Every finding on record at Pleasant View Shiawassee County Medical Care Facil

Based on observation, interview, and record review the facility failed to complete resident treatments per physician order for seven residents (R4, R5, R7, R8, R9, R10, R11) of eight residents reviewed. Findings include:A review of the facilities Facility Reported Incident (FRI) investigation summary revealed that on [DATE], Certified Nursing Assistant (CNA) D and RN E recognized that RN F was being inattentive to her assigned resident's needs. She was observed spending time on her personal cellphone with prolonged periods of sitting in the nurses station and had not completed a dressing for a resident but charted she had done so. These concerns were reported to the on-call manager, RN G on [DATE] at 6 PM. RN F was interviewed and reported that she believed she had completed the dressing. RN F was sent home after a second resident was found to not have their treatment done but it had been charted as completed. During the assessment and interview of residents assigned to RN F both R4 and R5 reported their treatments for day shift had not been completed. R4 was interviewed by RN E and stated that her treatment had not been completed, RN E assessed the wicking sheets that had been placed in R4's neck folds, chin, shoulder and chest. The wicking sheets were observed to have an odor and did not appear to have been recently changed. RN E asked RN F about it and she reported I thought that I did it, I must have clicked it by mistake. This treatment was charted on [DATE] at 2:02 PM by RN F. R5 was interviewed by RN E on [DATE] and reported that she did not receive her creams for her back and the antifungal powder for under her breasts. Documentation was reviewed and RN F had charted the treatments as being completed on [DATE] at 2:03 PM. Based on interviews and assessments on [DATE], the facility believed that all treatments except for R4 and R5's had been completed. Their investigation continued and included a camera review for RN Fs shift. During the camera review RN Fs shift, it was identified that she spent approximately 50% of her time seated at the nurses station while very intermittently accessing the vital signs binder and computer. The remainder of time she was sitting and or on her personal cellphone in the nurse's station. It was during the camera review that it was observed that RN F did not complete every treatment on [DATE] because she did not enter the room of every resident who had a treatment ordered. This concern was immediately reported to the administrator on [DATE] and reported to the State Agency on [DATE]. The facilities FRI investigation did not include information related to any additional residents (besides R4 and R5) that had been identified as not receiving their treatments from RN F on [DATE]. On [DATE] at 11:48 AM, during an interview with Director of Nursing (DON), when asked if their investigation had revealed additional residents that had not received their treatments from RN F on [DATE], she confirmed additional residents were identified and that the facility completed an incident report for each of them. On [DATE] at 12:21 PM, DON provided incident reports for 5 additional residents that did not receive treatments on [DATE] during RN Fs shift.A review of incident reports provided by DON revealed: an incident report dated [DATE] for R7 Nurse (RNF) failed to complete ordered treatments on [DATE] day shift. Treatments: Caldesene External Powder 81-15%, Apply to abdominal folds topically one time a day for protection.Monitor LLE (left lower extremity) stump for S/S (signs and symptoms) of breakdown.Clean right inner ankle with normal saline, dry and apply 1x3 band-aid., an incident dated [DATE] for R8 Nurse (RN F) failed to complete treatment orders on [DATE] for day shift. Treatments not completed: Hydrogen peroxide external gel 1.8%, Apply to forearms topically two times a day for sunburn for 3 weeks, an incident report dated [DATE] for R9 Nurse (RNF) failed to complete ordered treatments on [DATE] for day shift. Treatments: Clean tip of right pinky with normal saline, dry and cover with 1x3 band-aid. Discontinue when healed. Wound treatment: Right heel-Apply betadine, cover with Aquacel, secure with Conva-foam patch daily to right heel., an incident report dated [DATE] for R10 [DATE] 1100 to 1930 shift Nurse (RN F) failed to do resident's treatments: Cleansing of anterior and posterior cervical incision sites, and wound treatments on right glute/right gluteal cleft, an incident reported dated [DATE] for R11 (RN F) failed to complete treatments on [DATE] for day shift.R4A review of the medical record revealed R4 was admitted to the facility on [DATE], deceased on [DATE] and according to the Minimum Data Set (MDS) assessment dated [DATE], R4 scored 15/15 on the Brief Interview for Mental Status exam (which indicated intact cognition).R5On [DATE] at 1:19 PM, R5 was observed lying in bed. R5 reported that outside of the missed treatment, staff complete her prescribed treatments when they can and that they (staff) are pretty busy. She denied any complications from missed treatments. A review of the medical record revealed R5 was admitted to the facility on [DATE] and according to the Minimum Data Set (MDS) assessment dated [DATE], R5 scored 14/15 on the Brief Interview for Mental Status exam (which indicated intact cognition).R7On [DATE] at 3:30 PM, R7 was observed self-propelling in a manual wheelchair. During interview R7 reported he did not have any concerns with receiving prescribed treatments outside of the missed treatment. A review of the medical record revealed R7 was admitted to the facility on [DATE] and according to the Minimum Data Set (MDS) assessment dated [DATE], R5 scored 15/15 on the Brief Interview for Mental Status exam (which indicated intact cognition).R8On [DATE] at 3:34 PM, R8 was observed sitting up in a recliner. During interview R8 denied any overall concerns with receiving prescribed treatments besides a recently missed treatment. A review of the medical record revealed R8 was admitted to the facility on [DATE] and according to the Minimum Data Set (MDS) assessment dated [DATE], R8 scored 12/15 on the Brief Interview for Mental Status exam (which indicated moderately impaired cognition).R9A review of the medical record revealed R9 was admitted to the facility on [DATE] and discharged on [DATE] and according to the Minimum Data Set (MDS) assessment dated [DATE], R9 scored 10/15 on the Brief Interview for Mental Status exam (which indicated moderately impaired cognition).R10On [DATE] at 3:25 PM, R10 was observed sitting up at the edge of her bed. During interview R10 conveyed they had a missed treatment and denied any concerns with regularly receiving prescribed treatments. She added that she had 2 surgeries on her neck and she had been advised that the surgical sites look good. A review of the medical record revealed R10 was admitted to the facility on [DATE] and according to the Minimum Data Set (MDS) assessment dated [DATE], R9 scored 14/15 on the Brief Interview for Mental Status exam (which indicated intact cognition).R11A review of the medical record revealed R11 was admitted to the facility on [DATE] and according to the Minimum Data Set (MDS) assessment dated [DATE], R11 scored 15/15 on the Brief Interview for Mental Status exam (which indicated intact cognition). Seven residents were identified as not receiving treatments on [DATE] while under the care of RN F.

