .Activities will provide cups with sipping lids for all hot liquids served . Review of the State of (State Name) Department of Community Health Alert, titled, Scalding Injuries Caused by Excessive Hot Water: Food and Hot Beverage Temperatures, Revised August 5, 2008, revealed, Background: In all age groups, tap water scald injuries have been cited as the second most cause of serious burns. A scald is a burn caused by spills, immersion, splash, or contact with hot water, food and beverages, or steam. The elderly are particularly at increased risk because their skin tends to be less sensitive and reaction times are reduced, causing a tendency to not pull away from hot water quickly enough to avoid scalding. Their thinner skin also burns full depth (through the skin layers and into tissue) more quickly .Although Federal and State agencies do not specify temperatures appropriate to the consumption of hot beverages, facilities should be aware of the risk for harm to a resident from contact or consumption of hot beverages.Scalds can commonly occur from hot food, beverages, or steam . The estimated time for a person to receive second-degree burns was noted as follows: 120 degrees. Time to receive second-degree burn: 8 minutes. 124 degrees. Time to receive second-degree burn: 2 minutes. 131 degrees. Time to receive second-degree burn: 17 seconds 140 degrees. Time to receive second-degree burn: 3 seconds. 150 degrees. Time to receive second-degree burn: Less than one second. The Immediate Jeopardy that began on 10/23/24 was removed on 11/21/24, when the facility took the following actions to remove the immediacy: 1. Resident #132 remains a resident of the facility and as of 11/21/24 is being served their hot liquids in a stable thermal cup with a handle and is being offered assistance with hot liquids. 2. Like residents are residents that reside in the facility and receive hot liquids. On 11/21/24 at 12:15 p.m., like residents have been audited to ensure their liquids are being served in a stable, handled, thermal cup and staff are offering and/or providing assistance with set-up as needed. 3. Dietary staff have been re-educated on 11/21/24 to ensure hot liquids are being served in a stable, handled, thermal cup. Dietary staff has also been re-educated on ensuring hot liquids are being serviced at a temperature less than 160 degrees Fahrenheit. Any staff member who is currently not working will be reeducated prior to the start of their next shift of duty. 4. LPN/RN/CENA has been re-educated on 11/21/24 to ensure when meals are served resident with hot liquids are in a stable, handled, thermal cup and they are offering and/or providing assistance when serving hot liquids as needed. Any staff member who is currently not working will be reeducated prior to the start of their next shift of duty. 5. An Ad Hoc QA Committee meeting was held on 11/21/24 with the Medical Director and IDT (Interdisciplinary Team) to discuss the deficient practice and plan to ensure compliance. The NHA/Designee will conduct audits to ensure that hot liquids are served in a stable, handled, thermal cup. The NHA/Designee will audit to hot liquid temperature logs to ensure temperatures are less than 160 degrees Fahrenheit prior to leaving the kitchen. Audits will be completed weekly x 4 weeks and monthly x 2 months. Results of the audits will be taken to the QA committee for review and recommendation. Any areas of non-compliance will be addressed immediately. The Administrator is responsible for maintaining compliance. 6. The Administrator is responsible for sustained compliance.

Based on interview and record review, the facility failed to implement an effective water management plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all of the 86 residents in the facility. Findings include: On 11/20/24 at approximately 1:00 PM, the building water management plan was requested from the Maintenance Director MD C. On 11/20/24 at approximately 2:00 PM, MD C provided a binder including a policy titled Safe Water Temperature, and a document titled Water Management Program Plan that included weekly temperature logs for the following: toilets in two resident rooms in each of the buildings four halls; dish machine; laundry; and the kitchen hand sink. The water management program plan also included a monthly log of eyewash station flushes which was not signed. On 11/20/24 at 2:08 PM, during an interview, MD C explained that the facility's water is tested yearly for legionella by an outside company and that they do not have the results for this years test yet. MD C also confirmed that they do not have documentation of prior tests. MD C confirmed that the only prevention measures or surveillance that is performed in between the yearly water testing by the outside agency is a check of the water temps. MD C confirmed they do not have a flow mapping of the facility's plumbing included in the water management plan. On 11/20/24 at 12:47 PM, during an interview, the Nursing Home Administrator (NHA) explained that MD C is responsible for doing audits for water temps daily, checking for legionella twice per month including checking fixtures and running water, checking fixtures that are not utilized as much as others and checking for smells or abnormalities. During the interview the facility's water management plan was reviewed with the NHA. The NHA confirmed that the water management plan did not include all of the necessary components as outlined in the facility's water management program plan instructions. The NHA stated I don't have any additional information other than what is in here. If the water plan says that it should be done then it should be done.

Based on observation, interview, and record review, the facility failed to update one Resident's Care Plan (R132) of 19 residents reviewed for Care Plans, after a burn injury. This deficient practice resulted in limited interventions to prevent another burn injury. Findings include: On 10/23/24 at approximately 12:00 p.m., R132 sustained a second-degree burn on their abdomen after spilling a cup of hot water on themselves during the lunch meal, which leaked through their blanket, shirt, and onto their skin. On 11/20/24 at 11:59 a.m., an observation revealed R132's hot water was served in a foam cup and was temped on their lunch tray at 164 degrees Fahrenheit, which placed R132 at risk for additional burns due to above scalding temperature. On 11/20/24 at 1:00 p.m., an observation revealed the hot water was temped at 184.6 degrees from the kitchen hot water dispenser for beverages, which was above scalding temperature. On 11/19/24 at 11:05 a.m., R132 reported they were burned when they spilled hot tea on themselves. R132 stated, It was in a (name of) foam cup and was not very stable. Sometimes they serve it in a mug. R132 explained the incident happened a few weeks ago at the facility. R132 stated, I keep the cup away from me, and make sure I pick it up with both hands. R132 clarified they were afraid of spilling hot water on themselves, because 90% of the time it is (served in) a foam cup and lid. On 11/19/24 at approximately 12:25 p.m., Surveyors observed R132 in their room seated in a manual wheelchair with their cup of hot water for tea in front of them, in a foam cup with no lid. Surveyors observed the tray was not set up for R132, and the hot water temped at 124.4 degrees Fahrenheit. On 11/20/24 at 11:59 a.m., R132 was observed seated in their wheelchair in their room. Their lunch tray was delivered and set on R132's bedside table by the Activity Director, Staff G. R132's hot water for their tea was observed in a foam lidded cup. Surveyor requested permission to temp R132's hot water, which was granted by R132, with Staff G present. R132's hot water temped at 164 degrees using a digital food thermometer, above scalding temperature, with Staff G confirming they observed the same temperature. On 11/20/24 at approximately 12:29 p.m., the Unit manager, Licensed Practical Nurse (LPN) O, was asked about any changes they had implemented since R132's abdominal burn from hot water on 10/23/24. LPN O responded, .Staff deliver (R132's) tray and do the set-up and the tea bag. Surveyor asked about R132 being observed with foam cup with hot water. LPN O stated, They (kitchen staff) typically use the brown (thermal) cups with lids for (hot) liquids .They (kitchen staff) are supposed to temp it before it leaves the kitchen, and it (the cup) sits there (in the kitchen). Review of R132's Care Plan, accessed on 11/21/24, after the burn incident, revealed, The resident (R132) has actual impairment to skin integrity of the lower mid abdomen r/t (related to) burn . Date initiated: 10/23/2024 . The Care Plan revealed no new interventions respective to the wound treatments or the prevention of additional burns, including set-up of R132's meal tray, increased monitoring/supervision, the provision of proper adaptive equipment (cup), or ensuring the temperature of the hot water was in a safe range to prevent scalding burn injuries. Review of the policy, Care Plan - Comprehensive and Revision, revised 8/25/2023, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident .Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. The IDT (Interdisciplinary Team) reviews and updates the care plan when there has been a significant change in the resident's condition .

Based on interview and record review the facility failed to ensure labs were monitored and reported for one resident (R901) of four reviewed for lab values and a change in condition, resulting in mental status changes, vital sign changes, a delay in treatment for dehydration and hospitalization . Findings include: On 11/16/23 at 1:14 PM, a review of the the concerns were conducted with the emergency room physician who reported, I have never seen a sodium this high or a patient this dehydrated. It is unconscionable. Once you get over 160 the regular lab does not work well, so you have to use a process which takes into account how viscous or concentrated the blood is. (R901's) sodium level was at 198 (on 10/30/23) which is a fantastic abnormality. A normal sodium level is 136-145. R901 was severely dehydrated and was admitted to the (Intensive Care Unit) ICU due to the severe dehydration. How could doctor not have sent earlier? How could a nurse have accepted this and not sent (R901) out sooner? R901 was grossly neglected by (the contracted lab) and/or the (facility). Someone dropped the ball. The emergency room physician further noted that R901 received regular blood work and reported on 10/10/2023, R901's sodium level was 141. On 10/27/2023, R901's sodium level was 169. On 10/30/2023, R901 had a fever and was less responsive than usual and the facility sent R901 to the hospital for respiratory distress. A review of the record for R901 revealed R901 was admitted into the facility on [DATE]. Diagnoses included Hemiplegia/Hemiparesis (paralysis) Affecting the Right Side, Malnutrition, Alzheimer's and Diabetes. The Minimum Data Set assessment dated [DATE] indicated severely impaired cognition and R901 was dependent on staff for oral hygiene, bathing, personal hygiene, rolling left and right in bed, and moving from sitting to lying and lying to sitting. A review of a hospital emergency room report dated 10/10/23 at 8:41 PM documented R901 arrived from a sister facility for a clogged dobhof (smaller gauge nasogastric tube). The blood draw for comprehensive metabolic panel indicated the sodium was within normal limits but the Magnesium was low at 1.5. A review of the comprehensive metabolic panel (CMP) lab with collection, received and reported date of 10/20/23 documented a sodium level of 156 and a reference range of 135 - 145. The result was flagged as high. This result was highlighted in red and the key indicated this to be a critical result. No Report Comment nor Critical Notice comments were documented on the lab report. The report had a Reviewed by date of 10/30/23 at 09:07. (AM) The reported time documented was 2:18 PM. A review of the comprehensive metabolic panel (CMP) lab with collection, received and reported date of 10/27/23 documented a sodium level of 169 and a reference range of 135 - 145. The result was flagged as high. This result was highlighted in red and the key indicated this to be a critical result. The Report Comment was blank and the Critical Notice comments were No answer from the facility on 10/27/23. The report had a Reviewed by date of 10/30/23 at 10:09. (AM) The reported time documented was 2:48 PM. A review of the progress note by Licensed Practical Nurse (LPN) H dated 10/19/23 at 02:49 AM, documented, Enteral feeding via NG (Nasal gastric) was up but it was not going through . The note further documented attempts by two nurse to unclog the tube and that the physician said to send to the hospital but the daughter refused. The resident remained at the facility. Prior notes indicated food acceptance as low as five percent. The tube feeding was not documented as restarted. R901 would have had to receive all fluids by mouth as the tube was clogged. A review of a progress note by LPN H dated 10/20/2023 at 01:46 AM, documented, Resident received in bed and is resting at this time. Vitals are stable, no (complaint of) c/o pain or (shortness of breath) SOB and no signs of discomfort or (respiratory) RR distress note, SPO2 97% on room air, last BS checked 186. NG tube is in place but its clogged, (Physician) MD aware, recommended resident be sent to the hospital, but family member(daughter) declined. and one-on-one feeding is being done. (R901) needs total assistance with (activities of daily living) ADLs, bed mobility and transfer. (R901) is incontinent of bladder and (bowel movement) BM and care is provided and safety maintained per (plan of care) POC. A review of a progress note dated 10/20/23 by Nurse Practitioner (NP) T and attested by Physician U documented, .last admission (acute kidney injury) AKI in Sept (September) with (creatinine) CR 2.18 and sodium was 161. (Patient) Pt had AKI and Hypernatremia 9/1/23 was readmit at the hospital (diagnosis) dx, was stabilized with free water flushes. Recommendation: Check BMP weekly to avoid readmission . Timing of the visit was documented as 12:55 PM until 1:30 PM. A review of the progress note by NP K with encounter date of 10/22/23 documented, Chief Complaint SAR FU (Sub acute rehab follow up): Patient here for SAR after multiple recent hospitalization s .has been having ongoing issues related to malnutrition and poor feeding .NG (nasogastric tube) is malfunctioning due to possible clogging . CMP (basic metabolic panel) BMP from earlier today reviewed . No labs were drawn on this day. No indication of the critical result from 10/20/23 as reviewed was documented. A review of the progress note by NP K with encounter date of 10/24/23 documented, Chief Complaint SAR FU (Sub acute rehab follow up): Patient here for SAR after multiple recent hospitalization s .has been having ongoing issues related to malnutrition and poor feeding .NG (nasogastric tube) is malfunctioning due to possible clogging . CMP (basic metabolic panel) BMP from earlier today reviewed . No labs were drawn on this day. No indication of the critical result from 10/20/23 as reviewed was documented. A review of a physician note by Physician V dated 10/25/23 at 12:30 (PM) documented vital signs and that the feeding tube was clogged but there was no reference to the critical labs. A review of a progress noted by NP K dated 10/30/2023 at 8:59 AM, documented, Patient has a critical sodium level and decreased urinary output per nursing. Advised patient will need to go to the hospital. Per nursing daughter does not want patient to go to nearest hospital but to (hospital name) which could take several hours to get transport. Attempted to call daughter, voicemail full. A review of a progress note by LPN M dated 10/30/2023 at 12:03 (PM) documented, Resident labs report from this morning reflected high sodium level. NP and Residents daughter notified. NP wants to send resident to hospital. Resident's daughter wanted to request that the resident only be sent out to (hospital name). Nurse got (Assistant Director of Nursing) ADON involved to problem solving during emergent respiratory distress with resident. Resident was extremity lethargic, and vitals were unstable (blood pressure) 141/89, (temperature) T100.5 (pulse) P140 (Respirations) R30. Resident has poor peripheral pulse and crackles noted within the lungs upon auscultation. Nursing interventions were as follow (oxygen) O2 increased to 4L O2 currently 90% after albuterol (medication to improve oxygen transfer in lungs) treatment, Tylenol suppository administered for fever. A review of a progress note by LPN M dated 10/30/2023 at 12:30 (PM) documented, Resident has (signs and symptoms) S&S of respiratory distress following the (Nurse Practitioner) NP orders the resident was sent to (hospital) disregarding daughter wishes to keep (R901) at (facility) until she left work. A review of a progress note by LPN M dated 10/30/2023 at (5:41 PM) 17:41 documented, Resident (oxygen saturation) SPO2 was 85% before adding oxygen. Residents' vitals (blood pressure) 141/89, (temperature) T100.5 SPO2 85%, did not appear to be stable while on 2L (liters) of (supplemental oxygen) O2. Resident got bumped to 3L of oxygen while still SPO2 remain between 85-90%. Respiratory therapist ordered taking (R901) to 4L of O2 prior to discharge to (hospital). A review of a progress note by LPN Q dated 10/30/2023 at 06:33 (AM), documented, CNA reported to Nurse resident did not have any output for past hours. Writer called (physician) MD with no answer and left message for call back. (nurse practitioner)NP returned writer call, Writer notified MD of no output, Recent lab results, and bladder scan results. NP ordered a complete metabolic Panel, Bladder scan in 6 hours, and to encourage fluids. Safety maintained, call light in reach will (continue) cont. plan of care. On 11/20/23 at 11:31 PM, LPN F was asked about the care of R901 and reported R901 had a (nasogastric tube inserted through the nose and passed into the stomach) NG that was clogged and the nurse practitioner said to send out but the daughter said no. LPN F further noted that R901 would not always open their mouth during meal assistance and noted R901 to be alert but did not talk. LPN F was asked if the lab called in abnormal values and reported that the prior lab did but the current one does not and you just have to go in to the system and find out. On 11/20/23 at 11:36 AM, CNA E was asked about the care of R901 and reported: (R901) would eat on certain days and on others (R901) would refuse; R901 had any energy drinks the daughter would bring in, but did not drink them; and R901 was quiet and cooperative in care. On 11/20/23 at 11:42 AM, CNA D was asked about the care of R901 and reported: (R901) was a total care resident; Staff had to feed (R901) every meal and (R901's) intake of food and liquids was poor (less than 25% of each meal); and (R901) always looked like they were in pain. CNA D further reported R901 did not talk but would nod their head to questions. On 11/20/23 at 11:49 AM, LPN C was asked about the process for labs and the reporting of lab results and reported, when orders are received they are put into the system, they build a face sheet which is then put into the book for the lab to draw. The lab comes daily. LPN C reported it is good practice to check for lab results daily when they start their shift but may sometimes get busy and will check later or ask the managers to review. If there is a high or critical value they are not going to wait and will call the doctor. LPN C also noted there is a way to go in and mark the lab result as reviewed. On 11/20/23 at 3:24 PM, the lab results for R901 were reviewed with the Director of Nursing (DON). The DON reviewed the record and noted R901 was sent out for respiratory distress on 10/30/23 and saw a note from 10/30/23 for critical labs. It was noted that the lab were drawn and reported on 10/20/23 and 10/27/23 respectively and the DON was asked to find documentation the physician was notified and the result reported, I do not see a notification of physician for the 10/27/23 lab nor the 10/20/23 lab. The DON reported the nurse should have notified the physician or nurse practitioner. The DON was asked about the process for labs and reported that both shifts of nurses should review labs at start of their shift and should notify the physician and family of the results. The DON also noted that it is expected that the floor nurse completes this on the weekend as there are less management staff. The 10/20/23 lab draw and the 10/27/23 lab draw were both Fridays. On 11/20/23 at 4:04 PM, Contract Lab Staff P was called and asked about the process for reporting of critical results to a facility. Staff P reported: Our responsibility is to call the facility and we also have a communication called (name of system). (It was noted that the facility was not set up for name of system.) We will try to call two or three times and we also send them a fax result. Staff P was asked about the 10/27/23 lab report which documented the critical result for sodium and the note at the bottom which documented, Report comments: Critical Notice: No answer from the facility on 10/27/23. Staff P reported they reviewed a report which noted three tries were attempted but was able to to confirm a call at 12:00 PM and 3:40 PM to the facility phone number. It was reported that there was no answer and a voicemail was left. The phone and fax number were also requested. These phone numbers were confirmed as valid numbers by the facility Administrator via email. That's station 1 fax number yes that can be used as well. An email communication from the Administrator on 11/20/23 at 4:40 PM also documented, We do not have a confirmation for labs on (R901). They have a system called Slack that alerts us with critical labs. The DON/ Management team has been set up right now to have that ability to see critical labs. On 11/20/23 at 4:10 PM, a supervisor for the Contract Lab, Staff O was interviewed about the reporting of lab results and confirmed that any critical value is reported immediately to the facility and multiple attempts are made. The lab then confirms this as a true result. After reporting the values then the person to whom the value given is recorded on the system. Staff O also noted the use of the (name of) system and the availability of the results on the lab's portal which is available on the facilities computer system. On 11/20/23 at 4:27 PM, NP K (part of the medical team for R901) was asked about the expectation when residents have critical lab results and reported. I definitely expect some notification. NP K noted that multiple medical staff visit the residents and reported everybody has shared roles. NP K was asked about some symptoms of high sodium levels and reported that neurological and mental status changes and vital sign changes are possible. NP K further commented that when told the sodium was critical they told the nurse to call 911 and send the patient to the hospital and they did not care about daughter's hospital preference, R901 had to go. On 11/20/23 at 4:53 PM, the DON reported they had attempted to get a hold of the nurses who took care of R901 and noted two did not recall anything and the others did not respond or no longer worked at the facility. The DON noted they had called the lab and asked how critical labs are reported and that they called and used the SLACK system. The DON further noted they now had access to (name of system). The DON was also asked if the fax sent by the lab was available and reported the facility did not have a copy. The DON acknowledged the concern identified with the reporting of lab results. A review of the National Institute for Health (NIH) web site at https://www.ncbi.nlm.nih.gov/books/NBK441960/ documented, .Hypernatremia is defined as a serum sodium concentration of greater than 145 meq/l . The basic mechanisms of hypernatremia (high sodium) are water deficit and excess solute. Total body water loss relative to solute loss is the most common reason for developing hypernatremia. Hypernatremia is usually associated with hypovolemia, which can occur in conditions that cause combined water and solute loss, where water loss is greater than sodium loss or free water loss . Most patients present with symptoms suggestive of fluid loss and clinical signs of dehydration. Symptoms and signs of hypernatremia are secondary to central nervous system dysfunction and are seen when serum sodium rises rapidly or is greater than 160 meq/L . A review of the policy titled, Laboratory Results with issued date of 08/18/2023 revealed, .The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law .The laboratory or other testing source will report test results to the facility. The laboratory will call the facility to notify of critical or panic laboratory results. The laboratory will call the facility to notify of stat laboratory results. For facilities and laboratories integrated with the electronic health record PointClickCare (PCC), laboratory results will display in PCC under the resident ' s results tab, and unreviewed laboratory results can also be accessed under the Clinical Dashboard and under the Clinical Lab/Rx Results Dashboard in PCC. For facilities and laboratories not integrated with electronic health record PointClickCare (PCC), laboratory results may be faxed to the facility or retrieved from the laboratory ' s website. Those results will be uploaded into the resident ' s electronic health record in PCC under the documents tab. Laboratory results will be classified as Critical/Panic, Abnormal, or Normal, according to the lab parameters. Critical or Panic and Abnormal laboratory result notifications: Promptly notify physician or physician extender with lab result and resident current condition. If results are integrated with PCC, click [NAME] as Reviewed on the laboratory result and document response and any new orders as applicable If results are not integrated with PCC, document notification, response, and any new orders as applicable. Notify and document notifications to resident or resident representative, as applicable. Implement new orders, as applicable. If the physician fails to respond to the Critical or Panic laboratory results within 2 hours, place another call to the physician and/or the Medical Director . A review of the facility policy titled, Change in Condition Notification dated 08/09/23 revealed, It is the policy of the facility to notify the resident, his or her attending physician/practitioner, and the resident ' s designated representative of changes in the resident ' s medical/mental condition and/or status The nurse will notify the resident, the resident ' s physician/practitioner, and the resident ' s designated representative when there is: .A significant change in the resident ' s physical, mental, or psychosocial status, such as deterioration which includes life-threatening conditions or clinical complications .Significant Change in Condition Means that the condition will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions and that it impacts more than one area of the resident ' s health status, and requires interdisciplinary review and/or revision to the care plan.

