Every finding on record at Optalis Health and Rehabilitation of Grosse Pointe

This citation pertains to intake 2627057 and 2626819.Based on interview and record review, the facility failed to report an allegation of employee to resident abuse for one resident (R903) of two residents reviewed for abuse. Findings include:A review of intakes 2627057 and 2626819 revealed allegations of employee to resident abuse resulting in injury and hospitalization.On 9/29/25 at 10:06 AM, a phone interview was completed with R903 who explained they were currently hospitalized for a sustaining a concussion from being physically assaulted in the forehead with an unknown object causing bleeding by an unidentified agency staff member. R903 explained they contacted the local police after the incident and was transferred to the hospital on 9/16/25 following the incident.On 9/29/25 at 11:56 AM, an interview was completed with the Director of Nursing (DON) regarding the allegations of abuse reported by R903. The DON explained there were allegations of employee to resident abuse that allegedly occurred in the early morning hours of 9/16/25 however, after the facility investigated the concerns, they were unable to substantiate that abuse occurred.On 9/29/25 at 2:54 PM, the Nursing Home Administration (NHA) and DON were interviewed regarding the reporting of allegations of employee to resident abuse. The NHA and DON explained the facility investigation was completed within an hour of being informed of the allegations and determined there was no employee to resident abuse, and as a result, determined they didn't need to report the allegations to the State Agency.A review of the facility's Abuse policy revealed the following, The facility will ensure that all allegations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, and crimes are reported immediately to the Administrator and: Reported to the State Survey Agency immediately but not later than two hours after the allegation is made if the allegation involves abuse or results in serious bodily injury and to other officials (including adult protective services and/or law enforcement, when applicable or reported to State Survey Agency no later than 24 hours if the allegation does not involve abuse and does not result in serious bodily injury to the State Survey Agency and to other officials.

Based on interview and record review, the facility failed to offer and provide the COVID-19 immunization vaccine and education to 11 (Staff E, Staff F, Staff G, Staff H, Staff I, Staff J, Staff K, Staff L, Staff M, Staff N, and Staff O) of 99 staff members. Findings include:On 7/23/2025 at 10:04 AM, the Infection Control Preventionist (ICP) was asked about the facility's process for offering the COVID-19 vaccine to residents and staff. The ICP explained they still offer the vaccine to residents; however, it is no longer offered to staff.A review of the facility staff vaccine documentation provided by the facility did not reveal that unvaccinated staff were provided education regarding the benefits and potential risks associated with the COVID-19 vaccine, or that staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine. On 7/23/2025 at 1:05 PM, the ICP explained the facility stopped offering vaccines to staff at the beginning of the year (2025) at the facility, and if a staff member would like the vaccine, they are referred to their local pharmacy. The ICP was asked if there was documentation that shows that staff are being offered or declining the vaccine or vaccine education, and stated, No.A review of the facility's COVID-19 policy revealed the following, .Staff will be offered the Covid-19 vaccine unless the immunization is medically contraindicated, or the staff has already been immunized. Staff will be educated regarding the risks, benefits, and potential side effects associated with the vaccine in a form and manner they understand and receive a copy of the CDC Covid-19 VIS Sheet before being offered the vaccine. CDC Vaccine Information Statements (VIS) can be found at the Center for Disease Control and Prevention (CDC) website. If the vaccination requires multiple doses of vaccine, the staff are again provided with education regarding the benefits and potential side effects of the vaccine and current information regarding those additional doses, including any changes in the benefits or potential side effects, before requesting consent for administration of any additional doses. The staff member must be provided the opportunity to refuse the vaccine and to change their decision about vaccination at any time. The facility maintains documentation related to staff Covid-19 vaccination that includes, Staff education regarding risks and benefits associated with the Covid-19 vaccine. Staff were offered the Covid-19 vaccine or information on obtaining the Covid-19 vaccine.

Number of residents sampled: FacilityNumber of residents cited: PatternThis citation pertains to intakes 2560380, 2560402, 2560706, and 2560866.Based on observation, interview, and record review, the facility failed to ensure the safety and protection of six of six confidential female residents during a sexual abuse investigation. Findings include: Review of a Facility Reported Incident (FRI) submitted to the State Agency documented, On 07/10/2025, an unknown male patient (R66) talked (name of R45) into giving them oral sex while they were sitting in the wheelchair and (R66) was standing in the hallway. Two unidentified nurses' aides from the facility walked up on the two and reported the incident . On 07/22/25 at 12:16 PM, Assistant Director of Nursing (ADON) D was interviewed regarding the sexual abuse incident that was reported to the State Agency. R66 was identified as the alleged perpetrator and R45 as the alleged victim. ADON D indicated upon staff observation of the incident taking place, R66 was initially returned to their room after being separated from R45. ADON D said following completion of some initial resident and staff interviews, R66 was then moved to another room on the other side of the nurse's station further away from R45's room. Review of the facility record for R66 revealed an admission date of 12/02/23 with diagnoses including Diabetes Mellitus, Bipolar Disorder, and Vascular Dementia. The record further indicated R66 was able to ambulate in the facility using a cane and to mobilize further distances via wheelchair when needed. R66's Brief Interview for Mental Status (BIMS) score of 15/15 indicated intact cognition. On 07/22/25 at 2:47 PM, the facility Administrator (NHA) and the Director of Nursing (DON) were interviewed and reported R66 was initially returned to their room following the incident and was subsequently moved to another room which was on the same floor as R45 but around the corner of the T intersection where the nurse's station is located. The NHA indicated with this arrangement, R66 would be required to pass the nurse's station in order to access the end of the hallway which R45 resided in. When asked if they incorporated any additional protective measures, they reported they did not. They reported they felt there was limited risk of further abuse, as R45 was out of the facility being assessed at the hospital from 10:30 PM (7/10/25) until 7:30 AM the following day (7/11/25). They further reported the morning of (7/11/25), R66 was discharged to another facility at approximately 11:00 AM (3.5 hours after R45 returned to the facility). On 07/23/25 at 10:10 AM, the second-floor hallway, containing the room R66 was moved to, was observed to be directly accessible to approximately seven other rooms without being required to either pass or be within view of the nurse's station. Of these rooms, four were observed to be occupied by six female residents. During this observation there were intervals of time during which no staff were observed on the floor or at the nurse's station. On 07/23/25 at 2:29 PM, the NHA was interviewed and queried regarding the protection the six female residents on the unit between the hours of 6:00 PM on 7/10/25 to 11:00 AM on 7/11/25 from R66. The NHA indicated they felt appropriate precautions were taken due to the nurse's station being at the intersection of the hallway and stated, the nurse and the CENA's (Certified Nursing Assistants) are always on the floor, despite observations during the survey of staff not being present on unit. Review of the facility policy titled Abuse dated 05/24/23 revealed the Policy Overview statement Investigating allegations of abuse, neglect, misappropriation, mistreatment, and exploitation to include protecting residents during the investigation, and taking necessary actions as a result of the investigation. The Protection portion of the policy states The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: Providing a safe and secure environment for all patients .If a resident is the alleged perpetrator, the facility will ensure other residents are protected as determined by the circumstances, which may include but are not limited to resident room changes, increased supervision, or immediate transfer or discharge, if indicated.

This citation pertains to Intake:1217345 Based on interview and record review, the facility failed to document and properly administer insulin for one resident (R105) of four reviewed for medication administration. Findings include:A review of a complaint received from the State Agency revealed concerns that the resident's diabetes was not managed appropriately while admitted in the facility. A review of R105's medical record revealed they were admitted into the facility on 6/14/25 with diagnoses that included Critical Illness Myopathy, and Diabetes Mellitus, Type II with Hyperglycemia. Further review revealed the resident was cognitively intact and needed supervision to limited assistance for Activities of Daily Living. Further review of the medical record revealed the following order placed on 6/14/25, Insulin Lispro 100 UNIT/ML (milliliters) Solution Inject as per sliding scale: if 151 - 200 = 2 units Give 2 units; 201 - 250 = 4 units. Give 4 unit; 251 - 300 = 6 units Give 6 units; 301 - 350 = 8 units Give 8 units; 351 - 400 = 10 units Give 10 units, subcutaneously before meals and at bedtime for Diabetes management Notify Physician if BS (blood sugar) is less than 70 and/or greater than 400. Further review of R105's medical record revealed that on 6/15/25, the resident had a blood sugar reading of 570. A review of the resident's Medication Administration Record (MAR) revealed the resident was provided with the insulin however, documentation of the amount administered was missing, as well as documentation that the physician was notified of a blood sugar reading over 400. A review of R105's progress notes revealed the following, 6/23/2025 10:15am Nursing Progress Note .Resident was admitted with noted irregular blood sugars (hyperglycemia). On 6/18/25, there was a medication error where the resident did not receive insulin from nursing staff for a 395 BS . A review of the Incident and Accident report dated 6/18/25 revealed the following, Informed on 6/19/25 by sister, residents blood sugar was not obtained 6/18/25 at lunch, upon investigation NA (not applicable) documented on MAR for 12pm blood sugar. spoke with nurses who states she got busy and forgot, states after resident asked, she went to take but therapy had taken resident downstairs, so it was not done. nurse education on importance of blood sugar/insulin along with how to proceed if not taken on time . On 7/23/2025 at 12:33 PM, an interview was completed with the Director of Nursing (DON) regarding 105's missed medication administration. The DON acknowledged that the nurse did not provide the medication, and when interviewed she stated, I forgot. The DON confirmed the nurse did not contact the doctor per order. A review of the Medication-Insulin Administration policy revealed the following, .The type of insulin, dosage, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order .Document the administration in the medication record .

Based on observation, interview, and record review, the facility failed to post nurse staffing information daily affecting all 78 residents residing in facility. Findings include:On 7/21/2025 at 11:53 AM, a nurse staffing sheet was observed in the lobby. The nursing staff sheet was dated 7/9/2025 (12 days earlier). Receptionist B was asked if they posted the nurse staff information anywhere else in the facility. Receptionist B stated they only place it is posted is in the front lobby. At 11:57 AM, Admissions Director (AD) C was observed removing the nurse staffing sheet from the front lobby.On 7/23/2025 at 10:05 AM, an interview was conducted with Staffing Coordinator (SC) A. SC A reported they print out the nurse staffing sheets weekly, and they were in their office. SC A reported they forgot to put them out in the lobby daily.On 7/23/2025 at 12:31 PM, an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated they were aware of the issue and working with the unit manager to ensure it does not get overlooked again.A review of a facility policy titled, Staffing noted the following, .Nursing direct care staffing data will be posted on a daily basis in a location accessible to residents and visitors in a clear and readable format.

Based on observation interview and record review the facility failed to maintain sanitary conditions in the kitchen for 74 residents. Findings include: On 07/16/24 at 8:40 AM and on 07/18/24 at 7:54 AM, the main kitchen was observed with the Dietary Manager (DM) present and the following was noted: -two gnats were flying around the beverage dispenser; -a six inch puddle of water was observed between the coffle dispenser and the reach-in refrigerator; -a fly was flying around the dishwasher area; -food particles were under the garbage disposal-with a bucket under the disposal and on the floor at the left corner of the pre-rinse counter; -a tan colored sludge extended four (six inch) tiles out and 12 tiles down toward the dishwasher; -the dishwasher had a build up of food and sticky soil under the entire foot print of the unit; -the floor under the drying/clean side of the dishwasher had standing water which covered four tiles; -a test of a sanitizer bucket with the DM indicated it was light and not at the proper level for disinfection; -food debris was left on the 8 quart pot and scoops- three red, one blue, one yellow, one gray; -a box of meat was not fully closed to prevent air contamination. On 07/18/24 at 7:54 AM, the puddle behind the coffee dispenser was observed gone and left a tile size area of black soil. On 7/18/24 at 8:28 AM, staff were serving food from the breakfast tray line service and the following was observed: -a box of food placed into the reach in refrigerator by the DM; At 8:34 removed gloves to prepare items on the stove and placed on new gloves without hand hygiene in between; At 8:49 AM, the cook removed their gloves and walked over to the trash can and lifted the front edge of the trash can with the gloves in hand, entered the ice dispenser area, removed a carton of liquid eggs from a refrigerator, re-entered the main kitchen area, donned new gloves without hand hygiene and returned to food serving and plating; -at 8:51 AM, a fly was observed to land on a fluorescent light fixture by the entry door, the middle fixture in same line was without a cover and appeared rusty; the DM removed their gloves and completed some other tasks with the toaster and filling some oatmeal serving cups and hands were not observed to be washed between glove changes. The identified concerns were reviewed with the DM and the cook. It was noted they were waiting for a part for the disposal because it sprayed debris when in use and the floor was cleaned nightly. A pest control visit note dated 05/28/24 noted a leak behind the drink machine in the kitchen. A review of the policy titled, Kitchen Sanitation to Prevent the Spread of Viral Illness dated 2/2023 revealed, The Food service employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes in order to minimize the risk of cross contamination and spread of illness through food Use of Gloves i. Gloves are not a substitute for thorough and frequent hand washing. 1. When using gloves, always wash hands before touching or putting on new gloves. ii. Do not use latex or corn starch powder, which can transfer protein allergens from latex to person consuming food. iii. Use single use gloves for one task. iv. Change gloves: 1. Between each food preparation task. 2. After touching items, utensils or equipment not related to task. 3. After touching hair, face or any other source of contamination. 4. When leaving food preparation area for any reason. The food service director or designed shall enforce all principles of employee hygiene while preparing, storing and serving food to minimize spread of illness .

Based on observation, interview, and record review, the facility failed to perform hand hygiene during/after resident care for two residents (R26 and R44) and failed to sanitize patient care equipment after use for one resident (R218) of three residents reviewed for hand hygiene during care. Findings include: On 07/17/24 at 8:03 AM, Licensed Practical Nurse (LPN) J completed a medication administration and washed their hands to a count of five seconds. On 07/17/24 at 8:38 AM, LPN K completed a medication pass and did not complete hand hygiene after removal of their gloves. On 07/17/24 at 08:30 AM, Nurse D did not perform hand hygiene prior to beginning medication preparation. After Nurse D prepared some medications, it was determined stock medications were not available in the medication cart. Nurse D went to the medication storage room to obtain them. Hand hygiene did not occur before Nurse D left the medication cart. Nurse D did not perform hand hygiene when resuming medication preparation. On 07/17/24 at 08:30 AM, Nurse D obtained R218's blood pressure, administered R218's medication, and left the room. Nurse D did not sanitize the blood pressure apparatus. On 07/17/24 at 09:35 AM, Nurse E did not perform hand hygiene prior to beginning medication preparation. Nurse E completed preparing the mornings medication and entered the resident room with the blood pressure apparatus. Nurse E obtained R26's blood pressure and pulse and handed R26 the medication cup. R26 revealed to Nurse E that he wanted to hold off on taking the blood pressure medication and the water pill, providing an explanation to Nurse E and revealing he would take after therapy. Nurse E returned to the medication cart without performing hand hygiene. Nurse E then pulled all of the administered medication cards from the cart to enable the identification of the blood pressure pill and the water pill. Nurse E donned one glove after choosing the correct card, to identify the correct pills to remove. Nurse E then dumped similar looking tablets into her gloved hand and removed the correct pills, placing them in a separate medication cup. Nurse E removed her glove, hand hygiene was not performed. Medication was administered to R26. R26 dropped one capsule to the floor. Nurse E retrieved the capsule from the floor, identified it and placed in the cup with the other wasted medication. Hand hygiene was not performed. The blood pressure apparatus was not sanitized. On 07/17/24 at 09:35 AM, Nurse E left the medication cart with the medication to be wasted. Nurse E went to the medication storage room to place the wasted medication in the safe disposal container. Nurse E opened a new medication safe disposal container using a half donned glove, punctured the seal with their pen and dropped the medication in. Nurse E resealed the container and replaced under the sink. Nurse E removed the glove. Hand hygiene was not observed. On 07/17/24 at 09:35 AM, Nurse E left the medication storage area and returned to her medication cart. Nurse E began to prepare medication for the next resident. Hand hygiene was not performed. On 07/18/24 at 11:39 AM, a wound care observation for R44 was completed with the wound care consultant, unit manager and wound nurse. The heel wound was assessed by the wound consultant and upon completion their hands were washed less than 20 seconds. The keys for the treatment cart were used by the consultant to get supplies from the cart with a gloved hand. Gloves were removed and hands were washed approximately five seconds. The coccyx wound was then measured and by the wound consultant and gloves were doffed with hand washing for a count of five seconds. A picture was taken of a left heel wound by the wound consultant who had their forearms on the bed to point the camera at the wound. The consultant finished and doffed their gloves with hand washing for a count of five seconds. The phone was not wiped down prior to the consultant putting it in their pocket. The phone was then used without gloves by the consultant. On 07/17/24 at 1:03 PM, the infection control nurse reported hand washing should be done between gloves changes and should include the use of hand sanitizer or soap. If washed with soap hands should be washed for at least 20 seconds. The infection control nurse also reported the need to complete hand hygiene between care of residents and to clean the blood pressure cuff between residents. On 07/18/24 a review of the policy titled Hand Hygiene revised 4/14/23, revealed, Situations in which using soap and water or alcohol based hand rub can be used, before preparing or handling medications, before performing resident care procedures, after contact with a resident's skin, and after handling contaminated objects, equipment, dressings, etc .

This citation pertains to Intake MI00145395. Based on observation, interview, and record review, the facility failed to maintain clean, sanitary tube feeding equipment for one (R48) of two residents reviewed for tube feeding. Findings include: The facility record for R48 revealed an admitted [DATE] with diagnoses that included Cerebral Infarction and Gastrostomy Status. On 07/16/24 at 10:48 AM, R48 was observed in bed. The tube feeding pole and base were observed to be significantly soiled with tube feeding fluid. On 07/17/24 at 09:06 AM, R48 was observed laying in bed. The tube feeding was being administered. The tube feeding pole and base were observed to continue to be soiled as during the previous observation. On 07/17/24 at 02:42 PM, R48's tube feeding pole was observed to continue to be in the same soiled condition as during the previous observations. On 07/18/24 at 09:07 AM, R48's tube feeding pole and base were observed to continue to be in a significantly soiled condition as during the previous observations. On 07/18/24 at 11:12 AM, the facility Director of Nursing (DON) observed R48's tube feeding equipment with the surveyor and reported that the pole should not be in such a soiled condition. The DON reported their expectation is the equipment should be cleaned any time is becomes soiled. The DON reported that the cleaning of the equipment can be completed by clinical or housekeeping staff. Review of the facility policy Routine Cleaning and Disinfection dated 08/22 included the Policy statement It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. The Compliance Guidelines section further stated 1. Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge.

Based on interview and record review, the facility failed to provide timely notification of a change in condition for one (R65) of six residents reviewed. Findings include: Review of the facility record for R65 revealed an admitted [DATE] with diagnoses that included Anemia, Gastrointestinal Hemorrhage, and Acute Kidney Failure. A progress note dated 05/25/24 and timestamped 3:01 AM indicated R65 was found to be primarily unresponsive and had a blood pressure of 90/58. The progress note indicated the physician, (facility)management, and the family were notified and the resident was sent to the hospital. Further review of the record revealed R65 returned from the hospital on 05/25/24 at 11:00 AM after being treated in the emergency room for hypoglycemia. Review of R65's vital sign history indicated on 05/26/24 at 10:14 AM, the blood pressure reading was 84/58. There was no indication in the record this blood pressure was reported to the physician or that a follow-up blood pressure or action otherwise was taken. The next entry in R65's progress note was dated 05/26/24 and indicated R65 was found unresponsive at 5:10 PM. On 07/17/24 at 10:38 AM, R65's family member (FM) G was interviewed via phone call. FM G reported on 05/26/24, they had not been notified by the facility that the resident had any change in condition until after they were found unresponsive. On 07/18/24 at 11:50 PM, the facility Director of Nursing (DON) reported the parameters for reporting vital signs to the physician are determined on a resident to resident basis. The DON reviewed R65's blood pressure reading history with the surveyor and reported the 05/26/24 entry of 84/58 should have been reported to the physician and their expectation is that it would have been reported to the physician. Review of the facility policy Change in Condition Notification dated 08/09/23 states 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. - The nurse will document in the resident's medical record information relative to the resident's change in medical/mental condition or status (i.e., assessment, notifications, interventions, and response).

Based on observation, interview and record review, the facility failed to ensure dependent residents were repositioned or provided range of motion exercises for three residents (R35, R44, R116) of three whose positioning was reviewed. Findings include: R35 On 07/16/24 at 9:39 AM and 11:43 AM, 1:47 PM, 1:53 PM and 2:52 PM, R35 was observed to be supine in bed with the head of the the bed up around 20-30 degrees. R35 leaned toward the left side of the bed with their head at the left edge of the pillow. The legs/and or foot of the bed was elevated and R35 appeared to have heel boots on. A powered low air loss mattress unit was active at the foot of the bed. The TV was on. At 1:53 PM, Certified Nursing Assistant (CNA) F was asked about R35 and reported R35 needed assistance with repositioning had a wound to the heel and may have had a small open area on the tailbone or buttocks. R35 appeared asleep at times but did awaken to their name and the knock on the door. At 5:06 PM, R35 appeared supine in bed with no observable position change to the left or right. R35 appeared asleep, with the head of the bed up around 20-30 degrees, their head faced toward the left with their feet up. A pillow was visible to left side but only the arm of R35 appeared on it. On 07/17/24 at 7:40 AM, R35 was observed to be in bed, supine, a pillow on the left side which did not appear to be under the torso of R35. The head of bed the bed was up around 30-45 degrees. R35's head faced toward the right, appeared to have heel boots on with the lower legs elevated on a pillow and was dressed in hospital style gown. At 9:12 AM, staff entered the room of R35 for the breakfast meal tray and removed it. R35 was observed to be supine in bed, the torso toward the left side, and the head of bed up 30-45 degrees. R35 reported no concerns. At 9:49 AM, R35 was in a similar position and staff entered, reported to resident, I am here to help get you dressed. R35 remained in bed. At 10:41 AM, R35 remained in bed as before and appeared asleep as they did not easily awaken to the knock on the door or their name. At 12:24 PM, R35 was observed to be supine in bed with their torso toward the left side of the bed. R35 had a hospital style gown on gown on. R35 was asked about not getting out of bed as they were not dressed and reported they are not often out of bed or their room. At 2:29 PM and 4:56 PM, R35 was observed to be supine in bed with the tray table over the bed, R35 appeared asleep, with their eyes closed and their head over to left bottom corner of the pillow. On 07/18/24 at 7:40 AM and 10:41 AM, R35 was observed to be in bed, supine, their head over to left lower corner of the pillow and dressed in a hospital style gown. The head of the bed was up around 20-30 degrees with lower extremities elevated. At 10:41 AM, R35 awakened to the knock on door and reported they were not that active. At 11:00 AM, a skin observation was completed with the unit manager. The coccyx (buttocks area) had light purple discoloration area which surrounded the area, which blanched upon the application and release of pressure. A pillow was under the left arm which appeared swollen compared to the right, but no pillow or device was under the torso. R35 was not observed to be out of bed during the survey. A review of the record for R35 revealed, R35 was admitted into the facility on [DATE]. Diagnoses included Dementia, Muscle Weakness and Reduced Mobility. The Minimum Data Set (MDS) assessment dated [DATE] documented impaired cognition with a 5/15 Brief Interview for Mental Status (BIMS) score, no rejection of care, function range of motion limitation in both upper extremities and the need for substantial/maximal assistance for personal hygiene, to roll left or right, to sit up in bed, to sit at the side of the bed and to transfer. R35 was totally dependent for bathing and toileting hygiene. The care plan dated 03/11/24 documented at risk for changes in behavior and mood related to Dementia . at risk for pain related to weakness .implement .positioning to assist with pain and monitor for effectiveness . at risk for alteration in skin integrity .encourage and assist as needed to turn and reposition, use assistive devices as needed . ADL (activities of daily living) self care deficit .bed mobility times one person assist .encourage and or assist to reposition frequently . Exerts choice to refuse .refusals can change day to day .give resident choices and encourage to take an active role during daily care . R44 On 07/16/24 at 9:30 AM, R44 was observed to be on their back (supine) in bed, leaned toward the right side of the bed, with the head of the bed up around 30-45 degrees, the call light across the chest area and the bed up from the lowest position. R44 had a powered mattress set at alternating. R44 appeared asleep and was not awakened or opened their eyes to the call of their name. At 11:35 AM, R44 appeared to be supine in the same position. At 1:13 PM, R44 appeared to be supine in bed and the torso leaned more toward the right side of the bed. At 1:15 PM, a friend of the R44 reported they R44 could be out of bed more, was not getting their face washed daily and was not getting the range of motion exercises regularly. On 07/17/24 at 7:47 AM, R44 was observed to be in bed, supine (on their back), with the torso toward the right side of the bed, two pillows under their head, lower legs elevated and appeared to have heel boots on. R44 was dressed in a hospital style gown and the head of the bed was up around 45-60 degrees. The covers were up over the shoulders. R44's eyes were open with their head faced toward the TV on the right. The TV was on. A meal tray was at bed side, on the right and appeared to have been eaten. A powered unit for the bed mattress was active at the foot of the bed. At 8:38 AM, R44 was observed during the medication pass and appeared in the same supine position and cooperatively interacted with the nurse. At 9:00 AM, R44 was in the same position. At 9:46 AM, R44 appeared supine in bed as before, eyes closed and did not open them to the knock on the door and call of their name. The TV was on and R44 had their head down toward right the right shoulder. Devices to reposition left or right were not apparent. At 9:50 AM, therapy staff, knocked and entered room and exited out as quickly as they went in. On 07/17/24 at 10:44 AM, R44 was observed to be supine in bed as before. At 12:32 R44 appeared to be in the same supine position the eyes were open and R44's head faced toward the TV and over toward the right shoulder. R44 did not answer to the call of their name. R44 was dressed in a hospital style gown. The printed throw was visible at top of the shoulders. At 2:32 PM, R44 appeared supine as before. R44's head was farther off pillow and below the right corner of the pillow. The double pillows were in place. The head of bed was around 30-45 degrees. At 2:48 PM, Certified Nursing Assistant (CNA) C was asked about the care of R44 and reported R44 was completely dependent for care and needed help to turn/reposition in bed, to eat, wash up, for mouth care and incontinence care. CNA C also reported R44 liked to watch TV and since they were dependent for turning should be turned at least every two hours with a pillow or wedge. At 2:54 PM, R44 was observed with CNA C for devices an it was noted none were in place at the sides. A splint was observed to cover the left hand and wrist area. At 4:57 PM, R44 appeared to be on their back in bed, but more upright in the bed. On 07/18/24 at 7:43 AM, CNA F brought R44's breakfast tray in placed in on the bedside table and elevated the head of the bed to around 45-60 degrees. R44 appeared to be supine in bed, with the hospital style gown down off the shoulders. Staff seated themselves on right side of bed, TV on, and assisted R44 to eat. No obvious wedge or pillow was in place. At 10:44 AM, R44 was observed to be in bed, and appeared supine in bed, gown off shoulders, lower legs elevated, no obvious device for turning or reposition to the left or right. R44's head was turned/faced toward the right and at the side of pillow. At 9:58 AM, R44's functional status was reviewed with the Therapy Manager. The Therapy Manager reported R44 remained dependent for care upon the most recent therapy evaluations and was on occupational therapy for the establishment of a comfortable wear program for the splint. At 10:51 AM, CNA F was asked about the positioning needs of R44 and reported a pillow or wedge had been used and the resident did not like the wedge. The observation of R44 in a similar position was review with CNA F who reported R44 was turned/repositioned when changed due to incontinence and at times would resist turning and repositioning. At 11:11 AM, two CNA staff entered to complete care for R44. Pillows were noted under the legs but not to the sides of the torso. A lift sling had been placed under the resident. Range of motion to the lower extremities was not attempted. R44 was not observed to be out of bed during the survey. A review of the record for R44 revealed, R44 was admitted into the facility on [DATE]. Diagnoses included Stroke and Muscle Weakness. The Minimum Data Set (MDS) assessment dated [DATE] documented impaired cognition with a 3/15 BIMS, no rejection of care, functional range of motion limitation in both upper and lower extremities and total dependence for personal hygiene, to roll left or right, bathing, toileting hygiene and to transfer. The care plan dated 07/09/24 documented at risk for changes in behavior and mood . at risk for pain and has pain related to pressure ulcers .implement .positioning to assist with pain and monitor for effectiveness . at risk for alteration in skin integrity .administer treatment per physician orders .encourage and assist as needed to turn and reposition, use assistive devices as needed . has alteration in mobility .range of motion to be provided by staff during ADL task . A review of the active orders revealed an order dated 07/10/24 which indicated, Perform passive range of motion to bilateral lower extremities during resident care, two sets times twenty reps. A review of the task titled, Restorative Passive ROM (range of motion) program #1 documented three attempts since the order date of 07/10/24. One for five minutes on 07/11 and one for ten minutes on 07/13 and one refused on 07/16. Four additional dates were documented not applicable. R116 On 07/16/24 at 2:27 PM, R116 was observed to be in bed with the head of the bed up around 30-45 degrees. R116 was leaned over to right so that their right shoulder was at the end of the bed. On query R116 attempted to reach the left side of the bed and was unable to bring themselves to an upright position in bed. The food tray was angled away from the right side of the bed with some of the items eaten. At 5:24 PM, R116 was leaned over with their shoulder at the right side of the bed with the head of the bed up around 30-45 degrees. R116 reached over the bedside table and moved some items around. R116 acknowledged their position in bed and the noted they had been at the facility a couple of weeks. R116 commented they needed therapy for their legs. On 07/17/24 at 7:56 AM, R116 was observed to be in bed and appeared to be sleeping at they were not not awakened to the knock on the door and the head was over to the right shoulder. R116 was more upright in bed but remained off center to the right. At 11:07 AM, R116 reported they had therapy earlier. R116's torso was off center as before. At 12:46 PM R116 continued as before in bed. On 07/17/24 at 2:46 PM, R116 was flatter in bed with the head of the bed down, slightly off center to the right, The bed control was in hand. At 4:58 PM, R116 was observed to be in bed with the head of bed up around 20-30 degrees, the torso was toward the right edge of the bed. On 07/18/24 at 7:46 AM and 10:56 AM, R116 was observed to be in bed, the right shoulder over to right edge of bed and the head of bed up around 30-45 degrees. At 10:10 AM, R116 functional status was reviewed with the Therapy Manager. The Therapy Manager reported R116 refused physical therapy upon evaluation on 07/07/24 and acknowledged R116 had rigidity and impaired mobility. The manager noted occupational therapy would be working on sitting balance, wheelchair mobility and lower body bathing. It was noted by the therapy manager there were refusals on 7/15/24 and 07/17/24 with concerns for being hurt or pain or other excuse provided. R116 was not observed to be out of bed during the survey. A review of the record for R116 revealed, R116 was admitted into the facility on [DATE]. Diagnoses included Schizoaffective Disorder, Anxiety Disorder, Dementia and the Need for Assistance with Personal Care. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition with a 14/15 BIMS, Disorganized Thinking, rejection of care one to three days, functional range of motion limitation in both lower extremities and total dependence for bathing, for toileting hygiene, to roll left or right, to sit up and lay down from the side of the bed and to transfer. The care plan dated 07/03/24 documented at risk for changes in behavior and mood .offer choices to enhance sense of control . at risk for pain .Encourage/assist to reposition frequently to position of comfort .implement .positioning to assist with pain and monitor for effectiveness . at risk for alteration in skin integrity .encourage and assist as needed to turn and reposition, use assistive devices as needed . has alteration in mobility .range of motion to be provided by staff during ADL task . Resident chooses not to agree with the plan of care .Encourage resident to make decisions concerning timing of care . On 07/18/24 at 12:22 PM, the wound consultant Nurse Practitioner was asked about repositioning and with a low air loss or specialty mattress and reported they still recommend to reposition residents as tolerated. On 07/18/24 at 11:03 AM and 2:36 PM, the care of the identified residents was reviewed with the Director of Nursing (DON), The DON noted R116 was very resistive to care exhibited behaviors and would not let them touch even the trash can. It was further reported that it takes 4-5 people to get R116 together the DON acknowledged they could do better. For R44 the DON noted resistance to care at times and the presence of wounds and the reopening of a wound to the left foot. The DON reported that looking at everything the facility could improve on repositioning. For R35 the DON noted R35 could also be resistive to care at times and does not like to be turned. A review of the policy titled, Repositioning issued 08/09/23, revealed, .this procedure is to provide guidelines to promote comfort, assist in prevention skin breakdown, promote circulation and provide pressure relief for bedbound and chairbound residents .frequency of repositioning a bedbound or chairbound resident should be determined by: Level of resident's activity and mobility; type of pressure redistribution support surface in use -- turning and repositioning is still required on specialty surfaces but frequency ay be reduced; The condition of the resident's skin; The overall condition of the resident; Comfort levels of the resident; Resident preferences . Residents who are immobile and or dependent on staff for repositioning, should be repositioned every two hours .