Based on observation, interview, and record review, the facility failed to ensure accurate medical records for seven residents (R4, R5, R7, R8, R9, R10, R11) of eight residents reviewed. Findings include:A review of the facilities Facility Reported Incident (FRI) investigation summary revealed that on 5/16/26, Certified Nursing Assistant (CNA) D and RN E recognized that RN F was being inattentive to her assigned resident's needs. She was observed spending time on her personal cellphone with prolonged periods of sitting in the nurses station and had not completed a dressing for a resident but charted she had done so. These concerns were reported to the on-call manager, RN G on 5/16/26 at 6 PM. RN F was interviewed and reported that she believed she had completed the dressing. RN F was sent home after a second resident was found to not have their treatment done but it had been charted as completed. During the assessment and interview of residents assigned to RN F both R4 and R5 reported their treatments for day shift had not been completed. R4 was interviewed by RN E and stated that her treatment had not been completed, RN E assessed the wicking sheets that had been placed in R4's neck folds, chin, shoulder and chest. The wicking sheets were observed to have an odor and did not appear to have been recently changed. RN E asked RN F about it and she reported I thought that I did it, I must have clicked it by mistake. This treatment was charted on 5/16/26 at 2:02 PM by RN F. R5 was interviewed by RN E on 5/16/26 and reported that she did not receive her creams for her back and the antifungal powder for under her breasts. Documentation was reviewed and RN F had charted the treatments as being completed on 5/16/26 at 2:03 PM. Based on interviews and assessments on 5/16/26, the facility believed that all treatments except for R4 and R5's had been completed. Their investigation continued and included a camera review for RN Fs shift. During the camera review RN Fs shift, it was identified that she spent approximately 50% of her time seated at the nurses station while very intermittently accessing the vital signs binder and computer. The remainder of time she was sitting and or on her personal cellphone in the nurses station. It was during the camera review that it was observed that RN F did not complete every treatment on 5/16/26 because she did not enter the room of every resident who had a treatment ordered. This concern was immediately reported to the administrator on 5/21/26 and reported to the State Agency on 5/21/26.The facilities FRI investigation did not include information related to any additional residents (besides R4 and R5) that had been identified as not receiving their treatments from RN F on 5/16/26.On 7/2/2026 at 11:48 AM, during an interview with Director of Nursing (DON), when asked if their investigation had revealed additional residents that had not received their treatments from RN F on 5/16/26, the DON confirmed additional residents were identified and that the facility completed an incident report for each of them.On 7/2/26 at 12:21 PM, DON provided incident reports for 5 additional residents that did not receive treatments on 5/16/26 during RN Fs shift.A review of incident reports provided by DON revealed: an incident report dated 5/22/26 for R7 Nurse (RNF) failed to complete ordered treatments on 5/16/26 day shift. Treatments: Caldesene External Powder 81-15%, Apply to abdominal folds topically one time a day for protection.Monitor LLE (left lower extremity) stump for S/S (signs and symptoms) of breakdown.Clean right inner ankle with normal saline, dry and apply 1x3 band-aid., an incident dated 5/22/26 for R8 Nurse (RN F) failed to complete treatment orders on 5/16/26 for day shift. Treatments not completed: Hydrogen peroxide external gel 1.8%, Apply to forearms topically two times a day for sunburn for 3 weeks, an incident report dated 5/22/26 for R9 Nurse (RNF) failed to complete ordered treatments on 5/16/26 for day shift. Treatments: Clean tip of right pinky with normal saline, dry and cover with 1x3 band-aid. Discontinue when healed. Wound treatment: Right heel-Apply betadine, cover with Aquacel, secure with Conva-foam patch daily to right heel., an incident report dated 5/22/26 for R10 5/16/26 1100 to 1930 shift Nurse (RN F) failed to do resident's treatments: Cleansing of anterior and posterior cervical incision sites, and wound treatments on right glute/right gluteal cleft, an incident reported dated 5/22/26 for R11 (RN F) failed to complete treatments on 5/16/26 for day shift.Seven residents were identified as not receiving treatments on 5/16/26 while under the care of RN F, however RN F documented the treatments as being completed in the residents electronic medical record.On 7/2/26 at 2:11 PM, during an interview with DON, it was confirmed that RN F had not completed treatments for R4, R5, R7, R8, R9, R10 and R11 but had documented them as completed in the electronic medical record for each resident.On 7/2/26 at 3:55 PM DON reported that the expectation for documenting treatments is for them to be done in real time, once completed and accurately. DON reported that the facility provides frequent education on appropriate documentation.Record reviews for R4, R5, R7, R8, R9, R10 and R11 revealed on 5/16/26 RN F had documented on the Medication Administration Record that the prescribed treatments had been completed.A review of the facilities policy titled Charting/Documentation documented in part General guidelines.Be concise, accurate, complete and use objective terms.Document only the facts.