Deficient Practice Statement #2 This citation pertains to Intake: MI 833 Resident #715 (R715) Based on interview and record review, the facility failed to respond to a change in condition in a timely manner for one diabetic resident (R715) of two residents reviewed for a change in condition, resulting in a delay in assessing and monitoring, feelings of being ignored, and symptoms of [CONDITION(S)] (a condition in which your blood sugar level is lower than normal causing symptoms that include shakiness,sweating and dizziness). Findings include: Review of Intake: MI 833 revealed the following, Incident Summary. It was reported to facility staff that a nurse neglected [R715] by not checking [their] blood sugar level when [they] reported feeling hypoglycemic. A review of R715's medical record revealed that they were admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of R715's medical record revealed that the resident was cognitively intact and required extensive assistance for Activities of Daily Living (ADL's). Further review of R715's medical record revealed the following care plan, Focus: Endocrine System related to; Insulin Dependent Diabetes Date Initiated: [DATE]. Interventions: Report symptoms of hyperglycemia: excessive thirst/urination, hunger, weakness, N/V (nausea and vomiting), [MEDICATION(S)] breath. Report symptoms of [CONDITION(S)]: weakness, pallor, diaphoresis, vision changes, change in consciousness. Date Initiated: [DATE] . R715 was discharged from the facility on [DATE] therefore, the interview and statement provided by R715 on [DATE] at 10:50 AM was reviewed and reflected the following: Did you have an issue with the nurse the other night? 'I needed pain medicine and my [MEDICATION(S)] to go to sleep, I put my call light on. She told me I had to wait. I said okay. A little later, I'm still waiting, my sugar is low. I can feel when my sugar is low. I started sweating. I put my light back on. My friend was at the window. I can't move, I had surgery (pointing to foot). I can't get up by myself and I need help. I couldn't get my candy on my window to up my sugar and she was not coming.' What did the nurse say when you put your light on? 'She came back in and told me again I have to wait. I told her my sugar was low, she said she's not checking right now, I have to wait, She just keeps yelling I have to wait, I have to wait, I have to wait. I told her my sugar is too low and I needed help. She told me now I will be last.' Did she ever check your sugar? 'No.' Did anybody check your sugar? 'A man. My sugar was low and he got my snacks and a sandwich.' On [DATE] at 1:10 PM, an interview was completed with Confidential Witness F who stated the following, We went to visit [R715] .[R715] said [they're] not feeling good .I was outside of the window and was able to see and hear everything so I told [R715] to push the call light . Confidential Witness F further explained that the CNA (Certified Nursing Assistant L) came into the room to address R715's needs and could hear the nurse state, 'I'm across the hall I'll be there when I can. Confidential Witness F explained that the nurse didn't come, so R715 turned the call light back on and when the nurse came into the room, she turned off the call light and was rude to R715 by telling them, 'I told you to not push the call light. You're pulling me away from someone else. I have nine other people that I have to check blood sugars. I'm going to start at the other end of the hall and come back.' Confidential Witness F explained that they are actually a nurse, and observed R715 sweating profusely, and that they saw Nurse K come back into the room again and explained that she was not going to check R715's blood sugar. Confidential Witness F stated that they started to bang on the door for someone to let them in, as they just wanted someone to check R715's blood sugar, as they may have just needed to eat. Confidential Witness F was able to speak to the charge nurse, Nurse G and explained to him that R715's nurse was refusing to check their blood sugar, so Nurse G went and checked it, and it was 59 (According the the American Diabetes Associates, for someone with diabetes their blood sugar should be between ,d+[DATE]). Confidential Witness F explained that Nurse G provided food to R715 who reported feeling better. Confidential Witness F stated, I didn't understand how she could say those things. If she is treating someone like that when a family member is around, how is she treating these patients when she's alone with them? On [DATE] at 1:41 PM, an attempt to reach Nurse G was made to no avail however, a review of a progress note written by them revealed the following, [DATE] 20:54 (8:54 PM) Skilled Nursing Note Text: Patient complained to [their] friend who translated as patient speaks Spanish that [they were] diaphoretic (sweating heavily) and didn't feel right. Writer went to room and checked patients BS (blood sugar) it was 59, patient given juice and [MEDICATION(S)] sandwich. MD (medical doctor) notified of situation and gave order to cut patients NovoLog ,d+[DATE] (insulin) to 15 units breakfast and dinner, and recheck in 2 hrs (hours). Orders in place. On [DATE] at 1:57 PM, an telephone interview was conducted with Nurse K. She was asked about the incident regarding R715 and their blood sugar not being checked. Nurse K stated, I feel like this is retaliation by [nursing home] because I put in my 2 week notice .We were severely understaffed. There was a resident who was a fall risk and was noncompliant, and I had one CNA the family was visiting outside of the window. [R715] was not a scheduled blood sugar (check) for me .The family members were so rude, and I told the manager that I couldn't go back into the room so that I didn't get myself in trouble. I didn't get into it with anyone and I didn't neglect any patients . Nurse K further explained that R715 was overmedicated with long acting insulin, and that they bottomed out because [R715] was getting too much insulin . I feel I did the appropriate thing. [Nurse G went and got [R715] juice. There was no order to check [their] blood sugar at that time .I told R715 that I will check it, and I was working in between two rooms, I can't stop what I'm doing in the other room .I asked the unit manager for assistance with R715 . Nurse K was asked if she ever checked blood sugars for residents that were not ordered or scheduled, and she stated, Yes. A review of the interview and statement dated [DATE] at 11:40 AM from Nurse K reflected the following, Was there an issue with [R715] in [room number] on Wednesday evening? 'I wouldn't even go in there until that family went away from the window. Because last (less) then five minutes apart, [R715] put [their] light on and they kept having [them] do that. [R715] wasn't a scheduled blood sugar for the evening. We were short of staff so, I kept telling them I need to have a minute. I didn't go back because I saw where this was going to go. [Nurse G] ended up going in there. It wasn't even much of a conversation between us because I wasn't going back in there ' '[R715] wasn't an HS (at bedtime) blood sugar .The concern was [R715's] sugar kept dropping low, but [they weren't] a blood sugar for me. They didn't like the fact that I had 2 people before [R715]. I never went back into the room. They were rude so I never went back. I told Nurse G I wasn't going back until they left.' How many different times did [R715] put [their] light on? 'I think 3 different times in a matter of five minutes.' Did [R715] report to you that [their] blood sugar was low? '[R715] said [they] needed it checked. 'I said Ok, I have a few before you. I was doing the scheduled sugars first. [R715] wasn't a scheduled sugar. They kept saying it needed to be checked. I told them I was aware of everything that needed to be done for the patients-It was on the MAR (medication administration record). It was a limited conversation and not even a full minute.' Did they say why [R715] needed it checked? '[R715] said she just normally gets [theirs] checked.' Who was turning the call light off between those times? 'CNA L did first. I was in another room. The second time, it was like back to back, I stepped in there and they said [R715] needed checked. I told them I had a few people before [R715]. I turned the light off and left. It came back on and I don't know who turned it off that third time. I didn't go back.' After Nurse G checked [R715's] blood sugar what happened? 'Nurse G said [R715's] sugar was like 60. He went and got [R715] snacks. I gave [R715] some time before I went back. Nurse G put in orders to re-check [R715's] sugar and it was 180 when I re-checked [them]. R715 is a very sweet [person], it was the rude family.' Did you ever tell them that putting the light on wouldn't get you back in there faster? 'I limited what I said to them on purpose I didn't even go back. I don't recall saying that, but I don't know what all I said. I think I said some things out in the hall to [CNA L] about that but not to the family.' Did you ever tell them that [R715] would be the last one? 'No. I didn't say that to them.' Did you ever say you were working from one end of the hall to the other? 'I said I start in the front of the hall and work my way back. But it was to [CNA L] in the hallway.' On [DATE] at 9:40 AM, an attempt to contact CNA L was attempted to no avail. A review of their statement dated [DATE] with a time stamp of 12:35 PM reflected the following, Was there any issue between Nurse K and [R715] or the family? 'Nurse K started doing her med (medication) pass. There was family at [R715's] window and they kept putting the light on, they said [R715] wanted pain medicine. They were trying to rush her about something, I guess they wanted her to come quicker but she said when she was done she would be there.' How many times did you answer the call light? 'Twice. The first time they asked me to open the window shade and put socks on [R715], they had brought socks. The second time it was about pain medicine, The light kept coming on but I don't know what about, I was getting water and Nurse K told me about it.' Did Nurse K ever complain about the family in the hallway to you? 'She said she was doing her med pass and that she was going room to room and that she would be there when she could.' Do you know anything about the patient's blood sugar being low? 'No, I don't know nothing about that part.' A review of the facility's investigation outcome revealed the following, Based on the investigation the facility did not substantiate neglect as [R715's] needs were met by a nurse timely. However, it was determined [Nurse K's] response to the change of condition was inappropriate and failed to meet the Nursing Standards of Practice. [Nurse K] is no longer employed by the facility . On [DATE] at 2:49 PM, the Director of Nursing (DON) was asked about the outcome of the investigation, and their expectation for assessing a change in condition. The DON explained that Nurse K should have checked the resident's blood sugar and We held her to that standard. A review of the facility policy titled Change In Condition dated ,d+[DATE], revealed no significant information in regard to handling a change in condition timely. Deficient Practice Statement #1 This citation pertains to intake # MI 289. Based on interview and record review, the facility failed to respond to an acute change in condition timely for one resident (Resident #702) of two residents reviewed for a change in condition, resulting in lethargy, the inability to complete rehabilitation, a delay in appropriate treatment and hospitalization . Findings include: On [DATE] at 09:59 AM, Confidential Witness C was interviewed via telephone. Confidential Witness C explained that Resident #702 had developed Covid-19 in early December and had recovered from it and went to the facility for rehabilitation to get stronger. Confidential Witness C stated, We couldn't see (Resident #702 while in the facility) at all because of Covid. During the last days at the facility, (Resident #702) was out of sorts, I asked them to please check (Resident #702) because we remembered the last time (Resident #702) had a [CONDITION(S)] (Urinary Tract Infection) at a different facility. By the time they finally checked for a [CONDITION(S)], it was too late. [CONDITION(S)] called and they said (Resident #702) was unresponsive and they could not do [CONDITION(S)], so they sent (Resident #702) to the hospital where they remained until we brought them home on hospice and they died . Confidential Witness C was asked what change they noticed in Resident #702 to warrant their concern and stated, We could tell just by the way (Resident #702) was talking that something was wrong. They were speaking Arabic and broken English. They NEVER did that! They usually spoke to us in Arabic. They knew English and Arabic. Eventually when we would call, (Resident #702) quit answering the phone because they couldn't stay awake to even talk on it! A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #702 had a Brief Interview for Mental Status (BIMS) score of 03 out of 15, indicating a severely impaired cognition. Resident #702 had been admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #702 required extensive physical assistance for bed mobility and transfers. A record review of the progress notes revealed the following for Resident #702: [DATE] 05:14 (AM) .Patient A&O (alert and oriented) x ,d+[DATE], able to verbalize needs. Denies being in any pain/ discomfort at this time. Dx (diagnosis) are Pneumonia, [CONDITION(S)] (end stage renal disease) .Patient goes to [CONDITION(S)] .Patient is resting in bed, call light within reach, safety maintained. [DATE] 16:09 (04:09 PM) Social Services Note .Pt (Patient/Resident #702) said .feeling really good, pt said I'm doing 100%, I am very good. Pt reports .lives home with dtr (daughter) .Pt hopes to return home soon. [DATE] 10:00 (AM) NP (Nurse Practitioner) Progress Note .Chief Complaint - Acute Mental Status HPI - Staff nurse requesting evaluation on [Resident #702] regarding acute mental status changes. Patient's daughter .is also concern stating patient falling asleep while on phone and just not being (themselves). Upon examination at bedside, patient noted with no s/s (signs and symptoms) of acute distress. Patient alert to voice command. Patient is noted to be a little lethargic (tired/sluggish) and requiring stimulation to stay awake .Diagnosis 1 Plan .seen today for altered mental status. New order for labs CBC (complete blood count) and BMP (basic metabolic panel) Chest X-Ray and UA/CS (urinalysis/culture and sensitivity) Will continue to follow Medications reviewed not on any sedatives. Updated daughter .and staff nurse with with plan of care . [DATE] 13:04 (01:04 PM) Social Services Note .Discharge planning meeting held today with .NP .PT (Physical Therapy) .OT (Occupational Therapy), and dtr .via phone .Reviewed therapy progress in detail. Pt has been fatigued lately. Dtr reports pt has a hx (history) of wanting others to do for (them) instead of doing for (themselves). Pt has a walker, wheelchair, and shower chair at home .NP .reviewed a UA was collected and initial result shows possible [CONDITION(S)] but waiting on sensitivity; discussed labs did not indicate new liver function issue at this time; waiting on chest x-ray outcome; NP informed dtr that case was discussed with Dr. [Doctor] and NP informed dtr that fatigue can linger after COVID at times.Discussed anticipated d/c (discharge) date ,d+[DATE] and pt will require more assistance at home than prior; dtr voiced understanding .Plan at this time is rehab continues, waiting on test results, and potential d/c home ,d+[DATE]. [DATE] (Authored by NP B) 13:46 (01:46 PM) NP .Chief Complaint - Acute Altered Mental Status .staff nurse requesting evaluation .regarding abnormal labs and family care plan today. Patients labs reviewed: UA revealing clarity cloudy, blood 1+, protein 2+, [MEDICATION(S)] negative, leukocytes 2+, RBC ,d+[DATE], WBC (white blood cells) Bacteria moderate and hyaline casts ,d+[DATE]. Awaiting sensitivity. Chest x-ray still pending patient was at [CONDITION(S)] when radiologist came to facility. [MEDICATION(S)] level 39, D-Dimer 531, WBC 14.3 (elevated), and .BMP will need to be recollected due to lab error. Patient examined at bedside with no s/s of acute distress. Patient endorsing being tired and wants to get in bed. Patients lunch is open and in front of (them). Lunch is untouched. Attempted to assist patient with meal .only took a few sips of .juice. 1 Plan .seen today for follow up of altered mental status. UA reviewed awaiting culture new order for [MEDICATION(S)] 100 mg (milligrams) PO (by mouth) BID (twice per day) x 5 days. Will follow up with sensitivity Awaiting chest x-ray CBC reviewed with leukocytosis of 14.3. BMP -waiting redraw [MEDICATION(S)] level within normal limits 39. Will continue to follow Medications reviewed not on any sedatives Medical case discussed with Dr .agree with plan of care. Participated in Family care conference with Daughter .today. Plan of care discussed, reviewed current medications and labs. Informed of initiating empiric antibiotic while awaiting sensitivity. Order written for .anticipated discharge on Monday . [DATE] 12:25 (PM) Discharge Planning .spoke with dtr .via phone. Discussed .with NP r/t (related to) test results that were/are pending and facility determined D/C date ,d+[DATE] as previously discussed stands .Dtr requested SS (social services) check on pt due to pt not answering phone today. This phone call with dtr ended and SS went to pt's room and met with pt. Pt stated .was tired and did not want to talk to family on phone. SS provided encouragement but pt declined phone call; pt was sleepy, only opening eyes minimally and kept eyes closed for most of discussion. SS attempted to discuss d/c for Monday .with pt but pt was sleepy and said 'okay I go Monday' and fell back asleep. Pt has severe cognitive impairment as evidenced by last BIMS score. SS called dtr .back and notified dtr that pt stated .was tired and did not wish to speak on the phone . [DATE] 08:30 (AM) .During a.m. care, Nurse assistant observed pink, red tinged bowel movement, foul smelled, loose diarrhea. Resident was changed and dressed for [CONDITION(S)]. Resident c/o (complained of) .back pain. Nurse gave aspirin for back pain. Will continue to monitor. A record review of the therapy notes for Resident #702 revealed the following: Occupational Therapy OT Evaluation & Plan of Treatment (authored by OT J) .Start of Care: [DATE] .Potential for Achieving Rehab Goals: Patient demonstrates good rehab potential as evidenced by Able to make needs known, Motivated to participate, Motivated to return to prior level of living, Strong family support and Ability to follow 1-step directions . [DATE] (authored by OT J)- .Max Encouragement required to facilitate participation with cues to initiate/resume exercise, multiple rest breaks required .Barriers Impacting Treatment-c/o (complained of) fatigue with encouragement to increased sitting tolerance . [DATE] (authored by OT J)-BP (blood pressure) R (right) ,d+[DATE] .L (left) ,d+[DATE] (normal BP is ,d+[DATE]) .Skilled interventions focused on Dynamic balance activities during sitting .to increase strength .Response to Tx (treatment) .Actively participates with skilled interventions with MAX cues and encouragement .Barriers Impacting Treatments: Decreased alertness to task, decreased BP .Patient approached for therapy, patient stated, 'I am ready' , therapy was initiated but patient unable to maintain alertness/attention to task; vital signs taken, nurse informed of decreased participation, nurse reported was aware of decline. [DATE] (authored by OT J)- .Upon approach for therapy patient was sleepy and required multiple attempts for arousal .patient expressed desire to get in wheelchair for lunch .Patient required multiple cues to initiate/resume task .Patient was unable to complete with MAX PA (patient assist). CGA (contact guard assist) required to maintain sitting, sitting tolerance < (less than) 1 minute, patient reported .was unable to sit in wheelchair, 'I can't, I'm to tired', MAX PA required for sit to supine; CENA (Certified Educated Nurse Assistant) informed of BP and participation in therapy. [DATE] (authored by OT J)- .MAX encouragement required to facilitate participation, 'I tired'. Reviewed need to get ready for HD (hemodialysis) appointment, patient expressed understanding, but continued to state, 'I'm tired' through therapy session .Patient able to tolerate supported upright sitting (utilizing hospital bed for 10 minutes), 'lay me down tired' .Patient provided wash cloth to wash UB (upper body), patient did wash face, but abandoned task due to fatigue and falling asleep, MAX PA provided by staff to complete task .Response to Session Interventions: actively participates with skilled interventions with MAX cues and encouragement, 'I want to do, but I'm so tired' .Barriers Impacting Treatment .Fatigue and decreased alertness (sleepy) . [DATE] (authored by OT J)- .Hand over hand assistance required to initiate each exercise/set due to c/o fatigue and decreased alertness/sleepy . OT Discharge Summary (authored by OT J)- Patient will increase ability to stand Unsupported for > (greater than) 3 - 5 mins (minutes) .Baseline ([DATE]) 30 - 60 seconds .Discharge ([DATE]) 30 - 60 seconds (no improvement). Patient will increase activity tolerance for functional activities of choice to 15 mins in order to increase participation with ADL (activities of daily living) .Baseline ([DATE]) > (greater than) 3 - 5 mins (minutes) .Discharge ([DATE]) 1 - 3 minutes. Goal not met. Patient will improve ability to safely and efficiently put on and take off socks and shoes or other footwear with Supervision or Touching Assistance with use of no adaptive equipment .Baseline ([DATE]) Substantial/maximal assistance .Discharge ([DATE]) Substantial/maximal assistance. Goal not met. Patient will improve ability to complete toilet/commode transfers with Supervision or Touching Assistance .Baseline ([DATE]) Partial/moderate assistance .Discharge ([DATE]) Substantial/maximal assistance. Decline since baseline. Patient will complete all ADL/self care tasks with Setup or Clean-up Assistance .Baseline ([DATE]) Partial/moderate assistance .Discharge ([DATE]) Substantial/maximal assistance . Decline since baseline. Assessment and Summary of Skilled Services- .MOD/MAX PA required for BADL (basic activities of daily living) .performance has varied this week resulting in increased need for assistance, independence has varied from CGA to MAX PA with bed mobility and transfer .vial signs monitoring during functional task performance-decreased BP noted, nursing informed . Physical Therapy [DATE] (authored by Physical Therapist Assistant/PTA I) .BP .,d+[DATE] .Barriers Impacting Treatment: Marked fatigue . [DATE] (authored by PTA I) .Barriers Impacting Treatment: Fatigued . [DATE] .pt very anxious wanting to lay back down .Fatigue, anxiety with increased activity .shorter session, frequent rest periods. [DATE] .Compliant with skilled interventions however Pt unable to complete session due to level of alertness .Markedly reduced level of alertness . [DATE] .discontinued session due to low BP .Unable to treat (secondary to) to low BP, 2 readings, ,d+[DATE] and ,d+[DATE]. Discontinued session and informed nursing .Barriers Impacting Treatment: Low BP .Unable to treat, informed nursing. [DATE] (authored by PTA I) .Attempted exercises in sitting but Pt refused Pt able to maintain sitting balance unsupported but Pt requested to lay down pt report feeling very tired and not willing to attempt ambulation. Pt encouraged by therapist regarding discharge but Pt wants to stay in bed .Barriers Impacting treatment?=Yes .Barriers Impacting Treatment: Markedly reduced level of alertness .Treatment Modifications to Overcome Barriers: Frequent rest breaks and encouragement to participate .Ambulation Walk 10 feet=Patient refused .Unable to treat, informed nursing .Compliant with skilled interventions however Pt unable to complete session due to level of alertness .Care conference held earlier in the day with pts daughter. Expressed pts increased need for care upon discharge and all equipment needed for a safe transition home . PT Discharge Summary D/C Destinations: Hospital .Patient will improve ability to safely and efficiently transfer to and from bed to a chair .Baseline ([DATE]) Partial/moderate assistance .Discharge ([DATE]) Partial/moderate assistance .(no change). Patient will improve ability to safely transfer from lying on the back to sitting and ambulate on level surfaces 10 feet using two-wheeled walker .Baseline ([DATE]) Partial/moderate assistance .Discharge ([DATE]) Met on [DATE]. Patient will safely ambulate on level surfaces 40 feet .Baseline ([DATE]) Supervision or touching assistance .Discharge ([DATE]) Partial/moderate assistance. Indicating a decline. Patient will improve ability to safely and efficiently transfer to and from bed to a chair .Baseline ([DATE]) Partial/moderate assistance .Discharge ([DATE]) Partial/moderate assistance . No improvement. Patient will improve ability to transfer from lying on the back to sitting on the side of bed .Baseline ([DATE]) Partial/moderate assistance .Discharge ([DATE]) Supervision or touching assistance . Patient will safely ambulate on level surfaces 50 feet .Baseline ([DATE]) Partial/moderate assistance .Discharge ([DATE]) Partial/moderate assistance. No change. On [DATE] at 02:21 PM, NP B and the Director of Nursing (DON) were interviewed in regard to Resident #702's change in condition that eventually lead to their admission to the hospital. The DON explained that Resident #702 was admitted to the facility on the COVID Unit in isolation due to Resident #702 having the Coronavirus. NP B explained that she was asked to see Resident #702 and stated, We were doing telehealth at that time because of Covid. The daughter was concerned because (Resident #702) wasn't answering the phone or would tell them (the family) to 'leave me alone'. During that time, things were intense (with the family wanting to see residents and the Coronavirus), with COVID. NP B was asked about the labs that were ordered for Resident #702 and stated, The UA didn't grow anything after 2 days. Usually that means either it was negative or contaminated (the sample was not good). I put them (Resident #702) on something (an antibiotic) to cover if it (an infection) were a [CONDITION(S)] or pneumonia. We had a care conference because the daughter wanted one. NP B was asked if she knew why Resident #702 went to the hospital and explained that the [CONDITION(S)] Center had sent Resident #702 out for suspicion of GI bleed. (Resident #702) had an elevated D-dimer (500+) which was linked with patients having COVID and putting them at risk for blood clots. But, I was happy because in the hospital, it was 1500, so I was pleased (because it was coming down). NP B was asked about the red tinged stool that Resident #702 had the morning before [CONDITION(S)] and stated, (Resident #702) had pink tinged stool that morning ([DATE]) before [CONDITION(S)] and still went to [CONDITION(S)]. The DON and NP B were asked if there were any new orders in response to the abnormal finding of pink tinged stool. The DON stated, We educated the nurse on giving the resident aspirin (has blood thinning properties) with blood tinged stool. NP B was asked, given that Resident #702 was declining and not improving dispite the addition of antibiotics, why Resident #702 was not sent to an acute setting for more aggressive testing/treatment since they were a full code and stated, I didn't see a decline. NP B was asked about therapy notes with continued barriers to treatments due to decreased blood pressures and lethargy and stated,I was not aware. On [DATE] at 09:02 AM, PT H was interviewed in regard to the course of rehabilitation treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . PT H did complete the initial evaluation and stated, that he treated the Resident a few times but mostly PTA I treated Resident #702. PT H was asked if he recalled any changes in Resident #702 during treatment and stated, (Resident #702) was on [CONDITION(S)] and was less motivated on those days. I seen them on [DATE] and (Resident #702) refused to walk and their blood pressure dropped. I did tell the nurse. We did a care conference with the daughter, (Resident #702) showed some progress. I don't remember much. On [DATE] at 09:19 PM, PTA I was interviewed about Resident #702's course of therapy and explained that she was one of several that had treated Resident #702 and had not remembered much. PTA I stated, (Resident #702)'s blood pressure fluctuated. I don't remember that much because (Resident #702) was seen by several people. On [DATE] at 11:01 AM, OT J was interviewed in regard to Resident #702's therapy course received in the facility and stated,I vaguely remember, (Resident #702) was inconsistent. I had a whole team that worked with (Resident #702). (Resident #702) fluctuated between CGA (contact guard assistance) and max assist and went to [CONDITION(S)]. We did a care conference with the family and recommended 24 hour care. (Resident #702)'s participation varied. On [DATE] at 04:09 PM, an interview was completed via phone with [CONDITION(S)] Registered Nurse (RN E) in regard to the change in Resident #702's condition warranting a discharge to the hospital. RN E explained that Resident #702 was dropped off for [CONDITION(S)] on [DATE] but was unable to complete the treatment. RN E stated, (Resident #702) had a change in condition for the last month, I am not sure how the facility didn't see it, at the time, I didn't know if maybe the facility had changed their medications around or what. (Resident #702) had a dip in their vital signs and their blood pressure to warrant us to feel unsafe to do [CONDITION(S)]. I called the Doctor because they were less alert and their blood pressure had dropped, so we sent them to the hospital. On [DATE] at 04:35 PM Confidential Witness D was interviewed about the course of stay for Resident #702 while at the facility and explained that Resident #702 was placed in the facility in hopes of getting some more strength following a hospitalization due to Covid. Confidential Witness D stated, We started to notice, when we would call (Resident #702), they would speak to us in broken English, which was NOT the way (Resident #702) spoke at all. It got to the point where (Resident #702) quit answering the phone. We would call the facility and have them answer the phone and give it to (Resident #702) but (Resident #702) couldn't even stay awake to hold the phone long enough to talk to us! My sister begged them (the facility) to do a UA because (Resident #702) had one before (a urinary infection) and we learned how to recognize when (Resident #702) had an infection. By the time they listened to us, it was too late. I know that they dropped the ball! If they had reacted when we told them to, we would still have (Resident #702) to this day! A review of the facility policy titled Change In Condition dated ,d+[DATE], revealed no significant information in regard to handling a change in condition timely.