This citation pertains to Intake MI00143863. Based on observation, interview and record review, the facility failed to ensure pressure ulcer treatments were consistently provided as ordered for one (R501) out of three residents reviewed for pressure ulcers. Findings include: A review of the Intake allegation noted, It was alleged facility staff failed to provide adequate and appropriate care to prevent and/or treat pressure sores. A review of R501's medical record revealed, R501 was admitted to the facility on [DATE] and readmitted on [DATE], discharged [DATE], with diagnosis of Type II Diabetes and Protein calorie malnutrition. Further review of R501's medical record noted, Skin assessment dated , 3/13/24 Pressure ulcer acquired New, Unstageable Left ischial tuberosity. 12.5 area, 4.3 length, 4.0cm width . Notes Resident alert with arousal, oriented x1-2, and cooperative to care. Resident exhibiting s/s (signs and symptoms) of decline, refusing food, sleeping through treatment and ADL care. Unable to hold posture while up in wheelchair, exhibiting s/s of dehydration. Education: Expressed some discomfort during treatment r/t contractures. Treatment administered, unit supervisor, physician, and POA (power of attorney) notified. Will continue with current treatment regimen. Resident to continue to be followed weekly by wound care. Continue with current plan of care. R501's care plan noted, At risk for alteration in skin integrity related to weakness, debility, hx (history) of CVA (cerebral vascular accident) with RT (right) hemi, dementia, incontinence. Date Initiated: 02/12/2024. Goal: Decrease/minimize skin breakdown risks. Date Initiated: 02/12/2024. Intervention: Administer treatment per physician orders. Date Initiated: 11/17/2023. Barrier cream to peri area/buttocks as needed. Date Initiated: 02/12/2024. Observe skin condition with ADL (activities of daily living) care daily; report abnormalities. Date Initiated: 02/12/2024. A review of R501's Treatment Administration Record (TAR) revealed, blank documentation for the treatment of R501's ulcers for the months of January, February, and March. January order: Triad Hydrophilic Wound Dress External Paste (Wound Dressing) Apply to bilateral buttock topically every shift for and as needed for wound care. Start Date: 1/17/2024. The TAR was noted to be blank and without any documentation for this order. February order: Triad Hydrophilic Wound Dress External Paste (Wound Dressing) Apply to bilateral buttock topically every shift for and as needed for wound care. Start 2/04/2024. The TAR was noted to have blank/without documentation on 2/2, 2/5, 2/7-2/12/24. R501's care plan did not reveal interventions to address if R501 refused treatments or repositioning. On 5/7/2024 at 1:01 PM, the Director of Nursing (DON) was asked about R501's skin and the facility's expectation for following physician's orders. The DON explained that R501 had started to decline and had been in and out of the hospital. The DON acknowledge the treatments were not documented consistently, and the facility identified some issues with how wounds were being followed. The DON explained they completed a past non-compliance to correct the concerns with acquired wounds. The DON explained the expectation is to complete and document the wound treatments, if not completed to contact her and the physician. A review of the facility's policy titled, Skin and Wound Guidelines dated, 3/20/24, noted Policy Overview: To describe the process steps required for identification of residents at risk for the development of pressure injuries, identify prevention techniques and interviews to assist with the management of pressure injures and skin alterations . Treatments: . Treatments are ordered by the medical practitioner. A complete treatment order consists of the following: Site application, Cleansing agent, Frequency, including end date orders if applicable, Type of securement . During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included (interventions/actions to correct the past noncompliance). The facility was able to demonstrate monitoring of the corrective action and maintained compliance. Past Noncompliance - Quality of Care - Facility Acquired Pressure Ulcers #1. Facility currently has 5 residents with facility-acquired pressure ulcers. All residents have appropriate physician ordered treatments, weekly assessments and documentation, RD (Registered Dietician) following for nutritional support, care plan updated with appropriate interventions, physician and resident/representative aware and in agreement with plan of care. #2. Residents who reside in the facility have the potential to be affected. A facility-wide audit was conducted, and a skin sweep of all current residents was completed. All appropriate interventions are in place for residents with wounds, physician ordered treatments are in place, skin assessments are being completed weekly, wound V7 assessments are being completed every 7 days per policy, and residents at risk for wounds have interventions in care plan and at bedside, and admission skin checks are being completed with 2 nurses with appropriate interventions and physician ordered treatments in place. #3. Director of Nursing, or designee, will educate staff on turning and repositioning, floating heels and heel checks, weekly skin assessments, facility wound care policy, incontinence care, appropriate interventions related to skin care and high risk residents, initiating proper treatments based on facility formulary/products. #4. Director of Nursing, or designee, will audit 10 residents weekly x4 weeks to ensure that all residents are receiving weekly skin assessments and they are documented appropriately, that residents are being turned and repositioned with heels floated as tolerated, that facility wounds are being assessed at least every 7 days per policy, that wounds have appropriate physician ordered treatments placed upon identification of the wound. Results of these audits will be reviewed in Quality Assurance [QAPI] meeting to further guidance. #5. The Administrator will be responsible for achieving and maintaining compliance. Date of compliance 5/6/2024.

Based on observation, interview, and record review, the facility failed to 1) label/date multi-use medications per professional standards, maintain the cleanliness of a medication storage cart, properly store and label liquid medication and vials of tuberculin purified protein derivative (PPD), and 2) limit access to and promptly destroy discontinued controlled substances, resulting in the potential for drug diversion and/or ineffective or unsanitary medication administration that could affect all residents residing in the facility. Findings include: Controlled Medications are substances that have an accepted medical use (medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence. On 5/15/23 at 4:32 PM, the 1st floor high medication cart was observed to be unlocked and unattended in the hallway. No staff were observed in the vicinity. On 5/16/23 at 10:55 AM, the 2nd floor high medication cart was reviewed with Licensed Practical Nurse (LPN) A. An opened vial of insulin Lispro (fast acting insulin to treat high blood sugar) was observed with no open date present. Additionally, an opened insulin pen was noted without a legible resident label, and an opened bottle of glucometer strips was noted without an open date. Another opened insulin pen was noted with an open date, however, an incorrect (longer than 28 days) expiration date was written alongside the open date. LPN A removed the items from the cart and indicated they should have been properly labeled/dated. A middle drawer on the right side of the cart, holding liquid medications, was opened and noted to have multiple areas of dried, sticky red substance at the bottom. LPN A stated she would try to find time to clean out the drawer on her shift. A long, middle drawer was opened and noted to have medications stored with snack foods. LPN A was queried regarding the storage of medications with food items and indicated they should not be stored together. An opened bottle of saline was found in the medication cart without a resident label and open date. LPN A discarded the bottle of saline and indicated that saline is typically kept in a treatment cart. LPN A then indicated that the 2nd floor high cart currently contained multiple medication cards (controlled substances) from residents who were no longer in the facility. LPN A further explained that she did not feel comfortable being responsible for extra controlled medications, but that she and the other nurses do count and verify them at every shift change (which can be time-consuming). LPN A indicated that the facility does have a current process of tracking controlled medications but also indicated that the disposal of discontinued ones has been an issue. LPN A added that the facility does utilize agency nursing staff. Eight medication cards from the 2nd floor high cart containing controlled medications were reconciled with LPN A. Some of the cards dated back to 4/25/23, and per LPN A, were medications that had been discontinued or were from residents no longer residing in the facility. LPN A was then interviewed regarding the facility's process for the disposal of discharged residents' medications. During this interview, LPN A was queried specifically about how the facility disposes of or destroys controlled substances that have been discontinued or are leftover from residents who are no longer in the facility. LPN A stated that she heard conflicting information regarding who is responsible for the destruction of discontinued controlled substances. LPN A explained that she was told two nurses need to sign off when destroying controlled substances, but had also heard that management was supposed to come take the unused controlled medications out of the medication carts. On 5/16/23 at 11:17 AM, the 2nd floor medication room was then reviewed with LPN A. A large, double lock safe with a one-way drop slot was pointed out by LPN A. LPN A pulled on the drop slot handle but was unable to open it, due to the safe being packed full. LPN A explained that controlled medication cards were once dropped into the safe, but that it has not been emptied and therefore cannot hold any more cards. LPN A indicated that the Director of Nursing (DON) should have keys to the safe. Upon reviewing the medication fridge in the 2nd floor medication room, a bottle of liquid Diltiazem (for high blood pressure) was found in the freezer. The medication was frozen solid and the label indicated it was for a current resident in the facility. LPN A took the medication and stated someone must have put it in the freezer by mistake. Two opened vials of tuberculin PPD were found stored in the door of the medication fridge and were not labeled with open dates. LPN A was unsure if the tuberculin PPD should be stored in the door of the fridge, but removed them and indicated they should have been dated. On 5/16/23 at 11:25 AM, the 2nd floor low medication cart was reviewed with LPN B. An opened bottled of difluprednate eye drops for a current resident were found without an open date. An open levemir flexpen for the same resident was found with an open date of 2/27. Alongside the open date, a written expiration date read, 12/24 (Levemir flexpens are good for 42 days once opened). LPN B did not have an explanation for the flexpen dates, and indicated that the eye drops should have been dated when they were opened. Multiple other insulin pens were noted in the cart to be marked with the wrong dates to be disposed of. LPN B expressed the same concerns LPN A had regarding overflowing controlled medications. The 2nd floor low medication cart was found to contain six discontinued controlled medication cards, which were reconciled with LPN B. LPN B stated that she did not want to be responsible For something that shouldn't even be in the cart. A review of the cart's Master controlled substance logs with LPN B revealed multiple controlled medications were crossed off (meaning disposed of/destroyed) with only one nurse signature present. LPN B indicated that two nurse signatures should be present. On 5/16/23 at 12:06 PM, the medication safe in the 2nd floor medication room was observed with the Director of Nursing (DON). The DON indicated she had just recently started working at the facility. Upon inquiry regarding excess controlled medications, the DON stated that she was told there was a Pile-up of narcotics previously, but was under the impression they had been taken care of. The DON attempted multiple times to open the overflowing medication safe in the 2nd floor medication room, however, was unsuccessful in doing so. The DON added that discontinued controlled medications should not still be in medication carts. On 5/16/23 at 12:16 PM, the 1st floor high medication cart was reviewed with Unit Manager LPN C. Nine medication cards from the cart containing controlled medications were reconciled with LPN C. Per LPN C, the medications had been discontinued or were from residents no longer residing in the facility. LPN C explained that two nurses are supposed to witness and sign off on the destruction (in drug buster containers) of controlled medications that were no longer in use. On 5/17/23 at 1:27 PM, LPN C was interviewed and queried regarding the disposal of the discontinued controlled medications found in the 1st floor medication cart. LPN C indicated they were still in the medication cart because she needed to reference the facility's policy. LPN C reviewed the policy and indicated there was nothing regarding an expected length of time between the discontinuation of a controlled medication and its destruction. LPN C added that excess controlled medications left in medication carts for extended periods, Leave room for error .[either for them to go] missing, or med (administration) error. A review of the facility's policy titled, Medication Disposal, Destruction and Sending Home with Resident, dated 04.01.2022, revealed, When a resident expires or when a medication is discontinued, the medication should be removed from the medication storage area(s) and be disposed of according to destruction guidelines from FDA. This includes medication storage cupboards, medication carts and refrigerators .Controlled Substances will be destroyed and witnessed by any two of the following personnel, of which one must be an RN: RN - Director of Nursing RN or LPN - Assistant Director of Nursing RN or LPN Clinical Nurse Manager RN or LPN Quality Assurance Nurse Medication Administration Nurse (ONLY if teamed with a non-medication administration person listed - two medication administration nurses will not be allowed to destroy together) Licensed Pharmacist Certified Pharmacy Technician RN or LPN Consultant Nurse employed by the pharmacy 1. A destruction record will be retained by the facility for a period of seven (7) years. The proof of use sheet will indicate quantities and signatures of witnesses. A review of the facility's policy titled, Medication Storage, dated 05.04.2022, revealed, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls . Per 21 CFR Part 1317 (last amended 2023-05-16) - Disposal: S 1317.05 Registrant disposal. (1) Promptly destroy that controlled substance in accordance with subpart C of this part using an on-site method of destruction . S 1317.80 Collection receptacles at long-term care facilities. (a) A long-term care facility may dispose of controlled substances in Schedules II, III, IV, and V on behalf of an ultimate user who resides, or has resided, at such long-term care facility by transferring those controlled substances into an authorized collection receptacle located at that long-term care facility. When disposing of such controlled substances by transferring those substances into a collection receptacle, such disposal shall occur immediately, but no longer than three business days after the discontinuation of use by the ultimate user. Discontinuation of use includes a permanent discontinuation of use as directed by the prescriber, as a result of the resident's transfer from the long-term care facility, or as a result of death . <https://www.ecfr.gov/current/title-21/chapter-II/part-1317>

Based on observation interview and record review the facility failed to ensure dressing changes were completed timely per physician orders for one resident (R35) of two residents reviewed for dressing changes resulting in the potential for decreased effectiveness of the dressing and or the potential for delayed healing. Findings include: On 05/15/23 at 12:57 PM, R35 was asked about their care and treatments received were reviewed. R35 was observed to have dressings to both of their lower legs. The dressings covered the lower leg from the ankle to below the knee. The right leg had a gauze dressing wrapped with a stretchable fabric like tape (an unna boot). The tape had rolled back in places and the dressing appeared loose on the leg. This dressing did not have a date. The left leg had a rolled gauze dressing which appeared loose and was dated 05/13/23. R35 indicated the dressings had not been changed in a few days and the physician at the hospital had spoken with them about having the unna boot dressings changed every few days and that is was to help decrease the leg swelling. On 05/16/23 at 11:29 AM, during the an observation of an Intraveneous (IV) administration Licensed Practical Nurse (LPN) C was asked to observed R35's lower leg dressings. It was noted that the left leg dressing was dated 05/13/23 and the right leg dressing was not dated. A review of the facility record for R35 revealed R35 was admitted into the facility on [DATE]. Diagnoses include Abscess (infection) of the left foot, Diabetes and Cancer. A review of the Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition with 14/15 Brief Interview for Mental Status (BIMS) score and the need for extensive assistance of one person for transfer, bed mobility and toilet needs and limited assistance of one person for dressing and personal hygiene. The MDS also documented the presence of two venous or arterial ulcers. A review of the physician order dated 04/28/23 indicated the dressing for the left leg was to be changed every day shift every two days. A review of the May 2023 (Treatment Administration Record) TAR on 05/16/23 revealed the dressing changes to the lower legs were not documented as done on Monday 05/15/23. The dressing for the left leg was last documented as done on 05/12/23. The dressing for the left leg was also not documented as done on Sunday 05/07/23 and had been documented as done on 05/05/23. On 05/16/23 at 3:53 PM, LPN C reported that the dressing change for the lower legs had not been signed out on the Medication Administration Record (MAR) nor the TAR and that the need for a dressing change should have appeared in the computer for the nurse to change the dressing. LPN C confirmed that the leg dressings required changing. On 05/16/23 at 3:57 PM, the identified concerns were reviewed with the Director of Nursing and the (Regional Clinical Services Director) RCD. The RCD reported that the nurse should provide care and dressing changes according to physician orders. A review of the facility policy titled, Skin & Wound Policy with date approved of 04/2022 revealed, .It is also our policy to follow the treatment plans for any wound/skin concerns as ordered by physicians . 10. Guidelines for dressing selection may be utilized in obtaining physician orders (see Appendix A). a. The guidelines are to be used to assist in treatment decision making. b. Due to unique needs and situations of individuals, the guidelines may not be appropriate for use in all circumstances. c. The facility will follow specific physician orders for providing wound care. 11. Treatments will be documented on the Treatment Administration Record .

Based on observation, interview, and record review, the facility failed to provide routine dental services for one resident (R13) of three reviewed, resulting in the potential for further oral health decline. Finding include: On 5/15/23 at 10:07 AM, R13 was interviewed during the initial tour. R13 indicated that they would like to be seen by a dentist and felt as though they had not seen one in a long time. R13 was observed to have discolored teeth with many noted to be missing. A review of R13's record revealed that the resident was admitted into the facility on [DATE] with medical diagnoses of Paranoid Schizophrenia, Diabetes Mellitus Type 2, Dysphagia, and Heart Failure. A review of R13's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident is cognitively intact. The facility was asked to provide proof of dental visits for R13. The facility provided documentation for one visit dated 2/28/2022. On 5/17/23 at 9:29 AM, the Regional Clinical Services Director (RCD) was queried regarding dental visits for R13. The RCD stated that the company the facility uses has not been able to provide services in recent months, Due to the pandemic. No additional documentation was provided by the facility indicating that attempts were made to set up an annual/routine dental visit for R13, prior to survey exit. A review of the facility's policy titled, Dental Services, dated 4/30/19, revealed, Policy: It is the policy of this facility, in accordance with resident's needs, to assist residents in obtaining routine and emergency dental care . Routine Dental Services means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs) minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedures, e.g. taking impressions of dentures and fitting dentures .All actions and information regarding dental services, including any delays related to obtaining dental services, will be documented in the resident's medical record .All actions and information regarding dental services, including any delays related to obtaining dental services, will be documented in the resident's medical record.

This citation pertains to Intake number M100134887. Based on interview, and record review, the facility failed to prevent a fall with injury for one (R362) of four residents reviewed for falls resulting in a left ankle fracture and resident hospitalization . Findings include: Review of the facility record for R362 revealed an admitted [DATE] with diagnoses that included Lumbar spinal stenosis, Polyneuropathy, Quadriplegia and Repeated Falls. The Minimum Data Set (MDS) assessment dated [DATE] indicated R362 required primarily total/maximum assistance with activities of daily living. The Brief Interview for Mental Status (BIMS) assessment score of 14/15 indicated intact cognition. Review of R362's facility progress notes revealed reporting of a fall at 3:45 AM on 01/28/23. The progress note indicated R362 reported having slipped on the bed sheet attempting to get to the bathroom. R362 reported right arm pain and right upper extremity X-rays were ordered. No Incident Report associated with this fall was provided and no responsive fall risk reduction intervention was identified in the progress note. Further review of R362's facility progress notes revealed reporting of a fall at 6:38 AM on 01/30/23. This note indicated that R362 was found on the floor next to the bed and reported that they attempted to walk to the bathroom and acknowledged that they were non-ambulatory. R362 reportedly denied pain and demonstrated no injury and was assisted back to bed. No Incident Report associated with this fall was provided and no responsive fall risk reduction intervention was identified in the progress note other than will continue to follow plan of care. Additional review of R362's progress notes revealed reporting of a fall on 02/05/23. Review of the Incident Report associated with this fall and completed byLicensed Practical Nurse (LPN) L revealed R362 was found on the floor of their room adjacent to the bed. R362 reportedly indicated that they were attempting to complete therapy exercises and fell to the floor. No injuries were reported or identified. The notes section of the report dated 02/09/23 states Intervention is to round on the patient frequently while in bed. Care plan updated. Review of R362's care plan revealed the focus area At risk for falls due to history of falls, impaired mobility and balance, anti-depressant use. The interventions associated with this focus area include no mention of rounding or supervision otherwise. Further review of R362's progress notes revealed reporting of R362 being found on the floor watching TV at 5:09 AM on 02/12/23. No associated Incident Report was provided. No report of injury was noted and the R362 was reportedly assisted back to bed using a mechanical lift. No additional fall risk reduction intervention is identified in the progress note. Additional review of R362's progress notes revealed reporting of a fall at approximately 9:30 AM on 02/16/23. The associated Incident Report completed by LPN M indicated that R362 was sitting in their wheelchair and reached laterally to retrieve their cell phone from the nightstand causing the wheelchair to tip over sideways. R362 reported no pain and no injury was identified. The notes section of the report indicated that the responsive intervention was to make sure all belongings are within reach. Further review of R362's progress notes revealed reporting of a fall at approximately 5:30 AM on 02/20/23. The associated Incident Report completed by LPN L indicated that R362 was found on the floor next to the bed and that R362 expressed that they were attempting to get to the bathroom. No immediate complaint of pain or identification of injury was noted however it was noted that R362's family later requested an X-ray of the left ankle due to observed swelling and resident-reported pain. The notes section of the report identified the responsive intervention as place in common area when awake for supervision. Following completion of the left ankle/foot X-ray the progress note dated 02/22/23 indicated that the X-ray was negative for acute fracture and that R362 had been cleared for resumption of therapy. On 05/17/23 at 2:18 PM, LPN L reported that they did recall the reported fall incident on 02/20/23 after reviewing the medical record. LPN L stated that they did recall that R362 had a history of falls and indicated that R362 did require supervision due to unsafe behaviors. R362's progress note dated 03/02/23 indicated that the resident reported further left ankle pain/swelling from the previous fall and that a follow up X-ray was ordered as well as a Podiatry consult. Progress notes dated 03/03/23 indicate R362 continued to have left ankle swelling and pain and that the follow up X-ray indicated a left ankle fracture and in response the physician ordered the resident to be sent to the hospital. Review of the facility policy titled Fall Risk/Injury Prevention Assessment revealed under the Compliance Guidelines .5. Monitor the effectiveness of the interventions, and modify the interventions as necessary, in accordance with current standards of practice.

This citation pertains to Intake number MI00134837. Based on observation, interview and record review the facility failed to ensure incontinence care was completed timely when soiled for one resident (R40) of three reviewed for Activities of Daily Living (ADL) care, resulting in the resident brief saturated, leakage from the brief and the potential for moisture associated skin damage. Findings include: On 05/15/23 at 9:54 AM, the door to the room of R40 was closed. When the door was opened, a stale urine odor was noted. The mattress on the bed was bare. The fabric on the underside of the recliner arm appeared frayed. R40 did not respond to their name or the knock on the door and appeared to be sleeping. R40 was observed to be in a geri chair medical recliner. R40 was laying across the seat of the chair. R40's head was up against the arm of the chair with their legs over the opposite arm off the chairs. The back of the knees rested on the arm of the chair and the feet hung down at the side. R40's back was on the seat of of the chair. On 05/15/23 at 10:57 AM, R40 continued in the recliner as before except the legs were slightly crossed. The door to the room had remained closed and the urine odor was stronger and a puddle of fluid was observed under and to the side of the recliner. On 05/15/23 at 11:49 AM, the door to R40's room was closed and upon entry R40 was observed to be in the recliner situated as before. The wet spot on the floor was larger and the urine odor more pungent. There were no water cups or similar in the room. On 05/15/23 at 12:02 PM, Certified Nursing Assistant (CNA) H and I entered the room of R40 with linen items. The care of R40 was observed. The two CNA's exited for additional supplies and returned with a lift. The tube feeding was paused. CNA H put a sheet on the puddle of liquid on the floor. The CNAs then turned R40 upright in the recliner and rolled R40 side to side and placed the lift sling under R40. The brief appeared with a blue line which indicated R40 to be soiled. At 12:16 PM the nurse entered to disconnect the tube feeding. R40 was connected to the lift with the sling and raised over the bed for transfer into the bed. A wet irregular ring was visible around the back side of the sling and extended from the above the waistline to the upper thighs of R40. The brief appeared saturated. The CNA's washed up R40. Hand hygiene was not done between glove changes by CNA H. R40 made some confused responses to care when spoken to by the CNA's. On 05/15/23 at 12:40 PM, CNA H and CNA I were asked about the care of R40 and the concerns for R40 having been wet for an extended period of time. It was reported that there were just the two of them on for the day shift but they would usually have three and it was not the first time they had only two CNAs. They reported 22 residents were on the floor. The CNA assigned to R40 was asked if they had checked on R40 at the start of their shift and reported a visual check of the resident but not to check if R40 was wet. R40 was reported to be a heavy wetter. The CNAs reported they had a schedule of residents that needed to be up for therapy and had focused on them. R40 was not one of them. The CNAs reported they had just now come to check on R40. It was also reported that the nursing staff does not routinely help out with the incontinence care. A review of the record for R40 revealed R40 was admitted into the facility on [DATE]. Diagnoses included Brain Injury, Bipolar Disorder and Dysphagia (difficulty swallowing) following Stroke. The Minimum Data Set (MDS) assessment dated [DATE] indicated severely impaired cognition, the need for extensive assistance of one or two persons for transfer, bed mobility, locomotion, dressing, toilet use and personal hygiene and total dependence on one person for eating and bathing. The (Activities of Daily Living) ADL self care deficit care plan initiated 04/18/23 indicated, Assist with daily hygiene, grooming, dressing, oral care and eating as needed . The At risk for alteration in skin integrity related to impaired mobility, incontinence . care plan initiated 04/05/23 indicated, Decrease/minimize skin breakdown risks . On 05/16/23 at 4:08 PM, the Director of Nursing (DON) and Regional Clinical Services Director (RCD) was asked about the observations and concerns for R40. The RCD reported residents should be rounded on at least every couple of hours and more often as needed. A review of the facility policy titled, Activities of Daily Living (ADL's) approved 04/01/22 revealed, Policy: Resident needs for ADL care will be met according to resident specific care plan. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care; 2. Transfer and ambulation; multicasting . Compliance Guidelines . 4) A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .

Based on interview and record review, the facility failed to provide a nutritional supplement as ordered by the physician for one (R360) of four residents reviewed, resulting in resident dissatisfaction with care related to the lack of indicated/ordered nutritional supplementation. Findings include: Review of the facility record for R360 revealed an admitted [DATE] with diagnoses that included Acute Post-hemorragic anemia, Alcoholic Cirrhosis of Liver with Ascities and Esophageal Varices with Bleeding. The Minimum Data Set (MDS) assessment dated [DATE] indicated R360 required primarily supervision level assistance with activities of daily living. The Brief Interview for Mental Status (BIMS) assessment score of 7/15 indicated severe cognitive impairment. On 05/15/23 at 11:53 AM, during initial resident screening R360 was expressing some concerns regarding their food and stated I'm supposed to be getting Ensure (nutritional supplimental drink) and they don't give me that either. When questioned further about the Ensure, R360 reported that they had been taking Ensure previously and that the physician had ordered it. R360 reported that they had received the Ensure once or twice while in the facility but stated I don't think they've brought it in about 5 days On 05/15/23 at 2:13 PM, review of R360's active physician orders revealed the order dated 05/09/23 Ensure Plus One time a day with dinner Review of R360's current care plan revealed inclusion of the focus area Nutritional status which included the intervention Provide supplements as ordered [CNA, Diet, LPN, RN]. On 05/16/23 at 9:10 AM, R360 reported that they did not receive the Ensure supplement with their dinner tray the previous evening. When asked if they received anything that might be similar to Ensure (supplement shake, etc.) they reported they did not. On 05/16/23 at 12:10 PM, the facility Administrator (NHA) and the Regional Clinical Services Director (RCD) reported that the Dietary Department is responsible for following through on physician orders for supplements to be delivered with the resident's meal tray. On 05/16/23 at 12:15 PM, the Registered Dietician (RD) K verified that they transfer physician orders for supplements to the resident's meal ticket and verify that the supplement (or an appropriate alternative if necessary) is available in the kitchen supply. The kitchen staff then place the supplement on the meal tray according to the ticket. On 05/17/23 at 11:23 AM, review of R360's meal tickets dated 05/08/23 thru 05/16/23 verified inclusion of Ensure Plus - 8 ounce under the heading Nourishments. On 05/17/23 at 10:58 AM, The facility Director of Nursing (DON) reported that the expectation for physician orders is that they be followed as written. On 05/17/23 at 12 PM, the NHA reported that their expectation for physician orders is that they be implemented or further addressed if there is a concern regarding order accuracy/appropriateness. Review of the facility policy titled Nutritional Management dated 10/22 revealed under Compliance Guidelines .c. Developing and consistently implementing pertinent approaches.

Based on observation, interview and record review the facility failed to ensure care met professional standards for one (R24) of three residents observed during care resulting in unmet care needs and care not provided as ordered. Findings include: R24 On 05/16/23 at 8:11 AM, Licensed Practical Nurse (LPN) A was administering medications to R24 and the following concerns were observed: 1. LPN A was observed to draw insulin from a Novolog insulin pen with a syringe. LPN A was asked why they did not use the needle made for the pen and reported they did not feel the resident received the right amount of insulin when the pen was used. An observation of the insulin drawn up in the syringe revealed a small bubble. 2. R24 also receive 2 steroid inhalers; 'Umeclidinium bromide 62.5 mg one puff one time a day and Fluticasone Furoate/Vilanterol 200mg/25 mg. LPN A administered the first inhaler and before R24 could rinse their mouth, the resident had drank the rest of their Miralax (this was mixed with water). R24 then rinsed and spit out the water. The second inhaler was provided a few minutes later and the mouth was not rinsed. R24 had began to eat breakfast. The nurse was observed to wash her hands for 5 seconds during the medicaiton pass. On 05/16/23 at 4:15 PM, the medication observation concerns were reviewed with the Director of Nursing (DON), Administrator and Regional Clinical Services Director (RCD). The RCD reported, they (the facility staff) teach the nurse not to draw insulin from the insulin pen with a syringe. The RCD went on to say, Resident's should rinse their mouth after any powdered inhaler; and staff should wash their hands for at least 20 seconds, if not 30 seconds. The manufacturer's inserts for the medications indicate the side effect of thrush in your mouth or throat and mouth and throat pain and to Rinse your mouth with water without swallowing after use to help prevent this. A review of the facility policy titled, Hand Hygiene approved 08/01/22 revealed, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Hand hygiene technique when using soap and water: a)Wet hands with water. Avoid using hot water to prevent drying of skin. b) Apply to hands the amount of soap recommended by the manufacturer. c) Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. d) Rinse hands with water . The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .

Based observation, interview and record review, the facility failed to ensure a resident was upright and or greater than thirty degrees during tube feeding (liquid nutrition via a percutaneous endoscopic gastrostomy tube or PEG tube inserted into the stomach from an external site on the abdomen) for one resident (R40) of one resident reviewed for enteral (tube) feedings, resulting in the potential for reflux and aspiration into the lungs of the stomach contents. Findings include: On 05/15/23 at 9:54 AM, the door to the room of R40 was observed to be closed. R40 did not respond to their name or the knock on the door and appeared to be sleeping. R40 was observed to be in a geri chair medical recliner. R40 was laying across the seat of the recliner. R40's head was up against the arm of the recliner with their legs over the opposite arm off the side of the chair. The back of the knees rested on the arm of the chair and the feet hung down at the side. R40's back was on the seat of the chair. The tube feeding was active and running at 65 milliliters an hour into a PEG tube partially visible from under the hospital style gown worn by R40. The tube feed pole base was soiled with a icing like layer of a dried tan substance similar in color to the tube feeding in the bag of liquid R40 was receiving. The tray table was also spattered with a lighter tan color of a dried substance. On 05/15/23 at 10:57 AM, R40 continued in the recliner as before except the legs were slightly crossed. The door to the room had remained closed. The tube feeding remained active and had less than 100 milliliters left in the bag. On 05/15/23 at 11:49 AM, the door to R40's room was closed and upon entry R40 was observed to be in the recliner situated as before. The tube feeding was active at 65 milliliters an hour. On 05/15/23 at 12:16 PM the nurse entered to disconnect the tube feeding and the tube feeding was completed. On 05/15/23 at 5:20 PM, R40 was observed to be in bed, dressed in a hospital style gown, with the head of the bed up and the tube feeding active. A review of the record for R40 revealed R40 was admitted into the facility on [DATE]. Diagnoses included Brain Injury, Bipolar Disorder and Dysphagia (difficulty swallowing) following Stroke. The Minimum Data Set (MDS) assessment dated [DATE] indicated severely impaired cognition, the need for extensive assistance of one or two persons for transfer, bed mobility, locomotion, dressing, toilet use and personal hygiene and total dependence on one person for eating and bathing. The (Activities of Daily Living) ADL self care deficit care plan initiated 04/18/23 indicated, Assist with daily hygiene, grooming, dressing, oral care and eating as needed . The Need for feeding tube/potential for complications of feeding tube use related to (difficulty swallowing)dysphagia care plan initiated 04/07/23 indicated, .Elevated head 30-45 degrees .report signs of aspiration or intolerance of feeding . The At risk for alteration in skin integrity related to impaired mobility, incontinence . care plan initiated 04/05/23 indicated, Decrease/minimize skin breakdown risks . On 05/16/23 at 4:08 PM, the Director of Nursing (DON) and Regional Clinical Services Director (RCD) were asked about the observations and concerns for R40. The RCD reported resident should be rounded at least every couple of hours and more often as needed. It was noted that they would have to check policy but generally the resident should be at 30 degrees or higher as tolerated. It was noted that the nurse should check on the resident to ensure the tube feed is active and running properly. A review of the facility policy titled, Nasal Gastric Tube Feeding with date issued of 10/01/2011 revealed, Policy: To Improve liquid nourishment through a tube into the alimentary tract. To administer medication. Procedure: .6. Maintain head of bed elevated at a minimum of 30 degrees .15. Instruct resident to remain in an upright position for approximately one-hour post feeding. This prevents aspiration .

Based on observation, interview, and record review, the facility failed to ensure dressing changes were completed timely per physician orders and standards of care for one resident (R35) of two residents reviewed for dressing changes resulting in the potential for decreased effectiveness of the dressing and or the potential for delayed healing. Findings include: On 05/15/23 at 12:57 PM, R35 was asked about their care and treatments and reported they had been receiving antibiotic through a (peripherally inserted central catheter) PICC intravenous (IV) line in their right upper arm. The dressing for the PICC line was observed to have a transparent film dressing over a two by two inch white gauze dressing. The gauze dressing covered the IV line insertion site. The dressing was loose at the upper edge and rippled with movement of R35's arm. The date on the PICC dressing was 05/6/23. R35 commented that the previous line had come out and a new one was placed. On 05/16/23 at 11:29 AM, during the observation of an IV antibiotic administration, Licensed Practical Nurse (LPN) C was asked to observe the dressing on the PICC line. The dressing was loose at the top, had the two by two gauze dressing in place and was dated 05/06/23 as before. LPN C initially did not see a date on the dressing when asked to view the dressing. A review of the facility record for R35 revealed R35 was admitted into the facility on [DATE]. Diagnoses include Abscess (infection) of the left foot, Diabetes and Cancer. A review of the Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition with 14/15 Brief Interview for Mental Status (BIMS) score and the need for extensive assistance of one person for transfer, bed mobility and toilet needs and limited assistance of one person for dressing and personal hygiene. The MDS also documented the presence of two venous or arterial ulcers. A review of the May 2023 Medication Administration Record (MAR) documented three daily IV antibiotic administrations since the PICC line was placed on 05/06/23 through 05/15/23. The MAR documented that the PICC line was placed on 05/06/23. The MAR also indicated that the dressing had been changed by a nurse on 05/12/23 though it had not been done. A review of the active physician orders documented an order dated 05/05/23 which indicated a change to the IV/PICC line dressing was to be completed every Friday. On 05/16/23 at 3:53 PM, LPN C reported that the dressing change for the PICC line had not been done and confirmed the date on the PICC dressing was 05/06/23. LPN C also reported that the need for a dressing change would have appeared in the computer for the nurse to change the dressing. On 05/16/23 at 3:57 PM, the identified concerns were reviewed with the Director of Nursing and the (Regional Clinical Services Director) RCD. The RCD reported the gauze dressing was suppose to go away after 24 hour and the PICC line dressing in absence of a gauze dressing should be changed every seven days and when loose or no longer occlusive. The RCD reported that the nurse should provide care and dressing changes according to physician orders. A review of the facility policy titled, IV Dressing Changes for Central Lines, Midlines and Heparin Lock Peripheral Catheters with date issued of 09/27/16 revealed, .The catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection. A transparent dressing is the preferred dressing. If the patient is allergic to the transparent dressing, a sterile gauze and sterile tape dressing may be used . Considerations for Central Line Catheter and Midline Catheter Sterile dressing change using transparent dressings is performed: 1. 24 hours post-insertion or upon admission. 2. At least weekly. 3. If the integrity of the dressing has been compromised (wet, loose or soiled). When a transparent dressing is applied over a sterile gauze dressing it is considered a gauze dressing and is changed: 4. 24 hours post-insertion or upon admission. 5. Every two days. 6. If the integrity of the dressing has been compromised (wet, loose or soiled). Sterile gauze dressings must be occlusive and are changed: 7. 24 hours post-insertion or upon admission 8. Every two days. 9. If the integrity of the dressing has been compromised (wet, loose or soiled) . Assessment of the vascular access site is performed: 10. Upon admission and during dressing changes. 11. At least every 2 hours during continuous therapy. 12. Before and after administration of intermitted infusions. 13. At least once every shift when not in use. 14. Routinely for signs and symptoms of infusion related to complications at a frequency based on patient condition, age, type of medication, and rate of flow .

This citation pertains to intake MI00133793, MI00131797, MI00132161, and MI00132399. Based on observation, interview, and record review, the facility failed to implement wound care interventions per physician orders for two residents (R714 and R702) and enter wound care orders upon admission for one resident (R713) out of four reviewed for wounds, resulting in worsening of wounds, surgical intervention, and hospitalization . Findings include: Resident R714 On 2/21/2023 at 12:27 PM, R714 was observed in their room laying on their right side. R714 stated that they were in pain. R714 stated that the pain was on their bottom and that they had a wound on their bottom. R714 was not noted to be on any pressure relieving air mattress. A review of the medical record revealed that R714 admitted into the facility on [DATE] with the following diagnoses, Pressure Ulcer of Sacral Region, and Muscle Weakness. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13/15 indicating an intact cognition. R714 also required extensive two-person assistance with bed mobility. A review of the most recent skin assessment dated [DATE] revealed that R714 had a Stage Four pressure ulcer (deep wound reaching the muscles, ligaments or bones) on the Sacrum (buttocks region) A review of the physician orders revealed the following, Order: APM (Alternating Pressure Mattress) to bed. Status: Active. Revision Date: 12/16/2022. On 2/21/2023 at 12:39 PM, the Director of Nursing (DON) was asked to observe R714 and their mattress. The DON stated that R714 should have an air mattress, especially because R714 has a wound. Resident 713 A review of Intake called inot the State Agency (SA) noted the following, [R713] had a bedsore on coccyx and inner buttocks that progress from being managed with ointment to a Stage 4 (deep wound reaching the muscles, ligaments or bones) status. A review of the medical record revealed that R713 admitted into the facility on [DATE] with the following diagnoses, Peripheral Vascular Disease and Pressure Ulcer of Right Buttocks. A review of the most recent Minimum Data Assessment (MDS) set dated 12/19/2022 revealed a Brief Interview for Mental Status (BIMS) score of 6/15 indicating impaired cognition. R713 also required extensive two-person assist with bed mobility and transfers. A review of the Nursing Admission assessment dated [DATE] noted the following skin impairment, Site: 23) Coccyx. Description: dark red, no open areas, no discharge. A review of the progress notes revealed the following, Date:12/16/2022 at 11:21 AM. MP Wound Progress Note: HPI: This is a [AGE] year .today at [facility] for present on admission unstageable coccyx wound, unstageable left buttock wound, left hip Stage 2 (outer surface of skin damaged), left and right diabetic heels, and venous PVD (Peripheral Vascular Disease) of BLE (Bilateral Lower Extremities) . Discussed with Administration that the wound team was not made aware of present on admission unstageable wounds, Stage 2 hip wound, venous wound, or diabetic heel wounds until 12/16/2022. Consult was placed per nursing on admission, however unit manager or wound team was not alerted per protocol, picture was not captures on admission, and a wound care order was not obtained from the wound team or the primary team from nursing during the admission assessment .Discussed coccyx wound appearance with primary team, Keflex (antibiotic) 500 mg (milligram) Q8 (every eight hours) by mouth for seven days .Primary team will arrange possible surgical debridement. A review of the physician orders noted the following; Order: Cleanse coccyx with normal saline, pat dry, apply therahoney sheet, and cover with foam dressing every shift and PRN (as needed). Start: 12/10/2022. Order: Cleanse right and left hip wounds with NS (Normal Saline), dry, apply large foam dressing to each side. Start:12/16/2022. Order: Cleanse back of left hip with NS. Dry. Apply calazime to area and cover with foam. Start: 12/16/2022. Order: Cleanse Coccyx wound with NS. Dry. Apply Dakins 1/4 wet to dry on coccyx. Cover with large foam. Active:12/16/2022. On 2/22/2023 at 7:25 AM, an interview was conducted with Wound Care Nurse (WCN) K regarding R713. WCN K stated that they were not employed as the wound care nurse at that time. WCN K stated that if an admission comes in on the weekend, then the floor nurse should complete a full skin assessment, enter a wound consult, and put in an order until they can be seen. WCN K stated that they now go see every new admission, even if it's not documented that they have a wound, so nothing gets missed. 40384 R702 A review of Intake called inot the State Agency (SA) revealed the following, Complainant states the facility neglected to properly treat the resident when they were transferred. Complainant states the facility failed to put the resident's wound vac (vacuum assisted closure of wound) on for 3 days and when [they] visited today the wound vac was put on incorrectly . A review of R702's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Diabetes, Unspecified Open Wound to Right Foot, and Chronic Kidney Disease. Further review revealed that the resident was alert and oriented x 3 (person, place and time), and required extensive assistance for bed mobility, toileting and personal hygiene. Further review of R702's medical record revealed a hospital record dated from R702's admission to the hospital on 9/28/22, prior to admission onto the facility, .Patient with history of right heel ulcer treated with 4 separate courses of abx (antibiotics) since January 2022 without improvement. Pt. (patient) with history of diabetes and peripheral neuropathy, PAD (Peripheral Arterial Disease), nonhealing ulcer. MRI showed underlying osteomyelitis .Plan consult podiatry: s/p (status post) right foot debridement . Further review of the medical record revealed a podiatry note dated for 10/4/22, CC (chief complaint): Right heel wound. Patient was seen and examined today, in bed with wound vac in place functioning properly. [Family member] is present at bedside. [They were] updated. Patient is stable for discharge per podiatry. [R702] will need to be discharged with the wound vac and it will need to be changed every other day with adaptic placed over the graft site, then black foam, then wound vac adhesive Further review of R702's medical record revealed one progress note indicating the use of a wound vac,10/10/2022 06:35 (6:35 AM) Type: General Progress Note, The pt (patient) is alert and oriented x3. Although the pt has a language barrier pt is able to make needs know. Writer applied wound vac to the pt's right heel at 125 (1:25 PM). The pt denies any pan/discomfort. No concerns at this time. Further review of R702's medical record did not reveal physician orders for a wound vac, additional progress notes, or a care plan indicating the use of a wound vac. Further review of R702's 10/7/22 physician orders indicated the following for the care of R702's wound, Cleanse right heel w/ NS (normal saline). Pat dry. use packing gauze one time a day for wound care AND as needed for wound care .bilateral soft protective boots to be applied when patient in bed. On 2/22/23 at 7:26 AM, the Wound Care Nurse K was asked about their process for ensuring recommendations from the hospital are followed upon residents arrival to the facility. She explained that the goal is to review documentation, communicate with their physician internally, and the resident's outside physician to ensure that recommendations are being followed. On 2/22/23 at 10:48 AM, the Director of Nursing (DON) explained that her expectation is for the wound care nurse to ensure that recommendations are being followed for the care of residents' wounds. A review of the facility's Skin Management Guidelines did not address following recommendations/orders for wound care of residents being admitted from the hospital to the facility.

This is pertaining to intake 0 Based on interview and record review, the facility failed to maintain an environment free from verbal abuse for R506 and Unsampled Resident Bby a Certified Nursing Assistant (CNA), resulting in the potential to cause and experience humiliation, shame, or agitation and all other residents within the facility. Findings include: On 10/19/2020 at 11:09 AM, two attempts were made to contact R506 via phone. In addition, an attempt was made to contact R506's family member via phone. R506's phone was disconnected, and their family member's phone mailbox was full. A review of the electronic medical record noted R506 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident presented underwent a posterior [MEDICATION NAME] and lumbar fusion. A review of BIMS (Brief Interview for Mental Status) of 15 (meaning an Intact cognitive response). MDS (Minimum Data Set) dated 6/30/2020 noted R506 required extensive two-person physical assistance with bed mobility and transfers and supervision one-person physical assistance with walking in the room. A review of R506's care plan noted the following: Assist/encourage the resident needs to change position frequently. Alternate periods of rest with activity out of bed in order to prevent respiratory complications, dependent [MEDICAL CONDITION], flexion deformity and skin pressure areas . ADL training/adaptive equipment to improve self-care, home management training, meal preparation, safety procedures and/or instructions in use of assistive devices and/or technology . therapeutic exercises to develop strength, endurance, range of motion and/or flexibility. On 10/20/2020 at 11:46 AM, CNA A was interviewed via phone call and queried about the incident with R506. CNA A stated, I'm a straightforward person. I don't talk to everybody and sometimes these residents don't understand that. CNA A was asked if they moved quickly or threw R506's legs into the bed and CNA A stated, No I didn't. (R506) lied. I did not throw (R506's) legs into the bed. (R506) always asked me to lift (their) legs into the bed. (R506) could not lift (their) own legs because of back problems. I helped (R506) with getting back to bed. These patients are always lying because they are drug-seeking .I had 19 patients that day .I've been told that I'm mean .All my complaints are about me being mean. I'm not mean, I just don't play games with these people .But I've never harmed these people. A review of the facility's Incident Report dated 6/20/2020 noted the following: The Administrator and DON (Director of Nursing) re-interviewed the resident. The resident stated that (they) needed to go to the bathroom and asked the CNA (CNA A) for assistance getting into the wheelchair, but the CNA said No, you go on and get in it. According to the resident, the CNA pushed (R506) to the bathroom in the wheelchair and then told the resident to hold onto the rail and stand up. The resident stated (R506) struggled to pull (their) depends down by (themselves) .the CNA wheeled (R506) back to the bed and told the resident to get into bed .The resident said that the CNA told (R506) to scoot up towards the head of the bed and as (R506) was trying to do that, the CNA lifted (their) feet by (R506's) socks and threw (R506's) legs into the bed. The resident stated (CNA A) didn't tell me (R506) what was going to do that .I couldn't do anything besides lay there and hold onto the covers and shake .I've had (CNA A) before. (CNA A's) always snappy .(CNA A) treats me like I have [MEDICAL CONDITION] or something .I took that test I was negative .That's the way (CNA A) is. (CNA A's) always like that toward me .Somebody that's mean and does that to me .I don't want (CNA A anymore .Resident had tears rolling down (their) face. A review of the facility's Incident Report initiated on 6/20/2020 noted the following: The CNA was interviewed. (CNA A) stated, While she was still sitting on the bed, I helped (R506) lift (R506) legs and swung (R506) legs around into the bed. When I helped lift (R506) legs and cover them up, I went and got the phone and handed it to (R506) and that's when (R506) was moaning, hollering and screaming .I emptied the garbage and (R506) asked me for a pain pill. A review of the facility's Incident Report initiated on 6/20/2020 noted the following statement from Unsampled Resident B: (CNA A) was awful. (CNA A) was rude and obnoxious .I wanted to cuss (CNA A) out but I rebuked (CNA A) in the name of Jesus because 2 wrongs don't make a right. (CNA A) doesn't have much patience. (CNA A) was loud and obnoxious. A review of the Employee Warning Notice dated 6/29/2020 noted the following: During an investigation, numerous patients/residents communicated significant concerns regarding this employee's conduct in patient care areas .Termination of employment due to severity of work rule violation. A review of the One-on-One Inservice Record dated 4/30/2019 noted the following Inservice Topic/Title: (CNA A) Using appropriate (inappropriate) language in the hallway. Do not cuss in patient care areas. A review of the Employee Warning Notice dated 9/19/2019 noted the following: On 9/11/2019, (CNA A) failed to maintain acceptable standards of respect for and courtesy to a patient. There has been a pattern of customer service issues related to (CNA A). As a result, (CNA A) received additional customer service training and a one on one in-service in April 2019 and June 2019 . (CNA A) must use respectful tone and wording when communicating with customers/residents. (CNA A) must conduct (themselves) in a way that meets the circle of care standards. On 10/20/2020 at 2:10 PM, the Administrator was interviewed and queried about the incident regarding CNA A and R506. The Administrator stated, I received a call from (Nurse C) that (R506) said that (CNA A) threw (R506's) legs into the bed and was verbally abusive. (CNA A) was immediately suspended. (CNA A) was talked to, written-up, and sent back to Circle of Care (a customer service class) back in 2019 because of their behavior. Attempted to contact Nurse C via phone and was unable to leave a voice message. A review of the facility's Circle of Care dated on 9/19/2019 and signed by (CNA A) noted the following: I am Helpful by Choosing to be friendly and positive, making eye contact, smiling and saying hello in all interactions . Being courteous and respectful in all interactions .Beginning the task with a warm opening, explaining the steps of the task, engaging my customer in friendly conversation during the task and ending the task with a personal closing .Showing empathy and [MEDICATION NAME] to customers . Keeping customers informed and responding promptly to meet their needs .Resolving issues and concerns by remaining calm, listening, apologizing, taking action and thanking the customer for bringing the issue to my attention. A review of the facility's Patient Protection Abuse, Neglect, Exploitation, Mistreatment & Misappropriation Prevention policy noted the following: The facility must 1. Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.