Based on observations, interview and record review, the facility failed to ensure proper storage and labeling of medications for 3 (resident #16, resident #40 and resident #42) of 3 residents reviewed for medication storage. Findings include: On 6/9/25 at 10:29 AM, during an observation and interview with R42, 2 plastic medication cups with a pink cream in them and a tube of Benadryl/zinc oxide cream (an anti-itch cream) was observed in an unlocked cabinet next to the resident's sink. R42 stated the pink cream is what they apply to her buttocks when it is red. On 6/9/25 at 11:21 AM, during an observation of R40's room, 3 plastic medication cups were observed in an unlocked cabinet, next to resident's sink. Two cups had a pink cream in them and one had a green, gel-like substance in it. On 6/10/25 at 3:11 PM, 2 plastic medication cups containing pink cream and a tube of Benadryl/zinc oxide cream were observed to still be in R42's room in an unlocked cupboard. On 6/10/25 at 3:15 PM, 3 plastic medication cups containing a pink cream were observed in R40's room in an unlocked cupboard. On 6/10/25 at 3:17 PM, during an interview with Clinical Coordinator LPN I, when asked what her expectation is for medication storage related to some unsecured medications I had observed, she reported that they use up barrier creams quickly (what she assumed the pink cream was) and that they routinely store them in an unlocked cupboard next to the resident's sink. When asked if that is where they should be stored, she reported that sometimes they are stored in the resident's locked drawer (in their nightstand), depending on the resident. LPN I restated that they routinely store barrier cream in medication cups, unsecured in the resident's rooms. LPN I was asked how she would be able to determine how long the cream had been stored in the resident's room (in an uncovered plastic medication cup), she reported that she wouldn't know how long they had been there. When asked what the pink cream was LPN I reported she would have to look it up. On 6/10/25 at 3:20 PM, observed 3 cups of a pink cream in plastic medication cups with LPN I in R40's unlocked cabinet. LPN I reported that she was unsure of what the policy was for medication storage. On 6/10/25 at 3:23 PM, observed with LPN I, 2 plastic medication cups in the R42's unlocked cabinet, 1 contained a pink cream and 1 contained a white powder, in addition the tube of Benadryl/zinc oxide ointment was observed to still be present. LPN I removed all of the medication cups from each room and the tube of Benadryl/Zinc Oxide ointment. LPN I reported that she would dispose of the medications in a drug buster. On 6/10/25 at 4:37 PM, during an interview with Assistant Director of Nursing (ADON) C, when asked what her expectation is for medication storage, she reported that medications should not be left at the bedside, nurses are expected to apply creams and evaluate effectiveness, certified nursing assistants can apply non-medicated creams but they should not be left in the resident rooms, no treatment should be left in the resident rooms, residents could eat them. A review of the facilities policy titled Storage of Medications documented in part, Drugs and biologicals must be stored in containers in which they are received .Drugs for external use, as well as poisons, are clearly marked as such, and stored separately from other medications .Compartments containing drugs and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended . 27446

Based on observation, interview, and record review the facility failed to ensure the right to be treated with respect and dignity for one out of one residents (Resident #54) Findings Included: Per the facility face sheet Resident #54 (R54) was an [AGE] year old female who had resided at the facility since 12/22/2020. Diagnoses revealed R54 had Alzheimer's, dementia, alone with depression. Review of a facility investigation of an incident that the facility submitted on 6/3/2025 revealed Marketing Director G received an anonymous voicemail that the person wanted to make an anonymous complaint related to a possible HIPAA violation, and requested a return call. Assistant Director of Nursing (ADON) C was notified on the complaint. The complaint was revealed Certified Nurse Aid (CNA) H had taken a picture of R54 while R54 was sitting on the toilet, and put the photograph on her social media Instagram account (a photo and short-form video sharing social networking service.) Further review of the facility's incident report revealed that on 6/3/2025, ADON C had documented an interview with CNA H, who reported to her that she took the picture of R54 while she was sitting on the toilet. CNA H did not get a consent from R54 to take a picture of her. CNA H reported to ADON C R54 was aware she was taking the picture of her. The report revealed CNA H shared the photo on Instagram, had not taken photos of any other residents, and per the anonymous reporter the picture was on CNA H's Instagram account for possibly eight days. CNA H was removed from the facility. Continued review of the facility investigation revealed that the picture that was posted to CNA H's Instagram account had an Emoji (a pictogram/smiley face) of a face of R54's face, R54 had a nightgown on, and was identified by staff to be R54. Observation of the picture confirmed the Emoji face over R54's face. In an interview on 6/11/2035 at 11:17 AM, ADON C stated that the complaint had been brought to her attention due to an anonymous phone call. ADON C stated she interviewed CNA H and showed her the picture, asked her why did she took the picture and posted it on her Instagram account. ADON C said CNA H explained to her that it was a joke, and was meant to be funny. ADON C said she asked CNA H if R54 was aware she was taking the picture in which CNA H stated, she believed R54 was aware because she glanced at her when she had her phone out. ADON C said CNA H did not obtain from R54 nor R54's Durable Power of Attorney (DPOA) consent in writing to take a picture of her. ADON C said employees do not ever get or have consent to take a picture of a resident, and not with their own phone. ADON C stated that the facility had specific tablets that the activities staff used to take pictures to post on the facility's social media pages. ADON C further stated that all resident signed consents for pictures were filed with the Activities department. Review of the facility policy and procedure last revised on 3/25/2021, revealed Social media encompasses Internet applications that are based on user participation and allow for the creation and exchange of user-generated content including, but not limited to, posts, blogs, audio, video, text message, or other content. Examples of social media use include posting content or information on your own or another's Facebook, Twitter, Instagram, LinkedIn, blog, message service, website, chat room, web bulletin board, or other social media site . Never post a picture of a resident without prior authorization from the Administrator or designee. In an interview on 6/11/2025 at 12:28 PM, CNA H stated that R54 was on the toilet in the bathroom that was located in her room. CNA H said she was standing outside of the bathroom by R54's bed, and had full vision of R54 while she was on the toilet. CNA H said she took a picture of R54 as a joke and posted it to her Instagram account as a representation of herself, on the toilet and talking on the phone. CNA H said R54 was aware she was taking the picture, because R54 had been looking at her when she took the picture with her phone. CNA H said she did not tell R54 she was taking a picture of her, and was asked how then did R54 know a pictures was being taken. CNA H stated that was a good question, and said R54 would not have known she took the picture. CNA H stated she uploaded a bunch of pictures to her Instagram account, and the picture of R54 was included with the bunch of pictures. CNA H stated R54's face was covered up with an Emoji, and stated she did that with the Emoji, because she knew that she was not supposed to post pictures of residents on social media. CNA H said that what she did was wrong, and she never got permission. Review of CNA H's education revealed that CNA H was educated on Resident's Rights on 6/21/2024, and again on 6/1/2025. CNA H signed a, Letter of Understanding on 6/19/2025, which revealed CNA H received a personal copy of the facility's social media policy.