This citation pertains to intake MI 890. Based on interview and record review, the facility failed to transfer a resident via hoyer lift as stated in the care plan for 1 (#801) of 3 sampled residents reviewed for improper transfers and accidents, resulting in a resident being transferred from wheelchair to bed by two staff members with no hoyer lift, a right [MEDICAL CONDITION], surgical repair, and the likelihood of further serious injury. Findings include: On 11/9/18 at 10:16 AM, R#801 was interviewed regarding a recent hospitalization and hip injury. R#801 stated, It might have been the 17th (of October, (YEAR)), I came back from court. I was up in my wheelchair and they were trying to get me back into bed. I can't remember who it was but it was someone that works here. I heard something crack. Then I told the doctor that I needed to go to the hospital because I was hurting real bad in my leg. When queried further about the transfer from wheelchair to bed, R#801 explained, I think they put me from the wheelchair to the bed. There were two of them. I'm supposed to go to the hospital today to get my (surgical) stitches out. They moved me to the bed and I heard a crack. I don't think it was on purpose. It was around lunch time. The hospital didn't tell me what happened they just told me I needed surgery. A review of R#801's medical record, progress notes, and Minimum Data Set (MDS) assessment dated [DATE] were reviewed and revealed that the resident was first admitted into the facility on [DATE], required extensive assistance from two staff members for bed mobility and transfers, and had [DIAGNOSES REDACTED]. A review of the MDS assessment dated [DATE] revealed that the resident's Cognitive Skills for Daily Decision Making were Moderately Impaired. On 11/9/18 at 12:00 PM, Certified Nursing Assistant (CNA) A was interviewed regarding R#801 and transferring the resident from wheelchair to bed on 10/18/18. CNA A stated, (R#801) came back from court and needed to be transferred back to bed. (CNA B) was the aide and I was just helping. When the resident was gone they took all the stuff out of the room to clean and wax the floors, so (R#801) was sitting in the hallway and yelling about sitting in their wheelchair and wanting to go back to bed. We went to get the hoyer lift but (R#801) refused. We were trying to reposition (them) in the wheelchair but (they) were still yelling in the hall. We got (them) into the room and put down the high back of the wheelchair to line up with the flat bed. I grabbed (R#801's) sweatpants (at the waist) and (CNA B) was behind (and held under the resident's arms) and we transferred the resident to bed. (R#801) was still saying they were uncomfortable after they got into bed so we tried to reposition (them) as best we could. (R#801) did not tell us to stop, (the resident) had already been saying they were in pain when in their wheelchair. I went and told the nurse we put (R#801) into bed and that (they) were in pain. That was right before my shift was over. CNA A was then asked where staff can look up a resident's transfer status in the medical record. CNA A stated, It's in the Kardex (part of care plan). (R#801) had in the Kardex that (they) are a total assist, two person lift transfer. R#801's Kardex and Care Plan were reviewed at this time and revealed the following: Kardex: Transfers dependent with mechanical lift. Care Plan Focus Area: (R#801) continues to require assist with daily ADLS (activities of daily living) .has deficits related to Disease process as evidenced by need for daily ADL assist related to physical limitations, debility, muscle weakness, LBKA (Left [MEDICAL CONDITION]) . Date Initiated: 05/06/2016, Created on: 05/06/2016. Care Plan Interventions: Transfers dependent with mechanical lift, Date Initiated: 02/12/2017, Created on: 02/12/2017, Revision on: 09/14/2018. Two care givers at all times for care, Date Initiated: 09/14/2018. On 11/9/18 at 12:41 PM, CNA B was contacted via phone for an interview. A voicemail was left for call back, but no call back was received prior to exiting the facility. On 11/9/18 at 12:53 PM, CNA C was interviewed regarding R#801 and their transfer status. CNA C stated, I remember (R#801), they used to be on our side. (They were) a lift transfer, I think. We go to the Kardex to see where the transfer status is. We absolutely check it before we help anyone transfer (a resident). On 11/9/18 at 1:00 PM, R#801's progress notes were reviewed and revealed the following: Effective Date: 10/17/2018 22:46 (10:46 PM), Type: General Progress Note, Note Text: Pt (patient) yelling out in room for nurse, writer entered pt room, pt states I been hurting all day, i want to go to the .hospital writer asked pt where (pain is) pt states to right hip area, declined to allow writer to observe area, stating it hurts, can't you just send me out, pt declined writer to observe area or perform ROM (range of motion), also declines re positioning. Writer explained to pt that [MEDICATION NAME] (pain medication) has been increased from 50 mg (milligrams) to 100 mg for pain, asked pt if (they) would like to see how the increase in medication will work and pt states ok, [MEDICATION NAME] administered. Pt now yelling out nurse I'm hurting X 3, writer reentered room and pt states that medication, still didn't help pt again declined writer to observe area or attempt to re position for comfort. Writer phoned MD and states to send pt out per pt request r/t (related to) unrelieved pain. Now awaiting transportation to (hospital) r/t unrelieved pain per pt request. VS (Vital Signs) 135/75 HR (Heart Rate) 66 RR (Respiration Rate) 18 T (Temperature) 97.6. On 11/9/18, R#801's, Admission History and Physical, Collected On: 10/18/2018 at 07:58 (7:58 AM), from their hospitalization was reviewed and revealed the following: .(P)resents to ED (Emergency Department) for a complaint of R (Right) sided hip pain .felt as if .twisted (their) hip when (they) were being repositioned from .wheelchair .to bed .felt a pop sensation at (their) right hip twisted upon transfer from chair to bed .denies any recent falls or trauma .states sharp, severe, 7-8/10 pain in right hip without [MEDICAL CONDITION] . R#801's Operative Report, dated 10/18/18, from their hospitalization was also reviewed at this time and revealed the following: Date of Surgery: 10/18/18 Preoperative Diagnosis: [REDACTED]. Procedures: 1. Open reduction (realignment of broken bone through surgery) and internal fixation (placement of hardware to stabilize the bone so it can heal) of right subtrochanteric femur fracture .2. Negative pressure wound therapy, dressing with .incisional VAC (device for wound/surgical site healing) . Indications: The patient .experienced a popping sensation during a transfer in (their) right hip on 10/17/2018 .states that (they) had extreme pain in .right hip and was brought to (hospital) and found to have a right subtrochanteric femur fracture . On 11/9/18 at 2:55 PM, the Director of Nursing (DON) was interviewed regarding R#801's transfer on 10/17/18 and subsequent hospitalization . When asked what R#801's transfer status was at the time of the incident, the DON stated, (R#801) is a hoyer. The resident has been going to court hearings. That day, (the resident) was refusing to get out of bed. The staff did not use the hoyer to get (R#801) out of bed or back into bed that day. When (R#801) came back from court, (they) were yelling out in the hallway while their room was being deep cleaned. (The resident) wanted to get back into bed in their room. The DON was then asked how many CNAs provided the transfer back into bed and replied, Two CNAs. I understand why they did it but it was wrong. They should've told the nurse both times that (R#801) was refusing to use the hoyer before they transferred (the resident). They were educated one-on-one. They were shocked to find out about the [MEDICAL CONDITION]. The DON explained that the resident's physician had seen R#801 that day shortly after the transfer but, He (doctor) thought the complaints of pain were about (R#801)'s chronic left hip pain. The complaints were not much different than normal, but later on (R#801)'s nurse called me and told me the resident was in their room crying and in intense pain, and I told them to send (R#801) out. The facility Investigation Report, authored by the facility's Administrator and dated 10/24/18, was reviewed and revealed the following: Conclusion: .On (MONTH) 18, (YEAR) (R#801) complained of intractable hip pain and was sent to the emergency room .Upon further investigation it was identified that the nursing assistants that transferred (R#801) from (their) wheelchair back to (their) bed did not use the appropriate device when transferring (R#801). On 11/9/18, the facility document titled, Transfer: Bed-Chair/Wheelchair, dated 01/2011, was reviewed and did not address mechanical lift transfers in detail. The document revealed, Note: For transfers requiring use of a mechanical lift, please refer to manufacturer guidelines for use.

Based on observation, interview, and record review, the facility failed to identify, protect, investigate and report allegations of verbal and physical abuse voiced by two (#811 and 816) of 25 sampled residents reviewed for abuse, from a total of 25 sampled residents, resulting in the potential for further verbal and physical abuse of residents by a staff member with access to residents after the allegation of abuse was identified. This resulted in an Immediate Jeopardy to the health and safety of residents. The Immediate Jeopardy was identified on 12/17/15 at 9:00 a.m. The administrator was notified of the Immediate Jeopardy on 12/17/15 at 4:00 P.M. at which time a plan to remove the immediacy was requested. Findings include: The Immediate Jeopardy was removed on 12/17/15 when the facility submitted the acceptable plan of correction that was implemented and verified on site by the survey team. Although the IJ was removed, the facility ' s deficient practice was not corrected and remained isolated with no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Resident #811 During the initial tour on 12/15/15 between 8:30 a.m. and 9:30 a.m., Resident #811 reported that one of the aides had been rude and short (tempered) with her. A subsequent interview was conducted with Resident #811 on 12/17/15 at approximately 10:30 A.M. Resident #811 was asked to describe the incident of verbal abuse short-tempered and when the alleged mistreatment occurred. Resident #811 reported the incident occurred last week--on the last day of skilled therapy when she found CNA O going through her personal belongings in the nightstand. Resident #811 said she yelled at Certified Nurse Assistant (CNA) O and told her, Leave my stuff alone. CNA O was reported to reply, I'll do what I want. Resident #811 stated, People shouldn't have to deal with nastiness like that. I told my daughter about it and she told them (facility) about it, so they moved the CNA O to the other side of the building. I get nervous because I don't want to see her again. Direct Care Supervisor (DCS) A was interviewed on 12/16/15 at 3:30 p.m. and was asked whether Resident #811 reported concerns regarding care and how she was treated by staff. DCS A reported there were no concerns brought to her. At this time, DCS A was notified that Resident #811 voiced CNA O was rude when confronted about going through her (Resident 811's) personal belongings last week. DCS A responded, I'm in touch with the family on a regular basis, I'll talk to them. During an interview on 12/17/15 at 9:00 a.m., allegations voiced by Resident #811 regarding CNA O's disrespect were discussed with DCS A a second time. DCS A reported that CNA O does not work with Resident #811. During an interview, on 12/17/15 at 10:30 a.m., Resident #811 indicated that she saw CNA O outside her room last night (12/16/15) and it made her nervous. Resident #811 began to cry while explaining the anxiety caused by seeing CNA O on 12/16/15. On 12/17/15 at 11:15 a.m., DCS A and Social Worker N were interviewed regarding Resident #811's allegation. A document titled, Concern Form, that was completed by Nurse P for Resident #811, was provided and reviewed. DCS A reported Resident #811 reported a concern five minutes ago. The concern documented on the form indicated that CNA O treated Resident #811 rudely during an incident that occurred between the two of them. There was no evidence the facility identified the situation as an allegation of abuse; began an investigation to determine whether abuse may or may not have occurred; and that residents were protected after an allegation of abuse was made. A telephone call was placed to Resident #811's Durable Power of Attorney (DPOA) on 12/17/15 at 11:35 a.m. Resident #811's DPOA indicated that Resident #811 was upset from the rudeness he incident that happened with CNA O last week and stated, I told the ladies behind the front desk about the incident on my way out .and was told that the subject would be discussed in the facility's morning meeting. (The ladies behind the desk were identified as receptionists). During an interview, on 12/17/15 at 11:45 a.m., the Director of Nursing was interviewed regarding the facility's response to Resident #811's allegation and reported that CNA O has been relocated to another unit and told not to go down Resident#811's hall. On 12/17/15 at 12:00 p.m., CNA O was observed interacting and assisting residents. According to the daily work schedule, CNA O worked in the facility on 12/15/15 from 6 a.m. to 2 p.m.; 12/16/15 from 6 a.m. to 8 p.m.; and 12/17/15 from 6 a.m. to 4 p.m. (and scheduled to work on the same hall that Resident #811 lived). During an interview on 12/17/15 at 5:30 p.m., the Administrator reported CNA O was sent home after the notification of Immediate Jeopardy was made--at approximately 4:30 p.m. Review of medical record, on 12/15/15 at 4:30 p.m., revealed that Resident #811 was admitted into the facility with a [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS), dated [DATE], indicated that Resident #811 cognitive skills for daily decision making were impaired; however, Resident #811 understood information and was able to make her needs known. Review, on 12/17/15 at 5:30 p.m., of the facility's policy, dated 11/2011, and titled, Patient Protection Practice Guide revelaed, Employees are educated upon hire and annually on the abuse prevention program including the immediate reporting of any suspicion of abuse, neglect, misappropriation, or crime involving a patient The center must establish an environment where staff and patients who report abuse, neglect and/or misappropriation or reasonable suspicion of a crime are not fearful of reprisal and are protected from retaliation, both during and after the investigation of the event Patient Protection include immediately removing the patient from contact with alleged abuser during the investigation. If the incident involves a center employee, the employee is suspended pending completion of the invesigation. ( ) Resident #816 On 12/15/15 during the Resident Group Interview held at 2:30 PM, Resident #816 made the following statement: An aide made me take a shower by pulling me out the bed by my hair and arm. I did not like that and reported it to my daughter who spoke with the administrator. On 12/15/15 at 4:00 PM Resident #816's clinical record was reviewed and revealed the resident was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE] described that Resident #816 had impaired cognitive skills for daily decision making; however, understood others and was able to make her needs known. The MDS indicated the resident displayed no behavioral problems and did not refuse care. On 12/15/15 at 4:30 PM the Director of Nursing (DON) was informed of the above allegation of abuse identified during the Resident Group Interview and indicated that she had no knowledge of the alleged incident but would consult with the Administrator (Abuse Coordinator). On 12/16/15 at approximately 8:00 AM, the DON reported the facility was looking into Resident #816's allegation. On 12/17/15 at approximately 9:00 AM, the Director of Nursing was asked about the progress regarding the allegation voiced by Resident #816. The DON provided a document titled, Concern Form. Review of the form revealed Resident #816's allegation was followed-up on by the facility on 12/16/15 and the following was documented: Spoke to resident and family providing education on resident rights (DON). Resolution of Concern (Family) just wants reassurance that resident #816's showers are being provided. There was no evidence the resident's allegation of being pulled out of her bed by her hair and arm was investigated. On 12/17/15 at 9:30 AM, Resident #816's family member was contacted by phone and was asked about the allegation of physical abuse and stated, There was an incident and I spoke with one of the nurses, (identified as Employee 'J'--a nurse at the facility) about it .mother (Resident #816) stated they were making (forcing) her get out the bed to shower or to be cared for against her wishes. On 12/17/15 at 12:30 PM, Employee 'J' was interviewed by phone regarding the allegation. Employee 'J' stated, The family member was visiting and stated staff were trying to getting Resident #816 up for morning care and the resident refused .did not like how the aide handled the resident .I did not know who the aide was .or why it happened. I did not report it. During a follow up interview on 12/17/15 at 10:30 