Based on observation, interview and record review, the facility failed to ensure ongoing and comprehensive assessment and timely implementation of person-centered interventions pertaining to nutritional status for one (#14) of two Residents reviewed for nutrition, resulting in lack of identification and timely implementation of interventions and Resident #14 experiencing significant weight loss. Findings include: On 2/25/20 at 9:33 AM, Resident #14 was observed in their room. The room was dark, with no lights on, and the window shades closed. The Resident was in bed wearing a hospital gown with their eyes open. When asked if they had breakfast, Resident #14 indicated they did not think so and stated, I'm old and have a bad memory. Record review revealed Resident #14 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required limited to extensive assistance to perform Activities of Daily Living (ADLs). Detailed review of the MDS revealed the Resident needed limited assistance with eating, weighed 118 pounds, and was not receiving any additional nutritional approaches with care. On 2/26/20 at 9:33 AM, Resident #14 was observed in their room in bed in a hospital gown. The room was dark, with no lights on in the room and the shades and room curtain closed. An untouched breakfast tray, labeled for Resident #14, was sitting on top of the dresser on the opposite side of the room. An interview was conducted with the Resident. When queried if they had breakfast, Resident #14 indicated they had not and stated, I'm just glad you stopped by. Come back and we can have a cup of tea. When asked if they liked tea, Resident #14 revealed they liked tea and cookies and they would like to have cookies as well. At this time, Nursing Assistant M entered the room and removed the Resident's untouched, uneaten tray. When queried regarding collection of Resident #14's breakfast tray when the Resident had not ate, Nursing Assistant M stated, (Resident #14) never eat. I just give them their Ensure. Review of Resident #14's documented weights in the Electronic Medical Record (EMR) revealed the Resident experienced a 5.24% weight loss from 1/21/20 to 2/19/20 and a 15.95% weight loss from 11/26/19 to 2/19/20. Detailed review revealed the Resident had eight documented weights during their stay at the facility. Weights included: -11/26/19: 120.4 pounds (Lbs) -12/3/19: 120.4 Lbs -12/10/19: 119.2 Lbs -12/17/19: 118.2 Lbs -1/8/20: 107.8 Lbs -1/21/20: 106.9 -2/12/20: 105.2 -2/19/20: 101.2 On 2/26/20 at 12:30 PM, Resident #14 was observed in their room in bed wearing a hospital gown. When asked if they had ate lunch, Resident #14 indicated they had not. At 12:32 PM, Nursing Assistant M entered the room with the Resident's lunch tray. Nursing Assistant M was observed removing the Ensure supplement from the tray, placing it on the table in front of the Resident, and exiting the room with the Resident's lunch tray. The Ensure was open with a straw in it. The straw had a paper cover in place over the drinking end. After Nursing Assistant M exited the room, Resident #14 was asked if they were hungry. Resident #14 replied, How can I be hungry if I am just laying around in bed all day? The Resident then immediately grabbed the Ensure and placed the paper coated straw in their mouth. The paper became wet and the Resident was unable to remove the paper independently. Upon request, Nursing Assistant M returned to the Resident's room and an interview was conducted. When queried regarding Resident #14 being unable to drink the Ensure, Nursing Assistant M indicated all the Resident needed to do was take off the paper. Nursing Assistant M then removed the paper and exited the room. After the paper cover on the straw was removed, Resident #14 drank the entire bottle of Ensure in less than five minutes. An interview was conducted with Dietician H on 2/26/20 at 2:29 PM. When queried regarding Resident #14's weight loss, Dietician H indicated they were aware of the weight loss and stated, (Resident #14) had been declining and refusing to eat. When asked about the Resident's goal in regards to nutrition, Dietician H revealed the goal was for the Resident to maintain and gain weight. When queried regarding regarding interventions, Dietician H replied, Supplements, appetite stimulant, talked about preferences, encouragement (to eat), (Resident #14) declined a feeding tube. When asked if they had noticed Resident's room was always dark, Dietician H stated, That's true. Dietician H was then asked if sitting alone in bed, in a dark room encouraged eating and revealed it did not. When queried if the Resident received encouragement to eat and/or got up to eat in a social/group setting, Dietician H stated, There is a central dining area in the basement but the Activities Director ran that and we haven't had it since then. When asked for clarification, Dietician H revealed the Activities Director quit working at the facility in late 2019 and the facility had not had an Activity Director nor a centralized dining area since their departure. With further inquiry regarding interventions pertaining to the Resident's nutritional status and interventions, Dietician H reviewed the Resident's medical record and stated, [MEDICATION NAME] (appetite stimulant) and ProMod (nutritional supplement) were started on 1/18/20. Resident #14's nutritional care plan was reviewed with Dietician H at this time. The care plan was titled, Nutritional status as evidenced by anticipated weight loss r/t (related to) pt (patient) poor po (oral) intake, underweight, advanced age, hx (history) of weight loss . (Initiated: 11/30/19; Revised: 2/21/20). The care plan included the interventions: -Review weights and notify physician and responsible party of significant weight change (Initiated: 11/30/19) -Provide diet as ordered: Regular diet (Initiated: 11/30/19) -Pt (Patient) only consumes 2 meals/day per report; refusing one meal is normal for resident consistent with eating patterns Initiated: 2/19/20) -Provide ensure supplements with meals (Initiated: 2/21/20) When asked why the care plan did not include an intervention to encourage eating, Dietician H replied, I'm not sure. Dietician H was then queried regarding Resident #14's statements indicating they were appreciative of company and having tea and cookies. Dietician H revealed they had not considered the social aspects of eating. Meal observations of Resident #14 were described to Dietician H at this time. When queried if the tray being on the other side of the room, removing the Resident's tray and only leaving an Ensure with the paper over the straw was encouraging and assisting the Resident to eat, Dietician H stated, No. Resident #14's weight documentation were reviewed with Dietician H at this time. When queried regarding facility policy/procedure pertaining to the frequency Resident #14 should be weighted, Dietician Hstated, Weights should have been done weekly. When asked why the Resident had not been weighed weekly, an explanation was not provided by Dietician H. When queried regarding documentation indicating the same interventions, including ice were implemented in (MONTH) and February, Dietician H did not provide a response. When asked if the interventions in place were working, Dietician H replied, No. Dietician H was then queried why additional interventions were not implemented and a response was not provided. Review of Nutrition/Weight Progress Notes in the EMR were revealed with Dietician H at this time. Notes included the following: -1/13/20: Resident on Regular diet with regular texture. Intake recorded: 50-100% with hx (history) of refusing meals . underweight . Recommend encouragement/assistance with meals . -1/30/20: RD (Registered Dietician) spoke to resident r/t poor po intake/refusal of meals . chocolate candy bar and chips at bedside. RD encouraged resident to eat . added ice cream/chips to tray to encourage intake . started on appetite stimulant . -2/3/20: RD spoke to pt today r/t intake. Resident A/O (Alert/Orientated) . own decision maker. Pt explained (they are) just not that hungry. RD explained risks of not eating including death. RD educated resident on importance of receiving proper nutrients and risks associated with not eating meals. RD discussed . enteral nutrition. Resident would like to discuss nutrition via feeding tube with friend and physician . -2/19/20: RD spoke to pt (patient) r/t poor po intake. RD saw empty Ensure supplement at bedside; so pt does consume supplements. Resident told RD only usually eats 2 meals/day and that is normal . RD encouraged po intake and discussed menu preferences and filled out menu with resident. RD added ice cream to lunch and dinner trays . On 2/26/20 at 4:07 PM, Resident #14 was observed in their bed with their eyes closed. The room remained dark with the shades closed and the room divider curtain closed. An interview was conducted with the Director of Nursing (DON) on 2/27/20 at 1:34 PM. When queried regarding Resident #14's weight loss, observations of the Resident and interventions, the DON did not provide further explanation. When queried regarding the facility not offering socialized dining in a central dining area, the DON confirmed there was no central dining area due to the facility not having an Activity Director. The DON further revealed the facility was in the process of hiring a new Activity Director. Review of facility policy entitled, Weight Management Guideline (Dated 3/2018) revealed, The key for effective weight management is to appropriately identify weight variances and initiate nutrition strategies when indicated in time to reduce nutrition related complications. The treatment . depends on understanding the dynamic nature of the weight loss and attempting to identify root causes . Weight Schedule: For newly admitting patients, obtain weight upon admission and weigh weekly for . 4 consecutive weeks . The continued need for weekly weights due to nutritional concerns is determined by the interdisciplinary led by the registered dietitian . Assessment: The registered dietitian obtains adequate information in order to identify nutrition related weight problems. The assessment steps include evaluating intake, adequacy of diet . nutrition-related consequence . anthropometric measures . physical activity and habits, psychosocial factors . Interventions: Individualized interventions . are key to success in meeting care plan goals. Interviewing and visiting the patient during meals and throughout the day is an important part of determining what interventions to try. Evaluating the acceptance and effectiveness of the interventions, changing and trying different interventions is often necessary . Monitoring and Evaluation: Staff monitors and evaluates data directly related to the nutrition problem, goals and intervention strategies to determine the progress made . and whether interventions should be continued or revised .

This intake pertains to MI . Based on interview and record review, the facility failed to provide continuous watch to prevent a fall for one (#901) of three sampled residents reviewed for falls, resulting in a hairline [MEDICAL CONDITION] humerus. Findings include: On 11/21/18 at 8:50 AM, during a interview, Interested party stated, (Resident #901) was suppose to be discharge the same day (they) fell , but there was a mix up, so I let (them) stay. Later that day I got a call and was told that there was a fall out of bed and that they put (them) in the hallway to keep a closer watch. I got another call about (them) being transferred to the hospital because there was another fall. At the hospital they told me (they) had a hairline [MEDICAL CONDITION] humerus. On 11/21/18 at 11:10 AM, Resident #901's clinical record was reviewed and revealed, the following: Incident Report: Date of Incident: 10/22/18 at 12:01, Description of Incident: Upon entering room, staff witnessed pt lying next to (their) bed in a supine position. Staff assisted patient (pt) into bed. Pt complained of (c/o) lower back pain. Patient's Care: Assisted pt to hallway to closely monitor. Incident Cause: Pt has weakness in legs. Placed pt in hallway to be able to monitor pt more frequently. Incident Report: Date of Incident: 10/22/18 at 12:16. Description of Incident: Staff witnessed pt fall in hallway. Pt was lying in prone position. Pt c/o right shoulder pain . Center Action: Patients's Care. Pt transferred to hospital. 10/22/18 at 12:16 AM: Pt. has moderate anxiety and refuses to stay seated in wheelchair despite weakness in both legs. Pt has moderate signs of dementia . Progress Note: 10/21/18 at 20:49, Patient Safety Note Text: Upon entering room staff witnessed pt on ground next to bed. Pt was lying on her back. No apparent injuries. Staff assisted pt to bed. Pt (complained of) c/o of lower back pain. Pain medication given . Progress Note: 10/21/18 at 23:54 Discharge Planning/Discharge Note Text: Staff witnessed pt fall in hallway. Pt was lying in a prone position. Staff assisted pt into wheelchair. Pt c/o right shoulder pain . Pt transferred to (local hospital) . Facility Statement Certified Nurse Assistant (CNA) C: On the evening of the fall, I observed (#901) sitting in front of the nurses' station by the shower room, when I came onto shift. We said (#901) is usually anxious and we keep (them) in visual view. I was at the nurses station and close to the patient when I saw (901) standing up holding onto the wheelchair, (#901) took a couple of steps as I approached to get her and was prompting ( #901) to sit down, and (#901) fell down. ( #901) was walking towards room [ROOM NUMBER] D grabbing the wheelchair. We then assisted patient off the mechanical lift. (Resident #901) did complain of shoulder pain. Facility Statement CNA D The last time I seen patient was in (their) wheelchair at the nurses' station. They told me she had a fall earlier in (their) room. (CNA C) was watching (them) and was around the nurses' station most of the night, while she was still answering lights in nearby room. We made sure (they) was in visual view at all times that night. I know CNA C saw (them) fall, but it so quick that she could not prevent the fall. Review of At risk care plan for falls due to unsteady gait; dated 9/25/18 and revised on 10/23/18. Review of a Fall assessment dated [DATE]: Physical Performance Limitations . Impaired balance during transitions. Disease & Conditions Muscle weakness, Low levels of physical activities,[MEDICAL CONDITION](Cardiovascular accident), Documentation: Care Plan update. Yes. On 11/21/18 at 12:08 PM, attempts were made to interview CNA C and CNA D via telephone, but both CNA's did not return telephone calls by the end of the survey. On 11/21/18 at 12:10 PM, Nurse A was interviewed via phone and was asked about Resident's #901 fall that occurred on 10/22/18. Nurse A stated, (#901) was put in front of the nursing desk. Nurse A was asked for the reason Resident #901 was placed in the hallway. Nurse A stated, So that we could watch (them) after the earlier fall. Nurse A was asked if there was any staff at the desk to supervise the resident. Nurse A stated, No. Nurse A stated, I was about 20 feet away at the medication cart, and (#901) was towards the side of me. I was passing medications. Nurse A was asked if he saw Resident #901 get up from the wheelchair. Nurse A stated, No. I saw the resident once (they) stood up and (them) falling. Nurse A explained that he was not close enough to stop the fall. On 11/21/18 at 1:11 PM, during an interview, the Director of Nursing (DON) was asked what closely monitoring meant, and the DON stated,In visual view. The DON was asked how did the facility closely monitor Resident #901. The DON, stated We placed (Resident #901) at Nurses' station and there were people around on the unit. On 11/21/18 at 3:10 PM, during an interview, the Unit Manager (UM B) stated, that she conducted the investigation on Resident #901's fall. During the investigation UM B stated, (Resident #901) was placed in the hall for more eyes to be on (them). Certified Nursing Assistant (CNA C) reported that she had just ran into another room to answer a call light, but (Nurse A) was there in the hallway. CNA C reported off to the Nurse that she was going into a room. As she was coming back out of the room, she saw (Resident #901) getting up out of the wheelchair and take a few steps then fell . No one could get to (them) before the fall. UM B was asked if at anytime was Resident #901 not supervised. UM B stated, (Resident #901) was not on a one to one. Review of Resident #901 clinical record revealed, Resident #901 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment indicated Resident #901 had a cognitive impairment and required extensive assist of two people for transfers and extensive assist of one person for walking. A review of the facility's policy titled Falls Proactive Guide dated 12/11, noted, The purpose of the Falls Practice Guide is to describe the process steps for identification of patient fall risk factors and identification of patient fall risk factors and interventions and systems that may be used to manage falls. Fall management focuses on minimizing fall risk factors and fall related injuries while continuing to promote the patient's quality of life .

This citations pertains to MI 665. Based on observation, interview, and record review the facility failed to monitor, assess, and implement interventions to promote pressure ulcer healing and to prevent the development of seven facility acquired pressure ulcers for four sampled residents (#502, #503, #504, and #505) of four residents reviewed for pressure ulcers from a total of seven sampled residents resulting in the development of two Stage III pressure ulcers, five unstageable pressure ulcers, the undetermined development of a Stage III pressure ulcer, and the undetermined progress of two unstageable heel ulcers. This deficient practice resulted in substandard quality of care and led to negative outcome that pertained to pressure sore prevention, care, and treatment. Findings include: Resident #504 On 6/5/17 at 8:55 a.m., Resident #504 was observed in bed with the head of the bed at approximately a 30 degree angle. Resident #504 was laying on her back with both heels resting and pressing into the bed (not floated). In addition Resident #504 had a fecal pouch (used to collect fecal material), an indwelling Foley catheter (used to collect urine), and had a tube feeding (used to provide nutrition) infusing. Resident #504 was alert and was observed to be leaning slightly to her right side and when queried as to her position she stated, I'm in pain. I don't want to bother anybody. I'm cold but I don't want a heavy blanket. Further observation revealed no turning or repositioning devices in Resident #504's room. On 6/5/17 at 10:30 a.m., Resident #504 was observed in bed with her eyes closed. The tube feeding was not infusing at this time and Resident #504 remained in the same position. On 6/5/17 at 11:50 a.m., Resident #504 was observed in bed in the same position. An unidentified CNA (Certified Nurse Assistant) was observed to exit the room at 11:58 a.m. On 6/05/17 at 2:00 p.m., Resident #504 was observed in the same position. An unidentified CNA was standing at Resident #504's bedside. On 6/05/17 at 5:00 p.m., Resident #504 was observed to be lying in the same position. However, both of Resident #504's feet were placed on pillows. However, the heels rested and pressed into the pillow (the heels were not floated to offload pressure). On 6/06/17 at 8:05 a.m., Resident #504 was in bed on back with the head of the bed at more than a 45 degree angle with the tube feeding infusing. This position placed the resident in a sitting position which increases pressure on the buttocks. On 6/06/17 at 8:30 a.m., Resident #504 was observed in bed, on her back with the head of the bed at more than a 45 degree angle. Certified Nurse Assistant (CNA) E was queried and verified that Resident #504 required extensive one person physical assistance with turning and repositioning. On 6/06/17 at 11:30 a.m., Resident #504 received wound care from Nurse A and Wound Nurse Practitioner (NP) B and he following was observed. Upon repositioning Resident #504 onto her right side two areas covered with dressings were exposed and one area approximately the size of a quarter was revealed. The quarter sized area was red and appeared to be actively bleeding with the skin pulled back. Removal of the first dressing revealed a Stage IV Pressure Ulcer to the coccyx that Resident #504 was admitted with. A Stage IV pressure ulcer is, Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling (NPUAP, 2007). It measured 6.5 centimeters (cm) x 6.0 cm x 3.0 cm. During the assessment Wound NP B identified exposed bone and undermining between the one o'clock to the 11 o'clock position that measured 2.5 cm at its innermost part. NP B also noted that the area surrounding the larger wound was denuded, and that the white coating observed on Resident #504's vagina and surrounding areas looks like yeast. Nurse A was then queried regarding the second dressing and stated, That (dressing) must be for protection because I only have orders for a treatment to the coccyx wound. Upon completion of the assessment and wound treatment to the coccyx wound, Nurse A was asked to remove the covering (dressing) that was identified as being placed for protection on Resident #504's left buttock. Removal of the bandage revealed the following as described by Wound NP B, a facility acquired Stage III pressure ulcer that measured 6.0 cm x 6.0 cm x 0.2 cm, the wound bed had three less than pea-sized areas of necrotic tissue, and areas of scattered slough. A Stage III pressure ulcer is Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling (NPUAP, 2007). On 6/06/17 at 9:00 a.m., clinical record review revealed Resident #504 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Readmission assessment dated [DATE], Resident #504 presented alert with confusion. Review of the orders revealed on 6/05/17 maintain Foley for Stage IV pressure ulcer, daily body audit noted on 6/03/17, and to apply abdominal dressing to heel dated 6/03/17. There were no shower sheets since admission that would indicate that Resident #504's skin was being monitored for areas of skin concerns. A care plan dated 6/01/17 noted eschar (dead tissue) to the left foot. However, the admitting [DIAGNOSES REDACTED]. Clinical record review also revealed no documented evidence (nursing notes or care plans) that indicated Resident #504 was noncompliant with care. On 6/06/17 at 4:50 p.m., the DON was interviewed regarding Resident #504. The DON was informed that Resident #504 was observed to be in the same position (on back with heels not floated) at each observation on 6/05/17 despite nursing staff observed in the room. The DON was queried regarding Resident #504's care plans and revealed a care plan dated 6/1/17 that identified a Stage IV pressure ulcer to the coccyx. Interventions included to turn and reposition Resident #504 and float heels as able. The DON provided no verbal explanation as to why Resident #504 was not turned and repositioned to promote healing of the Stage IV pressure ulcer and prevent the development of the Stage III pressure ulcer. In addition the DON was unable to provide an explanation as to why the heels were not floated according to the care plan. When informed of the newly facility acquired Stage III pressure ulcer the DON explained that she needed to review the clinical record. Upon review of the clinical record the DON was unable to identify any nursing or medical documentation regarding the facility acquired Stage III pressure ulcer and added, I do not see a treatment order in place. When queried about the dressing that was applied to Resident #504's facility acquired Stage III pressure ulcer the DON was unable to provide a verbal explanation as to why staff would apply a dressing without an order or why there would not be any corresponding documentation regarding Resident #504's alteration in skin. When asked what nursing staff should do when an alteration in skin is identified the DON responded, If there is a new area (skin alteration) they (nurses) should contact the Medical Doctor to get an order or contact the Unit Manager. A nurse note dated 6/01/17 indicated that Resident #504 was admitted with a Stage III pressure ulcer to the coccyx and the Braden Scale indicated that Resident #504 was at moderate risk for the development of pressure ulcers. On 6/02/17 the Director of Nursing (DON) revised the clinical record to indicate that Resident #504 had a Stage IV pressure ulcer to the coccyx. The DON was queried regarding the incorrect documentation and stated, The nurse (C) who did the admission assessment should not have staged the pressure ulcer. The DON explained that staging pressure ulcers should be done by the physician or a wound care practitioner. Resident #502 On 6/05/17 at 10:35 a.m., Resident #502 was observed to be leaning forward at the waist while in bed. Resident #502 stated, Ladies! Help (resident's name) to get off my back. Ladies! Ladies! CNA F entered the room and verified that Resident #502 needed help to be repositioned because she always leans over to that side and she needs help to sit back up. Resident #502's feet were observed to be wrapped in gauze with the heels resting on a pillow (not floated to offload pressure). CNA F and I were observed to return Resident #502 to a sitting position and straightened out the pillows. However, the heels were not repositioned and remained pressing into the pillow. On 6/05/17 at 11:50 a.m., 2:15 p.m., and at 5:20 p.m., Resident #502 was observed in bed, leaning to the right side with both heels resting and pressing into the pillow (not floated). When queried at 5:20 p.m., Resident #502 explained that both of her heals hurt and her left leg was bandaged because it has a wound. On 6/06/17 at 9:30 a.m., clinical record review revealed Resident #502 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the admission Minimum Data Set ((MDS) dated [DATE], Resident #502 had severely impaired cognition but was able to make her needs known. Resident #502 required extensive physical assistance with all activities of daily living with the exception of eating. According to the MDS Resident #502 was at risk for the development of the pressure ulcers. However, Resident #502 had no unhealed pressure ulcers or venous/arterial ulcers at the time of the assessment. The Patient Readmission assessment dated [DATE], noted that Resident #502 had an open area, no drainage, 5.3 cm x 3.5 cm with slough to the buttocks, a left heel alteration in skin that measured 5.0 cm x 2.5 cm, and a 5.0 cm x 1.5 cm alteration in skin to the right heel. The Braden Scale during this assessment indicated that Resident #502 was at risk for the development of pressure ulcers. Review of acute care hospital record dated revealed Resident #502 was discharged with (1) a suspected deep tissue injury pressure ulcer wound on the left heel that measured 0.5 cm x 1.5 cm and was purple in color, (2) an unstageable pressure ulcer to the right heel that measured 1.5 cm x 3 cm and was purple in color (3) a Stage III pressure ulcer to the coccyx that measure 1.0 cm x 0.5 cm and was purple in color (4) a wound (no location noted) that measured 4.5 cm x 5.5 cm with slough and was white in color. Subsequent nursing notes revealed the following: 5/15/17 Resident #502 was extensive assist with activities of daily living and transfers. 5/17/17 unstageable 3.5 x 2.5 x 0.2 cm 5/25/17 presenting as a Stage II 3.7 cm x 2.9 cm x 0.3 cm. Bilateral heels and coccyx treatment provided by Nurse Manager. Stage II measuring 2.5 x 1.8 cm x 0.4 cm 5/31/17 Resident not available during wound NP rounds due to [MEDICAL TREATMENT] appointment. An order dated 5/8/17 documented, Wound care consult related to coccyx wound. However, there was no evidence that the wound care consult was completed. There was only documented evidence that the Wound NP was unable to see Resident #502's wound because the Resident #502 has [MEDICAL TREATMENT] on the days the Wound NP visits. Clinical record review revealed that a barrier cream was applied to Resident #502's Stage III coccyx wound. An order dated 5/08/17 noted, Float heels every day and every night. However, there was no care plan that included the intervention and no observations that Resident #502's heels were floated. Also, there were no subsequent measurements of the wounds to Resident #502's heels and no evidence that the heels were addressed by the foot doctor. On 6/06/17 at 11:00 a.m., during an interview with Wound NP B revealed ,I've not seen (Resident #502) because she's at [MEDICAL TREATMENT] on the day I visit. When queried regarding Resident #502's heels, Wound NP B explained, I see wounds from the knee up, the podiatrist takes care of the wounds from the knees down. Wound NP B was informed that nursing staff back-staged Resident #502's wound documenting that it had moved from a Stage III to presenting as a Stage II. When asked if wounds should be back-staged, Wound NP B stated, No. Is someone doing that? They should be described as a healing or improving Stage III or IV. Wound NP B was informed that nursing staff documented that Resident #502's Stage III coccyx was treated with a barrier cream. When asked if the barrier cream should be used on all wounds, Wound NP stated, No. Just Stage I's and II's. On 6/06/17 at 4:00 p.m., the DON was queried regarding Resident #502. The DON was informed that Resident #502's heels were not floated at any time during observation. The DON offered no verbal explanation. The DON was queried regarding the progress of the Suspected Deep Tissue injury to Resident #502's left heel and the unstageable pressure ulcer to the right heel. The DON reviewed the clinical record and was unable to provide documented evidence of whether or not the heels were improving since Resident #502 complained of heel pain and multiple observations showed that Resident #502's heels were resting on and pressing into pillows positioned under her feet. The DON explained that the podiatry notes should address the condition of Resident #502's heels. However, review of the podiatrists notes addressed Resident #502's left leg wound but did not address the heels. The DON added, I am not able to acquire any other documentation because their (podiatrist) office is closed. In addition, wound care was not able to be observed as Resident #502 was at [MEDICAL TREATMENT] from 11:00 am until the end of survey. Resident #505 On 6/06/17 at 4:00 p.m., clinical record review revealed that Resident #505 with [DIAGNOSES REDACTED]. According to the MDS dated [DATE], Resident #505 had intact cognition, required extensive one to two person physical assistance with all activities of daily living with the exception of eating. Resident #505 was assessed to be at risk for the development of acquired pressure ulcer and had no pressure ulcers upon admission. However, the MDS indicated that Resident #505 did have, moisture associated skin damage. Review of the nurses notes revealed the following: The Admission assessment dated [DATE], noted Resident #505 presented with, Coccyx has pinpoint open area, excoriation under both breast. On 4/28/17 nurse note documented, pressure ulcer, left buttock multiple open wounds to left buttock, no drainage noted. Left breast open wound. On 5/16/17 new orders for wound consult. On 5/16/17 the following areas were identified, Left medial buttock, left lateral buttock, right buttock, left lateral thigh unstageable pressure ulcer (1.4 cm x 1.5 cm x Unable to determine (UTD)), left lateral buttock unstageable (5.8 x 2.4 x UTD) left buttock unstageable (1.0 cm x 0.4 cm x UTD), right buttock unstageable (5.5 cm x 7.0 cm x UTD), and left breast unstageable (2.2 cm x 0.4 cm x UTD). An unstageable pressure ulcer is, Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined, (NPUAP, 2007). The ADL care plan dated 4/21/17 indicated to assist Resident #505 as needed due to physical limitations due to lower extremity weakness. An at risk for alteration for skin integrity care plan dated 4/21/17 noted to observe skin conditions with ADL care report abnormalities, encourage to reposition, provide preventative skin care. A care plan dated 5/16/17 revealed the following, Unstageable pressure ulcer related to diabetes, friction, impaired mobility, incontinence. Resident #505 had a noncompliant care plan related to [MEDICAL CONDITION] (surgical incision in neck to facilitate breathing) care only. Nursing notes revealed: On 5/24/17, Maximum assist with ADL's On 5/25/17, Right lateral thigh necrotic and slough tissue, drainage with odor noted, areas on right leg has necrotic areas On 6/06/17 at 1:55 p.m., during an interview, the DON was asked to identify interventions that were in place to prevent the development of multiple facility acquired pressure ulcers. The DON explained that Resident #505's skin was being monitored daily because she received a daily treatment to the left lateral buttocks. When asked if Resident #505's skin was being monitored daily how did Resident #505 present in one day the development of five unstageable pressure ulcers. The DON was unable to provide a verbal explanation. When asked what was the plan of care at admission to prevent the worsening of skin wounds and to prevent the development of five unstageable pressure ulcers. The DON reviewed the clinical record and stated Resident #505, did not have an actual care plan with interventions for a pressure ulcer at admission and that there should have been an actual skin alteration care plan in place to promote healing and prevent the development of five unstageable pressure ulcers. In addition, further review by the DON revealed that the plan of care was not revised between 4/21/17 through 5/16/17 to include the implementation of interventions as Resident #505's skin condition declined. Resident #503 On 6/06/17 at 3:00 p.m., clinical record review revealed that Resident #503 was admitted on [DATE] with [DIAGNOSES REDACTED]. Per the admission MDS dated [DATE] Resident #503 had intact cognition and required extensive physical assistance with all activities of daily living with the exception of eating. Resident #502 was at risk for the development of pressure ulcers and had no pressure ulcers upon admission. Review of the care plans revealed a pressure ulcer care plan initiated 3/15/17 that revealed the following, Unstageable pressure ulcer at coccyx related to Diabetes, impaired mobility, incontinence .encourage to turn and reposition, float heels as able . Physician orders [REDACTED]. A late skin note dated 3/16/17 documented, Noted Stage 3 pressure ulcer to sacrum measuring 5 cm x 5 cm x 0.2 cm with 70% granulation and 30% necrosis, moderate serosanguineous drainage. On 6/06/17 at 1:55 p.m., the DON was interviewed regarding Resident #503. The DON reviewed the clinical record and noted Resident #503 did not have any pressure ulcers on admission. When asked to identify when the Resident #503's facility acquired Stage III pressure ulcer was identified during a skin audit on 3/14/17 and revealed that Resident #503's skin was monitored and assessed daily. However, the DON was unable to explain if Resident #502's skin was's monitored daily why the wound was not observed prior to the development of a Stage III. An at risk for pressure ulcers care plan dated 2/24/17 included apply barrier cream. The DON explained that Resident #503 was able to reposition himself. The DON was queried regarding the intervention to float heels as able noted on the care plan dated 3/15/17. The DON was unable to explain why this intervention was added one day prior to the order to apply silver alginate to right heel ulcer. When asked about the right heel ulcer that Unit Manager Nurse K obtained a treatment order for, the DON reviewed the clinical record and stated, I can't confirm or deny that he had one. The DON attempted to contact Nurse K for further clarification because she could tell you if he had one or not but was unsuccessful. The DON and the Administrator offered to provide a contact number but it was not provided by the end of survey. On 6/06/17 at Unit Manager (UM) G (in attendance was Nurse Consultant J because UM G was new to her position) was asked to supply Skin Worksheets for Resident #'s 502 in order to provide documentation that nursing staff assessed and monitored the residents skin for any alterations. Only two Skin Worksheet could be located for Resident #505. Three Skin Worksheets were located for Resident #502 dated 5/15/17 no indication of skin concerns (refused bed bath) 5/22/17 revealed a wound to coccyx, 6/01/17 wound to coccyx and soreness to right leg. There were no Skin Worksheets for Resident #503. There were no Skin Worksheets for Resident #504. Unit Manager G and Nurse Consultant J were queried regarding the purpose monitoring residents skin and explained that it is done to identify any concerns with skin and address and treat the concerns. Unit Manager 'G explained that Nurses perform daily or weekly audits in order to identify skin concerns and nurse assistants can place Alerts in the kiosk to inform the nurses if there are any changes in skin conditions. At this time Unit Manager G and Nurse Consultant J were asked to provide evidence that Residents #502, #503, #504, and #505 skin was monitored and if nurses were alerted to any changes in condition. Unit Manager G and Nurse Consultant J reviewed the clinical records and explained that nurse assistants did not log any changes in skin to alert nursing staff for assessment and treatment for [REDACTED].#503, #504, and #505. Review of the facility's Skin Practice Guide issued 1/2013 revealed: The purpose of the Skin Practice Guide is to describe the process steps for identification of patients at risk for the development of pressure ulcers, identify prevention techniques and interventions to assist with the management of pressure ulcers and skin alterations. Based upon the findings of the MDS and other evaluations, the patient's initial plan of care is updated or a comprehensive care plan is developed to include individualized patient interventions that focus on the patient's specific risk factors. Individual interventions are selected based upon the patient's skin risk, past history, functional status and the patient's willingness to participate with the plan of care. The approaches for skin management are clear, specific and individualized for the patient's needs. Managing skin risk can be complex as there may be a combination of risk factors and causes. Regardless of the interventions that are put in place, a key factor to success is the timely review of the interventions as the patient's condition and needs change. Nursing assistants perform daily skin observations with routine care. The Skin Worksheet is completed by the nursing assistant at least two times per week with the patient's bath (shower, tub, bed). Results are submitted to the licensed nurse for review and follow-up as needed. Nursing assistants can initiate a New Alert in PCC to communicate changes in skin condition to the licensed nurse. Body positioning provides for pressure redistribution and can decrease pressure, friction and shear. The use of support surfaces and positioning devices can provide for additional pressure redistribution. Examples of possible interventions to consider include: minimize direct pressure over vulnerable areas and actual pressure ulcers, maintain head of bed elevation at less than 30 degree angle unless contraindicated, reposition frequently, elevate or float heels, even if patient is on specialty support surface. Patients have the right to refuse the care designed in the care plan. In this case, staff performs several tasks, including: documenting patient's refusal, trying to discover the basis for the patient's refusal, presenting a rationale for why the intervention is important, designing an alternate plan, update the care plan to reflect any changes in the patient's risk status. If a change in patient condition occurs, such as a deterioration in or development of new risk factors or skin alterations, the licensed nurse notifies the physician, wound team, family or responsible party and documents findings in the clinical record. The patient's current status and care needs. Communications with the physician, patient and family are documented in the clinical record.