This citation pertains to Intake MI00143380. Based on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans for two (Resident #20 and Resident #23) of six reviewed. Findings include: Resident #20 (R20) Review of the medical record revealed R20 admitted to the facility on [DATE] and was readmitted from the hospital on 3/4/24 and again on 3/13/24 with diagnoses that included humerus fractures of the right and left arm, dementia, pressure ulcer of the sacral region, pressure induced deep tissue damage of left heel, stage 2pressure ulcer of right heel, stage 2 pressure ulcer of left buttock, and stage 2 pressure ulcer of right buttock. Review of the Wound-Weekly Observation Tool dated 3/7/24 revealed R20 had a suspected deep tissue injury to her left heel. Special equipment included motorized air mattress, air cushion, and boots. The current treatment plan included skin prep . R20 was hospitalized from 3/7/24 until readmission to the facility on [DATE]. A Physician's Order dated 3/14/24 revealed an order for skin prep to both heels twice daily. This order was entered as a therapy order and therefore not transcribed onto the Treatment Administration Record (TAR) or Medication Administration Record (MAR). The treatment was not documented as completed twice daily. Review of R20's care plans failed to reveal any mention of an actual pressure injury skin impairment, boots, heels up device, or skin prep treatments. On 3/20/24 at 9:45 AM, R20 was observed in bed. R20 had both her heels floated off the bed on a heels up device. R20 had a visible suspected deep tissue injury to her left heel. The right heel was not able to be visualized. R20 did not have boots on her feet. On 3/22/24 at 8:55 AM, R20 was observed lying in bed. R20's heels were not floated off the mattress nor did R20 have boots in place. R20's heels were resting on the bed. The heels up device was against the wall and the boots were on the floor near the wall. In an interview on 3/22/24 at 9:33 AM, Registered Nurse (RN) E reported the only treatment R20 received was the dressing to her buttocks. In an interview on 3/22/24 at 10:58 AM, RN G reported R20 readmitted to the facility with pressure injuries to the right buttock, left buttock, right heel, and left heel. RN G reported the skin prep order on 3/14/24 was not entered on the MAR or TAR and therefore there was not any documentation that the treatment had been performed twice daily. RN G reported the heels up device or boots should also be on R20's care plan. 45038 Resident #23 (R23) Review of the medical record revealed R23 was admitted to the facility on [DATE] with diagnoses that included Respiratory Syncytial Virus (RSV), urinary tract infection, pneumonia, type 2 diabetes, and chronic obstructive pulmonary disease (COPD). During observation on 03/22/2024 at 10:33 a.m. R23's room door was closed. A sign was observed to be located beside R23's room door, which demonstrated he was on droplet precautions. Isolation cart was observed under the droplet precaution sign. Review of R23's medical record revealed a plan of care which stated, The resident has a Respiratory Infection RSV bronchiolitis. The plan of care did not demonstrate that R23 was in droplet precautions/isolation. R23's medical record also revealed a physician order Cefdinir Oral Capsule 300 mg (Milligrams), Give 1 capsule by mouth in the morning for RSV for 5 Days and give 1 capsule by mouth in the evening for RVS for 5 Days written 03/18/24. The same order had an end date of 03/24/2024. In an interview on 03/22/2024 at 10:46 Registered Nurse (RN) C explained that R23 was on droplet precautions/isolation because he had been admitted with Respiratory Syncytial Virus (RSV). She explained that he would be on those precautions/isolation until his antibiotic medication is finished. In an interview on 03/22/2024 at 11:45 a.m. Assistant Director of Nursing (ADON)/ Infection Preventionist (IP) D explained that it is her expectation that when a resident is placed on droplet precautions/isolation that the resident plan of care be updated to include what type of precautions/isolation are to be followed, which would demonstrate when it was initiated and when it could be discontinued. ADON/IP D reviewed R23's plan of care and confirmed that information regarding him being place on droplet precautions/isolation was not present in his plan of care. ADON/IP D could not explain why R23's plan of care did not include the expected information.