AM, Resident #816 stated, I have seen her (aide) again. I do not like her. The resident did not know the aide's name. ( ) The following plan of correction was submitted by the facility. It is the intent of the facility to report abuse according to the State Agency Reportable Events. Resident #811 and 816 continue to reside in the facility. Both residents were interviewed on 12-17-15 using the Abaqis abuse questions. No new information was obtained. Care plans were reviewed and revised as needed. Like residents are those residents ' residing in the center who may be the subject of alleged mistreatment, neglect, or abuse. Including injuries of unknown origin suspicious in nature and misappropriation of resident property. On 12-17-15, the alleged employee was suspended pending investigation. On 12-18-15 another employee was suspended pending investigation. On 12-17-15 107 residents residing in the center were interviewed using the Abaqis questions on abuse to ensure any issues were identified. Those residents who were non- interviewable had a full body assessment completed by nursing and Social Services/nursing completed a psychosocial assessment on them as well. Concern forms were completed as appropriate and forwarded to the abuse coordinator for review. The current system for reporting allegations was reviewed by the QA&A Committee and deemed to be incomplete. We have changed the process to include utilizing the concern form process. The concern forms will be utilized by staff for any patient issues and forwarded directly to the abuse coordinator for further review to ensure the proper investigation is completed and the correct decision is made on allegations of mistreatment versus customer service and reported in accordance with state law. The Administrator and DON were in-serviced on the prevent process which describes problem identification, and reporting, as well as the concern form process to establish a fluid process throughout the facility at all levels. The facility staff were in-serviced beginning 12-17-15 and 12-18-15 on abuse and reporting and added the concern form process to this in-service to ensure the staff forward all concerns and incidents to the abuse coordinator for review, and that no decisions are made at the floor level. Abuse training will increase to quarterly for staff. The IDT will complete 10 audits daily of random staff on reporting and the concern form process to ensure there is no communication issue. The IDT will interview 10 residents in a 7 day period to ensure the concern form process is working as intended. Audits will continue for 30 days or until otherwise directed by the QA&A Committee. In-servicing employees will continue until 100% complete. No employee will work the floor until in-serviced. The Administrator and or designee will monitor the concern form process, and the investigating and reporting process during the clinical meeting Monday through Friday. A summary of findings will be submitted to the QA&A Committee weekly for follow and recommendations. The Administrator is responsible for attaining and maintaining compliance. ( ) ( ) Deficient Practice #2: Based on observation, interview and record review the facility failed to ensure that an injury of unknown origin for one (#814) of 25 sampled residents reviewed for abuse from a total of 25 sampled residents was immediately reported to the Administrator of the facility and other officials and thoroughly investigated, resulting in an increased potential for unreported injuries of unknown origin or incidents of residents abuse . Findings include: On 12/15/15 during the intial tour, Resident #814 was observed in their room sitting up in wheelchair with two steri-strips to the right arm. The resident was questioned about the injury, but was not sure what happened. On 12/16/15 at 12:20 PM Nurse Manager D was interviewed regarding Resident #806's skin tears. Nurse Manager D stated, There should be a nursing note for skin tears. A review of the nurse notes found no documentation for a skin tear for November or December 2015. Per Nurse Manger D, we will assess and remove the dressing today and document our findings. At 2:15 PM the skin tear was observed with the nurse manager who identified that the dressing had been reinforced on 11/25/15 but there was no nursing documentation or incident report related to the skin tears. Nurse Manager D reported Resident #806 stated that the skin tear was possibly from being bumped during transported through the doorways, but she was not sure. The skin tear dressing to the wrist had been treated. The skin tear to elbow area was scabbed over with a redden area approximately three inches in length. Review of the nursing progress notes dated 12/16/15 revealed the nurse documented the removal of two dressing on right arm and documented: The area near elbow appeared resolved, it was pink and shiny in color. The second area near wrist was pink and shiny. A treatment order was initiated. On 12/16/15 at 3:00 PM, Resident #806's clinical record was reviewed. The resident was admitted [DATE] diagnosed with [REDACTED]. A review of the Minimum Data Set Assessment, dated 12/01/15 described Resident #806 had independent cognitive patterns and required extensive physical assistance from one or two staff members for activities of daily living that included bed mobility, transfers, dressing and hygiene. On 12/17/15 the facility Abuse policy for injuries of unknown source dated 2011, was reviewed. Injuries of Unknown Source .when the source of the injury was not observed by any person or the source could not be explained by the resident, and the injury is suspicious because the extent of the injury or the location of the injury, e.g., .or the incidence of injuries over time. ( )

This deficient practice has two deficient practice statements Deficient Practice #1: Based on observation, interview, and record review, the facility failed to ensure that a resident who was at risk for falls was provided a two person physical assist with mobility in bed during care for one (#806) of five sampled residents reviewed for falls from a total sample of 25, resulting in a fall and Resident #806 sustaining a hematoma to left forehead and fractures of the Left Tibia (leg) and Left clavicle (collarbone). Findings include: On 12/15/15 at 12:10 PM, Resident #806 was observed in room sitting up in bed. The resident was wearing a brace on her left leg. She complained of not always having enough staff, having to wait for help with care and transfers. On 12/15/15 at 5:00 PM, Resident #806's clinical record was reviewed. The resident was admitted [DATE] diagnosed with [REDACTED]. Review of Minimum Data Set (MDS), dated [DATE] revealed the resident was assessed with [REDACTED]. The MDS described that Resident #806 required extensive two person physical assistance with bed mobility and was totally dependent with two person physical assistance with transfers. The care plan dated 7/06/15 indicated Resident #806 was at risk for falls due to impaired sitting balance, poor coordination and vision deficit (wore patch over right eye). The Care plan approaches included: bed in low position, encourage to transfer and change positions slowly, have commonly used article within easy reach and provide assist to transfer as needed . There were no care plan interventions that addressed the resident's safety needs in bed. On 12/16/15 at 10:00 AM, the facility incident report and investigation of the fall, and interdisciplinary progress notes dated 9/26/15 at 8:30 PM were reviewed and the following was documented: Observed on the floor with hematoma on the left side of head, was informed by certified nurse aide (employee K) that during care the patient rolled out the bed . The resident complained of left shoulder and left leg pain. The nurse assessed and called the physician who ordered the facility to transfer Resident #806 to the hospital for evaluation and treatment. The emergency medical services (EMS) arrived at 9:30 PM and transported Resident #806 to the hospital. The resident returned to the facility on [DATE] with new fractures. The hospital transfer and radiological report showed fractures of the shaft of the left tibia (leg) and fracture of the left clavicle (shoulder). On 12/16/15 at 9:00 AM, Resident #806 was interviewed about the injury that occurred on 9/26/15 and stated, They gave me a bed bath, in the process of getting the bath I fell off the bed. She (employee K) was trying to change my bedding while I was in the bed. She needed help but was by herself. I was turned to the right side of bed. The oxygen tank was sitting there and when I fell it hit my head (on it) .I told her I was too close to the edge of the bed--and then I fell . I am a big person .I now have a cast on my left leg and wear a sling on the left arm. I have fractures. The resident was asked if she was able to move herself independently in bed and indicated that she required help. The resident reported frequent complaints of pain from the fracture of the left leg and shoulder. Employee 'J', who was the certified nurse aide (who provided care) to Resident #806, without another person assisting, was not available for interview. According to a written statement signed by Employee J, the nurse aide wrote the following: At 8:30 PM, I went in to give the patient a bath. The patient was turned, sheet was wet from the bed bath, so CNA changed the sheet. CNA went to grab cream for the resident's bottom turned around and seen the patient on ground (floor) .lose balance . On 12/16/15 at 10:00 AM the Director of Nursing (DON) was interviewed. She reported that the resident was being assisted with the bed bath--and one nurse aide was sufficient. The Director of Nursing reported Resident #806 decided to turn, trying to help the CNA when she rolled onto the floor. The facility falls policy and prevention program was requested but not received by the end of the survey. ( ) Deficit Practice #2 Based on observation, interview, and record review, the facility failed to ensure that a resident who was at risk for accidents was assessed for appropriateness of going outside and self-propelling down driveway (toward incoming traffic) of the facility, for one (#15) supplemental sampled resident reviewed for safety, resulting in a potential being struck by a car. Findings include: On 12/15/15 at 8:00 AM, upon entrance into the facility driveway from a busy urban seven lane highway (Ford Road), Resident #15 was observed in his wheelchair propelling himself self, in the driveway approximately 100 yards towards the front sidewalk. Upon entering the driveway (in car) the resident was asked where he was going and stated, Hi, I am going to the sidewalk to have a cigarette--off the facilities premises. At 2:00 PM the receptionist (Employee M), was asked about Resident #15's smoking habit and leaving the building. Employee M reported that after checking with the Unit Nurse, to make sure Resident #15 signed out for a Leave of Absence (LOA), she would unlock the door and allow the resident to propel himself outside. At 2:05 PM the Director of Nursing was interviewed about Resident #15 being observed propelling his wheelchair on the driveway--toward the sidewalk. The DON stated, This is a non smoking facility and the resident was assessed on admission and indicated that he did not smoke. If I had known he smoked the resident he would have been offered a patch to assist with not smoking or given the option to be transferred to a smoking facility. Additionally, independent resident are allowed to go on a LOA with physician orders. The Director of Nursing was asked about Resident #15's safety, propelling down the driveway, while it was dark. She offered no explanation. Resident #15's clinical record was reviewed. The resident was admitted [DATE]. [DIAGNOSES REDACTED]. The residents smoking assessment was incomplete and there was no physician order in place noting that the resident was medically stable or cleared to go off the premises safely on an LOA in his a wheelchair. A review of the Leave of Absence log noted that the resident of concern signed out on 12-10-15 at 3:00 PM, 12-11-15 at 11:45 AM, 12-12-15 at 10:00 AM and 1:00 PM, 12-13-15 at 9:10 AM, 1:15 PM and 4:33 PM, 12-14-15 at 9:20 AM and 12:00 PM and on 12-15-15, at 7:50 AM, 12:12 PM and 2:00 PM. Upon returning in the facility on 12-15-15 at 2:15 PM, the resident of concern was questioned by the DON about his Leave of Absence (LOA). The resident stated, I was smoking off the premises on the front sidewalk. The resident admitted to having cigarettes and a lighter. A review of the Leave of Absence policy dated 3/2010, Purpose: To provide a system for notification and documentation of a patient's leave of absence from the center authorized by the physician. Procedure: Obtain physician permission for leave of absence from the center and communicate to the patient .any restrictions or recommendations of the physician. ( )

This citation pertains to MI 809 and MI 243 Based on interview, and record review, the facility failed to ensure that fall interventions were in place for 1 (Resident #102) of 3 sampled residents reviewed for falls, in a total sample of 14, resulting in Resident #102 sustaining a hip fracture after a fall where the hipsters were not in place. Findings include: Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #102 was a [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #102 had severe cognitive impairments and required extensive assistance with transfers. Review of the Facility's Falls Practice Guide dated 12/2011, revealed "Fall reduction and injury prevention strategies that can be implemented upon admission may include, but are not limited to the following: ...use of hip protector products as clinically indicated..." Review of the At Risk for Falls Care Plan dated 9/20/12, revealed that on 3/11/13 Resident #102 had an intervention of "Hipsters on around the clock for patient safety" implemented. Review of the "Posey Fall Management" guidelines revealed "Posey Hipsters feature impact absorbing, soft foam pads over the critical fracture area to help reduce the risk of injuries from a fall, such as hip fractures". Review of the General Progress Notes dated 5/19/13 at 12:46 PM, revealed "Res (Resident #102) laying on right side in front of wheelchair in hallway...stat X-rays of Rt (right) hip, Rt shoulder, and Rt leg". Review of Resident #102's X-rays dated 5/19/13, revealed "there is a fracture of the right femur in the intertrochanteric region" (hip fracture). Review of the Facility's investigation revealed "At time of incident, hipsters were not in place". During an interview on 6/18/13, Unit Manager (UM) #3 stated Resident #102's "Hipsters should have been on, but they weren't. We looked for them, but couldn't find them." UM #3 reported that the hipsters were listed on the PIW (Patient Information Worksheet), but the Certified Nursing Assistant (CNA) did not place them on Resident #102. UM #3 stated "the CNA should have known" and the CNA "didn't have the PIW". During an interview on 6/19/13 at 8:35 AM, CNA #6 reported that she cared for Resident #102 on 5/19/13. When queried about Resident #102's hipsters, CNA #6 stated she "didn't have them on that day...they (the hipsters) weren't anywhere in the room. I didn't know she was supposed to have them on". During an interview on 6/19/13 at 2:05 PM, Director of Nursing (DON) #2 stated "hipsters were to reduce the risk of injury...we don't have a reason why hipsters weren't on her (Resident #102)" and "I agree we didn't follow the plan of care". ( )