THIS CITATION HAS TWO DEFICIENT PRACTICES. DEFICIENT PRACTICE #1: BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO DOCUMENT AND TREAT A KNOWN PRESSURE SORE ON THE HEEL FOR 12 DAYS AND FAILED TO IMPLEMENT APPROPRIATE INTERVENTIONS FOR A PRESSURE SORE ON THE COCCYX FOR ONE (#502) OF SIX SAMPLED RESIDENTS REVIEWED WITH PRESSURE SORES FROM A TOTAL OF 15, RESULTING IN THE WORSENING OF THE PRESSURE SORES. FINDINGS INCLUDE: DURING THE INITIAL TOUR ON 5/29/13 AT 9 AM, STAFF STATED THAT RESIDENT #502 HAD A LARGE PRESSURE SORE ON THE SACRAL AREA AND THE LEFT HEEL. ON 5/29/13 AT 9 AM, 11:40 AM, 12:45 PM, 1:25 PM, 3:40 PM, AND 4 PM, RESIDENT #502 WAS OBSERVED SITTING IN A WHEELCHAIR IN HIS ROOM WITH THE LEFT HEEL RESTING ON THE WHEELCHAIR FOOTREST. THE RESIDENT WAS ALERT AND APPEARED THIN. AT 4 PM, WHEN ASKED IF STAFF HAD MENTIONED TO HIM ABOUT LYING DOWN OR REPOSITIONING TO RELIEVE PRESSURE ON HIS BOTTOM, THE RESIDENT SAID, "SOMETIMES THEY DO, BUT DIDN'T MENTION IT SO FAR TODAY." THE RESIDENT WAS SITTING ON A STANDARD FOAM PRESSURE RELIEF CUSHION THAT OTHER RESIDENTS IN WHEELCHAIRS WERE OBSERVED TO HAVE. REVIEW OF RESIDENT #502'S HISTORY AND PHYSICAL (H&P) DATED 5/18/13 REVEALED THAT THE RESIDENT WAS admitted WITH PRESSURE SORES TO THE SACRAL AREA AND THE LEFT HEEL. A physician's orders [REDACTED]. SACRAL ULCER AND LEFT HEEL ULCER." PER REVIEW OF ADMISSION NURSES NOTES BY NURSE 'U' DATED 5/18/13: "OPEN AREA NOTED ON LEFT HEEL, MEASURES 3 X 3 CENTIMETERS (CM), AREA DRY, DARK IN COLOR, NO DRAINAGE NOTED." A "PRESSURE ULCER HEALING CHART" (PUSH TOOL) DATED 5/18/13 WAS REVIEWED THAT DOCUMENTED THAT THE PRESSURE SORE HAD NECROTIC (BLACK, DEAD) TISSUE. ON 5/30/13 AT 11:00 AM, FOLLOWING THE treatment of [REDACTED]. THE PRESENCE OF THE CONTRACTED WOUND CARE NURSE ('C'), NURSE 'C' ASKED NURSE 'B' IF SHE WAS FINISHED WITH RESIDENT #502'S WOUND CARE. NURSE 'B' NODDED YES AND THEY BOTH BEGAN TO LEAVE THE ROOM WHEN THEY WERE QUERIED ABOUT THE WOUND ON THE LEFT HEEL. NURSE 'C' SAID, "WHAT WOUND? I DON'T KNOW ANYTHING ABOUT A WOUND ON THE HEEL!" SHE LOOKED AT NURSE 'B' WHO SAID, "I DON'T KNOW ANYTHING ABOUT IT." WHEN THEY PULLED THE COVERS BACK, THE RESIDENT HAD A WHITE SOCK ON THE LEFT FOOT. SEROUS DRAINAGE WAS OBSERVED ON THE TOP SHEET AND ON THE BOTTOM SHEET UNDERNEATH THE RESIDENT'S HEEL THAT WAS RESTING ON THE MATTRESS. THE ENTIRE HEEL OF THE RESIDENT'S SOCK WAS COATED WITH FRESH AND DRIED DRAINAGE. ON 5/30/13 AT 11:05 AM, THE DIRECTOR OF NURSING (DON) ENTERED THE RESIDENT'S ROOM, SAW THE DRAINAGE ON THE SHEETS AND SOCK, AND WATCHED AS NURSE 'B' REMOVED THE SOCK. AS THE SOCK WAS BEING REMOVED, HALF OF THE DEAD TISSUE HAD STUCK TO THE INSIDE OF THE SOCK AND WAS PULLED OFF TO REVEAL BRIGHT RED BLOODY TISSUE WITH BLACK, DEAD TISSUE ON THE OTHER HALF OF THE HEEL. THE BLOODY AREA APPEARED AS A STAGE III (FULL THICKNESS SKIN LOSS) PRESSURE SORE. WHEN MEASURED, THE AREA HAD ENLARGED FROM 3 CM X 3 CM ON ADMISSION WITH NO DRAINAGE TO 5.7 CM X 4.5 CM WITH A LARGE AMOUNT OF DRAINAGE. REVIEW OF WOUND TREATMENT RECORDS AND NURSES NOTES FOR RESIDENT #502 REVEALED NO DOCUMENTATION OF A SORE ON THE LEFT HEEL SINCE 5/18/13 AND NO DOCUMENTATION THAT TREATMENT WAS EVER PROVIDED TO THE LEFT HEEL. NURSE 'B', NURSE 'C', AND THE DON DID NOT RESPOND WHEN QUERIED ABOUT THE LACK OF CARE AND SERVICES FOR THE LEFT HEEL PRESSURE SORE THAT WAS IDENTIFIED IN THE H&P, NURSES NOTES, AND THE PUSH TOOL, ALL DATED 5/18/13, AND IN THE "ACTUAL SKIN BREAKDOWN: SACRAL AND LEFT HEEL ULCER" CARE PLAN DATED 5/20/13. PER REVIEW OF CARE GUIDES DATED 5/29/13 THRU 5/31/13 AND THE UNDATED "PATIENT INFORMATION WORKSHEET" FOR RESIDENT #502, INTERVENTIONS INCLUDED, "FLOAT HEELS" AND "TURN AND REPOSITION EVERY TWO HOURS." THERE WAS NO MENTION OF WOUND TREATMENT OR PRESSURE RELIEF DEVICES FOR THE LEFT HEEL. PER FURTHER REVIEW OF RESIDENT #502'S CLINICAL RECORD: THE RESIDENT WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. BRADEN (PRESSURE ULCER RISK) SCORES DATED 5/18/13 AND 5/24/13 FOR RESIDENT #502 WERE 14, MEANING "MILD" RISK FOR DEVELOPMENT. THE H&P ALSO NOTED THAT THE RESIDENT HAD A "STAGE IV (FULL THICKNESS SKIN LOSS WITH BONE EXPOSURE) LARGE DECUBITUS ULCER (PRESSURE SORE)" ON ADMISSION. THE PCP'S PLAN INCLUDED, "CONTINUE LOCAL WOUND CARE. CONSULT THE WOUND CARE NURSE ('C'). MINIMIZE PRESSURE ON THE LOWER BACK AND REPOSITION EVERY TWO HOURS." THE 5/18/13 NURSES NOTES DOCUMENTED: "OPEN AREA ON COCCYX MEASURES 9.5 CENTIMETERS (CM) X 9.5 CM, 1 CM DEEP AREA PINK, NOTED WITH ESCHAR (DEAD TISSUE) IN CENTER, THIN LAYER COVERING BONE, MODERATE AMOUNT OF PURULENT (PUS) DRAINAGE NOTED." A physician's orders [REDACTED]."TREAT COCCYX WOUND: NORMAL SALINE CLEANSE, APPLY SANTYL ([MEDICATION NAME] AGENT), COVER WITH ABD (THICK PAD) CHANGE DAILY AND (AS NEEDED)." IN ADDITION TO RESIDENT #502 BEING OBSERVED SITTING CONTINUOUSLY ON A FOAM SEAT CUSHION FROM 9 AM UNTIL 4 PM ON 5/29/13, THE FOLLOWING WAS REVEALED REGARDING THE SACRAL PRESSURE SORE: ON 5/30/13 AT 8:45 AM, RESIDENT #502 WAS OBSERVED BEING TRANSPORTED TO THERAPY IN THE WHEELCHAIR, SITTING ON THE FOAM CUSHION. THERAPY DIRECTOR 'F' WAS QUERIED REGARDING THE TYPES OF PRESSURE RELIEF CUSHIONS AVAILABLE AT THE FACILITY. HE PRESENTED TWO, UNOPENED BOXES OF ROHO (SPECIALTY PRESSURE RELIEF) CUSHIONS AND STATED THAT GEL (SPECIALTY PRESSURE RELIEF) CUSHIONS WERE ALSO USED, BUT WERE CURRENTLY BEING USED BY RESIDENTS AND UNAVAILABLE. EMPLOYEE 'F' STATED THAT A VARIETY OF CUSHIONS COULD BE OBTAINED FROM THE SUPPLIER BASED ON A physician's orders [REDACTED]. ON 5/30/13 AT 10:45 AM, NURSE 'B' WAS OBSERVED PREPARING SANTYL (WOUND [MEDICATION NAME] AGENT) FOR treatment of [REDACTED]. NURSE 'C' TOLD NURSE 'B', "HE'S SUPPOSED TO GET SANTYL AND (CALCIUM) ALGINATE (A HIGHLY ABSORBENT DRESSING USED TO DECREASE SECRETIONS AND LIMIT BACTERIA)." WHEN ASKED WHY THERE WAS NO DOCUMENTED ORDER FOR ALGINATE DRESSINGS, NURSE 'C' STATED THAT SHE DID NOT WRITE an order for [REDACTED]."IT'S IN MY DICTATION (OF NOTES). IT SHOULD BE IN THE CHART." HOWEVER, THERE WERE NO DOCUMENTED NOTES BY NURSE 'C' IN THE RESIDENT'S CHART, UPON REVIEW. A DRESSING WAS OBSERVED TO THE SACRAL AREA DATED 5/28/13 7 AM-7 PM (SHIFT), WHICH INDICATED THAT THE DRESSING WAS NOT CHANGED IN TWO DAYS. (ON 5/30/13 AT 9:40 AM, WHEN ASKED ABOUT THE RESIDENT'S WOUND CARE, NURSE 'J' SAID, "I COULDN'T DO HIS WOUND (ON 5/29/13) BECAUSE HE DIDN'T HAVE ANY SANTYL (LEFT)" AND HAD TO ORDER MORE FROM THE PHARMACY.) THE DRESSING WAS SATURATED WITH THICK YELLOW PURULENT (PUS) DRAINAGE. THE RESIDENT HAD A LARGE, STAGE IV PRESSURE SORE UNDERNEATH WITH THE BONE EXPOSED. WHEN NURSE 'C' MEASURED THE WOUND, THE WOUND WAS 10.5 CM X 8.8 CM X 1.4 CM IN DIAMETER AND DEPTH. THE WOUND HAD DEVELOPED UNDERMINING (AN OPENING INSIDE THE WOUND LARGER THAN THE SURFACE OPENING, WHICH IS A SIGN OF WOUND DETERIORATION) AT THE 12 O'CLOCK TO 1 O'CLOCK POSITION (USING THE FACE OF A CLOCK AS A GUIDE), WHICH WAS NOT DOCUMENTED BEFORE. WHEN ASKED TO DESCRIBE THE DRAINAGE, NURSE 'C' SAID, "I WOULD RATHER DESCRIBE IT AS TURBID (DENSE, OPAQUE, CLOUDY). I DON'T LIKE THE WORD PURULENT BECAUSE THAT INDICATES INFECTION." NURSE 'B' APPLIED SANTYL TO THE WOUND AND AN ABD PAD. (BY THE END OF THE SURVEY, THERE WAS NO DOCUMENTED ORDER FOR USE OF CALCIUM ALGINATE DRESSINGS FOR THE SACRAL WOUND). NURSE 'A' ENTERED THE ROOM AND WAS QUERIED ABOUT A NURSES NOTE WRITTEN BY HER DATED 5/28/13: "PATIENT HAVING WOUND (DRESSING) CHANGE TWO TIMES A DAY WITH MODERATE DRAINAGE." NURSE 'A' STATED, "THE NURSES TOLD ME THAT THEY WERE HAVING TO CHANGE THE DRESSING MORE BECAUSE OF AN INCREASE IN DRAINAGE. WHEN ASKED IF NURSE 'C' HAD BEEN INFORMED, NURSE 'A' SAID, "I TOLD THE NURSE TO WRITE IT ON HER (NURSE 'C') LOG." THE LOG WAS IMMEDIATELY REVIEWED WITH NURSE 'A'. THERE WAS NO ENTRY FOR RESIDENT #502. AFTER REVIEW OF THE LOG, NURSE 'C' WAS THEN ASKED HOW OFTEN SHE SAW RESIDENTS' WOUNDS AT THE FACILITY. NURSE 'C' STATED THAT SHE SAW RESIDENTS WEEKLY EVERY THURSDAY. RESIDENT #502 WAS admitted to the facility on A FRIDAY (5/17/13). NURSE 'C' DID NOT SEE THE RESIDENT'S WOUNDS FOR THE FIRST TIME UNTIL HER REGULARLY SCHEDULED DAY ON THE FOLLOWING THURSDAY (5/23/13). PER REVIEW OF WOUND TREATMENT RECORDS AND NURSES NOTES, WOUND CARE WAS PERFORMED TO THE SACRAL AREA ON ADMISSION (5/17/13) BY NURSE 'U' (WHO WORKED THE NIGHT SHIFT AND DATED ALL NOTES FOR THE FOLLOWING DAY (5/18/13). AFTER 5/17/13, THERE WAS NO DOCUMENTED WOUND CARE PROVIDED UNTIL THE FOLLOWING MONDAY (5/20/13). THERE WAS NO DOCUMENTED WOUND CARE TO THE SACRAL AREA ON 5/21/13. NURSE 'C' WAS ASKED ABOUT THE CUSHION IN RESIDENT #502'S WHEELCHAIR. NURSE 'C' LOOKED AT THE STANDARD FOAM CUSHION AND SAID, "HE ALREADY HAS A CUSHION." WHEN ASKED WHETHER THAT TYPE OF CUSHION WAS RECOMMENDED FOR A STAGE IV PRESSURE SORE AND INFORMED THAT THE RESIDENT SAT IN THE CHAIR CONTINUOUSLY ON 5/29/13 FROM 9 AM TO 4 PM, NURSE 'C' SAID, "MAYBE HE SHOULD HAVE ANOTHER KIND. I WILL TALK TO THERAPY AND SEE IF THEY HAVE EVALUATED HIM FOR ANOTHER CUSHION." WHEN REVIEWED, RESIDENT #502'S THERAPY EVALUATIONS, DATED 5/18/13 AND 5/20/13, MENTIONED THE STAGE IV SACRAL PRESSURE SORE WAS PRESENT, BUT DID NOT MENTION A WHEELCHAIR CUSHION. ON 5/30/13 AT 11:20 AM, BACK-UP THERAPY MANAGER 'D' AND OCCUPATIONAL THERAPIST (OT) 'E' WERE QUERIED ABOUT THE CUSHION. OT 'E' STATED THAT, ON 5/20/13, WHEN TESTING THE RESIDENT'S SITTING BALANCE IN THE WHEELCHAIR ON A ROHO CUSHION, THE RESIDENT'S BALANCE WAS TOO POOR TO MAINTAIN A SITTING POSITION WITH THE CUSHION OR WITHOUT THE CUSHION. OT 'E' SAID, "HE HAS IMPROVED QUITE A BIT, SO MAYBE WE CAN TRY IT (SPECIALTY CUSHIONS) AGAIN." EMPLOYEES 'D' AND 'E' DID NOT RESPOND WHY THE NOTES DID NOT MENTION PRESSURE RELIEF CUSHIONS. ON 5/30/13 AT 1:15 PM, RESIDENT #502'S PCP WAS QUERIED ABOUT THE RESIDENT'S PRESSURE SORES. HE LOOKED AT THE RESIDENT'S H&P THAT HE WROTE, POINTED TO HIS DOCUMENTATION OF THE LEFT HEEL WOUND, AND SAID, "I DON'T KNOW WHY SHE (NURSE 'C') DIDN'T KNOW ABOUT THE HEEL. I WROTE IT RIGHT HERE." THE PCP STATED HE WAS UNAWARE THAT THE RESIDENT HAD INCREASED DRAINAGE TO THE SACRAL WOUND. AT 1:30 PM, THE ADMINISTRATOR DID NOT RESPOND WHY THE RESIDENT HAD A FOAM WHEELCHAIR CUSHION AND WHY THE LEFT HEEL WAS LEFT UNTREATED. ON 5/31/13 AT 9:15 AM, RESIDENT #502 WAS OBSERVED STILL SITTING IN THE WHEELCHAIR ON A FOAM CUSHION. THERE WAS NO DOCUMENTED TREATMENT ORDER FOR RESIDENT #502'S SACRAL WOUND FROM NURSE 'C' OR THE PHYSICIAN PRIOR TO 5/23/13, EXCEPT FOR AN INCOMPLETE ORDER DATED 5/18/13 FOR DRESSING CHANGES EVERY MONDAY-WEDNESDAY-FRIDAY WITH A WOUND VAC (A NEGATIVE PRESSURE DEVICE THAT PROMOTES HEALING BY CREATING A VACUUM TO REMOVE WASTE MATERIAL AND WOUND FLUIDS). HOWEVER, THE RESIDENT NEVER RECEIVED THE WOUND VAC, PER REVIEW OF THE CLINICAL RECORD. ON 5/31/13 AT 3 PM, NURSE 'I' WAS QUERIED ABOUT THE WOUND VAC. SHE STATED, "HIS (WOUND VAC) SUPPLIES WERE ALREADY ORDERED AND WERE HERE BEFORE HE GOT HERE AT THE END OF MY SHIFT (7 AM-7 PM). (NURSE 'U') WAS COMING ON DUTY. I TOLD HER ABOUT THE WOUND VAC. HE DID NOT HAVE THE WOUND VAC ON WHEN HE GOT HERE. HE HAD A DRESSING." AT 3:15 PM, THE DON WAS ASKED TO PROVIDE EVIDENCE THAT THE WOUND VAC WAS INITIATED/ATTEMPTED FOR RESIDENT #502, BUT THERE WAS NO DOCUMENTED EVIDENCE PROVIDED BY THE END OF THE SURVEY. THE WOUND CARE NURSE AT THE HOSPITAL THAT THE RESIDENT WAS TRANSFERRED TO THE FACILITY FROM, WAS QUERIED BY PHONE ON 6/3/13 AT 1:30 PM AND SAID THE FOLLOWING: "USUALLY WE DON'T SEND PATIENTS WITH [DEVICE] ON BECAUSE IT IS ANTICIPATED THAT THE STAFF AT THE OTHER PLACE WOULD NEED TO LOOK AT THE WOUND AND ASSESS IT. IT MAKES NO SENSE FOR THEM TO HAVE TO TEAR IT (THE WOUND VAC) APART TO LOOK AT THE WOUND, SO WE SEND THEM WITH A DRESSING ON." PER REVIEW OF THE FACILITY'S "SKIN PRACTICE GUIDE" DATED 1/2013: -STAGE III AND IV PRESSURE SORES ARE AT GREATER RISK FOR SUBSEQUENT BREAKDOWN AND "PATIENTS WITH DIABETES HAVE CONSISTENTLY BEEN SHOWN TO BE AT INCREASED RISK OF....PRESSURE ULCERS." -PREVENTIVE INTERVENTIONS INCLUDED, "REPOSITION FREQUENTLY IN BED AND CHAIR," CONSULT THE THERAPY TEAM, "ELEVATE HEELS" EVEN IF THE RESIDENT IS ON A SPECIALTY PRESSURE RELIEF MATTRESS, AND "COMPLETE SKIN OBSERVATIONS." -"REMEMBER, EVEN A SCORE THAT INDICATES NO RISK DOES NOT GUARANTEE THAT A PERSON WILL NOT DEVELOP A PRESSURE ULCER....IF A PATIENT IS AT LOW OR MODERATE RISK AND OTHER MAJOR RISK FACTORS ARE PRESENT...ADVANCE TO THE NEXT LEVEL OF RISK. IF A PRESSURE SORE IS PRESENT ON ADMISSION, THE RESIDENT IS "AUTOMATICALLY AT HIGH RISK." -IF A SKIN DISRUPTION IS FOUND, IT MUST BE IDENTIFIED BY A QUALIFIED PROFESSIONAL SUCH AS THE PHYSICIAN AND THE WOUND CARE NURSE SPECIALIST "IDEALLY WITHIN 24-HOURS OF ADMISSION." TREATMENT ORDERS MUST BE OBTAINED, NOTED, INITIATED, AND DOCUMENTED IN THE CLINICAL RECORD. -THE FACILITY MUST ENSURE "A PATIENT HAVING PRESSURE SORES RECEIVES NECESSARY TREATMENT AND SERVICES TO PROMOTE HEALING, PREVENT INFECTION, AND PREVENT NEW SORES FROM DEVELOPING." ( ) DEFICIENT PRACTICE #2 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO FOLLOW physician's orders [REDACTED]. FINDINGS INCLUDE: ON 5/29/13 AT 9:15 A.M., DURING THE INITIAL TOUR, NURSE "V" REPORTED THAT RESIDENT #504 HAD A PRESSURE ULCER AND A CULTURE OF THE WOUND WAS PENDING. ON 5/29/13 AT 12:00 P.M., RESIDENT #504 WAS NOTED SITTING IN HER WHEELCHAIR RESTING ON A SEAT CUSHION WATCHING TV. SHE WAS ALERT, PLEASANT, AND ANSWERED ALL QUESTIONS APPROPRIATELY. ON 5/30/13 AT 10:00 A.M., TREATMENTS TO RESIDENT #504'S WOUNDS WERE OBSERVED PERFORMED BY NURSE "B." WOUND #1: RIGHT THIGH SURGICAL WOUND MEASURED 12.1 CENTIMETERS (CM) X 5.7 CM. WITH FLAT DEPTH (3.9 CM). WOUND BED WAS RED. THE SURROUNDING TISSUE APPEARED MOIST. MINIMAL SEROSANGUINOUS DRAINAGE WAS NOTED. THE ANTI-FUNGAL CREAM WAS NOT APPLIED TO THE SURROUNDING TISSUE AS ORDERED. WOUND #2: LOCATED ON COCCYX AREA AND MEASURED 14.8 CM X 10.1 CM, DEPTH 2.0 CM. THE CENTER WOUND BED HAD NECROTIC TISSUE WITH YELLOW EDGES. THE PERI-WOUND WAS REDDENED. THE SURROUNDING TISSUE APPEARED MOIST. THE ANTI-FUNGAL CREAM WAS NOT APPLIED TO THE SURROUNDING TISSUE AS ORDERED. REVIEW OF THE CURRENT physician's orders [REDACTED]. NURSE "B" WAS UNAVAILABLE FOR INTERVIEW, AND DID NOT RESPOND BACK TO A TELEPHONE MESSAGE LEFT ON 5/31/13 AT 12:55 P.M. REQUESTING A RETURN PHONE CALL. RESIDENT #504'S FACE SHEET REVEALED AN ADMISSION INto the facility on [DATE] AND A RE-ADMISSION ON 4/15/13 WITH [DIAGNOSES REDACTED]. THE ADMISSION MINIMUM DATA SET (MDS), dated [DATE], INDICATED AN INTACT COGNITION AND EXTENSIVE ASSISTANCE WAS REQUIRED FOR ALL ACTIVITIES OF DAILY LIVING (ADL'S). A POLICY REGARDING FOLLOWING physician's orders [REDACTED]. ON 5/31/13 AT 2:10 P.M., THE DIRECTOR OF NURSES (DON) WAS INFORMED OF THE OMISSION OF THE ANTI-FUNGAL CREAM THAT WAS NOT APPLIED TO THE SURROUNDING TISSUE OF THE WOUNDS. THE DON PROVIDED NO EXPLANATION. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 7066. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO ADDRESS PROBLEMATIC WANDERING FOR ONE (#503) OF 3 SAMPLED RESIDENTS REVIEWED FOR SAFETY FROM A TOTAL SAMPLE OF 5, RESULTING IN RESIDENT #503 BEING PHYSICALLY ASSAULTED BY RESIDENT #18. FINDINGS INCLUDE: ON 11/16/12 AT 9:30 A.M., RESIDENT #503 WAS OBSERVED DURING THE INITIAL TOUR WITH A ONE TO ONE SITTER PRESENT. THE UNIT NURSE, LICENSED PRACTICAL NURSE (LPN) #7 REPORTED THAT THE RESIDENT WAS PUT ON ONE TO ONE SUPERVISION AFTER SHE (#503) WAS INVOLVED IN AN ALTERCATION WITH ANOTHER RESIDENT. REVIEW OF THE CLINICAL RECORD AND MINIMUM DATA SET (MDS) assessment dated [DATE] REVEALED THAT RESIDENT #503 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE RESIDENT WAS CODED AS HAVING SEVERELY IMPAIRED COGNITION, INATTENTION, DISORGANIZED THINKING, WANDERING BEHAVIOR AND THAT RESIDENT #503 WAS KNOWN TO "INTRUDE ON THE PRIVACY OR ACTIVITY OF OTHERS." ACCORDING TO THE INCIDENT REPORT DATED 11/05/2012 AT 9:30 P.M.," PATIENT (#503) WENT TO ROOM 220 AND SLEPT IN ONE OF THE BEDS AND PATIENT B (#18) WOKE UP AND SAW SOMEONE SLEEPING ON THE BED. PATIENT B (#18) WAS SCREAMING SAYING TO PATIENT (#503) TO GET OUT. PATIENT (#503) REFUSED. THE WRITER WAS TRYING TO GET HELP AND AS I TURNED MY BACK, PATIENT B (#18) GOT UP FROM HIS BED AND WENT TO THE NEXT BED AND STARTED HITTING AND PUNCHING (RESIDENT #503)." ON 11/19/2012 AT 12:00 P.M. AN X-RAY REPORT FOR RESIDENT #503 WAS REVIEWED THAT REVEALED "NO DEFINITE RADIOGRAPHIC EVIDENCE OF FACIAL BONES FRACTURED, FRACTURE AT THE MID PORTION OF THE NASAL BONES WITH NO DEPRESSION, AGE INDETERMINATE ..." REVIEW OF NURSE'S NOTES DATED 11/06/2012 AT 20:25 P.M. REVEALED, "FULL SKIN ASSESSMENT DONE. FULL ROM (RANGE OF MOTION) NOTED IN ALL EXTREMITIES. PURPLE AND REDDISH DISCOLORATION NOTED UNDER RIGHT EYE 0.5 CM LONG CIRCULAR TEAR NOTED ON RIGHT ELBOW. CLEANSED WITH NORMAL SALINE AND NON-ADHERENT GAUZE PLACED ON WOUND. SMALL DISCOLORATION NOTED ON TOP OF RIGHT WRIST..." ON 11/19/2012 AT 10:30 P.M., A TELEPHONE INTERVIEW WAS CONDUCTED WITH REGISTERED NURSE (RN) #10. RN #10 EXPLAINED THAT "IT WAS AROUND 9:00 P.M. AND I WAS PASSING MEDICATIONS WHEN I HEARD THE SOUND OF A RESIDENT CRY OUT. THE MALE RESIDENT (#18) WAS YELLING 'GET OUT, GET OUT.' I WENT TO THE ROOM TO SEE WHAT WAS GOING ON AND I SAW (RESIDENT #503) LYING IN THE EMPTY BED. SHE HAD WANDERED INTO THE ROOM, TAKEN OFF HER PANTS AND LAIN DOWN IN THE EMPTY BED. I TRIED TO GET HER TO GET UP AND TOLD HER THAT I WOULD TAKE HER TO HER OWN ROOM, BUT SHE BECAME COMBATIVE. I COULDN'T REMOVE (FROM THE ROOM) HER BY MYSELF AND THERE WAS NO STAFF AROUND TO ASSIST ME. I PULLED THE CURTAIN AND I TOLD THE MALE RESIDENT THAT I WOULD BE RIGHT BACK TO TAKE HER OUT OF THE ROOM AND HE SAID, 'OKAY.' I LEFT THE ROOM TO GET AN AIDE TO HELP ME WITH (#503) BUT BY THE TIME I GOT BACK TO THE ROOM, THE MALE RESIDENT HAD GOTTEN OUT OF BED AND WENT TO THE FEMALE RESIDENT AND BEGAN PUNCHING HER IN THE FACE." A TELEPHONE INTERVIEW WAS CONDUCTED WITH LPN #14 ON 11/21/12 AT APPROXIMATELY 2:00 P.M. WHO EXPLAINED THAT SHE WORKED ON THE SECOND FLOOR UNIT ON THE DAY OF THE INCIDENT INVOLVING RESIDENT #503."I WAS PASSING MEDICATIONS AND AS I WAS WALKING UP THE HALL, I HEARD YELLING COMING FROM ONE OF THE ROOMS. WHEN I WENT TO THE ROOM I SAW THE MALE RESIDENT (#18) HOLDING THE FEMALE RESIDENT'S (#503) HEAD WITH HIS LEFT HAND, WHILE REPEATEDLY BEATING HER, PUNCHING HER FORCEFULLY IN THE FACE WITH HIS RIGHT HAND. I SEPARATED THE MALE (#18) FROM THE FEMALE (#503) RESIDENT, AND RIGHT AT THAT MOMENT THE OTHER NURSE AND TWO AIDES ARRIVED TO THE ROOM TO ASSIST." REVIEW OF THE CLINICAL RECORD REVEALED THAT RESIDENT #18 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MDS ASSESSMENT REVEALED A BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) SCORE OF THREE WHICH INDICATED SEVERELY IMPAIRED COGNITION. THERE WAS NO DOCUMENTATION OF BEHAVIORAL SYMPTOMS. INTERVIEWS WITH DIRECT CARE STAFF REVEALED THAT RESIDENT #18 WAS USUALLY MILD MANNERED AND HAD NOT EXHIBITED PROBLEMATIC BEHAVIORAL SYMPTOMS BEFORE THE INCIDENT. WHEN ASKED ABOUT RESIDENT #503, STAFF MEMBERS STATED THAT RESIDENT #503 DID EXHIBIT PROBLEMATIC BEHAVIORS TOWARDS OTHERS. IT WAS UNCLEAR HOW RESIDENT #503 MANAGED TO WALK PAST STAFF AND ENTER ANOTHER RESIDENT'S ROOM, REMOVE HER CLOTHES AND LAY DOWN IN BED WITHOUT BEING NOTICED BY NURSING STAFF. THROUGHOUT THE SURVEY, INTERVIEWS WERE CONDUCTED WITH STAFF MEMBERS WHO REPORTED THAT THE FACILITY WAS OFTEN SHORT STAFFED, DUE MAINLY TO "CALL OFFS." INTERVIEWS WERE CONDUCTED WITH ALERT AND ORIENTED RESIDENTS WHO REPORTED THAT STAFFING WAS OFTEN "SPARSE." THE FACILITY SOCIAL WORKER (SW) #3 WAS INTERVIEWED ON 11/16/2012 AT 4:15 P.M. ACCORDING TO SW #3, SHE (#3) WAS NOT IN THE BUILDING AT THE TIME OF THE INCIDENT INVOLVING RESIDENTS #503 AND #18, BUT SHE INTERVIEWED THE RESIDENTS ON THE FOLLOWING DAY. SW #3 STATED, "BOTH RESIDENTS (#503 AND #18) INVOLVED ARE POOR HISTORIANS AND SEVERELY DEMENTED. NEITHER RESIDENT HAD ANY RECOLLECTION OF THE INCIDENT. THE MALE RESIDENT WAS MOVED TO ANOTHER FLOOR. STAFF IS AWARE OF THE FEMALE RESIDENT'S (#503) COGNITION. SHE IS ON A ONE TO ONE BECAUSE OF HER WANDERING AND FOR SAFETY REASONS." ON 11/20/2012 AT APPROXIMATELY 10 A.M., A STAFF MEMBER WHO WISHED TO REMAIN ANONYMOUS REPORTED THAT NURSE AIDES ARE REQUIRED TO CARRY "WALKIE TALKIES," BUT THEY (NURSE AIDES) DON'T ALWAYS CARRY THEM. THE STAFF MEMBER SAID, "IF STAFF HAD THE WALKIE TALKIES ON THEIR PERSON, AND USED THEM, THEN THE NURSE WOULD NOT HAVE HAD TO LEAVE THE ROOM. SHE COULD HAVE USED THE RADIO TO COMMUNICATE WITH THEM." ON 11/21/2012 AT 2:00 P.M., AN INTERVIEW WAS CONDUCTED WITH THE DIRECTOR OF NURSES (DON) #2 ABOUT THE INCIDENT AND SHE SAID "THE NURSE (RN #10) DIDN'T FOLLOW THE SAFETY PROTOCOL. SHE SHOULD HAVE NEVER LEFT THE RESIDENT. SHE DIDN'T CALL OUT FOR HELP." BOTH RESIDENT INVOLVED IN THE ALTERCATION WERE OBSERVED DURING THE INVESTIGATION. NEITHER RESIDENT WAS ABLE TO RECALL THE INCIDENT. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 066. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO ENSURE THAT ONE (#501) OF TWO SAMPLED RESIDENTS WHO RECEIVED [MEDICATION NAME] (GENERIC NAME [MEDICATION NAME], A SYNTHETIC OPIATE [MEDICATION NAME]) PATCH FOR PAIN RELIEF FROM A TOTAL SAMPLE OF FIVE, WAS ADMINISTERED THE MEDICATION CORRECTLY WHEN RESIDENT #501 HAD NEW PATCHES APPLIED BEFORE OLD PATCHES WERE REMOVED, RESULTING IN hospitalization AND THE NEED FOR INTUBATION (LIFE SUPPORT) FOR THE RESIDENT. FINDINGS INCLUDE: RECORD REVIEW ON [DATE] AT 2:00 P.M., REVEALED THAT RESIDENT #501 WAS A [AGE] year OLD FEMALE admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE INITIAL MINIMUM DATA SET (MDS) assessment dated [DATE], NOTED THAT RESIDENT #501 HAD MODERATELY IMPAIRED COGNITION, BUT WAS ALERT AND ORIENTED TO PERSON, PLACE AND TIME. FURTHER REVIEW OF CLINICAL RECORDS REVEALED THAT RESIDENT #501 WAS TRANSFERRED TO AN ACUTE CARE HOSPITAL FOR EMERGENCY CARE ON [DATE]. REVIEW OF NURSES' NOTES DATED [DATE] AT 12:44 P.M. REVEALED THAT "PATIENT WAS OBSERVED WITH A LOW BLOOD SUGAR OF 23. MEDICAL DOCTOR NOTIFIED AND INSTRUCTED NURSE TO ADMINISTER [MEDICATION NAME] INTRAMUSCULAR (IM) AND CALL 911 (EMERGENCY SERVICES). PATIENT WAS GIVEN [MEDICATION NAME] IM AND 911 WAS CALLED. PATIENT WAS TRANSPORTED TO HOSPITAL. FAMILY WAS PRESENT." ACCORDING TO THE ACUTE CARE TRANSFER SHEET DATED [DATE] AT 09:53 A.M. THE RESIDENT WAS A FULL CODE, WITH THE FOLLOWING VITAL SIGNS: BLOOD PRESSURE WAS ,[DATE]; PULSE 88; RESPIRATIONS 18; TEMPERATURE 98.4; O2 SATURATION 92%; AND BLOOD GLUCOSE LEVEL 23. THE REASON FOR TRANSFER WAS DOCUMENTED AS LOW BLOOD SUGAR REVIEW OF THE CONTROLLED SUBSTANCE RECORD (CSR) REVEALED THAT RESIDENT #501 RECEIVED THE FOLLOWING TWO MEDICATIONS ON THE DAY OF [DATE] BEFORE SHE WAS TRANSFERRED TO THE HOSPITAL: 1. [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME], NARCOTIC WITH [MEDICATION NAME]), 7XXX,[DATE] MILLIGRAMS (TWO) TABLETS BY MOUTH AT 12 A.M. THE ORDER FOR THIS MEDICATION WAS FOR 2 TABLETS TO BE TAKEN BY MOUTH EVERY 6 HOURS (6 A.M., 12 P.M., 6 P.M. AND 12 A.M.) AROUND THE CLOCK. IT WAS UNCLEAR IF THE 6:00 A.M. DOSE ON [DATE] WAS ADMINISTERED. 2. [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME], OPIOID NARCOTIC), 50 MICROGRAMS AND 12 MICROGRAM PATCHES APPLIED AT 6:00 A.M. THE ORDER FOR THIS MEDICATION WAS FOR TWO (2) [MEDICATION NAME] PATCHES, 50 MICROGRAMS (MCG) AND 12 MCG RESPECTIVELY, TO BE APPLIED TO THE RESIDENT'S SKIN EVERY THREE DAYS. THERE WAS NO DOCUMENTATION ON THE CSR THAT INDICATED THE LOCATION ON THE BODY WHERE THE PATCHES WERE PLACED; WHEN OLD PATCHES WERE REMOVED; OR, IF THERE WAS A WITNESS PRESENT DURING REMOVAL OF PATCHES. REVIEW OF THE [MEDICATION NAME] SYSTEM MANUFACTURER PACKAGE INSERT REVEALED THAT ADVERSE REACTIONS TO [MEDICATION NAME] INCLUDED [MEDICAL CONDITION]/HYPERTENSION, CENTRAL NERVOUS SYSTEM DEPRESSION, SEDATION, DROWSINESS, SEVERE RESPIRATORY DEPRESSION, AND DIAPHORESIS. "THE TIME OF PEAK IS 24 TO 72 HOURS. ELDERLY HAVE BEEN FOUND TO BE TWICE AS SENSITIVE AS YOUNGER PATIENTS TO THE EFFECTS OF [MEDICATION NAME]." REVIEW OF THE [MEDICATION NAME] SYSTEM MANUFACTURER PACKAGE INSERT REVEALED THE FOLLOWING INSTRUCTIONS FOR DISPOSAL: "BEFORE PUTTING ON A NEW [MEDICATION NAME] PATCH, REMOVE THE PATCH YOU HAVE BEEN WEARING. FOLD THE USED [MEDICATION NAME] PATCH IN HALF SO THAT THE STICKY SIDE STICKS TO ITSELF. FLUSH THE USED [MEDICATION NAME] DOWN THE TOILET RIGHT AWAY. A USED [MEDICATION NAME] PATCH MAY...EVEN LEAD TO DEATH..." ON [DATE] AT 10:00 A.M., AN INTERVIEW WAS CONDUCTED WITH LICENSED PRACTICAL NURSE (LPN) #4 WHO REPORTED THAT SHE SENT RESIDENT #501OUT TO THE HOSPITAL ON [DATE]. "SHE (#501) WAS SWEATY AND CLAMMY AND WAS CALLING OUT FOR HER HUSBAND. HER BLOOD SUGAR WAS 23. I CALLED THE DOCTOR AND WAS TOLD TO GIVE HER AN IM (INTRAMUSCULAR) INJECTION OF [MEDICATION NAME] (HORMONE/MEDICATION TO INCREASE BLOOD SUGAR), SO I DID THAT AND SHE (#501) WAS TRANSFERRED TO THE HOSPITAL." ON [DATE] AT 10:00 A.M., WHEN LPN #4 WAS ASKED ABOUT RESIDENT #501'S ORDER FOR [MEDICATION NAME], LPN #4 EXPLAINED THAT ON THE MORNING OF [DATE], WHEN SHE (#4) CAME ON DUTY AT 7:00 A.M., THE MIDNIGHT SHIFT NURSE (LPN #6), "SAID THAT SHE (#6) FORGOT TO APPLY THE [MEDICATION NAME] PATCHES ON THE RESIDENT (#501), SO SHE (#6) WALKED AWAY AND WENT TO THE RESIDENT'S ROOM TO ADMINISTER THE MEDICATION BEFORE SHE LEFT THAT DAY. I (#4) DIDN'T OBSERVE (LPN #6) APPLY THE ([MEDICATION NAME]) PATCHES." LPN #4 THEN REPORTED THAT LATER THAT MORNING ([DATE]), SHE (#4) WAS CALLED INTO RESIDENT #501'S THE ROOM BY A FAMILY MEMBER, WHO NOTICED THAT RESIDENT #501 WAS UNRESPONSIVE. ON ASSESSMENT OF RESIDENT #501, ON THE MORNING OF [DATE], LPN #4 SAID THAT RESIDENT #501 HAD FOUR (4) [MEDICATION NAME] PATCHES ON HER UPPER RIGHT CHEST. LPN #4 STATED, "THERE WERE TWO NEW PATCHES THAT WERE PLACED THAT MORNING (DATED [DATE] AT APPROXIMATELY 6:00 A.M.) AND TWO OLD PATCHES (DATE UNKNOWN)." ACCORDING TO LPN #4, SHE COMPLETED AN INCIDENT REPORT ABOUT THE DISCOVERY OF THE FOUR PATCHES FOUND ON THE RESIDENT #501'S CHEST. WHEN LPN #4 WAS ASKED WHAT SHE DID WHEN SHE DISCOVERED THE FOUR PATCHES ON THE RESIDENTS CHEST, SHE STATED, "I TOOK THE TWO OLDER PATCHES OFF." ON [DATE] AT APPROXIMATELY 10:00 A.M., LPN #4 WAS INTERVIEWED AGAIN ABOUT FINDING FOUR (4) [MEDICATION NAME] PATCHES ON RESIDENT #501'S CHEST. LPN #4 GAVE A DIFFERENT ACCOUNT OF THE INCIDENT. LPN #4 SAID THAT THE FOUR [MEDICATION NAME] PATCHES ON RESIDENT #501'S CHEST WERE NOT FOUND UNTIL THE PARAMEDICS ARRIVED AT THE FACILITY AT APPROXIMATELY 9:30 A.M. (AFTER LPN #4 CALLED THE PHYSICIAN), AT WHICH TIME LPN #4 REMOVED THE TWO OLDER PATCHES AND LEFT THE TWO NEW PATCHES IN PLACE. LPN #4 SAID THAT THE PARAMEDICS LATER REMOVED THE TWO REMAINING PATCHES BECAUSE RESIDENT #501'S BLOOD PRESSURE WAS LOW. LPN #4 SAID THAT SHE DID NOT INFORM THE PHYSICIAN ABOUT THE [MEDICATION NAME] PATCHES WHEN SHE TELEPHONED HIM INITIALLY BECAUSE AT THAT TIME, SHE CALLED TO REPORT THE LOW BLOOD SUGAR. LPN #4 REPORTED THAT SHE DID TELEPHONE THE PHYSICIAN BACK TO INFORM HIM OF THE [MEDICATION NAME] PATCHES, BUT BY THEN (12:30 P.M.) THE PHYSICIAN INFORMED HER THAT THE RESIDENT HAD EXPIRED AT THE HOSPITAL. IT WAS UNCLEAR WHY LPN #4 WAITED THREE HOURS TO INFORM THE PHYSICIAN OF THE POTENTIAL OVERDOSE OF [MEDICATION NAME]. REVIEW OF THE INCIDENT REPORT DATED [DATE], AT 12:28 P.M. REVEALED THAT THE NURSE "OBSERVED (RESIDENT #501) WITH 4 [MEDICATION NAME] PATCHES ON HER PERSON." THE INCIDENT REPORT FURTHER READ, "NURSE REMOVED TWO OF THE PATCHES," AND CONCLUDED WITH THE NOTATION THAT ON [DATE], AT 12:30 P.M., RESIDENT #501 WAS TAKEN TO A HOSPITAL. THERE WAS NO EXPLANATION OF THE TIME DISCREPANCIES. ON [DATE] AT APPROXIMATELY 10:00 A.M., LPN #4 WAS QUERIED ABOUT THE DISPOSAL OF [MEDICATION NAME] PATCHES AND DOCUMENTATION OF THE PLACEMENT OF PATCHES. LPN #4 EXPLAINED THAT THE DISPOSAL OF USED PATCHES WAS NOT WITNESSED BY ANOTHER STAFF MEMBER AND PLACEMENT INFORMATION WAS NOT DOCUMENTED ANYWHERE. THROUGHOUT THE SURVEY, SEVERAL OTHER STAFF NURSES WERE INTERVIEWED AND ASKED ABOUT THE FACILITY'S PROCEDURE OF REMOVAL AND DISPOSAL OF [MEDICATION NAME] PATCHES. NURSES REPORTED THAT THEY DID NOT DOCUMENT THE REMOVAL OF THE PATCHES AND THEY DID NOT HAVE A WITNESS PRESENT WHEN PATCHES WERE REMOVED. ON [DATE] AT 3:00 P.M., AN INTERVIEW WAS CONDUCTED WITH LPN #6, WHO REPORTED THAT SHE WORKED FROM THE OVERNIGHT SHIFT, 7:00 P.M. TO 7:00 A.M. ON [DATE] THROUGH [DATE]. ACCORDING TO LPN #6, SHE WAS ASSIGNED TO PROVIDE CARE FOR RESIDENT #501. LPN #6 REPORTED THAT ON HER SHIFT [DATE] THROUGH [DATE], SHE (#6) DISCOVERED THAT ALTHOUGH RESIDENT 501HAD BEEN SCHEDULED TO RECEIVE THE APPLICATION OF THE 2 [MEDICATION NAME] PATCHES ON [DATE], THOSE PATCHES HAD NEVER BEEN APPLIED. LPN #6 STATED THAT SHE (#6) COMPLETED A MEDICATION ERROR FORM AND SLIPPED IT UNDER THE DIRECTOR OF NURSE'S DOOR. ON THE MORNING OF [DATE], ACCORDING TO LPN #6, AT THE END OF THE SHIFT, SHE (#6) REPORTEDLY REMOVED TWO [MEDICATION NAME] PATCHES FROM RESIDENT #501 AND THEN APPLIED TWO NEW [MEDICATION NAME] PATCHES TO RESIDENT #501. LPN #6 STATED "I PUT A PATCH ON THE RESIDENT THAT WAS OMITTED. IT SHOULD HAVE BEEN PUT ON THE DAY PRIOR. THE LAST PATCH SHE HAD ON WAS PLACED [DATE], THE NEXT ONE WAS DUE [DATE]. I MADE OUT A MEDICATION ERROR FORM FOR THE OMITTED MEDICATION." LPN #6 SAID THAT SHE DISCARDED THE USED [MEDICATION NAME] PATCH IN THE SHARPS CONTAINER. LPN #6 STATED THAT SHE HAD BEEN TERMINATED FROM FACILITY EMPLOYMENT AFTER THIS INCIDENT. ACCORDING TO LPN #6, SHE (#6) WAS LATER TOLD THAT SHE SHOULD HAVE DONE A FULL BODY ASSESSMENT ON THE RESIDENT WHEN SHE APPLIED THE PATCHES BECAUSE ADDITIONAL PATCHES WERE FOUND ON THE RESIDENT 501'S BACK. "I FOUND THE TWO PATCHES ON HER CHEST AND I REMOVED THEM BEFORE I APPLIED ADDITIONAL PATCHES. I DIDN'T KNOW THAT I WAS SUPPOSED TO LOOK FOR MORE PATCHES. I WAS NEVER TRAINED ON THE ADMINISTRATION OF [MEDICATION NAME] PATCHES AT THE FACILITY." ON [DATE] AT 3:00 P.M., WHEN LPN #6 WAS QUERIED ABOUT THE CONDITION OF THE RESIDENT ON THE NIGHT BEFORE AND ON THE MORNING OF THE INCIDENT, SHE REPORTED THAT RESIDENT #501 SEEMED TO BE OKAY. SHE (#501) DID NOT SHOW ANY SIGNS OF DISTRESS OR ANY CHANGE OF CONDITION. ON [DATE] AT 3:30 P.M. REVIEW OF PROGRESS NOTES REVEALED NO DOCUMENTATION THAT SUGGESTED THAT RESIDENT #501 HAD A CHANGE OF CONDITION UNTIL AROUND 9:30 A.M., ON [DATE]. AN INTERVIEW WAS CONDUCTED WITH THE DIRECTOR OF NURSES (DON) #2 ON [DATE] AT 4:00 P.M. DON #2 REPORTED THAT "SHE (RESIDENT #501) WAS A HOSPICE RESIDENT AND died AS A RESULT OF MULTIPLE SYSTEM FAILURE." DON #2 WAS QUERIED AS TO WHEN SHE (#2) WAS NOTIFIED ABOUT THE INCIDENT. THE DON STATED, "I WAS OUT OF TOWN ON THE DAY OF THE INCIDENT. I FOUND OUT ABOUT IT WHEN I CAME BACK." WHEN THE SURVEYOR REQUESTED THE MEDICATION ERROR FORM THAT LPN #6 REPORTEDLY COMPLETED AFTER FINDING THE 4 [MEDICATION NAME] PATCHES ON RESIDENT #501'S CHEST, DON #2 STATED THAT SHE (#2) HAD NEVER RECEIVED A MEDICATION ERROR FORM FROM LPN #6. DON #2 STATED, "I THINK THAT WAS JUST A PROBLEM WITH THAT NURSE (LPN #6). SHE WASN'T A GOOD FIT, SO WE LET HER GO." THE FACILITY ADMINISTRATOR #1 WAS INTERVIEWED ON [DATE] AT APPROXIMATELY 9:30 A.M. ADMINISTRATOR #1 STATED, "THE RESIDENT WAS ACTIVELY DYING. SHE HAD NOT EATEN FOR A COUPLE OF DAYS." REVIEW OF THE CLINICAL RECORD FOR RESIDENT #501 DID NOT REVEAL ANY DOCUMENTATION THAT SUGGESTED THE RESIDENT WAS ON HOSPICE CARE OR ACTIVELY DYING. ON [DATE], AT 3 P.M., PHYSICIAN #9 WAS INTERVIEWED ABOUT RESIDENT #501. PHYSICIAN #9 EXPLAINED THAT LPN #4 PHONED HIM AND INFORMED HIM ABOUT RESIDENT #501'S LOW BLOOD SUGAR. PHYSICIAN #9 SAID THAT HE DID NOT RECALL LPN #4 SAYING ANYTHING ABOUT FOUR [MEDICATION NAME] PATCHES BEING FOUND ON RESIDENT #501. THE PHYSICIAN SAID THAT IF HE HAD BEEN MADE AWARE OF THE FOUR [MEDICATION NAME] PATCHES, HE WOULD HAVE INSTRUCTED THE NURSE TO REMOVE THE PATCHES IMMEDIATELY AND PERHAPS ADMINISTER [MEDICATION NAME] (ANTI-NARCOTIC MEDICATION). WHEN ASKED IF RESIDENT #501 WAS ACTIVELY DYING, THE PHYSICIAN REPLIED, "NO, SHE WAS NOT ACTIVELY DYING. WHY WOULD SHE BE THERE (AT A REHAB FACILITY) IF SHE WAS ACTIVELY DYING? SHE WOULD BE ON HOSPICE." REVIEW OF THE CORPORATE CARE POLICY ENTITLED "MEDICATION ADMINISTRATION: [MEDICATION NAME] DRUGS" DATED ,[DATE] REVEALED, UNDER PROCEDURE, "6. EXAMINE PATIENT'S CHEST, BACK, AND SHOULDERS FOR ANY RESIDUAL MEDICATION PATCHES. REMOVE PREVIOUS PATCH AND WIPE AWAY ANY REMAINING MEDICATION. DISPOSE OF CONTROLLED SUBSTANCE MEDICATION PATCHES BY FOLDING ON HALF AND DISCARDING INTO SHARPS CONTAINER." ON [DATE] AT 4:00 P.M., DIRECTOR OF NURSING #2 WAS ASKED IF NURSES WERE REQUIRED TO DOCUMENT THE LOCATION OF THE PLACEMENT OF [MEDICATION NAME] PATCHES AND IF THEY DISPOSED USED PATCHES USING A WITNESS, DON #2 SAID, "THEY (NURSES) SHOULD BE DOCUMENTING THE LOCATION, BUT THE REMOVAL AND DISPOSAL BEFORE PLACING A NEW PATCH IS A STANDARD OF PRACTICE." DON #2 FURTHER STATED THAT THE FACILITY PREVIOUSLY DISPOSED OF THE [MEDICATION NAME] PATCHES IN THE SHARPS CONTAINER, BUT WILL BEGIN TO IMPLEMENT DISPOSING OF THE USED PATCHES BY FLUSHING THEM DOWN THE TOILET. ON [DATE] AT 10 A.M., REVIEW OF HOSPITAL emergency room TRIAGE RECORDS REVEALED THAT ON [DATE], RESIDENT #501 ARRIVED AT THE HOSPITAL AT 10:23 A.M. ACCORDING TO THE TRIAGE RECORD, "PATIENT ALERT AND ORIENTED TIMES ONE. WAS FOUND UNRESPONSIVE AT NURSING HOME. BLOOD SUGAR 22 NOW BACK TO BLOOD SUGAR 74 AND MENTAL STATUS BACK NEAR BASELINE. PATIENT HAS NOT BEEN EATING ANYTHING; DECREASED APPETITE OVER PAST COUPLE OF WEEKS...SKIN TEMPERATURE (DOCUMENTED AS BEING) COOL/COLD." THE TRIAGE RECORD FURTHER DOCUMENTED THAT RESIDENT #501 RECEIVED ENDOTRACHEAL INTUBATION FOR AIRWAY PROTECTION AND WAS GIVEN FLUIDS FOR POSSIBLE DEHYDRATION AT THE HOSPITAL EMERGENCY DEPARTMENT. THE RESIDENT BECAME NONRESPONSIVE WHILE IN THE EMERGENCY DEPARTMENT. CARDIOPULMONARY RESUSCITATION WAS PROVIDED, BUT THE RESIDENT DID NOT SURVIVE. THERE WAS NO DOCUMENTATION IN THE HOSPITAL RECORDS THAT INDICATED THAT THE HOSPITAL HAD ANY KNOWLEDGE OF THE [MEDICATION NAME] PATCHES. THERE WAS NO DOCUMENTATION THAT INDICATED THE PHYSICIAN WAS AWARE OF THE FOUR [MEDICATION NAME] PATCHES, AND THERE WAS NO EVIDENCE THAT PARAMEDICS WHO TRANSFERRED RESIDENT #501 TO THE HOSPITAL REMOVED ANY [MEDICATION NAME] PATCHES FROM HER BODY. REVIEW OF THE FOOD ACCEPTANCE RECORDS DID NOT INDICATED THAT THE RESIDENT HAD A DECREASED APPETITE FOR WEEKS PRIOR TO THE INCIDENT. THE "DOCUMENTED AMOUNT OF MEAL TAKEN" REVEALED THAT RESIDENT #501 ATE MEALS EVERY DAY (THREE TIMES A DAY) FROM THE DAY SHE WAS admitted INTO THE FACILITY, WITH THE POSSIBLE EXCEPTION OF THREE DAYS WHEN STAFF MEMBERS FAILED TO DOCUMENT FOOD ACCEPTANCE AT BREAKFAST AND LUNCH (DATES [DATE], [DATE] AND [DATE]). THE TOTAL NUMBER OF [MEDICATION NAME] PATCHES ON RESIDENT #501'S BODY AT ONE TIME COULD NOT BE DETERMINED AND REMAINED UNCLEAR, AS STAFF MEMBERS GAVE INCONSISTENT RECOLLECTIONS OF THE INCIDENT AND NO DOCUMENTATION WAS MADE. LPN #6 REPORTED THAT SHE REMOVED TWO (2) PATCHES AND APPLIED TWO (2) PATCHES ON RESIDENT #501'S CHEST, BUT WAS TOLD THAT ADDITIONAL PATCHES WERE FOUND ON RESIDENT #501'S BACK. LPN #4 REPORTEDLY OBSERVED FOUR PATCHES ON RESIDENT #501'S RIGHT CHEST. IT WAS ALSO UNCLEAR WHY THE DISCHARGE ORDER DATED [DATE] WAS WRITTEN AND SIGNED BY DON #2 WHEN SHE (#2) REPORTED THAT SHE WAS OUT OF TOWN ON THE DATE OF THE INCIDENT. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 490, MI 490 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY: 1) FAILED TO ADDRESS COMPLAINTS OF PAIN FOR THREE RESIDENTS (502, 504, 506) OF THREE RESIDENTS REVIEWED FOR ADMINISTERING MEDICATIONS IN ACCORDANCE WITH physician's orders [REDACTED]. [REDACTED]. FINDINGS INCLUDE: #504 ON 8/29/12 AT 10:56 A.M., DURING A TOUR OF THE FACILITY, #504 WAS OBSERVED IN HER ROOM LAYING IN BED ASLEEP. CNA (CERTIFIED NURSING ASSISTANT) #1 WAS ASKED TO REPOSITION #504 FOR A BODY AUDIT. WHEN TURNED TO HER SIDE, #504 SCREAMED OUT IN PAIN AND FLAILED HER ARMS SAYING "NO!, NO!, OUCH!" CNA #1 REPORTED, "...SHE'S ALWAYS IN A LOT OF PAIN WHEN YOU MOVE HER..." WHEN ASKED IF SHE REPORTED #504'S PAINFUL RESPONSE TO THE NURSE, CNA #1 REPORTED, "...WHENEVER YOU TOUCH HER OR TRY TO MOVE HER, SHE (#504) SCREAMS OUT IN PAIN AND EVERY TIME, I ALWAYS GO AND TELL THE NURSE BUT THEY DON'T DO ANYTHING..." DURING AN OBSERVATION OF HER DRESSINGS, IT WAS OBSERVED THAT #504 HAD BILATERAL HEEL DRESSINGS THAT WERE DATED FOR 8/27/12. WHEN REPOSITIONED TO HER RIGHT SIDE, #504 WAS OBSERVED TO HAVE A HEALED WOUND TO HER COCCYX WITH A LARGE AREA OF CICATRIX TO THE SACROCOCCYGEAL AREA. THERE WERE NO OTHER DRESSINGS OBSERVED TO #504'S PERSON. RN #1, WHO ENTERED THE ROOM, WAS QUERIED ABOUT PAIN MEDICATIONS AND REPORTED, "...I'LL HAVE TO CHECK AND SEE WHAT SHE HAS ORDERED..." UPON RETURN, AT 11:25 A.M., RN #1 REPORTED, "...SHE (#504) GETS [MEDICATION NAME] 5/325, 2 TABLETS EVERY 4 HOURS AS NEEDED. SHE LAST RECEIVED PAIN MEDICATIONS ON 8/26/12. I TOLD HER NURSE BECAUSE SHE'S OBVIOUSLY IN PAIN. I CAN SEE MYSELF THAT SHE'S IN A LOT OF PAIN..." ON 8/29/12 AT 11:30 A.M., THE DIRECTOR OF NURSING (DON) ENTERED THE ROOM WITH THE SURVEYOR AND REPORTED, "...HER (#504) NURSE ACKNOWLEDGED THAT SHE COMPLAINS OF PAIN AND I CAN SEE THAT SHE'S IN PAIN. IF SHE'S IN THAT MUCH PAIN, WE NEED TO CALL THE DOCTOR AND HAVE THE PAIN MEDICATIONS SCHEDULED INSTEAD OF AS NEEDED..." THE DON THEN OBSERVED THE DRESSINGS TO #504'S BILATERAL HEELS THAT WERE DATED 8/27/12. WHEN ASKED WHY HER DRESSINGS HAD NOT BEEN CHANGED IN TWO DAYS, THE DON REPORTED, "...IT'S OBVIOUS THAT SOMEONE DIDN'T CHANGE HER DRESSINGS..." RN#1 LATER REPORTED THAT #504 "...ACTUALLY RECEIVED PAIN MEDICATIONS LAST NIGHT (8/28/12) AT 6:00 P.M....) RN#1 COULD NOT EXPLAIN WHY #504 HAD NOT RECEIVED PAIN MEDICATIONS SINCE THAT TIME IN LIGHT OF HER REPORTED COMPLAINTS OF PAIN UPON MOVEMENT. A REVIEW OF THE CLINICAL RECORD REVEALED THAT #504 WAS AN [AGE] year OLD FEMALE WHO WAS INITIALLY admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. BULKY DRY DRESSING ON BILATERAL HEELS FOR PROTECTION. DAILY PAIN ASSESSMENT..." THE DON COULD NOT EXPLAIN WHY THERE WAS NO DRESSING TO #504'S COCCYX AREA, WHY BILATERAL HEEL DRESSINGS HAD NOT BEEN CHANGED SINCE 8/27/12 AND WHY #504 HAD NOT RECEIVED PAIN MEDICATIONS FOR REPORTED COMPLAINTS OF PAIN. #502 A REVIEW OF THE FACILITY'S "ADMISSION RECORD" REVEALED THAT #502 WAS A [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DIAGNOSES REDACTED]. ON 8/30/12 AT 12:25 P.M., #502 INFORMED CNA#3 THAT SHE NEEDED PAIN MEDICATIONS FOR COMPLAINTS OF A HEADACHE AND NEEDED TO USE THE REST ROOM. CNA #3 THEN LEFT THE ROOM TO REPORT #502'S CONCERNS TO RN #2. ON 8/30/12 AT 2:25 P.M., RN #2 WAS OBSERVED ENTERING #502'S ROOM. #502 REPORTED THAT SHE STILL HAD NOT RECEIVED PAIN MEDICATION FOR HER HEADACHE. A REVIEW OF #502'S MEDICATION "ADMINISTRATION RECORD" FOR AUGUST 2012 REVEALED THAT #502 HAD ORDERS FOR THE FOLLOWING PAIN MEDICATIONS: "[MEDICATION NAME] HCL TAB 50 MG (MILLIGRAMS), ONE TAB (TABLET) PO (BY MOUTH) QID (FOUR TIMES A DAY) AS NEEDED (PRN) FOR PAIN..." "[MEDICATION NAME]-ACETEMINOPHEN (NARCOTIC PAIN MEDICATION) 5/325 MG PO Q6H (EVERY 6 HOURS) PRN PAIN..." "[MEDICATION NAME] TAB 325 MG 1 TAB PO QID PRN PAIN..." UPON EXITING #502'S ROOM, RN #2 WAS ASKED WHY #502 HAD NOT RECEIVED PAIN MEDICATION FOR COMPLAINTS OF A HEADACHE WHEN SHE REQUESTED MEDICATIONS AT 12:25 P.M.. RN #2 REPORTED, "...I WAS BUSY WITH PAPERWORK AT THE TIME THAT I HAD TO GET DONE..." WHEN ASKED IF SHE INFORMED THE DON OR ANOTHER NURSE SO THAT #502 COULD BE MEDICATED, RN #2 SAID "NO". ON 8/30/12 AT 2:40 P.M., CNA #3 REPORTED, I TOLD RN #2 TWICE THAT SHE NEEDED SOMETHING FOR PAIN..." ON 8/30/12 AT 3:15 P.M., THE FACILITY'S ADMINISTRATOR REPORTED, "...I JUST WANTED YOU TO KNOW THAT #502 WAS MEDICATED AT 2:30 P.M..." THE ADMINISTRATOR COULD NOT EXPLAIN WHY RN #2 FAILED TO ADDRESS #2'S COMPLAINTS OF PAIN AND WHY IT TOOK 2 HOURS BEFORE RECEIVING PAIN MEDICATION. #506 A REVIEW OF THE FACILITY'S ADMISSION SHEET REVEALED THAT #506 WAS admitted to the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. A PHYSICIAN'S NOTE DATED 7/16/12 REVEALED THAT #506, "...HAS A BILATERAL AKA (ABOVE THE KNEE AMPUTATION) SECONDARY [MEDICAL CONDITION](STROKE) AND SEVERE [MEDICAL CONDITION]. HE HAS SUFFERED MULTIPLE ISCHIAL WOUNDS OVER THE YEARS WITH PROLONGED ANTIBIOTICS AS WELL AS PAIN CONTROL. OTHER THAN COMPLAINTS OF GENERALIZED PAIN, THE PATIENT HAS SOUGHT ASSISTANCE FOR MULTIPLE PAIN MANAGEMENT PHYSICIANS AND WAS IN THE HOSPITAL FOR INTRACTABLE PAIN. STAGE IV DECUBITUS ULCERATION LEFT ISCHIUM WITH WOUND VAC AND HAVING ISCHIAL FLAP ON JULY 18, 2012. CHRONIC PAI[DIAGNOSES REDACTED]... A physician's orders [REDACTED]. ON 8/30/12 AT 2:20 P.M., #506 REPORTED TO SURVEYOR, "...I'M IN PAIN. I SENT SOMEONE DOWN TO TELL THE NURSE ABOUT A HALF HOUR AGO AND I'M STILL WAITING..." #506 WAS OBSERVED WITH FACIAL GRIMACES AND WAS NOTED TO BE RUBBING HIS LEFT THIGH AREA AND REPORTED PAIN AT LEVEL 9/10. ON 8/30/12 AT 2:30 P.M., WHEN ASKED WHY ASKED WHY RN #2 FAILED TO ADDRESS #506'S COMPLAINTS OF PAIN, RN #2 REPEATED THE ABOVE STATEMENT, "...I WAS BUSY WITH PAPERWORK..." ON 8/3/12 AT 2:40 P.M. CNA #1 SAID, "...I TOLD THE NURSE (RN #2) THAT HE (#506) WAS REQUESTING SOMETHING FOR PAIN. SHE (RN #2) WAS SITTING IN THE OFFICE..." ON 8/30/12 AT 3:40 P.M., THE DON OFFERED NO EXPLANATION.