This citation pertains to intake MI00141755. Based on observation, interview and record review, the facility failed to ensure appropriate care and treatment of a dialysis catheter/access site for one (Resident #3) of one reviewed for dialysis, resulting in the potential for infection. Findings include: Review of the medical record reflected Resident #3 (R3) admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included acute kidney failure, diabetes, stage 4 (severe) chronic kidney disease and Alzheimer's with late onset. The Significant Change in Status/Medicare 5 day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/22/23, reflected R3 scored 10 out of 15 (moderate impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was coded for receiving dialysis. A Physician's Order, dated 12/17/23, reflected, For Dialysis Patients: Assess Perma cath/ arteriovenous fistula. Chart findings assessed according to device. Continuous Bruit Present/Absent Continuous Thrill Present/Absent Pulse Present/Absent Dialysis Complete/Incomplete Chart on Findings: NO signs or Signs [sic] of: edema, swelling, bruising, skin discoloration, skin temp [temperature] changes, delayed cap [capillary] refill, pain, numbness, collateral vein distention, infection. If abnormal finding notify physician, chart interventions and actions. every shift every Mon [Monday], Wed [Wednesday], Fri [Friday]. During an interview on 1/25/24 at 2:49 PM, Certified Nurse Aide (CNA) C reported R3 was on checks every 15 minutes due to placing her hands in her bowel movements. CNA C reported they made sure R3's hands were clean, that there was no skin breakdown, and her dialysis access site (catheter) was checked. CNA C reported R3's access site usually had a dressing over it, but R3 liked to peel the dressing off. They would notify the nurses, who would replace the dressing. During an observation on 1/25/24 at 3:09 PM, CNA C and CNA D were observed to check R3's incontinence brief. Upon inquiry regarding R3's dialysis catheter/access dressing placement, CNA C moved the collar of R3's shirt, which revealed a dressing over the site, to the upper right chest region, dated 1/24/24. During a phone interview on 1/25/24 at 3:47 PM, Registered Nurse (RN) E reported R3 had been changed from checks every 30 minutes to every 15 minutes. RN E described R3 being incontinent of bowel and placing her hands in feces. RN E reported R3's dialysis catheter dressing was to remain clean, dry and intact, and an assessment of the site was done each shift. RN E reported R3 removed the dialysis catheter dressing frequently. According to RN E, R3 picked at the site and complained of itchiness. RN E reported the process of replacing the dialysis catheter/access site dressing included cleansing the area with normal saline and applying a clean dressing. When queried on the Personal Protective Equipment (PPE) used during the process, RN E replied that gloves were worn. On 1/26/24 at 8:44 AM, R3's room door was observed to be closed. At 8:45 AM, the door was opened, and a staff member exited, carrying two trash bags. A second staff member exited with R3's breakfast tray. On 1/26/24 at 9:00 AM, a staff member was observed to look into R3's room when passing by. During an interview on 1/26/24 at 9:00 AM, CNA F reported when going in to pick up R3's breakfast tray that morning, it was noted that she had a bowel movement. It was reported that she and another CNA went in to change and clean R3. CNA F reported R3 had a tendency to put her fingers in her feces, and she was checked on every 15 to 30 minutes. CNA F was uncertain if R3 had a dressing over her dialysis catheter site when providing care that morning. According to CNA F, the nurses checked that, and the nurse had been in that morning. On 1/26/24 at 9:14 AM, R3 was observed lying in bed, placing her right hand near the front and back of her incontinence brief. On 1/26/24 at 9:17 AM, Licensed Practical Nurse (LPN) G put gloves on and moved R3's collar to the side, revealing that there was not a dressing over R3's dialysis catheter/access site. LPN G exited the room, then returned at 9:23 AM. LPN G performed hand hygiene and opened a sterile CVC (central venous catheter) dressing change kit on R3's over-bed table. LPN G reported she wanted the sterile dressing out of the kit, as she did not know how long the prior dressing had been off. LPN G put on gloves from the kit, opened what was reported to be ChloraPrep from the kit and began to clean around the dialysis catheter/access site. Gauze and a clear dressing from the CVC dressing change kit were placed over the dialysis catheter/access site. A mask was not used during the dressing change. LPN G stated that off the top of her head, she did not know if the dressing change needed to be sterile, but the dressing had been pulled off, and she wanted to make sure the area was clean. LPN G stated that at times, R3's hands were not clean. She wanted to be sure that dialysis catheter site was clean, reporting it was a bad site for infection. LPN G reported CNAs should have been looking for R3's dressing when they were in the room. During an interview on 1/26/24 at 11:16 AM, RN H reported she had not seen R3's dialysis catheter/access site dressing that day and was unaware of whether or not the dressing had been intact. She stated RN J was the treatment nurse that day. RN H reported RN J would have been the one to check the dialysis catheter/access site dressing that morning. According to RN H, R3 had a tendency of removing the dressing. During an interview on 1/26/24 at 11:50 AM, Dialysis RN I reported masks were to be worn while changing the dialysis catheter/access dressing, but she was uncertain if that was indicated on the dialysis communication form. RN I reported there were three types of sterile dressings that dialysis used. The bottom of R3's dialysis communication forms, dated 1/19/24 and 1/24/24 reflected .**FOR CATHETERS (CVC), the dressing must remain intact and clean and dry at all times. If removed by the patient or soiled, make sure the limb clamps are closed and catheter caps are in place. Cleanse exit site with alcohol prep pad, ChloraPrep, or Betadine wipe/swab, and apply a sterile dressing after cleansing agent has dried. Promptly notify dialysis staff if this occurs. During an interview on 1/26/24 at 12:56 PM, RN J reported she had seen R3 prior to LPN G changing the dialysis catheter/access dressing that same morning. She stated she did not see or notice R3's dialysis catheter/access site or the dressing when she was in R3's room for treatments that same morning. RN J reported the only treatments were for powder to R3's (skin) folds and cream to her buttocks.