This citation pertains to intake MI 023. Based on record review, interviews, and observations the facility failed to provide adequate, appropriate supervision and assistance devices to prevent accidents when 1 of 4 sampled residents (resident #204), all reviewed for falls, was transferred onto the toilet without the use of a gait belt and while wearing inappropriate foot wear, resulting in the resident falling onto the bathroom floor and sustaining an acute left tibia fracture. Findings include: An Entrance Conference was held with the Administrator and Director of Nursing. The investigation findings were reviewed. The Director of Nursing identified that an investigation was completed. Approximately three hours following this incident, Resident #204 complained of pain in left lower extremities. The nurse assessed the area and notified the physician. Examinations were ordered, the resident was medicated for pain and ice was applied. The radiology report revealed an acute fracture of the left tibia. The resident was transferred to the hospital for further evaluation and transferred to the acute care facility for orthopedic follow-up. The Director of Nursing noted that the orthopedic doctor and radiology report felt the fracture is pathologic and conservative treatment was ordered. The Incident and Accident Report and nurse's notes dated 11-9-2011 at 5:30 P.M. was reviewed. It identified that while assisting the resident to the bathroom, the resident started to slip and was lowered to floor. The certified nurse aide (#1) asked aide #2 for assistance and helped the resident onto the toilet and then called the nurse into the room and informed of the fall. The resident was assessed. Vital signs were checked: blood pressure 127/68, pulse 82, and temperature 97.9. There were no initial symptoms of pain or range of motion concerns. The resident was offered PRN (as needed) pain medication but refused. The physician and family were contacted. The resident was monitored and at 8:00 P.M. complained of left ankle and foot pain. The resident's left ankle was assessed with [REDACTED]. The physician and family were notified. The physician ordered stat x-rays and PRN (as needed) medication was administered. The radiology report results, dated 11-9-2011 (time not indicated), noted an acute mildly displaced fractures of the left distal tibia and fibula metaphysis, moderate degree of osteoporosis and mild degenerative arthritis. On 11-10-2011 at 12:20 A.M. the resident was transferred to the emergency room for additional evaluation and treatment. The family was notified. Resident #204's clinical record was reviewed. The resident was admitted ,[DATE] and had [DIAGNOSES REDACTED]. The nursing home resident assessment and care screening dated 9-16- noted independent cognitive patterns with mild confusion as evidence of short-term memory impairment. The resident required extensive assistance with activity of daily living and was frequently incontinent of both bowel and bladder. A care plan was in place for fall risk with interventions that included: to encourage and assist to wear proper non-slip footwear, to provide assist with transfer and ambulation. The resident required a one-person assist with all transfers with use of gait belt. The resident was readmitted [DATE] with updated [DIAGNOSES REDACTED]. On 11-22-11 at 1:30 P.M. aide #1 was interviewed by phone. The aide stated, "The resident is limited assistance times one person assist. (Resident #204) stood with slippers (without a gripper bottom) on. We did a two step pivot in front of the toilet. Then, her feet began to slide (due to slippers without a gripper bottom). I had to sit her on the bathroom floor and got help from (aide #2) to sit (resident #204) onto the toilet." Aide #1 voiced being concerned that the resident did not want to urinate on herself. She stated, "The gait belt is standard but I did not have it on. I was chastised by the Director of Nursing but I do not feel that it would have prevented the fall." The personal file for the Certified Nurse Aide (aide #1) was reviewed. The employee had license that were current with no abuse findings. An employee warning notice dated 11-14-2011 (time not indicated) stated on 11-9-2011 the employee failed to properly transfer resident to the toilet by not using a gait belt or ensuring that proper footwear was in place, which resulted in the resident being lowered to the floor. The resident sustained [REDACTED]. The employee was educated on transfer and gait belts as part of the daily uniform for all certified nurse aides. On 11-22-2011 at 4:00 P.M. resident #204 was interviewed. The resident was observed lying in bed, appropriately dressed and groomed. The resident was verbal on approach and had recall of slipping while being assisted to bathroom and fracturing her left ankle. The resident was verbal of occasional pain and use of pain medication. ( ).

THIS CITATION CONTAINS MULTIPLE DEFICIENT PRACTICES. DEFICIENT PRACTICE #1 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT STAFF PROVIDED SAFE TRANSFERS VIA FULL SLING MECHANICAL LIFT FOR ONE (#'S 519) OF 4 RESIDENTS REVIEWED FOR TRANSFERS OUT OF A TOTAL SAMPLE OF 26, RESULTING IN AN IMMEDIATE JEOPARDY (IJ) TO THE RESIDENT'S HEALTH AND SAFETY, TWO FALLS DURING STAFF ASSISTED TRANSFERS, RESIDENT MENTAL ANGUISH AND FEELINGS OF TRAUMATIZATION AND THE POTENTIAL FOR SERIOUS HARM OR DEATH. FINDINGS INCLUDE: AN IMMEDIATE JEOPARDY (IJ) WAS IDENTIFIED ON 9/20/11 AT 5 PM. THE ADMINISTRATOR WAS NOTIFIED OF THE IJ ON 9/30/11 AT 8:30 AM. THE IJ WAS REMOVED ON 9/30/11 BASED ON THE FACILITY'S IMPLEMENTATION OF CORRECTIVE ACTIONS ON 9/30/11, AS VERIFIED ONSITE ON 9/30/11. ALTHOUGH THE IJ WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED AND REMAINED AS A PATTERN OF ACTUAL HARM THAT IS NOT IMMEDIATE JEOPARDY. ON 9/21/11 AT 1:00 P.M., DURING A RESIDENT GROUP MEETING WITH 12 ALERT AND ORIENTED RESIDENTS, THREE OF TWELVE RESIDENTS (#'S 515, 519 AND 1) COMPLAINED THAT SOME FACILITY CERTIFIED NURSING ASSISTANTS (CNAS) WERE NOT ADEQUATELY TRAINED. RESIDENT #519 REPORTED THAT SHE HAD BEEN DROPPED TWICE WHILE CNAS WERE TRANSFERRING HER FROM THE WHEELCHAIR TO BED, USING A MECHANICAL LIFT. RESIDENT #519 STATED THAT SHE WAS "SCARED TO DEATH EVERY TIME SHE GETS IN THE LIFT NOW." RESIDENT #1 STATED THAT RESIDENT CONCERNS WITH CNA COMPETENCY IN USING THE HOYER LIFTS HAD BEEN DISCUSSED AT LEAST TWICE DURING RESIDENT COUNCIL MEETINGS, INCLUDING THE PREVIOUS MONTH'S MEETING. HOWEVER, A REVIEW OF RESIDENT COUNCIL MINUTES REVEALED NO DOCUMENTATION OF THIS. ON 9/22/11 AT 2:30 P.M., RESIDENT #519 WAS INTERVIEWED REGARDING TWO FALLS DURING CNA ASSISTED MECHANICAL LIFT TRANSFERS WHILE IN THE FACILITY. THE RESIDENT WAS SEATED IN A WHEELCHAIR, WAS ALERT AND ORIENTED, AND REPORTED WEAKNESS AND OCCASIONAL PARALYSIS OF THE LOWER EXTREMITIES (LEGS). THE RESIDENT STATED THAT SHE HAD "BEEN DROPPED" TWICE DURING CNA ASSISTED MECHANICAL LIFT TRANSFERS. THE RESIDENT EXPRESSED UNDER NEARLY IDENTICAL CIRCUMSTANCES SHE WAS NOW EXTREMELY FEARFUL OF USING THE LIFT AND VERY WORRIED ABOUT "BEING DROPPED" AGAIN AND SUFFERING SEVERE INJURIES. RESIDENT #519 REPORTED THAT THE FIRST FALL WITH THE MECHANICAL LIFT OCCURRED "ABOUT TWO MONTHS AGO." THE RESIDENT STATED THAT SHE DID NOT REPORT THE FALL BECAUSE SHE FELT THAT "ANYONE CAN MAKE A MISTAKE" AND SHE "DIDN'T WANT TO GET ANYONE IN TROUBLE." THE RESIDENT REPORTED THE FALL OCCURRED AROUND 4:30 P.M., TO 5:00 P.M., WHEN SHE WAS TRANSFERRED TO BED FROM THE WHEELCHAIR. SHE STATED THAT HER ASSIGNED CAREGIVER POSITIONED THE LIFT SLING AND HOOKED IT UP TO THE LIFT, AND THEN REQUESTED ASSISTANCE FROM ANOTHER CNA. THE RESIDENT DESCRIBED THE SECOND CNA AS "BETTER TRAINED." THE RESIDENT STATED THAT WHEN THE CNAS BEGAN TO LIFT HER UP OUT OF THE CHAIR, THEY NOTICED THAT THE LIFT SLING WAS IMPROPERLY POSITIONED UNDER HER BUTTOCKS CAUSING HER TO LOSE BALANCE. THE RESIDENT STATED THAT THE CNAS TRIED TO SET HER BACK DOWN IN THE WHEELCHAIR BEFORE SHE fell BUT MISSED THE EDGE OF THE WHEELCHAIR AND SHE SLID TO THE FLOOR. THE RESIDENT STATED SHE HAD SORE RIBS ON THE LEFT SIDE "FOR A FEW DAYS." WHEN QUERIED, THE RESIDENT STATED SHE DID NOT WANT TO IDENTIFY THE CNAS INVOLVED AS "I DON'T WANT TO GET THEM IN TROUBLE." RESIDENT #519 REPORTED THE SECOND FALL FROM A MECHANICAL LIFT HAPPENED TWO DAYS AGO, ON 9/20/11, AT BETWEEN 4:30 P.M. TO 5:00 P.M., WHILE SHE WAS BEING TRANSFERRED FROM THE WHEELCHAIR TO BED. THE RESIDENT STATED THAT A CNA HOOKED THE SLING UP TO THE LIFT AND GOT ASSISTANCE FROM ANOTHER CNA FOR THE TRANSFER. WHEN THEY LIFTED HER UP OUT OF THE WHEELCHAIR, THE CNAS NOTICED THAT THE LIFT SLING WAS INCORRECTLY POSITIONED UNDER THE RESIDENT'S BUTTOCKS, CAUSING THE RESIDENT TO LOSE BALANCE. THE RESIDENT STATED THE CNAS TRIED TO LOWER HER BACK INTO THE WHEELCHAIR BUT DID NOT HAVE ENOUGH TIME, SO SHE SLID TO THE FLOOR. THE RESIDENT STATED THAT ONE OF THE CNAS CAUGHT HER BY THE RIGHT ARM TO BREAK HER FALL, RESULTING IN SOME SWELLING AND PAIN IN THE MUSCLE ABOVE THE RIGHT ELBOW. THE RESIDENT SAID THAT, THIS TIME SHE WAS SO "TRAUMATIZED" BY THE FALL AND WORRIED THAT IT HAPPENED FOR A SECOND TIME, THAT SHE DID REPORT IT TO THE UNIT MANAGER, NURSE "G". WHEN QUERIED, RESIDENT #519 REFUSED TO IDENTIFY THE CNAS INVOLVED IN THE INCIDENT, STATING, "I DON'T WANT TO TELL YOU BECAUSE THEY TAKE CARE OF ME ALL THE TIME." ON 9/22/11 AT 2:20 P.M., RESIDENT #519'S CLINICAL RECORD AND FACILITY INCIDENT & ACCIDENT REPORTS (I&A) WERE REVIEWED WITH THE UNIT MANAGER, NURSE "G". RESIDENT #519'S FACE SHEET DOCUMENTED ADMISSION to the facility on [DATE]. A PHYSICIAN'S EVALUATION HISTORY DATED 6/21/11 DOCUMENTED THE RESIDENT'S [DIAGNOSES REDACTED]. A MINIMUM DATA SET ASSESSMENT ((MDS) dated [DATE] DOCUMENTED THE RESIDENT HAD NO COGNITIVE IMPAIRMENTS, EXHIBITED NO PROBLEM BEHAVIORS, BUT NEEDED EXTENSIVE ASSISTANCE FROM TWO STAFF FOR MOBILITY IN BED AND TRANSFERS TO THE WHEELCHAIR, DID NOT AMBULATE (WALK), AND NEEDED STAFF ASSISTANCE TO MAINTAIN BALANCE DURING TRANSFERS BETWEEN BED AND CHAIR. RESIDENT #519'S NURSING CARE PLAN FOR ACTIVITIES OF DAILY LIVING (ADLS), DATED 7/1/11, REVEALED THE INTERVENTION, "TRANSFER WITH (MECHANICAL) LIFT WITH TWO (PERSON) ASSIST." PHYSICAL THERAPY CASE MANAGEMENT NOTES FOR 7/18/11 THRU 7/25/11 AND A THERAPY FOLLOW UP COMMUNICATION DATED 7/26/11 FAILED TO DOCUMENT AN ASSESSMENT OF RESIDENT #519'S ABILITY TO SAFELY TRANSFER VIA MECHANICAL LIFT, BUT DOCUMENTED THAT THE RESIDENT NEEDED PHYSICAL ASSISTANCE OF TWO PERSONS FOR TRANSFER VIA A STAND UP LIFT. THERE WAS NO MENTION FOR USE OF THE STAND UP LIFT ON THE ADL CAREPLAN OR AN INDICATION THAT THE ADL CAREPLAN WAS UPDATED AFTER THE PHYSICAL THERAPY NOTES FOR 7/18/11 THRU 7/26/11. A REVIEW OF NURSING NOTES REVEALED NO DOCUMENTATION OF ANY FALL OR ACCIDENT FOR RESIDENT #519 PRIOR TO 9/20/11. A NURSING NOTE DATED 9/20/11 AT 5:20 P.M., DOCUMENTED THE FOLLOWING, "RESIDENT ALERT AND VERBAL. C/O (COMPLAINED) OF DISCOMFORT. (ILLEGIBLE) LOWERED RESIDENT TO FLOOR. NO BRUISING. DENIES HITTING HEAD." THERE WAS NO DOCUMENTATION TO EXPLAIN WHAT HAD OCCURRED TO CAUSE THE RESIDENT TO BE LOWERED TO THE FLOOR OR WHY THE NURSE NEEDED TO DOCUMENT THAT THE RESIDENT WASN'T INJURED. ALL FACILITY INCIDENT REPORTS (I&A) FOR RESIDENT #519 WERE REQUESTED AND ONE INCIDENT REPORT WAS PROVIDED. THIS I&A WAS SIGNED BY THE DIRECTOR OF NURSING (DON) ON 9/21/11. THE REPORT DOCUMENTED THAT RESIDENT #519 HAD SUFFERED A "FALL WITHOUT INJURY (OR MINOR)" ON 9/20/11 AT 5:00 P.M. THE QUESTION TITLED "WAS A MEDICAL DEVICE INVOLVED?" WAS LEFT BLANK (UNCOMPLETED). THE LOCATION WAS "PATIENT ROOM". THE DESCRIPTION OF THE INCIDENT WAS INCOMPLETE AND STARTED WITH THE PHRASE, "DURING APPLICATION, RESIDENT SLID FROM W/C (WHEELCHAIR) LANDING ON BUTTOCKS. CNA MAINTAINED CONTROL OF UPPER BODY, SITTING RESIDENT ON BUTTOCKS. RESIDENT C/O DISCOMFORT OF RIGHT ARM ONLY (FROM CNA HOLDING ONTO ARM)." WHEN ASKED WHETHER THE NURSING NOTE AND THE I&A DOCUMENTING THE 9/20/11 INCIDENT FOR RESIDENT #519 MET FACILITY GUIDELINES AND STANDARDS OF PRACTICE FOR DOCUMENTATION OF ACCIDENTS. UNIT MANAGER "G" REPORTED THAT THE INCIDENT SHOULD HAVE BEEN DESCRIBED INCLUDING THE CNAS INVOLVED IDENTIFIED. UNIT MANAGER "G" ALSO SAID BECAUSE THE INCIDENT WAS RELATED TO A CNA ASSISTED TRANSFER USING A MECHANICAL LIFT SHOULD HAVE BEEN DOCUMENTED. UNIT MANAGER "G" WAS UNABLE TO EXPLAIN WHY THIS HAD NOT BEEN DONE. WHEN QUERIED, UNIT MANAGER "G" COULD ALSO NOT EXPLAIN WHY DOCUMENTATION OF THE INCIDENT HAD BEEN DELEGATED TO CHARGE NURSE "I" AS SHE (UNIT MANAGER G) WAS THE PERSON RESIDENT #519 FIRST REPORTED THE INCIDENT TO ON 9/20/11. UNIT MANAGER "G" COULD NOT EXPLAIN WHY SHE DID NOT FOLLOW STANDARDS OF PRACTICE AND FACILITY PRINCIPLES OF DOCUMENTATION FOR ACCIDENTS AND INCIDENTS, AND DOCUMENT THE IDENTITY OF THE INVOLVED CNAS HERSELF WHEN RESIDENT #519 FIRST TOLD HER ABOUT THE INCIDENT, RIGHT AFTER IT HAPPENED. WHEN QUERIED, THE UNIT MANAGER "G" DENIED KNOWLEDGE OF ANY OTHER FALLS INVOLVING CNA ASSISTED MECHANICAL LIFT TRANSFERS. WHEN ASKED WHETHER THE CNAS HAD REPORTED RESIDENT #519'S FALL ON 9/20/11 TO THE NURSE, THE UNIT MANAGER STATED, "I'M SURE THAT THEY DID. THEY REPORTED IT TO NURSE "I" WHO FILLED OUT THE I&A AND WROTE THE NURSING NOTE DESCRIBING THE INCIDENT." WHEN QUERIED, UNIT MANAGER "G" STATED THAT EVEN A CONTROLLED SLIDE ONTO THE FLOOR IS CONSIDERED A FALL, CNAS SHOULD REPORT IT TO THE CHARGE NURSE, WHO SHOULD COMPLETE AN I&A. UNIT MANAGER "G" WAS UNABLE TO IDENTIFY THE CNAS INVOLVED IN THE INCIDENT AND STATED THAT SHE WOULD HAVE TO LOOK AT THE STAFFING SCHEDULE FOR THAT DAY TO SEE WHO WAS ASSIGNED TO THAT HALLWAY. THIS INFORMATION WAS NOT PROVIDED BY THE TIME OF EXIT. HOWEVER, ON 9/30/11, DURING THE EXTENDED SURVEY, RECORD REVIEW OF FACILITY STAFFING'S ASSIGNMENT REVEALED THAT CNA 'Z' WAS ASSIGNED TO THE RESIDENT ON 9/20/11. WHEN INTERVIEWED BY PHONE REGARDING THE INCIDENT ON 9/30/11 AT 2 PM, CNA 'Z' STATED THAT SHE WAS ASSISTED BY CNA 'AA' DURING THE ATTEMPTED TRANSFER WITH THE MECHANICAL LIFT AND SAID, "NOTHING LIKE THIS HAS HAPPENED BEFORE (A FALL)." ON 9/23/11 AT 11:00 A.M., THE ADMINISTRATOR WAS INTERVIEWED REGARDING RESIDENT #519'S TWO FALLS DURING CNA ASSISTED TRANSFERS BY MECHANICAL LIFT, AND STATED HE WAS UNAWARE OF ANY FALLS RELATED TO A MECHANICAL LIFT TRANSFER. THE ADMINISTRATOR STATED HE DID NOT BELIEVE THAT THERE WAS A PROBLEM WITH CNA COMPETENCY FOR MECHANICAL LIFT TRANSFERS, AS THERE WERE NO I&A DOCUMENTING FALLS INVOLVING MECHANICAL LIFT TRANSFERS. THE ADMINISTRATOR STATED THAT A SLIDE TO THE FLOOR WAS CONSIDERED A FALL, AND CNAS WERE REQUIRED TO REPORT ALL RESIDENT FALLS TO THEIR CHARGE NURSE, WHO WAS REQUIRED TO COMPLETE A FACILITY INCIDENT REPORT, BUT COULD NOT EXPLAIN WHY THERE WAS NO DOCUMENTATION THAT THE CNAS REPORTED EITHER RESIDENT #519'S 9/20/11 FALL OR THE FALL "TWO MONTHS AGO" TO A NURSE, AND WHY THE UNIT MANAGER COULD NOT IDENTIFY THE INVOLVED CNAS. ON 9/23/11 AT 10:00 A.M., THE NURSE WHO WAS IDENTIFIED BY UNIT MANAGER "G" AS THE PERSON WHO WOULD KNOW MORE ABOUT RESIDENT #519'S FALL ON 9/20/11, NURSE "I" WAS INTERVIEWED IN THE PRESENCE OF THE ADMINISTRATOR. NURSE "I" REPORTED THAT UNIT MANAGER "G" CALLED HER INTO RESIDENT #519'S ROOM ON 9/20/11 TO COMPLETE AN I&A. NURSE "I" STATED THAT THE RESIDENT WAS "CRYING" AND "HYSTERICAL", AND STATED THAT SHE WAS "DROPPED" BY THE CNAS DURING A MECHANICAL LIFT TRANSFER BECAUSE "THE SLING HADN'T BEEN PUT ON PROPERLY". WHEN QUERIED, NURSE "I" STATED THAT THE UNIT MANAGER TOLD HER ON 9/20/11, THAT "THE RESIDENT MAY HAVE BEEN DROPPED BEFORE DURING A (MECHANICAL) LIFT TRANSFER." THIS WAS IN CONTRADICTION TO THE STATEMENT MADE BY UNIT MANAGER "G" ON 9/22/11 AT 2:20 P.M., THAT SHE WAS UNAWARE OF ANY OTHER INCIDENTS INVOLVING MECHANICAL LIFT TRANSFERS. NURSE "I" STATED SHE DID NOT RECEIVE ANY REPORT OF RESIDENT #519'S FALL ON 9/20/11 FROM THE CNAS, WHICH CONTRADICTED THE STATEMENT MADE BY NURSE "G" ON 9/22/11 AT 2:20 P.M. THE NURSING NOTE DATED 9/20/11 AT 5:20 P.M., AND THE I&A DATED 9/21/11 WERE REVIEWED WITH THE ADMINISTRATOR, WHO STATED THAT THEY WERE INCOMPLETE AND DID NOT PROVIDE ENOUGH ACCURATE INFORMATION TO IDENTIFY CAUSATIVE FACTORS. THE ADMINISTRATOR STATED THAT THE DOCUMENTATION DID NOT INDICATE CLEARLY THAT RESIDENT #519 HAD SUFFERED A FALL DURING A CNA ASSISTED HOYER LIFT TRANSFER, AND WITHOUT THIS INFORMATION, THE EAGLE ROOM TEAM WAS UNABLE TO IDENTIFY THE APPROPRIATE CORRECTIVE MEASURES AND STAFF TRAINING NEEDED TO PREVENT THIS FROM REOCCURRING. ON 9/23/11 AT 12:55 P.M., THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED AND REPORTED THAT THE EXPECTATIONS FOR I&AS WERE, "THEY SHOULD BE FILLED OUT COMPLETELY AND ACCURATELY EACH TIME A RESIDENT FALLS OR IS INJURED", AND NOTED THAT THIS WAS NOT DONE FOR RESIDENT #519'S FALL ON 9/20/11, OR FOR THE FALL THAT OCCURRED "TWO MONTHS PREVIOUSLY". THE DON NOTED THAT SLIDING TO THE FLOOR IS STILL CONSIDERED A FALL AND SHOULD BE REPORTED TO THE CHARGE NURSE AND DOCUMENTED. THE DON NOTED THAT THE NURSING NOTE DESCRIBING RESIDENT #519'S FALL ON 9/20/11 WAS INCOMPLETE AND MISLEADING. THE DON ALSO STATED, "I HAVE INSERVICED (EDUCATED) THE NURSES ON DOCUMENTATION OF ACCIDENTS AND INJURIES AND FILLING OUT THE I&A SO WE CAN DETERMINE THE ROOT CAUSE OF THE ACCIDENT AND IMPLEMENT THE APPROPRIATE CORRECTIVE MEASURES", BUT COULD NOT EXPLAIN WHY RESIDENT #519'S PREVIOUS FALL "TWO MONTHS AGO" WAS NOT DOCUMENTED, AND WHY THE 9/20/11 FALL DOCUMENTATION WAS INCOMPLETE AND MISLEADING. THE DON ALSO STATED THAT IT WAS "AN EXPECTATION" THAT CNAS SHOULD IMMEDIATELY TELL THEIR CHARGE NURSE WHEN A RESIDENT FALLS, AND COULD NOT EXPLAIN WHY THE CNAS DID NOT DO THIS FOR RESIDENT #519'S FALL ON 9/20/11, OR WHEN SHE fell TWO MONTHS EARLIER. THE DON WAS UNABLE TO STATE WHETHER THE SAME CNAS WERE INVOLVED IN BOTH OF RESIDENT #519'S FALLS DURING THE MECHANICAL LIFT TRANSFERS, OR WHETHER THEY HAD ATTENDED INSERVICE TRAINING AND PERFORMANCE COMPETENCY EVALUATIONS. A FACILITY FALLS PREVENTION POLICY WAS REQUESTED AND A CORPORATE "FALLS PRACTICE GUIDE", DATED 4/2008 WAS PROVIDED THAT PROVIDED NO GUIDANCE ON ACCURATE AND COMPLETE DOCUMENTATION OF FALLS, OR OF CNA RESPONSIBILITY TO REPORT FALLS TO THEIR CHARGE NURSE. ON 9/30/11 AT 4:59 P.M., THE FACILITY PRESENTED THE FOLLOWING PLAN OF CORRECTION: 1. THE FACILITY TOOK IMMEDIATE ACTION THROUGH QUALITY ASSESSMENT AND ASSURANCE RELATIVE TO ALLEGATION THAT IT FAILED TO ENSURE A SAFE TRANSFER OF RESIDENT #519 USING A FULL SLING MECHANICAL LIFT. EDUCATION WAS PROVIDED ON APPROPRIATE MECHANICAL LIFT USAGE. ON SEPTEMBER 30 2011 12 OF 40 NURSES AND 13 OF 69 CENA'S RECEIVED EDUCATION AND DEMONSTRATION RETURN COMPETENCY ON THE FOLLOWING: MECHANICAL LIFT USAGE, APPROPRIATE LIFT PER CARE PLAN, ASSESSMENT OF APPROPRIATE SLING SIZE, APPROPRIATE INFORMATION RELATED TO TRANSFERS FOUND NON CENA'S KARDEX. AS OF 9/30/2011 THERE REMAINS 28 NURSES AND 56 CENA'S REQUIRING EDUCATION WHICH WILL BE COMPLETED PRIOR TO THE START OF THEIR NEXT SCHEDULED SHIFT WITH RETURN DEMONSTRATION. EDUCATION FOR LICENSED NURSES AND CENA'S WILL BE COMPLETED BY 9?30/2011 OR THEY WILL NOT BE ALLOWED TO WORK. IMMEDIATE QUALITY ASSESSMENT AND ASSURANCE COMMITTEE WAS HELD RELATIVE TO RESIDENT #519. FACILITY HAS 3-4 HOYER LIFTS IN SERVICE. MAINTENANCE DIRECTOR INSPECTED LIFTS THAT ARE IN SERVICE AND FOUND NO MECHANICAL DEFICIENCIES; SLINGS ARE IN WORKING ORDER. RESIDENT #519 HAD HEAD TO TOE ASSESSMENT BY NURSE WITH NO CHANGES NOTED. #519 WAS EVALUATED BY THERAPY AND SEEN BY SOCIAL WORK. #519 CONTINUES TO PARTICIPATE IN DAILY ACTIVITIES IN THE FACILITY. THE RESIDENT'S CARE PLAN AND MODE OF TRANSFERS HAS BEEN REVIEWED WITH UPDATES AS INDICATED. SOCIAL SERVICES HAS INTERVIEWED RESIDENT RELATED TO POTENTIAL PSYCHO-SOCIAL NEEDS NO CHANGES IN MOOD OR BEHAVIOR NOTED. APPROPRIATE REFERRALS IF INDICATED FOR ANY IDENTIFIED CONCERNS WILL BE COMPLETED BY 9/30/11. RESIDENT #519 REMAINS IN THE CENTER. 