THIS CITATION PERTAINS TO INTAKE #MI 897 BASED ON INTERVIEWS AND RECORDS REVIEW THE FACILITY FAILED TO ENSURE THAT 1 OF 4 SAMPLED RESIDENTS (#101), REVIEWED FOR ACCIDENTS, FROM A TOTAL SAMPLE OF 6, RECEIVED THE NECESSARY SUPERVISION AND ASSISTANCE DEVICES TO ENSURE RESIDENT #101'S SAFETY, RESULTING IN A FALL AND FRACTURED LEFT SCAPULA. FINDINGS: ACCORDING TO THE FACE SHEET DATED 6/19/2012, RESIDENT #101 WAS A [AGE] year OLD FEMALE WHO HAD LIVED AT THE FACILITY SINCE 5/30/2012. THE MINIMUM (MDS) data set [DATE] DOCUMENTED THAT RESIDENT #101 HAD IMPAIRED DECISION MAKING, LONG-TERM MEMORY LOSS, SHORT- TERM MEMORY LOSS, AND HAD DIFFICULTY FOCUSING HER ATTENTION. RESIDENT #101 HAD DOCUMENTED DISORGANIZED THOUGHT CONTENT. RESIDENT #101 had a history of [REDACTED]. RESIDENT #101 WAS CONTINENT OF BLADDER AND BOWEL. A FALLS CARE PLAN DATED 5/30/2012 IDENTIFIED RESIDENT #101 AT RISK FOR INJURY DUE TO IMPAIRED MOBILITY, COGNITIVE DEFICITS AND POOR SAFETY AWARENESS. TO ENSURE HER SAFETY, STAFF WERE TO REINFORCE THE NEED TO CALL FOR ASSISTANCE AND IMPLEMENT A LOW BED WITH FALL MATS ON EITHER SIDE OF HER BED. admission orders [REDACTED]. ADMISSION NURSING NOTES DATED 5/30/2012 AT 7:53 P.M., DOCUMENTED THAT RESIDENT #101 WAS A "NEW ADMIT WITH (THE) DX ([DIAGNOSES REDACTED]." NURSES DOCUMENTED THEY PROVIDED RESIDENT #101 WITH A LOW BED, CALL LIGHT AND ORIENTATION TO THE USE OF HER CALL LIGHT. THE PHYSICIAN'S ADMISSION HISTORY AND PHYSICAL DATED 5/31/2012 DOCUMENTED THAT RESIDENT #101 WAS admitted TO THE FACILITY AFTER SHE fell . SHE WAS diagnosed with [REDACTED]." THERAPY NOTES DATED 5/31/2012 DOCUMENTED THAT RESIDENT #101 WAS A "FALL RISK" DUE TO HER DECREASED SAFETY AWARENESS. OCCUPATIONAL THERAPY NOTES DATED 5/31/2012 DOCUMENTED THAT RESIDENT #101 WAS ASSESSED AND FOR HER SAFETY REQUIRED MINIMALLY ONE STAFF MEMBER TO PROVIDE ASSISTANCE WHILE SHE GOT DRESSED, TOILETED OR TRANSFERRED. PHYSICAL THERAPY NOTES DATED 5/31/2012 DOCUMENTED THAT RESIDENT #101 WAS ASSESSED AND FOR HER SAFETY REQUIRED MINIMALLY ONE STAFF MEMBER TO PROVIDE ASSISTANCE WITH ALL AMBULATION AND TRANSFERS. A PHYSICIAN CONSULT DATED 6/01/2012 DOCUMENTED THAT RESIDENT #101 REQUIRED STAFF ASSISTANCE FOR HER FUNCTIONAL MOBILITY AND ACTIVITIES OF DAILY LIVING. AN INCIDENT REPORT DATED 6/03/2012 DOCUMENTED THAT RESIDENT #101 WAS ALONE IN HER BEDROOM, TRANSFERRED WITHOUT STAFF ASSISTANCE INTO A STANDING POSITION, TRIED TO TIE HER SHOE AND fell BACKWARD INTO A MOVING WHEELCHAIR WHICH CAUSED HER TO LAND ON THE FLOOR. THE CORRECTIVE ACTION STAFF LISTED ON THE SAME INCIDENT REPORT WAS "RE-EDUCATION ON CALL LIGHT USE AND LOCKING THE WHEELCHAIR WHEN ATTEMPTING TO SIT AND STAND." THE FALLS CARE PLAN WAS AMENDED BY STAFF ON 6/03/2012, BUT NO NEW INTERVENTIONS WERE ADDED. STAFF SIMPLY DOCUMENTED THAT THEY (STAFF) GAVE RESIDENT #101 RE-EDUCATION AND REINFORCEMENT ABOUT WHEELCHAIR SAFETY. NURSING NOTES DATED 6/06/2012 DOCUMENTED THAT RESIDENT #101 REQUIRED CONTINUED EDUCATION TO USE HER CALL LIGHT TO ASK FOR ASSISTANCE. DESPITE THIS ASSESSMENT, THE MEDICAL RECORD FAILED TO REVEAL ANY NEW INTERVENTIONS IMPLEMENTED TO ENSURE RESIDENT 101'S FUTURE SAFETY. NURSING NOTES DATED 6/07/2012 DOCUMENTED THAT RESIDENT #101 WAS ALONE IN HER BEDROOM AND TRANSFERRED WITHOUT STAFF ASSISTANCE FROM HER BED AND fell TO THE FLOOR. AFTER THIS FALL, RESIDENT #101 COMPLAINED OF LEFT SHOULDER AND BACK PAIN. THE FACILITY FAILED TO PROVIDE THE REQUESTED INCIDENT REPORT FOR THIS OCCURRENCE PRIOR TO THE EXIT DATED OF 7/16/2012. THE FALLS CARE PLAN WAS AMENDED BY STAFF ON 6/07/2012, BUT NO NEW INTERVENTIONS WERE ADDED. STAFF SIMPLY WROTE STAFF ASSISTANCE WAS NEEDED WITH ALL TRANSFERS AND AMBULATION, A REQUIREMENT THERAPY MADE FOR RESIDENT #101 ON 5/31/2012. THERAPY NOTES DATED 6/07/2012 REVEALED RESIDENT #101 REQUIRED MINIMALLY ONE STAFF MEMBER TO BE PRESENT FOR ALL TRANSFERS AND AMBULATION. NURSING NOTES DATED 6/10/2012 AT 1:47 A.M. DOCUMENTED THAT RESIDENT #101 SELF-TRANSFERRED AND AMBULATED INTO HER BATHROOM WITHOUT STAFF ASSISTANCE AND WITHOUT USING HER WHEELCHAIR. THE NURSE DOCUMENTED THAT RESIDENT #101 WAS REEDUCATED ON THE USE OF HER CALL LIGHT AND REQUIRED "CONTINUAL REMINDERS TO CALL FOR ASSISTANCE." DESPITE THIS ASSESSMENT, THE MEDICAL RECORD FAILED TO REVEAL ANY NEW INTERVENTIONS IMPLEMENTED TO ENSURE RESIDENT #101'S FUTURE SAFETY. NURSING NOTES DATED 6/10/2012 AT 6:57 P.M. DOCUMENTED THAT STAFF FOUND RESIDENT #101 ON HER LEFT SIDE, LYING ON HER BATHROOM FLOOR AFTER SHE "ATTEMPTED TO SELF TRANSFER." NURSING ASSESSMENTS IDENTIFIED LEFT SHOULDER PAIN, REDNESS AND SWELLING TO THE RESIDENTS UPPER LEFT BACK. PHYSICIAN ORDERS [REDACTED].M. REQUIRED STAFF TO OBTAIN A LEFT SHOULDER X-RAY. A RADIOLOGY REPORT DATED 6/11/2012 NOTED THAT RESIDENT #101 HAD A FRACTURE "THROUGH THE BODY OF THE (LEFT) SCAPULA." THERAPY NOTES DATED 6/13/2012 DOCUMENTED THAT RESIDENT #101 STILL REQUIRED MINIMALLY ONE STAFF MEMBER TO BE PRESENT FOR ALL TRANSFERS AND AMBULATION. DURING THE EXIT CONFERENCE ON 7/16/2012 AT 3:15 P.M., THE DIRECTOR OF NURSING AND ADMINISTRATOR REVIEWED THE MEDICAL RECORD AND SAID RESIDENT #101 DID NOT HAVE THE REQUIRED LEVEL OF STAFF SUPERVISION NECESSARY TO SAFELY TRANSFER ON 6/03/2012, 6/07/2012 OR 6/10/2012 AND SHE fell EACH TIME. ADDITIONALLY, THEY SAID STAFF FAILED TO IMPLEMENT ANY NEW INTERVENTIONS TO ENSURE THE FUTURE SAFETY OF RESIDENT #101 AFTER EACH OF THESE FALLS. THEY SAID THOUGH REORIENTATION TO EQUIPMENT WAS IMPORTANT, IT WAS NOT A NEW INTERVENTION OR ENOUGH TO ENSURE RESIDENT #101'S FUTURE SAFETY AFTER EACH FALL, BASED ON HER DOCUMENTED COGNITIVE IMPAIRMENTS.