Based on observation, interview and record review, the facility failed to complete accurate Minimum Data Set (MDS) assessments for three (Resident #9, #66, #70) of 20 reviewed, resulting in inaccurate assessments. Findings include: Resident #66 (R66) Review of the medical record revealed R66 was admitted to the facility on [DATE] with diagnoses that included rheumatoid arthritis, major depressive disorder, chronic pain, and glaucoma. Review of the quarterly MDS with an Assessment Reference Date (ARD) of 5/16/23 revealed during the seven-day look back period, R66 received the following medications all seven days: injections, insulin, anticoagulant, antidepressant, antibiotic, antipsychotic, antianxiety, hypnotic, diuretic, and opioid. Review of the Medication Administration Record (MAR) revealed during the seven-day look back period, R66 received antidepressant and opioid medication for seven days. R66 did not receive an injection, insulin, anticoagulant, antibiotic, antipsychotic, antianxiety, hypnotic, or diuretic. In an interview on 06/13/23 at 2:17 PM, MDS Nurse D reported she used the MAR when coding medications on MDS assessments. MDS Nurse D reviewed R66's MAR and MDS with an ARD of 5/16/23 and reported R66 did not receive an injection, insulin, anticoagulant, antibiotic, antipsychotic, antianxiety, hypnotic, or diuretic during the seven-day look back period. MDS Nurse D reported the MDS was inaccurate. 34705 Resident #9(R9) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R9 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included neurocogitive disorder with lewy bodies, diabetes mellitus, hypertension (high blood pressure), end stage renal disease with dialysis, and depression. Continued review of the MDS reflected R9 required dialysis treatment. The MDS reflected no modifications of diet according to section K. Review of the MDS, dated [DATE], reflected R9 was not receiving dialysis treatments and had been completed by MDS Nurse D. Continued review of the MDS reflected R9 received modified diet. Review of the Physician orders, dated 6/1/23 through current, reflected R9 received dialysis three times weekly and had orders for pureed diet with nectar thick liquids. During an interview on 6/13/23 at 3:09 PM, Registered Nurse (RN) I reported was R9's nurse and reported R9 had dialysis 3 times weekly and had a modified diet with pureed food and nectar thick liquids. During an interview on 6/13/23 at 3:13 PM, MDS Nurse D reported had worked as the MDS Nurse for eight years at the facility. MDS Nurse D verified R9 MDS, dated [DATE], was not marked for dialysis and should have been. MDS Nurse D reported R9's MDS had been modified on 3/14/23 and reported had thought that correction was made and reported was unsure why it had not been corrected. During an interview on 6/14/23 at 8:39 AM, Certified Dietary Manager (CDM) H reported working at facility for [AGE] years. CDM H reported R9 required modified diet that included pureed diet and nectar thick liquids and reported had been on that same modified diet for several months. CDM H reported she was responsible for completing section K of the MDS and verified R9's MDS, dated [DATE], was not accurate and must have missed on accident. CDM H reported the MDS should have reflected R9 received a modified diet same as the MDS dated [DATE]. 46955 Resident # 70 Review of the medical record reflected that Resident # 70 (R70) was readmitted to facility 4/28/23 with diagnoses including stage 2 pressure ulcer of sacral region, chronic obstructive pulmonary disease, acute and chronic respiratory failure, moderate protein-calorie malnutrition, and weakness. Review of the significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/15/23 reflected that R70 had one Stage 2 pressure ulcer that was present upon admission/reentry. In an observation and interview on 6/12/23 at 12:09 PM, R70 was observed lying in bed, on back, with head of bed at an approximate 45-degree angle eating lunch. R70 stated that she had a sore on her bottom, couldn't remember if the wound had been present upon facility admission, and that the wound just didn't seem to be getting any better. In an observation and interview on 6/14/23 at 9:20 AM, R70's sacral wound was observed during the completion of wound care by Licensed Practical Nurse (LPN) F. R70 was observed to have an open area at sacrum with visible depth. Granulation tissue (pink or beefy red tissue with a shiny, moist appearance) noted at central aspect of wound base with stringy, yellow slough (necrotic tissue that adheres to the ulcer bed) noted at the wound base borders. Visible undermining (a pocket of dead space under the skin originating from the edges of the wound and extending outward under the skin) observed at proximal (top aspect) wound edge. Intact, light pink tissue noted to surround wound. In an interview with LPN F upon the completion of wound care, LPN F confirmed that she had frequently completed R70's sacral wound care since her readmission, that the wound was approximately the same size, and that the wound had gotten deeper as the current treatment was helping to decrease the slough that had been present in the wound base since admission. Review of R70's medical record completed with the following findings noted: Reentry Skin Only Evaluation dated 4/28/23 at 5:24 PM indicated a suspected deep tissue injury-depth unknown to R70's coccyx. No wound measurement or description was noted to be included within assessment. Nurse Practitioner (NP) Progress Note dated 5/4/23 stated, Visit Type: Wound Care .CHIEF COMPLAINT .Wound care consult for initial assessment and evaluation of wound .HISTORY OF PRESENT ILLNESS .referred to wound services related to a noted wound found on sacrum. This wound is the result of pressure and based on assessment and description is noted to be a stage III .PHYSICAL EXAM .Skin .1. Sacrum stage III-There is a moderate amount of serosanguineous drainage from this area. Wound bed consists of 70% (percent) epithelial tissue, 10% granulation tissue and 20% yellow adherent slough .Addendum Details: This visit represent initial evaluation completed 4/28/23 . NP Progress Note dated 5/5/23 stated, Visit Type: Wound care .CHIEF COMPLAINT .Wound care consult for initial assessment and evaluation of wound .HISTORY OF PRESENT ILLNESS .referred to wound services related to a noted wound found on sacrum. This wound is the result of pressure and based on assessment and description is noted to be a stage III .PHYSICAL EXAM .Skin .1. Sacrum stage III-this site measures 8.5 x 8.5 centimeters with a depth of .01 centimeters. There is a moderate amount of serosanguineous drainage from this area. Wound bed consists of 80% epithelial tissue and 20% yellow adherent slough . NP Progress Note dated 5/11/23 stated, Visit Type: Wound Care . CHIEF COMPLAINT .Wound care consult for follow-up assessment and evaluation of wound .HISTORY OF PRESENT ILLNESS .referred to wound services related to a noted wound found on sacrum. This wound is the result of pressure and based on assessment and description is noted to be a stage III .PHYSICAL EXAM .Skin .1. Sacrum stage III-this site measures 4.0 x 4.0 centimeters with a depth of .01 centimeters .Wound bed consists of 80% epithelial tissue and 20% yellow adherent slough . NP Progress Note dated 5/18/23 stated, Visit Type: Wound Care .CHIEF COMPLAINT .Wound care consult for follow-up