2. 30 LIKE RESIDENTS ARE THOSE USING FULL SLING MECHANICAL LIFT FOR TRANSFERS. RESIDENTS WHO HAVE BEEN IDENTIFIED AS USING FULL SLING MECHANICAL LIFT FOR TRANSFERS HAVE BEEN REVIEWED BY NURSE MANAGERS FOR APPROPRIATE MECHANICAL LIFT USAGE AND CARE PLANS REVIEWED WITH REVISIONS AS WARRANTED. 3. EDUCATION WAS PROVIDED RELATIVE TO APPROPRIATE MECHANICAL LIFT USAGE WITH RETURN DEMONSTRATION. ON SEPTEMBER 30, 2011 12 OF 40 NURSES AND 13 AF 69 CENAS RECEIVED EDUCATION ON THE FOLLOWING: MECHANICAL LIFT USAGE, APPROPRIATE LIFT PER CARE PLAN, ASSESSMENT OF APPROPRIATE SLING SIZE, APPROPRIATE INFORMATION RELATED TO TRANSFERS FOUND ON CENA KARDAX. INCIDENT PROCESS FLOW CHART TO BE FOLLOWED IN THE EVENT OF AN ACCIDENT OR INCIDENT. AS OF 9/30/2011 THERE REMAIN 28 NURSES AND 56 CENAS REQUIRING EDUCATION WHICH WILL BE COMPLETED PRIOR TO THE START OF THEIR NEXT SCHEDULED SHIFT. EDUCATION FOR LICENSED NURSES AND CENAS WILL BE COMPLETED BY 9/30/1011 OR THEY WILL NOT BE ALLOWED TO WORK. 4. THE DON OR DESIGNEE SHALL COMPLETE RANDOM OBSERVATIONS OF FULL SLING MECHANICAL LIFT TRANSFERS OF 20% OF IDENTIFIED LIKE RESIDENTS STARTING 9/30/11. SOCIAL SERVICES OR DESIGNEE SHALL COMPLETE RANDOM INTERVIEWS OF 20% OF IDENTIFIED LIKE RESIDENTS WEEKLY FOR 4 WEEKS FOR POTENTIAL PSYCHO-SOCIAL CONCERNS. FINDINGS OF AUDITS/CONCERNS SHALL BE SUBMITTED TO FACILITY QAA FOR FOLLOW-UP AND RESOLUTION. 5. THE ADMINISTRATOR IS RESPONSIBLE FOR ATTAINING AND MAINTAINING COMPLIANCE. ( , , , , , ) DEFICIENT PRACTICE #2 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT TWO PERSON'S ASSISTED IN A FULL SLING MECHANICAL LIFT FOR ONE ( # 526) SAMPLED RESIDENT OF TWO RESIDENTS SAMPLED, RESULTING IN POTENTIAL FALLS WITH INJURY. FINDINGS INCLUDE: ON 9/30/11 AT 8:45 A.M., DURING THE EXTENDED SURVEY, AN OBSERVATION WAS MADE OF A FULL SLING MECHANICAL LIFT WITH CERTIFIED NURSE ASSISTANT (CNA) "X" ON RESIDENT #526. CNA "X" APPLIED AN EXTRA LARGE SLING UNDERNEATH THE RESIDENT AND PROCEEDED TO CONNECT THE SLING ATTACHMENT CLIPS TO THE ATTACHMENT POINTS ON THE LIFT. CNA "X" THEN LIFTED RESIDENT #526 UP WITH THE MECHANICAL LIFT FROM THE RESIDENTS BED AND TRANSFER HER TO THE AWAITING WHEELCHAIR. CNA "X" DID THE PROCEDURE WITHOUT ANY ASSISTANCE. WHEN QUERIED CNA "X" ABOUT THE SINGLE PERSON LIFT TRANSFER, SHE SAID "SHE (THE RESIDENT) IS A ONE PERSON LIFT TRANSFER." "THAT INFORMATION IS ON THE PATIENT INFORMATION WORKSHEET (PIW)." ON 9/30/11 AT 9:00 A.M., REVIEW OF THE CURRENT MEDICAL RECORD AND THE PIW FOR RESIDENT #526 REVEALED THAT THE RESIDENT WAS admitted on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ASSESSMENT ((MDS) dated [DATE] IDENTIFIED THE RESIDENT AS COGNITIVELY INTACT AND REQUIRED TWO PERSON, EXTENSIVE ASSISTANCE WITH TRANSFERS. THE PIW, UNDATED ON 9/30/11, DOCUMENTED "LIFTING DEVICE ASSIST X 2." REVIEW OF THE CURRENT ACTIVITIES OF DAILY LIVING (ADL) PLAN OF CARE, HAD AN INTERVENTION OF TRANSFER WITH TOTAL LIFT "WITH TWO PERSON ASSIST." ON 9/30/11 AT 3:00 P.M., QUERIED UNIT MANAGER (UM) "G" WAS QUERIED REGARDING RESIDENT #526'S MECHANICAL LIFT ASSISTANCE STATUS, SHE SAID SHE WAS "GOING TO LOOK AT HER (THE RESIDENT'S) CHART, AND GET BACK TO YOU." UM "G" DID NOT RETURN WITH ANY ADDITIONAL INFORMATION BY THE TIME OF THE EXTENDED SURVEY EXIT. PER THE FACILITY'S "MECHANICAL LIFT" POLICY, DATED 3/10; "ALTHOUGH ON PERSON CAN OPERATE MOST MODELS OF HYDRAULIC LIFTS, IT'S ADVISABLE TO HAVE TWO STAFF MEMBERS PRESENT TO STABILIZE AND SUPPORT THE PATIENT." ( ) DEFICIENT PRACTICE #3 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT SAFETY DEVICES WERE IMPLEMENTED AS ORDERED AND ADEQUATE SUPERVISION WAS PROVIDED TO PREVENT FALLS, INCLUDING A FALL WITH INJURY FOR FOUR (#'S 507, 511,513 AND 514) OF 11 SAMPLED RESIDENTS REVIEWED FOR FALLS OUT OF A TOTAL SAMPLE OF 26, RESULTING IN A TRANSFER TO THE HOSPITAL emergency room FOR SUTURES (STITCHES), CONTUSIONS (BRUISES WITH SWELLING) OF THE FACE, HIP PAIN, AND A CLOSED HEAD INJURY, AND THE POTENTIAL FOR INJURIES FROM ADDITIONAL FALLS. FINDINGS INCLUDE; ON 9/20/11 AT 9:00 A.M., RESIDENT #514 WAS IN A WHEELCHAIR IN THE ROOM, WITH A PERSONAL SAFETY ALARM ATTACHED TO THE WHEELCHAIR. THE RESIDENT WAS ALERT WITH CONFUSION AND MEMORY IMPAIRMENT. ON 9/22/11 AT 2:40 P.M., RESIDENT #514'S CLINICAL RECORD AND FACILITY INCIDENT AND ACCIDENT REPORTS WERE REVIEWED WITH THE UNIT MANAGER, NURSE "G". RECORD REVIEW REVEALED THAT THE RESIDENT WAS FOUND ON THE FLOOR ON 8/5/11 AT 7:00 P.M. WITH HEAD AND FACE INJURIES. RESIDENT #514 WAS TRANSFERRED TO THE HOSPITAL FOR EMERGENCY CARE. RECORD REVIEW DOCUMENTED THE RESIDENT REQUIRED SUTURES (STITCHES) OF THE FOREHEAD WITH A [DIAGNOSES REDACTED]. A FACE SHEET DOCUMENTED RESIDENT #514 WAS REadmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ASSESSMENT ((MDS) dated [DATE] DOCUMENTED THE RESIDENT HAD SEVERE COGNITIVE IMPAIRMENT (DEMENTIA). THE MDS ALSO DOCUMENTED THAT THE RESIDENT NEEDED EXTENSIVE PHYSICAL ASSISTANCE FOR BED MOBILITY, TRANSFERS, AMBULATION (WALKING), DRESSING, EATING, AND HYGIENE, AND WAS INCONTINENT OF BOWEL AND BLADDER. THE MDS CODED THE RESIDENT'S ABILITY TO BALANCE AS UNSTEADY, NEEDING HUMAN ASSISTANCE TO STABILIZE WHILE MOVING FROM SITTING TO STANDING, WHILE WALKING, AND WHEN MOVING BETWEEN BED AND WHEELCHAIR. REVIEW OF THE ADMISSION PHYSICIAN ORDERS [REDACTED]. CHECK PLACEMENT Q (EVERY) SHIFT." A FACILITY INCIDENT REPORT (I&A) DATED 8/5/11 REVEALED RESIDENT #514 WAS FOUND ON THE FLOOR OF HER ROOM ON 8/5/11 AT 7:00 P.M. THE "DESCRIPTION OF INCIDENT" STATED, "OBSERVED ON FLOOR IN ROOM. LACERATION (DEEP CUT THROUGH ALL LAYERS OF SKIN) TO FOREHEAD AND UPPER LIP NOTED. PT DID NOT KNOW SHE HAD FALLEN OR WHY, C/O (COMPLAINED) OF HEAD AND BACK PAIN. EMS (EMERGENCY MEDICAL SERVICE) CALLED. PATIENT TRANSPORTED TO HOSPITAL." THERE WAS NO DOCUMENTATION TO INDICATE THAT THE RESIDENT'S PERSONAL ALARM WAS IN PLACE AND FUNCTIONING, AS ORDERED BY THE PHYSICIAN. A NURSING NOTE DATED 8/6/11 AT 08:20, DOCUMENTED THE FOLLOWING, 'THIS WRITER WAS MADE AWARE THAT PATIENT FOUND LYING ON FLOOR IN HER ROOM AT 0700 ON 8/5/11. LACERATION ON LEFT FOREHEAD AREA APPROXIMATELY 1 INCH BY 1/4 INCH WITH BLOODY DRAINAGE. PATIENT C/O HEAD AND BACK PAIN AT THIS TIME. AT 11:00 P.M., PATIENT RETURNED FROM HOSPITAL VIA AMBULANCE, ALERT TO NAME ONLY. PATIENT DID NOT REMEMBER OR EVEN KNOW THAT SHE fell DOWN. SHE HAD SEVEN SUTURES LEFT FOREHEAD AREA. LEFT UPPER LIP EDEMATOUS (SWOLLEN). PATIENT EDUCATED AS TO IMPORTANCE OF ASKING FOR ASSISTANCE WITH WALKING." THE UNIT MANAGER, NURSE "G" WAS QUERIED ABOUT THE EVENTS LEADING UP TO RESIDENT #514'S INJURY ON 8/5/11, AND WAS UNABLE TO STATE WHETHER THE PERSONAL ALARM WAS IN PLACE AND FUNCTIONING AT THE TIME OF THE INJURY, AS ORDERED BY THE PHYSICIAN. THE UNIT MANAGER STATED THAT RESIDENT #514'S ALARM SHOULD HAVE ALARMED IF THE RESIDENT STOOD UP, AND COULD NOT EXPLAIN WHY THERE WAS NO DOCUMENTATION OF THIS. WHEN QUERIED, NURSE "G" ALSO COULD NOT EXPLAIN HOW A RESIDENT WITH SEVERE COGNITIVE IMPAIRMENT WOULD REMEMBER TO ASK STAFF FOR ASSISTANCE BEFORE ATTEMPTING TO GET UP. A HOSPITAL ER ATTENDING NOTE FOR RESIDENT #514 DATED 08/05/11 AT 22:38, REVEALED THE FOLLOWING, "HISTORY OF PRESENT ILLNESS: ACCORDING TO EMS THE PATIENT WAS SITTING IN HER WHEELCHAIR AND GOT UP TO WALK ON HER OWN. PATIENT IS A FALL RISK AND NOT ALLOWED TO DO THIS ON HER OWN. THEY STATE ACCORDING TO THE FACILITY STAFF THAT THE PATIENT fell FORWARD LANDING ON HER FACE ON A HARD FLOOR." THE ER REPORT NOTED THAT THE RESIDENT RECEIVED SEVEN STITCHES FOR A ONE AND 1/2 INCH LACERATION ON THE UPPER FOREHEAD. RESIDENT #514'S INTERIM (TEMPORARY POST ADMISSION) NURSING CARE PLANS FOR FALLS PREVENTION PRIOR TO THE 8/5/11 FALL WERE REQUESTED BUT NOT PROVIDED. ON 9/23/11 AT 12:00 P.M., THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED REGARDING RESIDENT #514'S 8/5/11 INJURY, AND COULD NOT PROVIDE ANY EVIDENCE THAT RESIDENT #514'S ALARM WAS IN PLACE AND FUNCTIONING AT THE TIME OF THE RESIDENT'S FALL ON 8/5/11. WHEN QUERIED, THE DON COULD NOT EXPLAIN WHY RESIDENT #514 WAS NOT ADEQUATELY SUPERVISED PRIOR TO THE FALL, BUT WAS FOUND ON THE FLOOR BY AN UNIDENTIFIED PERSON. A FACILITY FALLS PREVENTION POLICY WAS REQUESTED AND A CORPORATE "FALLS PRACTICE GUIDE", DATED 4/2008 WAS PROVIDED THAT PROVIDED NO GUIDANCE ON CONSISTENT IMPLEMENTATION OF SAFETY DEVICES TO PREVENT FALLS. ( ) ON 9/20/11 AT 12:10 P.M., RESIDENT #511 WAS IN THE ROOM IN A WHEELCHAIR, WITH A RIGHT WRIST BRACE AND A CERVICAL COLLAR (NECK BRACE), A HALF TRAY TABLE ON THE WHEELCHAIR, AND SENSOR PAD ALARMS (PERSONAL SAFETY DEVICE) ON THE WHEELCHAIR AND BED. THE RESIDENT WAS ORIENTED TO SELF, WITH SOME CONFUSION. THE RESIDENT WAS CALLING OUT, "HELP! HELP! I NEED TO GO TO THE TOILET. HELP!" THE RESIDENT'S CALL LIGHT WAS ON THE FLOOR, OUT OF REACH. THE RESIDENT CONTINUED TO CALL FOR HELP FOR 25 MINUTES, UNTIL CNA "M" ENTERED THE ROOM AT 12:35 P.M. ON 9/20/11 AT 12:35 P.M., CNA "M" ENTERED THE ROOM TO ASSIST RESIDENT #511. RESIDENT #511 STATED "PLEASE, I NEED TO GO TO THE TOILET SO I DON'T MAKE IT IN MY PANTS." ON 9/22/11 BETWEEN 8:45 A.M., AND 12:30 P.M., RESIDENT #511 WAS OBSERVED SEATED IN A WHEELCHAIR WITH NO SENSOR PAD ALARM ATTACHED. AT 12:30 P.M., UPON REQUEST, CNA "M" CHECKED RESIDENT #511'S WHEELCHAIR, AND CONFIRMED THAT THERE WAS NO SENSOR PAD ALARM APPLIED. ON 9/22/11 AT 2:40 P.M., RESIDENT #511'S CLINICAL RECORD AND INCIDENT REPORTS (I&A) WERE REVIEWED WITH THE UNIT MANAGER, NURSE "G", AND REVEALED THE RESIDENT HAD FALLEN THREE TIMES IN THE FACILITY PER NURSING NOTES, BUT I&A WERE FOUND FOR ONLY TWO OF THE FALLS. RESIDENT #511'S FACE SHEET DOCUMENTED ADMISSION to the facility on [DATE]. A physician's orders [REDACTED]. A MINIMUM DATA SET ASSESSMENT ((MDS) dated [DATE], DOCUMENTED THAT RESIDENT #511 HAD SEVERE COGNITIVE IMPAIRMENT (DEMENTIA), NEEDED EXTENSIVE STAFF ASSISTANCE FOR MOBILITY IN BED, AMBULATION (WALKING), DRESSING, EATING AND HYGIENE, AND NEEDED EXTENSIVE ASSISTANCE FROM TWO STAFF FOR TRANSFERS FROM BED TO THE WHEELCHAIR. THE MDS ALSO DOCUMENTED THAT RESIDENT #511 WAS CONTINENT OF STOOL, FREQUENTLY INCONTINENT OF BLADDER, had a history of [REDACTED]. AN ADMISSION FALLS RISK assessment dated [DATE] NOTED THAT RESIDENT #511 WAS AT HIGH RISK FOR FALLS. HOSPITAL DISCHARGE/TRANSFER INSTRUCTIONS FOR RESIDENT #511, DATED 8/21/11 REVEALED THE FOLLOWING "SPECIAL INSTRUCTIONS", "FALL PRECAUTIONS". ADMISSION physician's orders [REDACTED]. CHECK PLACEMENT EACH SHIFT AND AS NECESSARY. A NURSING CARE PLAN FOR "AT RISK FOR FALLS" FOR RESIDENT #511, DATED 8/31/11 INCLUDED THE FOLLOWING INTERVENTIONS, "BED BOLSTERS AT ALL TIMES WHEN RESIDENT IS IN BED", "ENSURE THAT ALARM IS IN PLACE WHEN IN WC/BED", "CHECK PLACEMENT Q (EACH) SHIFT AND PRN (AS NECESSARY)", "LOW BED WITH MATS", "REINFORCE NEED TO CALL FOR ASSISTANCE." A POST ADMISSION INTERIM (TEMPORARY) CARE PLAN FOR FALLS FOR RESIDENT #511 WAS REQUESTED BUT NOT PROVIDED. A NURSING NOTE DATED 8/25/11 (NO TIME NOTED), DOCUMENTED RESIDENT #511 SUFFERED A FALL, "PATIENT (PT) OBSERVED ON FLOOR NEXT TO WHEELCHAIR, PT SAID SHE WAS TRYING TO GET IN BED, PT EDUCATED ON SAFETY AND THE USE OF CALL LIGHT." THERE WAS NO DOCUMENTATION OF THE ALARM SOUNDING, AND NO DOCUMENTATION OF WHETHER THE ALARM WAS IN PLACE AND FUNCTIONING AT THE TIME OF THE FALL, OR WHETHER THE ALARM WAS IN PLACE WHEN THE RESIDENT WAS PLACED IN BED AFTER THE FALL. A FACILITY INCIDENT REPORT (I&A) DATED 8/25/11 AT 3:14 P.M., DOCUMENTED THAT RESIDENT #511 HAD SUFFERED A FALL ON 8/25/11 AT 3:13 P.M. THE I&A NOTED, "PATIENT TRYING TO GET UP UNASSISTED FROM WHEELCHAIR TO BED." THERE WAS NO FURTHER DESCRIPTION OF THE EVENT. "DESCRIBE POSSIBLE CAUSE OF INCIDENT" WAS DOCUMENTED AS, "PATIENT GETTING OUT OF CAR UNASSISTED." UNIT MANAGER "G" WAS QUERIED ABOUT THIS, AND WAS UNABLE TO PROVIDE DOCUMENTATION THE ALARM WAS IN PLACE AND FUNCTIONING AT THE TIME OF THE FALL. THE UNIT MANAGER WAS QUERIED AS TO WHY RESIDENT #511'S ALARM WAS NOT IN PLACE ON THE MORNING OF 9/22/11, AND REPORTED "IT WAS A COMPUTER GLITCH ON THE PIW (PATIENT INFORMATION WORKSHEET) (CNA DAILY CARE GUIDE), THE ALARM GOT DELETED OFF." THE UNIT MANAGER WAS UNABLE TO PROVIDE DOCUMENTATION THAT PIW ON 8/25/11 NOTED THE ALARM. THE THE UNIT MANAGER "G" WAS ALSO UNABLE TO STATE WHETHER THE CALL LIGHT HAD BEEN IN REACH AT THE TIME OF RESIDENT #511'S FALL ON 8/25/11, OR WHETHER THE RESIDENT USUALLY TOOK A NAP IN THE AFTERNOON, AND WAS NOT PUT TO BED ON TIME ON THAT DATE. THE UNIT MANAGER REPORTED THAT CORRECTIVE MEASURES TO PREVENT FALL REOCCURRENCE WERE TO EDUCATE THE RESIDENT ON THE USE OF THE CALL LIGHT WHEN NEEDING TO AMBULATE, AND OT (OCCUPATIONAL THERAPY) TO EVALUATE THE RESIDENT FOR A SEATING EVALUATION, WHICH RESULTED IN THE APPLICATION OF A HALF TRAY TABLE TO THE WHEELCHAIR TO HELP WITH SEATED BALANCE. IT WAS UNCLEAR HOW THIS WOULD PREVENT THE RESIDENT FROM ATTEMPTING TO TRANSFER OUT OF THE WHEELCHAIR WITHOUT ASSISTANCE. THE UNIT MANAGER WAS UNABLE TO EXPLAIN HOW A RESIDENT WITH MEMORY IMPAIRMENT AND ADVANCED DEMENTIA WOULD REMEMBER TO USE THE CALL LIGHT BEFORE GETTING UP, AND HOW THIS WOULD WORK IF THE CALL LIGHT WAS OUT OF REACH, AS WAS OBSERVED ON 9/20/11 AT 12:10 P.M. ON 9/24/11 AT 9:30 A.M., THE REHABILITATION DIRECTOR REPORTED THAT RESIDENT #511'S HALF TRAY TABLE WAS A TRUNK STABILIZATION DEVICE, NOT A RESTRAINT , AS IT WOULD NOT STOP UNASSISTED TRANSFERS, AND COULD NOT EXPLAIN WHY THIS WAS CONSIDERED A CORRECTIVE MEASURE TO PREVENT FALLS DUE TO UNASSISTED TRANSFERS. A NURSING NOTE DATED 8/28/11 AT 7:45 A.M., DOCUMENTED THAT RESIDENT #511 SUFFERED A SECOND FALL IN THE FACILITY. THE NOTE STATED, "AT 5:30 A SAFETY ALARM STARTED. STAFF ENTERED ROOM OBSERVE PT BEDSIDE ON PADDED FLOOR MAT. ALL FALL PRECAUTIONS AS ORDERED WITH BEDSIDE BOLSTERS ADDED. CALL LIGHT IN REACH." AN I&A DATED 8/28/11 AT 8:08 A.M., DOCUMENTED THE SAME FALL, ON 8/28/11 AT 7:45 A.M.,WITH NO ADDITIONAL INFORMATION. A NURSING NOTE DATED 8/30/11 AT 2:50 A.M., REVEALED THAT RESIDENT #511 SUFFERED A THIRD FALL IN THE FACILITY, DOCUMENTING, "AT 1:15 A.M., PT WAS OBSERVED ON FLOOR ON HER KNEES WITH PT LEANING ON BED WITH CAST OFF THAT WAS ON RIGHT ARM. PT ALREADY HAD FLOOR PADS, BED IN LOWEST POSITION AND ASKED PT TO USE CALL LIGHTS IF SHE NEEDED ANYTHING. SAFETY ALARM ON BED WITH BED BOLSTERS. CALL LIGHT WITHIN REACH." THE UNIT MANAGER "G" WAS UNABLE TO PROVIDE A FACILITY INCIDENT REPORT FOR RESIDENT #511'S FALL ON 8/30/11, AND STATED THAT SHE WAS UNAWARE OF THIS FALL. ON 9/23/11 AT 12:50 P.M., THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED, AND WAS UNABLE TO PROVIDE ANY ADDITIONAL INFORMATION OR AN I&A FOR RESIDENT #511'S FALL ON 8/30/11. THE DON STATED THAT THE EAGLE ROOM TEAM COULD NOT EFFECTIVELY ASSESS FOR ROOT CAUSES OF A RESIDENT'S FALLS AND THEN DETERMINE APPROPRIATE CORRECTIVE MEASURES, IF FACILITY I&A WERE NOT COMPLETED WHEN FALLS OCCURRED. THE DON COULD NOT EXPLAIN WHY RESIDENT #511'S CALL LIGHT WAS OUT OF REACH, AND WHY THE RESIDENT HAD TO CALL OUT FOR HELP FOR 25 MINUTES TO GET TOILETING ASSISTANCE. THE DON COULD ALSO NOT EXPLAIN WHY A SAFETY ALARM WAS DELETED FROM THE PIW OF A RESIDENT AT HIGH RISK FOR FALLS, AND WHY STAFF DID NOT NOTICE THAT THE ALARM WAS MISSING FROM THE CARE GUIDE BEFORE IMPLEMENTING CARE. THE FACILITY POLICY ON DOCUMENTATION OF FALLS, AND FALLS PREVENTION WAS REQUESTED, AND A CORPORATE MANUAL TITLED, "FALLS PRACTICE GUIDE", DATED 04/2008 WAS PROVIDED, BUT FAILED TO PROVIDE ANY ADDITIONAL INFORMATION. ( ) ON 9/20/11 AT 09:10 A.M., DURING THE INITIAL TOUR OF THE GREEN UNIT, RESIDENT #513 WAS UP IN A WHEELCHAIR IN THE DINING ROOM EATING. THE RESIDENT HAD NO SAFETY DEVICES ATTACHED TO THE WHEELCHAIR. AT 11:45 A.M., RESIDENT #513 WAS OBSERVED SCOOTING TO THE END OF THE WHEELCHAIR. THE RESIDENT THEN LIFTED HER UPPER BODY OUT OF THE WHEELCHAIR AND SWUNG HERSELF IN BED. THERE WAS NO STAFF IN ATTENDANCE AND NO ALARM SOUNDED TO LET STAFF KNOW THAT THE RESIDENT HAD SELF-TRANSFERRED OUT OF THE WHEELCHAIR UNTO TO THE BED WITHOUT ASSISTANCE. ON 9/21/ 11 AT 9:10 A.M., RESIDENT #513 WAS OBSERVED UP IN A WHEELCHAIR IN THE DINING ROOM EATING BREAKFAST. THERE WAS NO SAFETY DEVICE ATTACHED TO THE RESIDENT'S WHEELCHAIR. ON 9/22/11 AT 2:15 P.M., RESIDENT #513 WA