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PERFORM CONSISTENT SKIN ASSESSMENTS, AND IMPLEMENT INTERVENTIONS FOR THE PREVENTION OF PRESSURE ULCERS FOR ONE (#410) OF SEVEN RESIDENTS REVIEWED FOR PRESSURE ULCERS, OUT OF A TOTAL OF 15 SAMPLED RESIDENTS, RESULTING IN A FACILITY ACQUIRED PRESSURE ULCER. FINDINGS INCLUDE: ON 6/21/11 AT 9:35 A.M., DURING THE INITIAL ROUNDS WITH THE FIRST FLOOR UNIT MANAGER (NURSE G), IT WAS REPORTED THAT RESIDENT #410 HAD BLISTERS ON BILATERAL HEELS, A FOLEY CATHETER, AND WAS CONFUSED. RESIDENT #410 WAS OBSERVED RECEIVING THERAPY. ON 6/22/11 AT 11:15 A.M., RESIDENT #410 WAS OBSERVED SITTING IN HIS WHEELCHAIR NEXT TO HIS BED. BOTH OF HIS FEET WERE NOTED WRAPPED IN KERLIX. HE WAS ABLE TO ANSWER SHORT SIMPLE QUESTIONS APPROPRIATELY. ON 6/22/11 AT 1 P.M., RECORD REVIEW REVEALED THAT RESIDENT #410 WAS admitted INto the facility on [DATE] AND RE-admitted on [DATE] WITH [DIAGNOSES REDACTED]. THE RESIDENT'S ADMISSION MINIMUM DATA SET (MDS), dated [DATE], INDICATED THE RESIDENT HAD AN INDEPENDENT COGNITION AND REQUIRED EXTENSIVE ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING (ADL'S), TRANSFERS, AND FOR BED MOBILITY. THE MDS INDICATED THAT RESIDENT #410 DID NOT HAVE ANY PRESSURE ULCERS, BUT WAS AT RISK FOR DEVELOPING PRESSURE ULCERS. ON 6/23/11 AT 9:50 A.M., AN OBSERVATION OF THE RESIDENT'S HEELS WERE DONE WITH THE FACILITY'S CONTRACTED NURSE PRACTITIONER/WOUND NURSE (NURSE I). OBSERVATIONS OF THE LEFT HEEL AFTER THE REMOVAL OF THE DRESSING REVEALED A BLACK COLOR DISCOLORED BLISTER THAT MEASURED 6.8 CENTIMETERS (CM) X 8.6 CM. THE BLISTER AREA MOVED WHEN NURSE "I" PALPATED IT. NURSE "I" STATED, "IT IS 20% DRIED OUT. IT IS FLUID FILLED. IT IS MUCH BETTER THAN LAST WEEK. IT IS SLOWLY DRYING OUT." THE LEFT HEEL WAS CLEANSED WITH NORMAL SALINE (NS) AND A DRY BULKING DRESSING WAS APPLIED. THE REMOVAL OF THE DRY BULKY DRESSING ON THE RIGHT FOOT REVEALED A BLACK COLORED BLISTER THAT MEASURED 7.1 CM X 8.6 CM. AGAIN, NURSE "I" REPORTED THAT IT WAS FLUID FILLED AND WAS 20% DRIED OUT. THE RIGHT HEEL WAS CLEANSED WITH NS AND A DRY BULKY DRESSING WAS APPLIED. NURSE "I" REPORTED THAT THE FACILITY WANTED HER TO CHECK RESIDENT #410'S BOTTOM (BUTTOCK/SACRAL) AREA WHILE SHE WAS THERE. WHEN NURSE "I" REMOVED RESIDENT #410'S PANTS AND BRIEF, AN OPEN AREA WAS NOTED ON THE LEFT BUTTOCK. NURSE "I" PERFORMED MEASUREMENTS ON THE OPEN AREA THAT REVEALED A SIZE OF 3.6 CM X 1.1 CM AND 0.2 CM DEPTH. NURSE "I" REPORTED THE OPEN AREA AS A STAGE THREE (III) PRESSURE ULCER. THERE WAS A MINIMAL AMOUNT OF SLOUGH AND A SMALL NECROTIC AREA INSIDE THE WOUND. NURSE "I" STATED, "THIS IS A STAGE III PRESSURE ULCER BASED ON THE PRESENCE OF SLOUGH. I AM GOING TO WRITE an order for [REDACTED]. THIS AREA IS NEW TO ME. IT WAS NOT REPORTED TO ME." THE BILATERAL HEEL BLISTERS AND THE LEFT HIP PRESSURE ULCERS WERE FACILITY ACQUIRED PRESSURE ULCERS. REVIEW OF THE INITIAL/ADMISSION SKIN ASSESSMENT, DATED 6/7/11, INDICATED NO OPEN AREAS. THE ASSESSMENT REVEALED DOCUMENTATION THAT READ, "HAS EXCORIATION TO INSIDE OF BOTH BUTTOCKS. BILATERAL HANDS MULTIPLE BRUISES." THE ASSESSMENT DID NOT INDICATE BLISTERS TO THE HEELS NOR ANY OPEN AREAS TO THE HIPS AND/OR SACRAL AREA. REVIEW OF THE "AT RISK FOR ALTERATION IN SKIN INTEGRITY RELATED TO: FRAGILE SKIN," CARE PLAN, INITIATED ON 6/3/11, INCLUDED ONE INTERVENTION. THE INTERVENTION DOCUMENTED WAS TO "NOTIFY PHYSICIAN AND SIGNIFICANT OTHER OF ANY CHANGE IN SKIN CONDITION." THERE WERE NO INTERVENTIONS DOCUMENTED FOR THE PREVENTION OF PRESSURE ULCERS NOR ANY INTERVENTIONS FOR THE ACTUAL BLISTERS ON THE HEELS. REVIEW OF THE FACILITY'S "SKIN ALTERATION RECORD, DATED 6/16/11, INCLUDED THE INITIAL DOCUMENTATION FOR THE HEEL BLISTERS. THE RIGHT HEEL BLISTER MEASURED 6.2 CM X 6.8 CM AND WAS DESCRIBED AS DARK AND PURPLE. THE LEFT HEEL BLISTER MEASURED 7.0 CM X 7.0 CM AND WAS DESCRIBED AS DARK AND PURPLE. ON 6/23/11 AT 10:10 A.M., THE UNIT MANAGER (NURSE G) WAS QUERIED REGARDING RESIDENT #410'S SHOWER SHEETS AND THE RESIDENT'S SKIN CARE PLAN REGARDING THE ONE INTERVENTION LISTED. NURSE "G" OFFERED NO EXPLANATION AS TO WHY SHE ONLY LISTED ONE INTERVENTION ON THE CARE PLAN DESPITE THE RESIDENT'S RISK FACTORS FOR DEVELOPING PRESSURE ULCERS. NURSE "G" REPORTED THAT THE FACILITY WAS UNABLE TO LOCATE THE SHOWER SHEETS FOR THE RESIDENT (SKIN ASSESSMENTS ARE INCLUDED ON SHOWER SHEETS). NURSE "G" STATED, "WE CAN'T LOCATE HIS SHOWER SHEETS FOR THE LAST THREE WEEKS. I DIDN'T KNOW HE HAS A STAGE III PRESSURE ULCER TO HIS BUTTOCK. THE NURSES DID NOT INFORM ME. I ONLY GO ON WHAT THEY TELL ME." THE BRADEN SCALES (TOOL USED FOR DETERMINING RISK FOR DEVELOPING PRESSURE ULCERS) WERE REVIEWED WITH NURSE "G." THE BRADEN SCALE PERFORMED ON 6/2/11 REVEALED A SCORE OF 16 (15-18 SCORE INDICATED A LOW RISK FOR THE DEVELOPMENT OF A PRESSURE ULCER. THE BRADEN SCALE PERFORMED ON 6/7/11 REVEALED A SCORE OF 15. THE BRADEN SCALE PERFORMED ON 6/13/11 REVEALED A SCORE OF 15, AGAIN INDICATED A LOW RISK FOR THE DEVELOPMENT OF PRESSURE ULCERS. NURSE "G" WAS ASKED IF THE BRADEN SCALE WAS THE ONLY TOOL UTILIZED FOR DETERMINING THE RISK FOR PRESSURE ULCERS. THERE WERE NO OTHER TOOLS COMPLETED OR DOCUMENTED. NURSE "G" DID NOT GIVE AN ANSWER. WHEN RESIDENT #410'S MEDICAL HISTORY WAS REVIEWED, NURSE "G" REPORTED THAT HE WAS A HIGH RISK FOR THE DEVELOPMENT OF PRESSURE ULCERS. ON 6/23/11 AT 11:25 A.M., THE DIRECTOR OF NURSING (DON) WAS INFORMED OF THE NEW ACQUIRED PRESSURE ULCER ON RESIDENT #410'S LEFT HIP BUTTOCK AND STATED, "WHERE DID THAT COME FROM?" ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 339 FINDINGS INCLUDE BASED ON OBSERVATIONS, INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO IMPLEMENT PREVENTIVE INTERVENTIONS TO PREVENT A FALL FOR ONE (#508) OF NINE SAMPLED RESIDENTS WHO WAS IDENTIFIED AS A FALLS RISK, RESULTING IN RESIDENT #508 SUSTAINING TWO FALLS WITH COMPLAINTS OF PAIN. ACCORDING TO RESIDENT #508'S RESIDENT ADMISSION INFORMATION SHEET, RESIDENT #508 WAS admitted to the facility on [DATE]. ACCORDING TO RESIDENT #508'S ADMISSION PHYSICIAN'S ORDERS DATED 9/16/10, RESIDENT #508 WAS admitted WITH [DIAGNOSES REDACTED]. RESIDENT #508'S NURSING ADMISSION EVALUATION DATED 9/16/10 INDICATED THAT RESIDENT #508 WAS ALERT AND ORIENTED TO PERSON, PLACE TIME AND SITUATION, WAS admitted WITH THROBBING PAIN TO HER RIGHT GROIN AREA FROM A RECENT SURGERY, AND WAS DEPENDENT ON STAFF FOR TRANSFERS, BED MOBILITY, BATHING, DRESSING AND TOILETING. RESIDENT #508'S NURSING ADMISSION EVALUATION ALSO DOCUMENTED THAT THE resident had a history of [REDACTED]. ADDITIONALLY, THE NURSING ADMISSION EVALUATION DOCUMENTED THE FOLLOWING: "...CHAIRFAST: ABILITY TO WALK SEVERELY LIMITED OR NON-EXISTENT. CANNOT BEAR OWN WEIGHT AND/OR MUST BE ASSISTED INTO CHAIR OR WHEELCHAIR..." "...COMPLETELY IMMOBILE: DOES NOT MAKE EVEN SLIGHT CHANGES IN BODY OR EXTREMITY POSITION WITHOUT ASSISTANCE..." RESIDENT #508'S NEW ADMISSION HISTORY AND PHYSICAL REPORT DATED 9/20/10 DOCUMENTED "...SHE DID HAVE A FALL OVER THE WEEKEND..." "...FALL PRECAUTIONS ARE IN PLACE..." ON 9/21/10 AT 1:03 P.M., DURING A MEDICATION PASS OBSERVATION, RESIDENT #508 WAS OBSERVED LAYING IN BED IN A SUPINE POSITION. RESIDENT #508 WS NOTED TO BE OBESE AND HAD A TRAPEZE OVER HER BED. RESIDENT #508'S DAUGHTER WAS SITTING AT HER BESIDE. DURING AN INTERVIEW, RESIDENT #508'S DAUGHTER STATED, "...MY MOTHER IS NOT DOING TOO WELL TODAY BECAUSE SHE fell AGAIN..." WHEN ASKED TO ELABORATE, RESIDENT #508 AND HER DAUGHTER STATED THAT RESIDENT #508 WAS IN ANOTHER ROOM, WHERE SHE fell OUT OF THE BED AND WAS MOVED TO THIS CURRENT ROOM. RESIDENT #508 STATED "...I fell TWICE..." RESIDENT #508'S DAUGHTER STATED "...SHE (#508) WAS MOVED TO THIS ROOM BECAUSE SHE KEPT FALLING..." RESIDENT #508 FURTHER STATED THAT THE SECOND TIME SHE fell , SHE WAS REACHING UPWARD TOWARDS HER TRAPEZE AND ROLLED OVER OFF THE BED. WHEN ASKED IF SHE WAS INJURED, RESIDENT #508 SAID SHE EXPERIENCED SOME PAIN TO HER GROIN AREA BUT WAS OTHERWISE ALL RIGHT. RESIDENT #508'S DAUGHTER THEN STATED, "...WE ASKED IF WE COULD HAVE SIDE RAILS PUT ON THE BED TO KEEP HER FROM FALLING BUT THE NURSE TOLD US IT COULDN'T BE DONE BECAUSE STATE LAWS WOULDN'T ALLOW IT..." A REVIEW OF RESIDENT #508'S FALLS CARE PLAN DATED 9/16/10 DOCUMENTED THE FOLLOWING: "...MINIMIZE RISK FOR INJURY RELATED TO FALLS..." "...MINIMIZE RISK FOR FALLS..." "...BED IN LOWEST POSITION..." "...MONITOR FOR AND REPORT CHANGES IN GAIT..." "...ENSURE THAT ALARM/DEVICE IS IN PLACE WHEN IN WHEELCHAIR/BED/GERI CHAIR..." ACCORDING TO RESIDENT #508'S CLINICAL RECORD, THERE WAS NO ALARM IN PACE TO ALERT STAFF OF A POSSIBLE FALL UNTIL 9/18/10 AFTER RESIDENT #508 HAD SUSTAINED A FALL FROM HER BED. A REVIEW OF RESIDENT #508'S PHYSICIAN'S PHYSICAL THERAPY ORDER DATED 9/17/10 IDENTIFIED RESIDENT #508 AS A FALLS RISK AND ORDERED THE FOLLOWING: "...PT EVALUATION AND TREATMENT "...GAIT TRAINING..." "...THERAPEUTIC EXERCISES..." "...THERAPEUTIC ACTIVITY..." "...WHEELCHAIR MANAGEMENT..." "...ELECTRICAL STIMULATION..." "...COMMUNITY/WORK REINTEGRATION..." ALTHOUGH RESIDENT #508 WAS IDENTIFIED AS A FALLS RISK ON ADMISSION, THERE WERE NO PHYSICIAN'S ORDERS FOR FALL PRECAUTIONS OR INTERVENTIONS TO BE IMPLEMENTED ON ADMISSION. A REVIEW OF THE FACILITY'S INCIDENT REPORT DATED 9/18/10 DOCUMENTED THAT ON 9/18/10 AT 1:15 A.M., "...RESIDENT ON FLOOR NEXT TO BED IN ROOM. RESIDENT STATES I TRIED TO GET UP AND I KNOW MY LEGS ARE WEAK. I WANT TO START PRACTICING WALKING..." THE INCIDENT REPORT FURTHER DOCUMENTED: "...WAS A MEDICAL DEVICE INVOLVED? NO..." INTERVENTIONS "...BED ALARM PLACED ON BED..." A PHYSICIAN'S ORDER DATED 9/18/10 ORDERED "BED ALARM WHILE IN BED". THERE WERE NO FALL PRECAUTIONS IMPLEMENTED TO PREVENT FALLS FOR RESIDENT #508 AND NO PHYSICIAN'S ORDERS TO IMPLEMENT SPECIFIC FALL PRECAUTIONS UNTIL 9/18/10 AFTER RESIDENT #508'S FALL. AND ON 9/21/10, THERE WERE NO SIDE RAILS ON RESIDENT #508'S BED AS REQUESTED. A REVIEW OF THE FACILITY'S INCIDENT REPORT DATED 9/21/10 DOCUMENTED THAT ON 9/21/10 AT 3:30 P.M., "...RESIDENT ROLLING OVER IN BED AND STARTED FALLING OUT OF BED YELLING FOR HELP..." "...BILATERAL MATS ADDED FOR SAFETY..." THERE WERE NO FLOOR MATS TO CUSHION A FALL IF IT OCCURRED AND RESIDENT #508'S BED WAS NOT IN IT'S LOWEST HORIZONTAL POSITION. ADDITIONALLY, THERE WERE NO BOLSTERS APPLIED TO RESIDENT #508'S BED TO KEEP HER FROM ROLLING OFF THE BED IN THE EVEN OF A FALL. A PHYSICIAN'S ORDER DATED 9/21/10 ORDERED "BILATERAL FLOOR MATS ADDED FOR SAFETY". THERE WAS NO PHYSICIAN'S ORDER FOR BILATERAL FLOOR MATS UNTIL AFTER RESIDENT #508 SUSTAINED HER SECOND FALL. ON 9/22/10 AT 10:37 A.M., DURING AN INTERVIEW WITH THE FIRST FLOOR UNIT MANAGER, (STAFF #4), SHE REPORTED THAT RESIDENT #508 HAD TWO FALLS SINCE BEING admitted on [DATE]. STAFF #4 SAID THAT RESIDENT #508 WAS IDENTIFIED AS A FALLS RISK ON ADMISSION. ADDITIONALLY, STAFF #4 STATED THAT SHE "...MOVED RESIDENT #508 TO ANOTHER ROOM INITIALLY BECAUSE THE WIDTH OF THE MATTRESS DIDN'T FIT THE BED FRAME AND I FELT SHE WOULD ROLL OFF THE BED..." STAFF #4 FURTHER SAID THAT RESIDENT #508 WAS OBESE AND REQUIRED A BARIATRIC BED BUT THERE WERE NO BARIATRIC BEDS AVAILABLE AND THAT AN APPROPRIATE FITTING MATTRESS WOULD HAVE TO BE ORDERED TO FIT THE CURRENT BED FRAME. STAFF #4 SAID THAT RESIDENT #508'S MATTRESS WAS ILL FITTING AND "...DID NOT FIT THE FRAME ON EITHER BED SO IF SOMEONE SAT ON THE EDGE OF THE MATTRESS, THEY WOULD SLIP OFF BECAUSE THE FRAME WAS NOT BIG ENOUGH TO SUPPORT THE MATTRESS..." STAFF #4 ACKNOWLEDGED THAT THE BED THAT RESIDENT #508 WAS TRANSFERRED TO WAS STILL NOT A BARIATRIC BED. A REVIEW OF RESIDENT #508'S PHYSICAL THERAPY EVALUATION DATED 9/17/10 INDICATED A [DIAGNOSES REDACTED]. HOWEVER, THE EVALUATION DID NOT ASSESS RESIDENT #508'S NEED FOR A BARIATRIC BED. A REVIEW OF RESIDENT #508'S OCCUPATIONAL THERAPY EVALUATION DATED 9/17/10 DOCUMENTED THAT RESIDENT #508 had a history of [REDACTED]. THE EVALUATION FURTHER DOCUMENTED THAT RESIDENT #508 HAD POOR SITTING BALANCE AND SEVERELY DIMINISHED ACTIVITIES OF DAILY LIVING (ADLS). THE OCCUPATIONAL THERAPY EVALUATION, HOWEVER, DID NOT ASSESS RESIDENT #508'S NEED FOR A BARIATRIC BED. ON 9/22/10 AT 11:08 A.M., DURING AN INTERVIEW WITH THE ADMINISTRATOR AND THE INTERIM DIRECTOR OF NURSING (IDON), WHEN QUERIED ABOUT RESIDENT #508'S FALLS, (IDON) SAID "...SHE (#508) ROLLED OUT OF BED BUT THERE WERE NO INJURIES..." WHEN ASKED WHAT INTERVENTIONS WERE IN PLACE, THE IDON SAID "...WE PUT A SENSOR PAD ON HER BED THE FIRST TIME AND NOW SHE (#508) HAS A LOW BED, A SENSOR PAD AND FALL MATS ON THE FLOOR..." WHEN ASKED WHY RESIDENT #508 DID NOT HAVE BOLSTERS ON HER BED IF SHE had a history of [REDACTED]. WHEN ASKED WHY SIDE RAILS WERE NOT APPLIED TO RESIDENT #508'S BED AS REQUESTED BY THE RESIDENT AND HER DAUGHTER, AND WHY RESIDENT #508 AND HER DAUGHTER WERE TOLD THAT STATE LAWS DID NOT ALLOW THE RAILS ON THE BED, THE IDON AND ADMINISTRATOR SAID "...WE DIDN'T KNOW THEY WANTED THEM..." WHEN ASKED WHY RESIDENT #508'S BED WAS NOT IN IT'S LOWEST HORIZONTAL POSITION AND WHY THERE WERE NO FALL MATS ON THE FLOOR TO LESSEN THE IMPACT OF A FALL SHOULD IT OCCUR, THE IDON SAID "...SHE (#508) SHOULD HAVE HAD THE MATS ON THE FLOOR NEXT TO HER BED AND I DON'T KNOW WHY HER BED WASN'T IN IT'S LOWEST HORIZONTAL POSITION..." NEITHER THE ADMINISTRATOR NOR THE IDON COULD EXPLAIN WHY RESIDENT #508 WAS DENIED SIDE RAILS WHEN REQUESTED, WHY THERE WERE NO FALL MATS ON THE FLOOR AND WHY RESIDENT #508'S BED WAS NOT IN THE LOWEST HORIZONTAL POSITION AS INDICATED IN THE CARE PLAN AND AS ORDERED BY THE PHYSICIAN. NEITHER THE ADMINISTRATOR NOR THE IDON COULD EXPLAIN THE DECISION NOT TO APPLY BOLSTERS TO RESIDENT #508'S BED TO KEEP HER FROM ROLLING OFF ONTO THE FLOOR. ADDITIONALLY, THE ADMINISTRATOR AND IDON HAD NO COMMENT REGARDING RESIDENT #508'S ILL FITTING MATTRESSES. REVIEW OF THE FACILITY'S FALLS PROCESS FLOW ALGORITHM (UNDATED) DOCUMENTED: "...CONTACT PHYSICIAN FOR ORDERS..." "...INITIAL PLAN OF CARE..." "...ONGOING FALL PREVENTION STRATEGIES..."