assessment and evaluation of wound .HISTORY OF PRESENT ILLNESS .This wound is the result of pressure and based on assessment and description is noted to be a stage III .PHYSICAL EXAM .Skin .1. Sacrum stage III-this site measures 3.5 x 2.3 centimeters with a depth of 0.01 centimeters .Wound bed consists of 50% epithelial tissue and 50% yellow adherent slough . NP Progress Note dated 5/25/23 stated, Visit Type: Wound Care .CHIEF COMPLAINT .Wound care consult for follow-up assessment and evaluation of wound .HISTORY OF PRESENT ILLNESS .This wound is the result of pressure and based on assessment and description is noted to be a stage II .PHYSICAL EXAM .Skin .1. Sacrum stage II-this site measures 1.8 x 1.8 centimeters with a depth of .01 centimeters .Wound bed consists of 100% of yellow adherent slough . NP Progress Note dated 6/2/23 stated, Visit Type: Wound Care .CHIEF COMPLAINT .Wound care consult for follow-up assessment and evaluation of wound .HISTORY OF PRESENT ILLNESS .This wound is the result of pressure and based on assessment and description is noted to be a stage II .PHYSICAL EXAM .Skin .1. Sacrum stage III-this site measures 1.5 x 1.5 centimeters with a depth of 0.3 centimeters .Wound bed consists of 70% of yellow adherent slough and 30% epithelial tissue . NP Progress Note dated 6/8/23 stated, Visit Type: Wound Care .CHIEF COMPLAINT .Wound care consult for follow-up assessment and evaluation of wound .HISTORY OF PRESENT ILLNESSES .This wound is the result of pressure and based on assessment and description is noted to be a stage II .PHYSICAL EXAM .Skin .1. Sacrum stage III-this site measures 2.5 x 1.1 centimeters with a depth of 0.3 centimeters .Wound bed consists of 70% of yellow adherent slough and 30% epithelial tissue . WOUND - WEEKLY OBSERVATION TOOL dated 5/4/23 stated, First Observation, no reference. Wound was indicated as a current stage II pressure ulcer at sacrum measuring 85mm (millimeters) x 85mm x 1mm with epithelial tissue and slough (20%) in wound base. WOUND - WEEKLY OBSERVATION TOOL dated 5/11/23 stated, NP at bedside. Wound was indicated as current stage II pressure ulcer at sacrum measuring 40mm x 40mm x 1mm with slough (90%) in wound base. WOUND - WEEKLY OBSERVATION TOOL dated 5/18/23 stated, NP at bedside. Wound was indicated as a current stage II pressure ulcer at sacrum measuring 35mm x 23mm with slough (50%) in wound base. WOUND - WEEKLY OBSERVATION TOOL dated 5/26/23 stated, NP at bedside. Wound was indicated as a current stage II pressure ulcer at sacrum measuring 18mm x 18mm with slough (100%) in wound base. WOUND - WEEKLY OBSERVATION TOOL dated 6/2/23 stated, NP at bedside. Wound was indicated as a current stage II pressure ulcer at sacrum measuring 15mm x 15mm x 3mm with epithelial tissue and slough (70%) in wound base. WOUND - WEEKLY OBSERVATION TOOL dated 6/8/23 stated, NP at bedside. Wound was indicated as a current stage II pressure ulcer at sacrum measuring 25mm x 11mm x 3mm with epithelial tissue and slough (70%) in wound base. Undermining and tunneling was indicated to be present. In an interview on 6/14/23 at 10:16 AM, Registered Nurse/Wound Nurse (RN/Wound Nurse) E confirmed that she was wound care certified, completed weekly wound assessments on all residents with pressure ulcers in the presence of a NP that specialized in wound care, and that the NP diagnosed and staged the wounds. RN/Wound Nurse E confirmed familiarity with R70, that she routinely completed R70's wound assessments, and that R70 had an ongoing Stage 2 pressure ulcer at sacrum since 4/28/23 readmission. Per RN/Wound Nurse E, R70 had a current Stage 2 pressure ulcer with undermining, tunneling, and slough. During the same interview, RN/Wound Nurse E stated that Registered Nurse/Minimum Data Set Nurse (RN/MDS Nurse) D had questioned her regarding R70's sacral pressure ulcer stage at the time of the Significant Change MDS completion (with ARD of 5/15/23) as NP notes dated 5/4/23 (addendum details within note indicated that visit represented initial evaluation completed 4/28/23), 5/5/23, and 5/11/23 indicated the ulcer as a Stage 3 and the Weekly Wound Observation Tool assessment that she had completed indicated the ulcer as a Stage 2. RN/Wound Nurse E further stated that upon discussion with NP G that routinely rounded and assessed R70's wound with her, that the NP was going to clarify R70's sacral wound as a Stage 2 pressure ulcer and therefore RN/MDS Nurse D coded the ulcer as a Stage 2 on the Significant Change MDS with an ARD of 5/15/23. In a telephone interview on 6/14/23 at 10:53 AM, Nurse Practitioner (NP) G stated that she was certified in wound care, confirmed familiarity with R70 and that she had been following R70's sacral wound for several weeks. Per NP G, R70's sacral wound presented as a Stage 3 pressure ulcer at her initial assessment (noted to be completed 4/28/23) and had presented as a Stage 3 pressure ulcer in all subsequent assessments as indicated in her progress notes dated 5/4/23 (addendum details within note indicated that visit represented initial evaluation completed 4/28/23), 5/5/23, 5/11/23, and 5/18/23. NP G stated that the notations in her 5/25/23, 6/2/23, and 6/8/23 progress notes that reflected a Stage 2 pressure ulcer at R70's sacrum were inaccurate and was not sure why she had documented this but would be completing addendums to correct as stated the wound presented and continues to present with slough and/or granulation tissue as well as with undermining and tunneling (in the most recent 6/8/23 assessment) making the wound an ongoing Stage 3. NP G further stated that prior to the time that she had completed her first assessment on R70, the wound may have presented as a Stage 2 pressure ulcer but that from the time she first assessed the wound on 4/28/23 (as indicated in NP Progress Note dated 5/4/23), R70's sacral wound was a Stage 3 pressure ulcer. In an interview on 06/14/23 at 11:19 AM, RN/MDS Nurse D confirmed completing R70's Significant Change MDS with an ARD of 5/15/23, stated that she based her MDS coding for a pressure ulcer on documentation from the facilities wound care nurse, and that she coded R70's pressure ulcer as a Stage 2 pressure ulcer based on the WOUND - WEEKLY OBSERVATION TOOL dated 5/11/23 completed by RN/Wound Nurse E. RN/MDS Nurse D stated that she had went back and forth on whether to code it as a Stage 2 (based on the 5/11/23 facility wound nurse assessment) or a Stage 3 (based on the 5/11/23 NP assessment/progress note) but proceeded to code as a Stage 2 after conferring with RN/Wound Nurse E. RN/MDS nurse D stated that she had never spoke with NP G directly about R70's wound presentation/stage and that based on NP G's 5/11/23 assessment and progress note, the MDS with an ARD of 5/15/23 was inaccurate as should have been coded as a Stage 3 pressure ulcer. In an interview on 6/14/23 at 11:46 AM, Assistant Director of Nursing (ADON) C reviewed R70's WOUND - WEEKLY OBSERVATION TOOL dated 5/11/23 completed by RN/Wound Nurse E that indicated a Stage 2 pressure ulcer at sacrum, NP G's Progress Note dated 5/11/23 that indicated a Stage 3 pressure ulcer at sacrum, confirmed the discrepancy, and acknowledged that based on NP G's 5/11/23 assessment and documentation that the Significant Change MDS with an ARD of 5/15/23 should have indicated that R70 had one Stage 3 pressure ulcer (instead of one Stage 2 pressure ulcer as the assessment reflected).