THIS CITATION HAS MULTIPLE DEFICIENT PRACTICES: 1. BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE INTERVENTIONS TO MAINTAIN SKIN INTEGRITY FOR ONE (#501) OF 13 SAMPLED RESIDENTS REVIEWED FOR PRESSURE SORES FROM A TOTAL OF 26, RESULTING IN THE DEVELOPMENT OF A PRESSURE SORE. FINDINGS INCLUDE: ON 9/20/11 AT 4 PM, THE CLINICAL RECORD FOR RESIDENT #501 WAS REVIEWED WITH THE DIRECTOR OF NURSING (DON). THE RESIDENT WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. THE RESIDENT HAD STAPLES TO THE RIGHT HIP DUE TO SURGICAL REPAIR OF THE FRACTURE. THE 8/22/11 MINIMUM DATA SET (MDS) NOTED THAT THE RESIDENT REQUIRED EXTENSIVE ASSISTANCE WITH TRANSFERS AND BED MOBILITY. SHE WAS ALSO NON-AMBULATORY AND HAD TWO STAGE TWO (II) (PARTIAL SKIN THICKNESS) PRESSURE SORES (IDENTIFIED AS BLISTERS) AT THE SURGICAL SITE. RESIDENT #501'S ADMISSION assessment dated [DATE], NOTED THAT THE RESIDENT WAS AT "LOW RISK" WITH A SCORE OF 15, FOR DEVELOPMENT OF PRESSURE SORES PER THE BRADEN (PRESSURE SORE) RISK SCALE. THERE WAS NO DOCUMENTED SKIN INTEGRITY CARE PLAN AFTER ADMISSION ON 8/13/11, UNTIL 8/22/11. THE CARE PLAN NOTED HOWEVER, THAT THE RESIDENT HAD A BRADEN SCORE OF 13 (MODERATE RISK). THE CARE PLAN ALSO NOTED THAT THE RESIDENT WAS "AT RISK" FOR ALTERATION IN SKIN INTEGRITY WITH EVEN THOUGH, PER TREATMENT RECORDS, ON 8/21/11, THE RESIDENT BEGAN TO RECEIVE WOUND CARE FOR A PRESSURE SORE ON THE CENTER OF HER BACK. THE CARE PLAN INTERVENTIONS INCLUDED: ENCOURAGE AND ASSIST TO REPOSITION AS NEEDED AND USE PILLOWS/POSITIONING DEVICES AS NEEDED. THE TREATMENT RECORDS NOTED THAT RESIDENT #501 WAS TO RECEIVE A DAILY WOUND TREATMENT WITH [MEDICATION NAME] AND A DRESSING CHANGE BY THE 7 PM-7 AM SHIFT. THE RECORD INDICATED THAT THE TREATMENT WAS NOT DONE ON 8/25 AND 8/26/11 WITH NO DOCUMENTED REASON WHY. WHEN THE TREATMENT BEGAN ON 8/21/11, THERE WAS NO DOCUMENTED DESCRIPTION OF THE PRESSURE SORE AND THERE WAS NO MENTION IN NURSES NOTES ON 8/21/11 THAT THE RESIDENT EVEN HAD A WOUND. WHEN QUERIED ABOUT THE MISSING DOCUMENTATION AND THE MISSED TREATMENTS, THE DON SAID, "I DON'T KNOW WHAT TO TELL YOU." ON 8/23/11, AN ORDER WAS WRITTEN FOR A WOUND CONSULT WITH THE WOUND SPECIALTY TEAM. ON 8/23/11, THE WOUND TEAM SAW THE RESIDENT AND NOTED: PRESSURE ULCER, STAGE THREE (III) (FULL SKIN THICKNESS DOWN TO UNDERLYING TISSUE), MID LUMBAR SPINE, MEASURING 2.0 X 2.2 CENTIMETER (CM)WITH NO DEPTH. THE WOUND HAD A MODERATE AMOUNT OF SEROUS (BLOODY) DRAINAGE. A PRESSURE REDUCTION MATTRESS, DAILY [MEDICATION NAME] TREATMENT WITH DRESSING, AND FREQUENT REPOSITIONING WAS RECOMMENDED. ON 8/30/11, THE WOUND CARE ORDER WAS CHANGED FROM [MEDICATION NAME] TO SANTYL (A [MEDICATION NAME] AGENT) AND [MEDICATION NAME] (ANTIBACTERIAL) POWDER DAILY FOR 14-DAYS AND "FREQUENT REPOSITIONING." THERE WAS NO DOCUMENTED REASON FOR THE TREATMENT CHANGE OR DESCRIPTION OF THE WOUND DRAINAGE. ON 9/21/11 AT 1:45 PM, RESIDENT #501'S SKIN WAS OBSERVED. THE RESIDENT WAS ALERT, THIN, AND FRAIL. THE RESIDENT HAD A CURVATURE OF THE SPINE WITH A BONE PROJECTING OUTWARD AT THE MIDDLE OF THE SPINE WITH A DRESSING ON TOP OF THE AREA. THE DRESSING WAS REMOVED TO REVEAL A STAGE III PRESSURE SORE, MEASURING 1.9 X 1.3 X 0.4 CM (CENTIMETERS) IN DIAMETER AND DEPTH. THE WOUND HAD A MODERATE AMOUNT OF PURULENT (PUS) DRAINAGE AND WAS SURROUNDED BY A BORDER OF BRIGHT RED, [MEDICAL CONDITION], INFLAMED TISSUE. ON 9/6/11, AN ORDER WAS WRITTEN FOR A PILLOW BEHIND THE RESIDENT'S BACK WHILE IN THE WHEELCHAIR. THE 8/22/11 SKIN INTEGRITY CARE PLAN WAS NOT REVISED WHEN THE PRESSURE SORE TO THE SPINE WAS DISCOVERED. ON 9/7/11, A NEW CARE PLAN, "STAGE III PRESSURE ULCER TO MID-LUMBAR SPINE," WAS INITIATED WITH THE INTERVENTION: "PILLOW BEHIND BACK IN WHEELCHAIR." HOWEVER, ON 9/21/11 AT 8:50 AM, ON 9/23/11 AT 9 AM, AND ON 9/23/11 AT 12:45 PM, RESIDENT #501 WAS SITTING IN THE WHEELCHAIR WITH NO PILLOW BEHIND THE BACK TO RELIEVE PRESSURE. AFTER THE BRADEN SCALE WAS DONE ON 8/13/11 FOR RESIDENT #501, SUBSEQUENT BRADEN SCALES, DATED 8/20/11, 8/24/11, 9/3/11, AND 9/10/11, WERE LEFT BLANK. IN ADDITION, TREATMENT RECORDS INDICATED THAT THE 8/30/11 ORDER FOR SANTYL AND [MEDICATION NAME] TREATMENTS X 14 DAYS, WERE NOT DONE ON 8/31, 9/1, 9/2, 9/3, 9/4, AND 9/5/11. THE ORDER WAS RE-WRITTEN ON 9/6/11 FOR SEVEN MORE DAYS. THE WOUND CARE WAS NOT DONE ON 9/9, 9/10, AND 9/11/11. THE RESIDENT WAS SEEN BY THE WOUND TEAM ON 9/13/11. THE SANTYL AND [MEDICATION NAME] TREATMENTS WERE CONTINUED, BUT WERE NOT DONE ON 9/19/11. THERE WAS NO DOCUMENTED REASON WHY THE TREATMENTS WERE NOT DONE AS PRESCRIBED. WHEN QUERIED ON 9/23/11 AT 2:30 PM ABOUT THE MISSED TREATMENTS AND BLANK BRADEN SCALES, NURSE UNIT MANAGER 'C' WAS UNABLE TO STATE WHY. HE STATED THAT THE WOUND SHOULD HAVE BEEN DOCUMENTED UPON DISCOVERY AND BRADEN SCALES SHOULD HAVE BEEN COMPLETED WEEKLY AFTER ADMISSION. HE WAS UNABLE TO EXPLAIN WHY THE RESIDENT'S PROTRUDING SPINAL BONE WAS NOT PROTECTED TO PREVENT DEVELOPMENT OF THE PRESSURE SORE ESPECIALLY IN LIEU OF DECLINE IN MOBILITY FROM THE [MEDICAL CONDITION]. PER THE FACILITY'S SKIN PRACTICE GUIDE DATED 7/2008: "AFTER COMPLETION OF THE INITIAL ADMISSION SKIN EVALUATION, THE BRADEN SCALE MUST BE COMPLETED WEEKLY FOR FOUR WEEKS TOTAL, QUARTERLY, AND AS CLINICALLY INDICATED. A CARE PLAN MUST BE DEVELOPED THAT MEETS THE RESIDENT'S NEEDS WITH INTERVENTIONS THAT MAY INCLUDE: TURNING AND REPOSITIONING AND TREATMENT AS ORDERED. THE CARE PLAN MUST BE REVIEWED AND UPDATED TO REFLECT THE RESIDENT'S CURRENT STATUS." ( ) # 2: BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE PROPER WOUND CARE FOR ONE (#505) OF 13 SAMPLED RESIDENTS REVIEWED FOR PRESSURE SORES FROM A TOTAL OF 26, RESULTING IN THE POTENTIAL FOR DELAYED HEALING OF A PRESSURE SORE DUE TO WOUND CONTAMINATION. FINDINGS INCLUDE: ON 9/20/11 AT 11:45 A.M., RESIDENT #505 WAS OBSERVED ENTERING THE ROOM IN A WHEELCHAIR, PROPELLED BY CERTIFIED NURSING ASSISTANT (CNA) "M". THE RESIDENT WAS ALERT AND ORIENTED, AND REPORTED THAT SHE WAS RETURNING FROM A SHOWER. THE RESIDENT STATED SHE NEEDED ASSISTANCE WITH SHOWERING, WHICH HAD BEEN PROVIDED BY CNA "M". RESIDENT #505 REPORTED THAT SHE WAS EXPECTING A VISIT FROM THE WOUND CARE TEAM THAT DAY TO TREAT A DEEP PRESSURE ULCER (BEDSORE) SHE HAD DEVELOPED OUTSIDE THE FACILITY. CNA "M" TRANSFERRED THE RESIDENT TO BED AND ASSISTED THE RESIDENT TO REPOSITION TO THE SIDE. THE RESIDENT HAD A DEEP CAVERNOUS ULCER ON THE LEFT GLUTEUS (BUTTOCK). THERE WAS NO DRESSING ON THE WOUND. CNA "M" REMOVED A CLEANSING WIPE FROM A DRAWER AND USED IT TO WIPE THE INSIDE OF ULCER ON THE LEFT BUTTOCK. A FOUL ODOR WAS NOTED AS THE CNA REMOVED THE WIPE. THE CNA THEN APPLIED A CLEAN BRIEF TO THE RESIDENT, REMOVED GLOVES, WASHED HANDS AND LEFT THE ROOM. CNA "M" WAS THEN QUERIED ABOUT CARE OF RESIDENT #505'S WOUND, AND REPORTED THAT SHE (THE CNA) REMOVED THE DRESSING BEFORE THE SHOWER, BUT DID NOT PUT DRESSINGS BACK ON, "THE WOUND TEAM DOES IT." WHEN QUERIED ABOUT CLEANING THE WOUND WITH THE WIPE, CNA "M" STATED, "I DIDN'T WANT HER TO GET AN INFECTION FROM LEAVING SHOWER WATER INSIDE THE WOUND." ON 9/20/11 AT 1:00 P.M., WOUND CARE FOR RESIDENT #505 BY THE WOUND TEAM WAS OBSERVED FOR RESIDENT #505'S STAGE FOUR (IV) (FULL THICKNESS WOUND, EXPOSING BONE, TENDONS OR FASCIA) PRESSURE ULCER ON THE LEFT GLUTEUS. THE WOUND WAS 3.4 CENTIMETERS (CM) LONG BY 1.0 CM WIDE, BY 1.8 CM DEEP, WITH PALE EDGES, A PINK BASE WITH PATCHES OF TAN SLOUGH (MOIST DEAD TISSUE) AND HEAVY SERO SANGUINOUS (BLOOD AND TISSUE FLUIDS) DRAINAGE. THE NURSE PRACTITIONER (NP) "W" STATED, "IT GOT A LOT BIGGER THIS WEEK." WHEN QUERIED, THE WOUND NURSE "L" STATED CNAS SHOULD NOT CLEAN STAGE IV PRESSURE SORES. BOTH NP "P" AND WOUND NURSE "L" STATED THAT WIPES SHOULD NEVER BE USED TO CLEAN A STAGE IV PRESSURE SORE, CLEAN GAUZE PADS SHOULD BE USED WITH EITHER WOUND CLEANSER OR NORMAL SALINE. WOUND CARE NURSE "L" STATED THAT THE CNA PROBABLY TOOK THE DRESSING OFF TO GIVE THE RESIDENT A SHOWER, BUT SHE SHOULD HAVE COVERED THE WOUND WITH A CLEAN, DRY TOWEL AND GOTTEN THE NURSE TO DRY THE WOUND WITH A GAUZE PAD AND PUT A TEMPORARY GAUZE DRESSING ON UNTIL THE WOUND TEAM CAME. REVIEW OF RESIDENT #505'S CLINICAL RECORD REVEALED A FACE SHEET DOCUMENTING THE RESIDENT'S MOST RECENT ADMISSION TO THE FACILITY WAS ON 5/25/11. [DIAGNOSES REDACTED]. A MINIMUM DATA SET ASSESSMENT ((MDS) dated [DATE] REVEALED THE RESIDENT WAS COGNITIVELY INTACT, NEEDED EXTENSIVE ASSISTANCE WITH MOBILITY IN BED, TRANSFERS, AND HYGIENE, DID NOT WALK, HAD A [MEDICAL CONDITION] (OPENING THROUGH THE ABDOMEN INTO THE BOWEL) FOR BOWEL MOVEMENTS, AND AN INDWELLING URINARY CATHETER (TUBE INSERTED INTO THE BLADDER TO DRAIN URINE). THE MDS NOTED THE RESIDENT HAD A STAGE IV PRESSURE SORE MEASURING 2.4 BY 0.8 BY 2.0 CM. AT THE TIME OF ASSESSMENT. REVIEW OF A WOUND CARE PROGRESS NOTE FOR RESIDENT #505, DATED 9/13/11, DOCUMENTED THAT THE LEFT GLUTEAL STAGE IV PRESSURE ULCER WAS 2.4 CM BY 0.5 CM BY 1.2 CM WITH A PINK BASE AND MODERATE SLOUGH ON THAT DATE. THE MEASUREMENTS DOCUMENTED BY THE WOUND TEAM ON 9/21/11 REVEALED THE WOUND HAD INCREASED IN SIZE AND DEPTH, MEASURING 3.4 CM BY 1.0 CM, BY 1.8 CM. ON 9/23/11 AT 12:50 P.M., THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED AND REPORTED THAT CNA "M" SHOULD NOT HAVE WIPED RESIDENT #505'S PRESSURE ULCER, AS WOUND CARE SHOULD BE DONE BY LICENSED PERSONNEL (DOCTORS AND NURSES). THE FACILITY POLICY ON WOUND CARE AND DRESSING CHANGES WAS REQUESTED AND A MANUAL TITLED "SKIN PRACTICE GUIDE", DATED 7/2008 WAS PROVIDED AND REVIEWED WITH THE DON AND FOUND TO CONTAIN NO CONCRETE DIRECTIONS FOR CNAS. THE FACILITY POLICY TITLED "DRESSING CHANGE: NON STERILE (CLEAN) AND STERILE (ASEPTIC) DATED 12/2009 WAS REVIEWED WITH THE DON AND FOUND TO CONTAIN NO STATEMENTS INDICATING A STAGE IV PRESSURE SORE SHOULD NOT BE CLEANED WITH AN INCONTINENCE CARE WIPE, OR THAT CNAS SHOULD NOT CLEAN STAGE IV PRESSURE SORES. THE FACILITY JOB DESCRIPTION TITLED, "NURSE AIDE" DATED 8/02, REVISED 2/08 WAS REVIEWED WITH THE DON AND CONTAINED NO STATEMENTS TO THE EFFECT THAT CNAS SHOULD NOT PROVIDE WOUND CARE FOR PRESSURE SORES. ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO IMPLEMENT TIMELY INTERVENTIONS TO MAINTAIN ACCEPTABLE NUTRITIONAL PARAMETERS FOR ONE (#501) OF SIX SAMPLED RESIDENTS REVIEWED FOR WEIGHT CHANGES FROM A TOTAL OF 26, RESULTING IN SEVERE WEIGHT LOSS. FINDINGS INCLUDE: ON 9/20/11 AT 1:30 PM, RESIDENT #501 WAS OBSERVED IN BED RUBBING HER THROAT AND CHEST AREA. SHE WAS ALERT, AND APPEARED THIN AND FRAIL. SHE SAID, "CAN YOU GIVE ME SOMETHING FOR THIS [MEDICAL CONDITION] REFLUX. I'M HAVING SUCH A HARD TIME. I MUST HAVE EATEN TOO MUCH. THIS IS WHAT HAPPENS. I NEED A PILL." NURSE UNIT MANAGER 'C' WAS INFORMED OF THE RESIDENT'S COMPLAINT OF INDIGESTION AND HER MEDICATION RECORD WAS REVIEWED. THE RESIDENT HAD an order for [REDACTED]. MANAGER 'C' SAID, "I WILL NOTIFY THE NURSE TAKING CARE OF (THE RESIDENT)." ([MEDICATION NAME] WILL BE MENTIONED LATER IN THE CITATION). ON 9/21/11 AT 11:35 AM, RESIDENT #501'S CLINICAL RECORD WAS REVIEWED WITH THE REGISTERED DIETITIAN (RD) 'B'. THE RESIDENT WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. [MEDICAL CONDITION] (BRITTLE BONES), AND [MEDICAL CONDITIONS] REFLUX DISEASE (GERD) PER THE MEDICATION RECORDS. THE RESIDENT ALSO HAD TWO BLISTERS AT THE SITE OF THE SURGICAL REPAIR FOR THE [MEDICAL CONDITION]. THE FOLLOWING WEEKLY WEIGHTS WERE RECORDED IN THE "WEIGHTS AND VITALS SUMMARY" FOR RESIDENT #501: 8/15/11=108 POUNDS. 8/22/11=106 POUNDS 8/29/11=98 POUNDS, A SEVERE 9 PERCENT (%) WEIGHT LOSS IN TWO WEEKS. THE RESIDENT'S [MEDICATION NAME] (PROTEIN) LEVEL WAS 2.8 (NORMAL RANGE=3.5-4.9), PER A 8/29/11 LAB REPORT. 9/5/11=91 POUNDS. 9/12/11=90 POUNDS. 9/19/11=88.6 POUNDS, A SEVERE 18% WEIGHT LOSS IN ONE MONTH. RD 'B' WAS QUERIED ABOUT RESIDENT #501'S USUAL ADULT BODY WEIGHT. RD 'B' WAS UNABLE TO VERIFY THE WEIGHT. THERE WAS NO USUAL BODY WEIGHT NOTED IN THE RESIDENT'S NUTRITIONAL RISK ASSESSMENT WRITTEN BY RD 'B' ON 8/15/11. RD 'B' WAS UNABLE TO EXPLAIN WHY IT WAS NOT DOCUMENTED. THE RD WAS ASKED ABOUT THE RESIDENT'S FOOD INTAKE. THE RD STATED THAT THE RESIDENT'S INTAKE WAS GOOD BUT WAS UNABLE TO VERIFY THAT SHE OBSERVED THE RESIDENT'S INTAKE WHEN THE ASSESSMENT WAS DONE. PER THE NUTRITION ASSESSMENT, THE RESIDENT'S FOOD INTAKE WAS 76-100% "PER (THE) PATIENT." THE RD NOTED, "MET WITH RESIDENT AT BEDSIDE. STATES APPETITE IS PRETTY GOOD." PER THE NUTRITION ASSESSMENT, RESIDENT #501 WAS AT "HIGH RISK" FOR NUTRITIONAL COMPLICATIONS DUE TO GERD, DEMENTIA, THE SKIN BLISTERS, AND SWALLOWING DIFFICULTIES. WHEN ASKED ABOUT INTERVENTIONS, ON ADMISSION, TO HELP PREVENT THE 10 POUND WEIGHT LOSS BETWEEN 8/15 AND 8/29/11, RD 'B' SAID, "SHE HAD [MEDICAL CONDITION] WHEN SHE CAME IN. I USUALLY ALLOW UP TO 10 POUNDS (OF WEIGHT FROM FLUIDS) WHEN RESIDENTS ARE admitted FROM THE HOSPITAL BECAUSE THEY ARE USUALLY ON INTRAVENOUS FLUIDS (IV)." THE RD HOWEVER, DID NOT INDICATE IN THE NUTRITION ASSESSMENT THAT THE RESIDENT HAD [MEDICAL CONDITION]. THE RD WAS ASKED IF SHE OBSERVED THE RESIDENT TO BE [MEDICAL CONDITION]. THE RD STATED THAT SHE DID NOT MAKE THE OBSERVATION BUT OBTAINED THE INFORMATION FROM THE RESIDENT'S CHART. SHE WAS UNABLE TO LOCATE ANY MENTION IN THE CHART THAT THE RESIDENT HAD [MEDICAL CONDITION] ON ADMISSION. RESIDENT #501 WAS PLACED ON A MECHANICAL SOFT DIET ON 8/15/11. SUPPLEMENTS WERE NOT RECOMMENDED. WHEN ASKED WHY, RD 'B' SAID,"SHE (RESIDENT) DIDN'T LIKE SUPPLEMENTS THE LAST TIME SHE WAS HERE (THE RESIDENT WAS IN THE FACILITY JANUARY-MAY 2010). THE RD NOTED IN THE ASSESSMENT, "DECLINES (NUTRITIONAL) SUPPLEMENTS." THE RD WAS UNABLE TO VERIFY THAT SUPPLEMENTS WERE ATTEMPTED AND DECLINED ON THIS ADMISSION. THE RD DID NOT RECOMMEND ENHANCED/FORTIFIED (HIGH CALORIE, HIGH PROTEIN) FOODS IN LIEU OF SUPPLEMENTS. THE RD WAS UNABLE TO STATE WHY. RD 'B' NOTED IN RESIDENT #501'S NUTRITION ASSESSMENT, "(ORAL) INTAKE-ENCOURAGEMENT BENEFICIAL. PATIENT EATS INDEPENDENTLY IN ROOM." WHEN ASKED WHY THE RESIDENT DID NOT EAT IN THE DINING ROOM FOR CLOSER MONITORING, ASSISTANCE, AND ENCOURAGEMENT, RD 'B' SAID, "SHE LIKES EATING IN HER ROOM. THE RD WAS UNABLE TO VERIFY THAT AN ATTEMPT WAS MADE TO PLACE THE RESIDENT IN THE DINING ROOM FOR MEALS. ON 8/29/11, THE RD NOTED THAT THE RESIDENT'S WEIGHT HAD DECREASED FROM 108 TO 98 POUNDS. THE RD COMPLETED A "TELEPHONE ORDER" FORM ON 8/29/11 FOR THE PHYSICIAN TO ORDER A SUPPLEMENT, "NUTRITIONAL JUICE AT BREAKFAST," FOR RESIDENT #501. ON 8/31/11, RD 'B' WROTE IN NOTES "WILL ADD MAGIC CUPS (DIETARY SUPPLEMENT) (FOR) LUNCH AND DINNER" AND "WILL ADD ENHANCED FOODS" IN ADDITION TO THE NUTRITIONAL JUICE AT BREAKFAST "TO MEET INCREASED NEEDS." ON 8/31/11, THE RD COMPLETED A "TELEPHONE ORDER" FORM FOR THE PHYSICIAN TO ORDER THE MAGIC CUPS AT LUNCH AND DINNER AND ENHANCED FOODS. WHEN ASKED, THE RD STATED THAT THE RESIDENT WAS TO RECEIVE ONE ENHANCED FOOD ITEM PER DAY FROM ALL THREE MEALS. ON 8/31/11, THE RD WROTE, "PER PATIENT REQUEST, WILL ADD SOFT FOODS TO TRAY SUCH AS JELLO, PUDDING, APPLESAUCE FOR EASE IN CHEWING." THE RD STATED THAT THE JELLO WAS "ENHANCED." THE RD WAS UNABLE TO EXPLAIN, WHEN ASKED, WHY THESE ITEMS WERE NOT ADDED INITIALLY ON ADMISSION TO SUPPLEMENT THE RESIDENT'S DIET. PER RESIDENT #501'S ADMISSION MINIMUM DATA SET ((MDS) dated [DATE], THE RESIDENT WAS COGNITIVELY INTACT, HAD NO WEIGHT LOSS, BUT REQUIRED EXTENSIVE ASSISTANCE FOR EATING. ON 9/2/11, A SIGNIFICANT CHANGE MDS WAS DOCUMENTED FOR RESIDENT #501 THAT RD 'B' DEFERRED TO FOR ADDITIONAL INFORMATION ON THE RESIDENT'S NUTRITIONAL STATUS. PER THE MDS HOWEVER, WHICH WAS SIGNED BY THE RD ON 9/7/11, THE RESIDENT WEIGHED 98 POUNDS AND HAD NOT EXPERIENCED ANY WEIGHT LOSS, WHICH CONTRADICTED THE WEIGHT OF 91 POUNDS RECORDED ON THE WEIGHT RECORD. INTERVENTIONS ON THE "ALTERED NUTRITION" CARE PLAN FOR RESIDENT #501 DATED 8/22/11, INCLUDED: "ENCOURAGE AND ASSIST AS NEEDED TO CONSUME ALL FOODS, FLUIDS, AND/OR SUPPLEMENTS PROVIDED." A NEW CARE PLAN FOR ALTERED NUTRITION DATED 9/7/11 NOTED, "WEIGHT LOSS MAY OCCUR...." AND DID NOT ADDRESS THAT THERE WAS AN ACTUAL 9% WEIGHT LOSS BY THAT TIME. INTERVENTIONS INCLUDED, "ADMINISTER MEDICATIONS/NUTRITIONAL SUPPLEMENTS PER PHYSICIAN ORDER." HOWEVER, THE FOLLOWING WAS OBSERVED: ON 9/20/11 AT 9:30 AM, RESIDENT #501'S MEAL TICKET ON HER BREAKFAST TRAY DID NOT LIST ENHANCED FOODS. ON 9/21/11 AT 8:50 AM, ENHANCED FOOD WAS NOT NOTED ON THE MEAL TICKET. THE RESIDENT WAS DOZING OFF IN HER ROOM WITH AN UNTOUCHED BREAKFAST TRAY IN FRONT OF HER. AT 1 PM, THE MEAL TICKET ON THE RESIDENT'S LUNCH TRAY DID NOT LIST ENHANCED FOODS, OR THE MAGIC CUPS SHE WAS SUPPOSED TO RECEIVE FOR LUNCH. THE ITEMS WERE NOT OBSERVED ON HER TRAY. THE RESIDENT ATE APPROXIMATELY 50% OF THE FOOD IN HER ROOM AND WAS LAYING IN BED. SHE SAID, "I'M LAYING DOWN BECAUSE OF THIS REFLUX TO HELP ME DIGEST MY FOOD. I CAN'T EAT TOO MUCH OR IT BOTHERS ME." WHEN ASKED ABOUT EATING IN THE ROOM, THE RESIDENT SAID, "I DON'T MIND GOING TO THE DINING ROOM, IF SOMEONE TAKES ME." ON 9/21/11 AT 12 NOON, THE RESIDENT'S MEAL TICKETS FOR ALL THREE MEALS ON 9/21/11, WERE REQUESTED FROM ASSISTANT DIETARY MANAGER (DM) 'D'). THE MEAL TICKETS DID NOT MENTION ENHANCED FOODS OR THE MAGIC CUPS. ON 9/22/11 AT 9:30 AM, RD 'B' PRESENTED PRINT OUTS OF THE RESIDENT'S FOOD ACCEPTANCE RECORDS. THE RECORDS LISTED THE TOTAL PERCENTAGE OF EACH MEAL THAT THE RESIDENT CONSUMED, NOT EACH FOOD ITEM. WHEN ASKED SPECIFICALLY ABOUT THE ENHANCED FOOD/SUPPLEMENTS PROVIDED TO THE RESIDENT AND CONSUMED DURING EACH MEAL, THE RD SAID, "I DON'T KNOW. IT (THE PRINT OUT) DOES NOT SHOW THAT." THE FOLLOWING WAS LATER REVEALED: ON 9/23/11 AT 10:20 AM, DIETARY MANAGER (DM) 'A' WAS QUERIED REGARDING THE RESIDENT'S DIET AND A SECOND MEAL TICKET FOR ALL THREE MEALS ON 9/21/11, WAS REQUESTED. THIS TIME, THE MEAL TICKET LISTED ENHANCED FOODS THREE TIMES A DAY, FOR BREAKFAST, LUNCH, AND DINNER, AND THE MAGIC CUPS. ON 9/23/11 AT 10:45 AM, DM 'A' AND THE ASSISTANT DM 'D' WERE ASKED WHY THE 9/21/11 MEAL TICKET THAT THEY EACH PRESENTED, HAD CONFLICTING DIETARY ORDERS. THEY STATED THAT RD 'B' TOLD ASSISTANT DM 'D' "YESTERDAY (9/22/11)" THAT RESIDENT #501'S "MEAL TICKETS NEEDED TO BE UPDATED AND TO ADD MAGIC CUPS AND ENHANCED FOOD." WHEN ASKED, DM 'A' STATED THAT THESE ITEMS WERE PROVIDED BY DIETARY STAFF AS THEY MADE UP THE MEAL TRAYS AND THAT IF THE ITEMS WERE NOT LISTED ON THE MEAL TICKETS, DIETARY STAFF WOULD NOT HAVE KNOWN TO PROVIDE THEM. THUS, THE RESIDENT DID NOT RECEIVE MAGIC CUPS OR ENHANCED FOODS, AS ORDERED, PRIOR TO 9/22/11. PER A LAB REPORT DATED 9/16/11, THE RESIDENT'S [MEDICATION NAME] LEVEL DECREASED FROM 2.8 ON 8/29/11 TO 2.7. ON 9/23/11 AT 12:45 PM, RESIDENT #501 WAS OBSERVED SITTING IN HER ROOM IN A WHEELCHAIR WITH THE LUNCH TRAY IN FRONT OF HER ON THE OVER BED TABLE. THE TABLE WAS AT SHOULDER HEIGHT AND COULD NOT BE ADJUSTED TO A LOWER HEIGHT. THE RESIDENT ATTEMPTED TO EAT SOUP FROM A BOWEL THAT WAS ON THE FAR END OF THE TRAY. EACH TIME SHE TRIED TO SPOON SOUP INTO HER MOUTH, THE SOUP SPILLED ONTO THE FOOD ENTREE BEFORE REACHING HER MOUTH. WHEN ASKED IF SHE WANTED TO EAT IN THE DINING ROOM, THE RESIDENT SAID, "I COULD IF SOMEONE TOOK ME. I CAN'T MOVE THIS," WHILE PLACING HER HANDS ON THE WHEELS OF THE WHEELCHAIR. RD 'B' ENTERED THE ROOM AND WAS UNABLE TO EXPLAIN WHY THE RESIDENT WAS NOT TAKEN TO THE DINING ROOM AND WHY SHE WAS EATING AT A TABLE THAT WAS TOO HIGH WITH THE FOOD ITEMS NOT CONVENIENTLY IN REACH. ON 9/23/11 AT 1:00 PM, RESIDENT #501 WAS IN BED. SHE STATED, "I HAVE TO LAY DOWN TO HELP ME WITH DIGESTION OR I HAVE TROUBLE." AT 1:30 PM, 9/9/11 PROGRESS NOTES WERE REVIEWED WITH MANAGER 'C' THAT DOCUMENTED: "PER PATIENT, DIFFICULTY TOLERATING FOOD....ADD [MEDICATION NAME]." MANAGER 'C' WAS UNABLE TO EXPLAIN WHY [MEDICATION NAME] WAS NOT ORDERED FOR THE RESIDENT, WHO WAS admitted WITH A [DIAGNOSES REDACTED]. WHEN TOLD, FOR A SECOND TIME, THAT THE RESIDENT WAS HAVING PROBLEMS WITH DIGESTION, HE SAID, "I WILL NOTIFY THE DOCTOR TO SEE IF ANOTHER TYPE OF MEDICATION NEEDS TO BE ORDERED." PER THE FACILITY'S UNDATED WEIGHT MANAGEMENT POLICY: "PROACTIVE PREVENTION OF SIGNIFICANT UNINTENDED WEIGHT CHANGES INCLUDED FACILITY WIDE SYSTEMS AND PROCESSES KNOWN TO POSITIVELY IMPACT THE INTAKE OF MEALS AND/OR BETWEEN MEAL SNACKS. INDIVIDUALIZE WHAT WORKS BEST FOR PATIENTS WHO TYPICALLY UNDER EAT, SUCH AS MEALTIME FEEDING ASSISTANCE OR BETWEEN MEAL SNACKS, OVERSIGHT BY DIRECT CARE STAFF WITH PRESENCE DURING MEALS, AND DINING ENVIRONMENT ENHANCEMENTS. EARLY ATTENTION TO NUTRITIONAL NEEDS AND PREVENTION OF WEIGHT LOSS DURING PERIODS OF STRESS SUCH AS SURGERY MUST BE CONSIDERED." THE RD MUST IDENTIFY AND TREAT WEIGHT PROBLEMS BY VALIDATING THE PROBLEM WITH THE INTERDISCIPLINARY TEAM AND RE-EVALUATING AND MAKING REVISIONS AS NEEDED. VERBAL PROMPTING, ENCOURAGEMENT, AND MORE GENERALIZED SOCIAL INTERACTION CAN SIGNIFICANTLY IMPROVE MANY RESIDENT'S FOOD AND FLUID CONSUMPTION DURING MEALS AND BETWEEN MEALS. TRYING DIFFERENT INTERVENTIONS IS OFTEN NECESSARY TO ACHIEVE THE DESIRED IMPROVEMENT IN THE RESIDENT'S CONDITION. ( )