THIS CITATION PERTAINS TO INTAKE NUMBER MI 339 FINDINGS INCLUDE: BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ACCOMMODATE THE NEEDS AND PROVIDE AN APPROPRIATE SIZED BED FOR ONE (#508) OF NINE SAMPLED RESIDENTS WHO REQUIRED A BARIATRIC BED, RESULTING IN RESIDENT #508 ROLLING OFF AN ILL-FITTING MATTRESS AND SUSTAINING TWO FALLS WITH COMPLAINTS OF PAIN. FINDINGS INCLUDE: BASED ON OBSERVATIONS, INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO IMPLEMENT PREVENTIVE INTERVENTIONS TO PREVENT A FALL FOR ONE (#508) OF NINE SAMPLED RESIDENTS RESULTING IN RESIDENT #508 SUSTAINING TWO FALLS WITH COMPLAINTS OF PAIN. ACCORDING TO RESIDENT #508'S RESIDENT ADMISSION INFORMATION SHEET, RESIDENT #508 WAS admitted to the facility on [DATE]. ACCORDING TO RESIDENT #508'S ADMISSION PHYSICIAN'S ORDERS DATED 9/16/10, RESIDENT #508 WAS admitted WITH [DIAGNOSES REDACTED]. RESIDENT #508'S NURSING ADMISSION EVALUATION DATED 9/16/10 INDICATED THAT RESIDENT #508 WAS ALERT AND ORIENTED TO PERSON, PLACE TIME AND SITUATION, WAS admitted WITH THROBBING PAIN TO HER RIGHT GROIN AREA FROM A RECENT SURGERY, AND WAS DEPENDENT ON STAFF FOR TRANSFERS, BED MOBILITY, BATHING, DRESSING AND TOILETING. RESIDENT #508'S NURSING ADMISSION EVALUATION ALSO DOCUMENTED THAT THE resident had a history of [REDACTED]. ADDITIONALLY, THE NURSING ADMISSION EVALUATION DOCUMENTED THE FOLLOWING: "...CHAIRFAST: ABILITY TO WALK SEVERELY LIMITED OR NON-EXISTENT. CANNOT BEAR OWN WEIGHT AND/OR MUST BE ASSISTED INTO CHAIR OR WHEELCHAIR..." "...COMPLETELY IMMOBILE: DOES NOT MAKE EVEN SLIGHT CHANGES IN BODY OR EXTREMITY POSITION WITHOUT ASSISTANCE..." RESIDENT #508'S NEW ADMISSION HISTORY AND PHYSICAL REPORT DATED 9/20/10 DOCUMENTED "...SHE DID HAVE A FALL OVER THE WEEKEND..." "...FALL PRECAUTIONS ARE IN PLACE..." ON 9/21/10 AT 1:03 P.M., DURING A MEDICATION PASS OBSERVATION, RESIDENT #508 WAS OBSERVED LAYING IN BED IN A SUPINE POSITION. RESIDENT #508 WS NOTED TO BE OBESE AND HAD A TRAPEZE OVER HER BED. RESIDENT #508'S DAUGHTER WAS SITTING AT HER BESIDE. DURING AN INTERVIEW, RESIDENT #508'S DAUGHTER STATED, "...MY MOTHER IS NOT DOING TOO WELL TODAY BECAUSE SHE fell AGAIN..." WHEN ASKED TO ELABORATE, RESIDENT #508 AND HER DAUGHTER STATED THAT RESIDENT #508 WAS IN ANOTHER ROOM, WHERE SHE fell OUT OF THE BED AND WAS MOVED TO THIS CURRENT ROOM. RESIDENT #508 STATED, "...I fell TWICE..." RESIDENT #508'S DAUGHTER STATED "...SHE (#508) WAS MOVED TO THIS ROOM BECAUSE SHE KEPT FALLING..." RESIDENT #508 FURTHER STATED THAT THE SECOND TIME SHE fell , SHE WAS REACHING UPWARD TOWARDS HER TRAPEZE AND ROLLED OVER OFF THE BED. WHEN ASKED IF SHE WAS INJURED, RESIDENT #508 SAID SHE EXPERIENCED SOME PAIN TO HER GROIN AREA BUT WAS OTHERWISE ALL RIGHT. RESIDENT #508'S DAUGHTER THEN STATED, "...WE ASKED IF WE COULD HAVE SIDE RAILS PUT ON THE BED TO KEEP HER FROM FALLING BUT THE NURSE TOLD US IT COULDN'T BE DONE BECAUSE STATE LAWS WOULDN'T ALLOW IT..." A REVIEW OF RESIDENT #508'S FALLS CARE PLAN DATED 9/16/10 DOCUMENTED THE FOLLOWING: "...MINIMIZE RISK FOR INJURY RELATED TO FALLS..." "...MINIMIZE RISK FOR FALLS..." "...BED IN LOWEST POSITION..." "...MONITOR FOR AND REPORT CHANGES IN GAIT..." "...ENSURE THAT ALARM/DEVICE IS IN PLACE WHEN IN WHEELCHAIR/BED/GERI CHAIR..." ACCORDING TO RESIDENT #508'S CLINICAL RECORD, THERE WAS NO ALARM IN PACE TO ALERT STAFF OF A POSSIBLE FALL UNTIL 9/18/10 AFTER RESIDENT #508 HAD SUSTAINED A FALL FROM HER BED. A REVIEW OF RESIDENT #508'S PHYSICIAN'S PHYSICAL THERAPY ORDER DATED 9/17/10 IDENTIFIED RESIDENT #508 AS A FALLS RISK AND ORDERED THE FOLLOWING: "...PT EVALUATION AND TREATMENT "...GAIT TRAINING..." "...THERAPEUTIC EXERCISES..." "...THERAPEUTIC ACTIVITY..." "...WHEELCHAIR MANAGEMENT..." "...ELECTRICAL STIMULATION..." "...COMMUNITY/WORK REINTEGRATION..." ALTHOUGH RESIDENT #508 WAS IDENTIFIED AS A FALLS RISK ON ADMISSION, THERE WERE NO PHYSICIAN'S ORDERS FOR FALL PRECAUTIONS OR INTERVENTIONS TO BE IMPLEMENTED ON ADMISSION. A REVIEW OF THE FACILITY'S INCIDENT REPORT DATED 9/18/10 DOCUMENTED THAT ON 9/18/10 AT 1:15 A.M., "...RESIDENT ON FLOOR NEXT TO BED IN ROOM. RESIDENT STATES I TRIED TO GET UP AND I KNOW MY LEGS ARE WEAK. I WANT TO START [MEDICATION NAME] WALKING..." THE INCIDENT REPORT FURTHER DOCUMENTED: "...WAS A MEDICAL DEVICE INVOLVED? NO..." INTERVENTIONS "...BED ALARM PLACED ON BED..." A PHYSICIAN'S ORDER DATED 9/18/10 ORDERED "BED ALARM WHILE IN BED". THERE WERE NO FALL PRECAUTIONS IMPLEMENTED TO PREVENT FALLS FOR RESIDENT #508 AND NO PHYSICIAN'S ORDERS TO IMPLEMENT SPECIFIC FALL PRECAUTIONS UNTIL 9/18/10 AFTER RESIDENT #508'S FALL. AND ON 9/21/10, THERE WERE NO SIDE RAILS ON RESIDENT #508'S BED AS REQUESTED. A REVIEW OF THE FACILITY'S INCIDENT REPORT DATED 9/21/10 DOCUMENTED THAT ON 9/21/10 AT 3:30 P.M., "...RESIDENT ROLLING OVER IN BED AND STARTED FALLING OUT OF BED YELLING FOR HELP..." "...BILATERAL MATS ADDED FOR SAFETY..." THERE WERE NO FLOOR MATS TO CUSHION A FALL IF IT OCCURRED AND RESIDENT #508'S BED WAS NOT IN IT'S LOWEST HORIZONTAL POSITION. ADDITIONALLY, THERE WERE NO BOLSTERS APPLIED TO RESIDENT #508'S BED TO KEEP HER FROM ROLLING OFF THE BED IN THE EVEN OF A FALL. A PHYSICIAN'S ORDER DATED 9/21/10 ORDERED "BILATERAL FLOOR MATS ADDED FOR SAFETY". THERE WAS NO PHYSICIAN'S ORDER FOR BILATERAL FLOOR MATS UNTIL AFTER RESIDENT #508 SUSTAINED HER SECOND FALL. ON 9/22/10 AT 10:37 A.M., DURING AN INTERVIEW WITH THE FIRST FLOOR UNIT MANAGER, (STAFF #4), SHE REPORTED THAT RESIDENT #508 HAD TWO FALLS SINCE BEING admitted on [DATE]. STAFF #4 SAID THAT RESIDENT #508 WAS IDENTIFIED AS A FALLS RISK ON ADMISSION. ADDITIONALLY, STAFF #4 STATED THAT SHE "...MOVED RESIDENT #508 TO ANOTHER ROOM INITIALLY BECAUSE THE WIDTH OF THE MATTRESS DIDN'T FIT THE BED FRAME AND I FELT SHE WOULD ROLL OFF THE BED..." STAFF #4 FURTHER SAID THAT RESIDENT #508 WAS OBESE AND REQUIRED A BARIATRIC BED BUT THERE WERE NO BARIATRIC BEDS AVAILABLE AND THAT AN APPROPRIATE FITTING MATTRESS WOULD HAVE TO BE ORDERED TO FIT THE CURRENT BED FRAME. STAFF #4 SAID THAT RESIDENT #508'S MATTRESS WAS ILL FITTING AND "...DID NOT FIT THE FRAME ON EITHER BED SO IF SOMEONE SAT ON THE EDGE OF THE MATTRESS, THEY WOULD SLIP OFF BECAUSE THE FRAME WAS NOT BIG ENOUGH TO SUPPORT THE MATTRESS..." STAFF #4 ACKNOWLEDGED THAT THE BED THAT RESIDENT #508 WAS TRANSFERRED TO WAS STILL NOT A BARIATRIC BED. A REVIEW OF RESIDENT #508'S PHYSICAL THERAPY EVALUATION DATED 9/17/10 INDICATED A [DIAGNOSES REDACTED]. HOWEVER, THE EVALUATION DID NOT ASSESS RESIDENT #508'S NEED FOR A BARIATRIC BED. A REVIEW OF RESIDENT #508'S OCCUPATIONAL THERAPY EVALUATION DATED 9/17/10 DOCUMENTED THAT RESIDENT #508 had a history of [REDACTED]. THE EVALUATION FURTHER DOCUMENTED THAT RESIDENT #508 HAD POOR SITTING BALANCE AND SEVERELY DIMINISHED ACTIVITIES OF DAILY LIVING (ADLS). THE OCCUPATIONAL THERAPY EVALUATION, HOWEVER, DID NOT ASSESS RESIDENT #508'S NEED FOR A BARIATRIC BED. ON 9/22/10 AT 11:08 A.M., DURING AN INTERVIEW WITH THE ADMINISTRATOR AND THE INTERIM DIRECTOR OF NURSING (IDON), WHEN QUERIED ABOUT RESIDENT #508'S FALLS, (IDON) SAID "...SHE (#508) ROLLED OUT OF BED BUT THERE WERE NO INJURIES..." WHEN ASKED WHAT INTERVENTIONS WERE IN PLACE, THE IDON SAID "...WE PUT A SENSOR PAD ON HER BED THE FIRST TIME AND NOW SHE (#508) HAS A LOW BED, A SENSOR PAD AND FALL MATS ON THE FLOOR..." WHEN ASKED WHY RESIDENT #508 DID NOT HAVE BOLSTERS ON HER BED IF SHE had a history of [REDACTED]. WHEN ASKED WHY SIDE RAILS WERE NOT APPLIED TO RESIDENT #508'S BED AS REQUESTED BY THE RESIDENT AND HER DAUGHTER, AND WHY RESIDENT #508 AND HER DAUGHTER WERE TOLD THAT STATE LAWS DID NOT ALLOW THE RAILS ON THE BED, THE IDON AND ADMINISTRATOR SAID "...WE DIDN'T KNOW THEY WANTED THEM..." WHEN ASKED WHY RESIDENT #508'S BED WAS NOT IN IT'S LOWEST HORIZONTAL POSITION AND WHY THERE WERE NO FALL MATS ON THE FLOOR TO LESSEN THE IMPACT OF A FALL SHOULD IT OCCUR, THE IDON SAID "...SHE (#508) SHOULD HAVE HAD THE MATS ON THE FLOOR NEXT TO HER BED AND I DON'T KNOW WHY HER BED WASN'T IN IT'S LOWEST HORIZONTAL POSITION..." NEITHER THE ADMINISTRATOR NOR THE IDON COULD EXPLAIN WHY RESIDENT #508 WAS DENIED SIDE RAILS WHEN REQUESTED, WHY THERE WERE NO FALL MATS ON THE FLOOR AND WHY RESIDENT #508'S BED WAS NOT IN THE LOWEST HORIZONTAL POSITION AS INDICATED IN THE CARE PLAN AND AS ORDERED BY THE PHYSICIAN. NEITHER THE ADMINISTRATOR NOR THE IDON COULD EXPLAIN THE DECISION NOT TO APPLY BOLSTERS TO RESIDENT #508'S BED TO KEEP HER FROM ROLLING OFF ONTO THE FLOOR. ADDITIONALLY, THE ADMINISTRATOR AND IDON HAD NO COMMENT REGARDING RESIDENT #508'S ILL FITTING MATTRESSES. REVIEW OF THE FACILITY'S FALLS PROCESS FLOW ALGORITHM (UNDATED) DOCUMENTED: "...CONTACT PHYSICIAN FOR ORDERS..." "...INITIAL PLAN OF CARE..." "...ONGOING FALL PREVENTION STRATEGIES..."