THIS CITATION HAS MULTIPLE DEFICIENT PRACTICES: DEFICIENT PRACTICE #1 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ASSESS AND TREAT PAIN EFFECTIVELY AND IN A TIMELY MANNER FOR TWO (#'S 509 AND 510) OF 11 SAMPLED RESIDENTS REVIEWED FOR PAIN FROM A TOTAL OF 26, RESULTING IN PROLONGED PAIN AND DISCOMFORT. FINDINGS INCLUDE: ON 9/20/11 AT 12:40 P.M., RESIDENT #510 WAS OBSERVED LAYING IN BED COMPLAINING OF PAIN. RESIDENT #510 STATED, "I'M IN A LOT OF PAIN I NEED MY MEDICATIONS." THE RIGHT KNEE PAIN WAS RATED A 9/10 (ON A SCALE OF 1 - 10, WITH 1 BEING THE LEAST AMOUNT OF PAIN). RESIDENT #510 TURNED HER NURSE CALL LIGHT ON. THE UNIT SECRETARY ENTERED THE ROOM AT 12:56 P.M. THE UNIT SECRETARY LEFT AFTER NOTING #510'S PAIN. AT 1:05 P.M., NURSE "S" ENTERED THE ROOM AND GAVE RESIDENT #510 PAIN MEDICATION (ONE [MEDICATION NAME] 10 MG (MILLIGRAM)/325 MG). ON 9/21/11 AT 9:10 A.M., RESIDENT #510 WAS OBSERVED LAYING IN BED READING. SHE REPORTED HER RIGHT KNEE PAIN WAS AN 8/10, AND STATED, "THE PAIN IS NOT BEING CONTROLLED AND THEY ARE NOT GIVING ME MY PAIN MEDICATIONS EVERY FOUR HOURS ON TIME. I HAVE TO ASK FOR IT 30 MINUTES IN ADVANCE IN ORDER FOR ME TO RECEIVE IT EVERY FOUR HOURS. I'LL GO HOME AND TAKE MY OWN MEDICATIONS IF THEY CAN'T GET MY PAIN UNDER CONTROL HERE. I TOLD MY DOCTOR THAT I NEED MORE PAIN MEDICATION AND I NEED TO HAVE SOME OTHER PAIN MEDICATION IN BETWEEN THE DOSES OF [MEDICATION NAME] (PAIN MEDICATION) TO HELP WITH THE PAIN WHEN IT WEARS OFF BEFORE THE NEXT SCHEDULED DOSE OF [MEDICATION NAME]." ON 9/21/11 AT 9:25 A.M., REVIEW OF RESIDENT #510'S FACE SHEET REVEALED AN ADMISSION INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE ADMISSION NURSING ASSESSMENT, DATED 9/19/11 REVEALED THE RESIDENT HAD AN INDEPENDENT COGNITION WITH NO DEFICITS. MINIMAL ASSISTANCE WAS REQUIRED WITH ACTIVITIES OF DAILY LIVING (ADL'S). REVIEW OF THE ADMITTING physician's orders [REDACTED]. 1. [MEDICATION NAME] 200 MG (MILLIGRAMS) BY MOUTH EVERY 12 HOURS. 2. [MEDICATION NAME] 10/325 MG BY MOUTH EVERY FOUR HOURS. 3. [MEDICATION NAME] 50 MG BY MOUTH EVERY SIX HOURS AS NEEDED FOR PAIN. REVIEW OF THE MEDICATION ADMINISTRATION RECORD(MAR) INDICATED THAT RESIDENT #510 RECEIVED THE [MEDICATION NAME] 50 MG BY MOUTH TWO TIMES ON 9/20/11, BUT THERE WAS NO ASSESSMENT OF PAIN DOCUMENTED AT THE TIME THAT THE PAIN WAS REPORTED, NOR WAS THERE A RE-ASSESSMENT OF PAIN AFTER THE ADMINISTRATION OF THE [MEDICATION NAME] TO EVALUATE ITS EFFECTIVENESS. ON 9/21/11 AT 10:20 A.M., RESIDENT #510 WAS OBSERVED BEING TRANSPORTED TO THERAPY AND REPORTED THAT SHE HAD NOT RECEIVED HER PAIN MEDICATION. REVIEW OF THE MEDICATION ADMINISTRATION RECORD (MAR) REVEALED NO DOCUMENTATION THAT THE RESIDENT HAD RECEIVED THE PAIN MEDICATION ([MEDICATION NAME] 10 MG/325 MG), NOR THE AS NEEDED PAIN MEDICATION, [MEDICATION NAME] 50 MG. THERE WAS NO DOCUMENTATION OF ON THE BACK OF THE MAR THAT INDICATED AN ASSESSMENT OF PAIN, NOR THE ADMINISTRATION OF PAIN MEDICATION. ON 9/21/11 AT 1:50 P.M., RESIDENT #510 COMPLAINED OF (A SCORE OF 7 OF A SCALE OF 10) RIGHT KNEE PAIN AND STATED, "I DID NOT GET ANY MEDICATION BEFORE I WENT TO THERAPY THIS MORNING. I WAS NOT FULLY ABLE TO PARTICIPATE IN THERAPY DUE TO MY PAIN." THE RESIDENT FURTHER REPORTED THE REASON FOR HER ADMISSION HERE WAS "ONLY FOR ANTIBIOTIC TREATMENT AND THERAPY FOR THE RECENT RIGHT KNEE REVISION SURGERY." REVIEW OF THE MAR INDICATED THAT RESIDENT #510 RECEIVED THE ORDERED [MEDICATION NAME] AT 5 A.M. AND AT 9:23 A.M. ON 9/21/11, BUT THERE WAS NO DOCUMENTED ASSESSMENT OF THE PAIN NOR THE ASSESSMENT OF THE EFFECTIVENESS OF THE PAIN MEDICATION. FURTHER REVIEW OF THE physician's orders [REDACTED]. APPLY ICE PACK FOR 15 TO 20 MINUTES AS NECESSARY..." REVIEW OF THE MAR DID NOT DOCUMENT THE APPLICATION OF THE ICE PACK NOR THE EFFECTIVENESS FOR THE ALLEVIATION OF THE RIGHT KNEE PAIN. ON 9/21/11 AT 2:10 P.M., RESIDENT #510 WAS QUERIED REGARDING THE USE OF ICE PACKS TO ASSIST IN ALLEVIATING HER PAIN. RESIDENT #510 STATED, "I HAVE NOT HAD AN ICE PACK SINCE I'VE BEEN HERE...MAYBE BECAUSE I DIDN'T ASK. I DIDN'T KNOW THAT I COULD HAVE ONE. I JUST NEED SOMETHING STRONGER FOR THE PAIN." ON 9/22/11 AT 8:50 A.M., RESIDENT #510 WAS OBSERVED LAYING IN BED WITH A WARM AND MUSHY ICE PACK AT THE FOOT OF HER BED. THE RESIDENT STATED, "I ASKED FOR MEDICATION AT 6:30 A.M. AND HAVE NOT GOTTEN ANY YET." WHEN SHE WAS QUERIED ABOUT HER RIGHT KNEE PAIN, SHE STATED, "IT IS A 9/10 (SEVERE PAIN). I HAVE NOT HAD ANY PAIN MEDICATIONS SINCE 11 P.M. LAST NIGHT." REVIEW OF THE NARCOTIC SIGN OUT SHEET FOR THE MEDICATION [MEDICATION NAME] INDICATED THE RESIDENT RECEIVED HER LAST DOSE ON 9/21/11 AT 9:23 A.M. THE MAR INDICATED THAT RESIDENT #510 HAD HER LAST DOSE OF [MEDICATION NAME] ON 9/21/11 AT 9:23 A.M. THE MAR DID NOT INDICATED ANY USE OF THE PAIN MEDICATION [MEDICATION NAME] 50 MG EITHER. ON 9/22/11 AT 9 A.M., RESIDENT #510'S ASSIGNED NURSE (NURSE "U") STATED REGARDING HER PAIN, "SHE RECEIVED HER LAST DOSE OF [MEDICATION NAME] ON 9/21/11 AT 11 P.M. SHE HAS TO ASK FOR IT IF SHE WANTS/NEEDS IT." THERE WAS NO EXPLANATION PROVIDED AS TO WHY THE PAIN MEDICATION [MEDICATION NAME] WAS NOT SIGNED OUT AS GIVEN AT 11 P.M. ON 9/21/11. THERE WAS NO ASSESSMENT OF THE RESIDENT'S PAIN AT THIS TIME EITHER. ON 9/22/11 AT 11:45 A.M., THE UNIT MANAGER (NURSE "C") WAS QUERIED REGARDING PAIN CONTROL AND PAIN GOAL FOR RESIDENT #510. NURSE "C" STATED, "I WILL REVIEW HER CHART AND REPORT BACK TO YOU AS TO THE DOCTOR'S FINDINGS. THE PAIN DOCTOR SAW HER TODAY. THEIR RECOMMENDATIONS WERE TO CONTINUE CURRENT PAIN MANAGEMENT." NURSE "C" WAS INFORMED OF THE NURSES NOT UTILIZING THE NUMERIC PAIN SCALE, NOT ASSESSING RESIDENT #510'S PAIN PRIOR TO THE ADMINISTRATION OF PAIN MEDICATION, AND THE NURSES NOT EVALUATING THE EFFECTIVENESS OF THE PAIN MEDICATION AFTER ADMINISTRATION. NURSE "C" OFFERED NO EXPLANATION. ON 9/22/11 AT 1:10 P.M., REVIEW OF THE FACILITY'S "PAIN PRACTICE GUIDE," ISSUE DATE OF 1/2008, REVEALED THE FOLLOWING DOCUMENTATION AS IT RELATES TO RESIDENTS' PAIN: "LISTEN TO WHAT THE PATIENT SAYS, ANTICIPATE PAIN, PREVENT PAIN FROM OCCURRING AS PRACTICABLE PER PATIENT ESTABLISHED GOAL. INDIVIDUAL PAIN RATING SCALES ARE COMPLETED AS PART OF THE ADMISSION EVALUATION AND FINDINGS ARE DOCUMENTED DAILY ON THE MEDICATION ADMINISTRATION (MAR), INCLUDING IDENTIFICATION OF THE TYPE OF SCALE USED. THE NUMERIC PAIN RATING SCALE IS USED FOR ALERT AND ORIENTED PATIENTS. IN USING THE NUMERIC RATING SCALE, THE PATIENT IS ASKED TO IDENTIFY HOW MUCH PAIN THEY ARE HAVING BY CHOOSING A NUMBER FROM 0 (NO PAIN) TO 10 (THE WORST PAIN IMAGINABLE)." THE FACILITY'S "PAIN PRACTICE GUIDE" NOTED, "OBTAIN PAIN SCALE SCORES DAILY AND BEFORE AND AFTER ADMINISTRATION OF ROUTINE AND PRN (AS NECESSARY) [MEDICATION NAME]. SCORES ARE DOCUMENTED ON THE MAR." REVIEW OF RESIDENT #510'S CARE PLAN FOR PAIN, DATED 9/21/11, REVEALED THE FOLLOWING INTERVENTIONS: "1. ADJUST TIMES OF ADL AND TREATMENT ACTIVITIES SO THAT THEY OCCUR AFTER [MEDICATION NAME] BENEFITS HAVE BEEN ACHIEVED. 2. ADMINISTER PAIN MEDICATION AS PER MD ORDERS AND NOTE THE EFFECTIVENESS 3. EVALUATE PAIN CHARACTERISTICS: INTENSITY, LOCATION, PRECIPITATING/RELIEVING FACTORS 4. NOTIFY PHYSICIAN IF PAIN FREQUENCY/INTENSITY IS WORSENING OR IF CURRENT [MEDICATION NAME] REGIMEN HAS BECOME INEFFECTIVE." ON 9/22/11 AT 3:50 P.M., THE DIRECTOR OF NURSES (DON) WAS QUERIED REGARDING #510'S UNCONTROLLED PAIN. THE DON STATED, "I'LL LOOK INTO THAT." THERE WAS NO FURTHER EXPLANATION PROVIDED BY THE TIME OF THE SURVEY EXIT. ( ) ON 9/22/11 AT 11:45 AM, RESIDENT #509 SAID DURING AN INTERVIEW, "I DIDN'T HAVE ANYTHING ORDERED FOR PAIN AT FIRST. THE PAIN WAS STARTING TO GET UP THERE (ELEVATE), SO THEY GOT AN ORDER. I GUESS THE DOCTOR FORGOT." THE RESIDENT WAS OBSERVED TO HAVE A DRESSING AROUND THE RIGHT FOOT WITH A DRAIN COMING FROM THE FOOT CONNECTED TO A [DEVICE]. ON 9/23/11 AT 9:20 AM, THE RESIDENT'S CHART WAS REVIEWED WITH NURSE MANAGER 'C.' THE RESIDENT WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. PER THE RESIDENT'S ADMISSION assessment dated [DATE], THE RESIDENT WAS "PRESENTLY EXPERIENCING PAIN" DUE TO "RECENT SURGERY" AND AN "ORTHOPEDIC CONDITION," THE PAIN WAS "GENERALIZED" AND "ACHING," AND WAS RELIEVED BY "MEDICATION." THERE WERE NO PAIN MEDICATIONS ORDERED FOR THE RESIDENT PER REVIEW OF THE admission orders [REDACTED]. ON 9/13/11, THE RESIDENT WAS PRESCRIBED [MEDICATION NAME] EVERY SIX HOURS AS NEEDED. WHEN QUERIED ABOUT THE LACK OF PAIN MANAGEMENT FROM 9/2/11 UNTIL 9/13/11 FOR RESIDENT #509, MANAGER 'C' WAS UNABLE TO EXPLAIN WHY. HE SAID, "USUALLY WE ORDER AT LEAST TYLENOL ON ADMISSION." ( ) DEFICIENT PRACTICE #2 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO CONSISTENTLY PERFORM WOUND CARE FOR ONE (#509) OF 13 RESIDENTS REVIEWED FOR WOUNDS, OUT OF A TOTAL SAMPLE OF 26 RESIDENTS, RESULTING IN THE POTENTIAL FOR WORSENING OF THE WOUND AND INFECTION. FINDINGS INCLUDE: THROUGHOUT EACH DAY OF THE SURVEY, RESIDENT #509 WAS OBSERVED SITTING IN A WHEELCHAIR WITH HIS RIGHT FOOT WRAPPED WITH A DRESSING AND ELEVATED WITH A DRAINAGE TUBE EXTENDING FROM THE FOOT. ON 9/20/11 AT 3:40 PM, HIS FOOT WAS OBSERVED WITH WOUND CARE NURSE 'L.' THE FOOT WAS SWOLLEN WITH AN OPEN WOUND ON THE BALL OF THE FOOT. A DRAIN WAS INSERTED INTO THE WOUND ATTACHED TO A VACUUM THAT CONTAINED A SMALL AMOUNT OF BROWN DRAINAGE. ON 9/20/11 AT 4 PM, THE CLINICAL RECORD FOR RESIDENT #509 WAS REVIEWED WITH THE DIRECTOR OF NURSING (DON). THE RESIDENT WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. NURSE 'L' LISTED THE FOLLOWING ORDERS ON RESIDENT #509'S WOUND CARE RECORD: #1. ON 9/2/11-DAILY PACKING TO RIGHT FOOT WITH MESALT (AN IMPREGNATED DRESSING FOR CLEANING DEEP, DRAINING, INFECTED WOUNDS). #2. ON 9/16/11 (WRITTEN BY NURSE 'L')-"NEGATIVE PRESSURE WOUND THERAPY (THE VACUUM), CHANGE EVERY MONDAY AND FRIDAY AND AS NEEDED." ON 9/16/11, NURSE 'L' ADDED ANOTHER ORDER TO THE WOUND RECORD: #3. "WOUND (VACUUM) TO BE CHANGED BY (FACILITY) NURSE ON MONDAY AND DOCTOR'S OFFICE ON FRIDAY FOLLOW-UP." THE WOUND RECORD NOTED THAT ORDER #1 WAS PERFORMED ON 9/17/11 (SATURDAY) BY A FACILITY STAFF NURSE. NURSE 'L' WAS QUERIED ABOUT ORDER #1 BEING PERFORMED ON 9/17/11. NURSE 'L' STATED THAT ORDER #1 WAS DISCONTINUED ON 9/16/11. SHE WAS UNABLE TO EXPLAIN WHY SHE DID NOT DISCONTINUE THE ORDER ON THE WOUND CARE RECORD. SHE WAS ASKED TO CLARIFY WHO WAS SUPPOSED TO PERFORM ORDER #2, WHICH SEEMED TO CONFLICT WITH INSTRUCTIONS IN ORDER #3. SHE STATED THAT ORDER #3 WAS TO BE FOLLOWED. SHE WAS UNABLE TO STATE WHY SHE LEFT ORDER #2 ON THE TREATMENT RECORD. NURSE 'H' CIRCLED HER INITIALS ON 9/19/11 (MONDAY), WHEN THE [DEVICE] WAS TO BE CHANGED BY NURSING STAFF. THERE WAS NO DOCUMENTED EXPLANATION WHY THE RESIDENT MISSED HAVING THE [DEVICE] CHANGED. WHEN QUERIED ON 9/20/11 AT 4 PM ABOUT THE CONFLICTING DOCUMENTATION AND MISSED TREATMENT, THE DON SAID, "I DON'T KNOW WHAT TO TELL YOU. YOU CAN ASK (NURSE 'H') ABOUT IT. AT 4:30 PM, NURSE 'H' SAID, "I DID NOT FEEL COMFORTABLE DOING IT (CHANGING THE [DEVICE]). I AM NOT FAMILIAR WITH IT. SO, I EXPLAINED IT TO (RESIDENT #509). I SHOULD HAVE DOCUMENTED IT." ( )

REFER TO INTAKE # MI 834 AND MI 836 BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT PHYSICAL ALTERCATION BETWEEN 2 (RES. #800 AND RES. #803) OF 6 SAMPLED RESIDENTS RESULTING IN POTENTIAL FOR POOR SELF ESTEEM AND PHYSICAL HARM FOR RESIDENT #800 AND OTHER RESIDENTS. FINDINGS INCLUDE: THE FACILITY INCIDENT REPORT DATED 3/8/11 AT 7:00 PM, WAS REVIEWED BY THE SURVEYOR ON 3/16/11, IT WAS REPORTED THAT: RESIDENT #803 ASSAULTED RESIDENT #800 AND BIT RESIDENT #800 RIGHT RING FINGER IN THE HALLWAY. BOTH RESIDENTS WERE SEPARATED. RESIDENT #800 WAS TRANSFERRED TO THE HOSPITAL FOR EVALUATION AND TREATMENT. RESIDENT #800 WAS [AGE] years OLD admitted TO THE FACILITY FOR REHABILITATION DUE TO RIGHT WRIST FRACTURE. SHE WAS ALERT AND ORIENTED, WITH NO MEMORY IMPAIRMENT. RESIDENT #800'S STATEMENT DATED 3/9/11, WAS REVIEWED. SHE DESCRIBED: RESIDENT #803 HIT HER ON THE BACK OF HER HEAD, GRABBED HER SHIRT BY THE SHOULDER AND PULLED IT. THEN RESIDENT #803 TURNED AROUND HER AND GRABBED HER RIGHT HAND AND BIT HER RIGHT RING FINGER. RESIDENT #800 EXPERIENCED PAIN AND DISCOMFORT AT THAT TIME. THE ADMINISTRATOR STATED ON 3/16/11 AT 10:45 AM THAT RESIDENT #803 WAS IMMEDIATELY SENT TO THE hospital on [DATE]. SHE WAS PETITIONED FOR PSYCHIATRIC CARE. NURSE #3 STATED ON 3/16/11 AT 11:40 AM, THAT BOTH RESIDENTS WERE IN THE HALLWAY NOT VISIBLE TO WHERE HE (THE NURSE) WAS SITTING AT THE NURSE'S STATION. NURSE #3 STATED THAT HE HEARD RESIDENT #800 SCREAM BUT COULD NOT SEE WHAT WAS HAPPENING. HE GOT UP AND WENT TO WHERE BOTH RESIDENTS WERE AND SAW RESIDENT #803 GRABBING ON TO RESIDENT #800'S LEFT ARM. HE admitted THAT HE DID NOT WITNESS RESIDENT 803 BITE RESIDENT 800, BUT UPON ASSESSMENT AFTER BOTH WERE SEPARATED, RESIDENT #800 HAD SOME SWELLING AND SOME DISCOLORATION ON HER RIGHT RING FINGER. THERE WAS NO BLEEDING, NO OPEN SKIN BUT RESIDENT #800 SAID SHE WAS SCARED. EARLIER THAT DAY, STAFF SAID, RESIDENT #803 THREW ALL HER BELONGINGS ON THE FLOOR AND SHE RESIDENT #803 HAD BEEN HITTING OTHER STAFF. RESIDENT #803 WAS EATING IN THE HALLWAY SO THAT THE STAFF COULD KEEP AN EYE ON HER, BUT NO STAFF WAS SUPERVISING OR WATCHING RESIDENT #803 IN THE HALLWAY WHEN THE ALTERCATION HAPPENED. CERTIFIED NURSE ASSISTANTS (CNA) WERE PROVIDING CARE IN THE NEXT HALL. ANOTHER NURSE CAME TO RESPOND TO THE SCREAM BUT WAS NOT WATCHING RESIDENT #803 AT THAT TIME. RESIDENT #803'S CLINICAL RECORD REVEALED SHE HAD SEVERAL EVENTS OF PHYSICAL AGGRESSION 3/1/11 THROUGH 3/8/11. RESIDENT #803 WAS EASILY AGITATED, REFUSED TO TAKE MEDICATIONS AND WAS RESISTIVE WITH THE CARE PROVIDED BY STAFF. ON 3/5/11 AT 8:30 AM, RESIDENT #803 THREW WATER ON HER ROOM MATE. ON 3/7/11, SHE ATTEMPTED TO HIT ANOTHER RESIDENT DURING THERAPY. THERE WAS NO EVIDENCE THAT A BEHAVIOR CAREPLAN WAS INITIATED FOR RESIDENT #803. THE FACILITY FAILED TO PRESENT A BEHAVIOR LOG FOR RESIDENT #803 UPON REQUEST. RESIDENT #803 WAS PETITIONED OUT TO THE HOSPITAL ON ON 3/8/11 AFTER THE RESIDENT TO RESIDENT ALTERCATION OCCURRED. A FAMILY MEMBER STATED THAT RESIDENT # 803 SHOULD HAVE BEEN SUPERVISED WHILE WITH OTHER RESIDENTS. HER MOTHER (RESIDENT #800) EXPERIENCED ANXIETY RIGHT AFTER THE INCIDENT. RESIDENT #800'S CLOTHES WERE RIPPED AND HER FINGER WAS GETTING DAILY TREATMENT AFTER THE ALTERCATION. ACCORDING TO THE SOCIAL WORKER #4 ON 3/16/11 AT 2:17 P.M., THAT ALTHOUGH HE WAS ASSIGNED TO BOTH RESIDENTS, HE DID NOT MEET WITH EITHER RESIDENT #800 OR RESIDENT #803 AFTER THE 3/8/11 INCIDENT. SW #4 DID NOT MAKE ANY SOCIAL WORKER'S NOTES THAT ADDRESSED THE PHYSICAL ALTERCATION THAT OCCURRED IN 3/8/11. FURTHER, HE DID NOT REFER RESIDENT #800 FOR PSYCHIATRIC SERVICES AFTER THE 3/8/11 INCIDENT FOR EVALUATION. HE AGREED THAT HE DID NOT INITIATE A BEHAVIOR CAREPLAN FOR RESIDENT #803 AFTER THE EARLIER INCIDENTS THAT OCCURRED ON 3/5/11 WHEN RESIDENT #803 THREW WATER ON ANOTHER RESIDENT AND ON 3/7/11 WHEN SHE ATTEMPTED TO ASSAULT ANOTHER RESIDENT AT THE THERAPY ROOM. SW #4 WAS NOT ABLE TO PRESENT A LOG OF RESIDENT #803'S BEHAVIOR FROM 3/1/11 THROUGH 3/8/11, AND DID NOT HAVE A REVISED CAREPLAN TO MAKE SURE FUTURE PHYSICAL ABUSE TO OTHER RESIDENTS WOULD NOT OCCUR. ( )