This citation pertains to intake number MI00130737. Based on interview and record review the facility failed to ensure one out of two residents (Resident #2) was free from accidents, resulting in Resident #2 falling out of bed, and sustaining an ankle fracture while receiving care. Findings Included: Per the facility face sheet Resident #2 (R2) had been a resident at the facility since 7/23/2019. Diagnoses included muscle weakness, right and left shoulder, and right hand contractors. R2 no longer resided at the facility at the time of the onsite investigation. Record review of a facility incident report (FRI) dated 7/5/2022 revealed R2 fell out of bed while being repositioned and sustained a fracture to her right ankle. The FRI revealed R2 was a quadriplegic, was non-verbal, and required two staff members for extensive assistance for bed mobility and care. The report further revealed that on 7/4/2022 R2 fell out of bed while receiving care by Certified Nurse Aid (CNA) C. The FRI revealed that CNA C had not followed R2's care plan regarding her extensive assistance needs by two staff members, and had provided incontinence care and repositioning of R2 by herself. The report revealed that R2 had fallen out of bed when CNA C had rolled R2 towards her which caused CNAC to lose her footing resulting in R2 rolling out of her, and sustaining a fracture to R2's right tibula and fibula (bones of the lower leg). Record review of X-ray results dated 7/5/2022, revealed R2 had a fractured tibula and fibula that was an acute (recently occurred) fracture. Review of R2's care plans revealed R2 had a Focus of .ADL (activities of daily living) self-care performance deficit r/t (related to) respiratory distress syndrome, paraplegia, contractors., dated 7/24/2019. The care plan revealed an intervention that R2 required extensive assist by two staff members for repositioning and turning in bed. The intervention was dated 7/24/2019. In an interview on 3/7/2023 at 1:00 PM, CNA C stated that on 7/4/2023 she went to see R2 before breakfast, CNA C said she had called to get assistance from another staff member but stated no one responded. CNA C said she had washed R2, and then left to get linen and when she had returned R2 had shifted to her left side closer to the left side of the bed. CNA C said she called for help because R2 was to close to the side of the bed, but no staff responded to her call for help so she rolled R2 towards herself, grabbed a draw sheet that was underneath R2 and pulled R2 towards herself. CNA C said that was when she lost her footing and both R2 and herself landed on the floor. CNA C said she knew how to care for a resident by the resident's Kardex (CNA guide to resident specific care and reflects what the resident's care plan states). CNA C then stated that the CNAs were to print out resident's Kardex's at the beginning of each shift and carry the printed Kardex with them. CNA C said she did not look to see what R2's required staff assistance was for bed mobility before she had turned R2. In an interview on 2/7/2023 at 1:45 PM, Licensed Practical Nurse (LPN) D stated that at the time he did not know R2's plan of care. LPN D said he recalled seeing CNA C providing care to R2, and did ask CNAC if she needed help, but CNA C told him no. LPN D also stated that CNA C did not request his assistance with R2's bed mobility either. LPN D said R2 was not able to move the lower half of her body, nor her legs, and was non-verbal. LPN D stated that he responded to R2's room at the time of R2's fall, and upon entering the room R2 was on the floor. LPN D further stated that the CNAs were to print out a copy of resident's Kardex at the start of their shift. In an interview on 3/7/2023 at 2:50 PM, CNA E stated that she was working when the incident occurred, and that the CNAs carried walkie talkies. CNA E said she did received a call from CNA C over her walkie talkie to assist with R2's bed mobility and care. CNA E said she had told CNA C that she would be there in a minute after she finished some charting documentation, but stated that CNA C did not wait for her to get to R2's room. CNA E said an emergency call went out and upon arriving to R2's room she observed R2 on the floor. CNA E said that all the CNAs were required to review all assigned resident's Kardex prior to providing care, and were also required to print the Kardex's at the start of their shift to carry with them. Record review of CNA C's employee file revealed that she was termination from her employment at the facility on 7/12/2022 related to R2's fall out of bed, and failure to follow R2's care plan/Kardex. CNA C's filed had also revealed that she had been signed off on training for the use of a resident's Kardex, and following of a resident's care plan when providing resident care on 5/4/2021. In an interview on 3/9/2023 at 10:25 AM, Director of Nursing (DON) B said that it was her expectation that when a resident's care plan revealed the resident required a two person assist for care then two staff members were to provide the care, and if help was not available then the CNA was not to proceed until help arrived. DON B said a resident's Kardex was what CNAs were to refer to prior to providing care, and had all the resident's care plan information on it. DON B also stated that the CNAs were to print out all their resident's Kardex at the start of every shift and review it.

This citation pertains to intake number MI00130737. Based on interview and record review the facility failed to ensure one out of eight residents (Resident #2) plan of care was followed, resulting in Resident #2 falling out of bed, and sustaining an ankle fracture while receiving care. Findings Included: Per the facility face sheet Resident #2 (R2) had been a resident at the facility since 7/23/2019. Diagnoses included muscle weakness, right and left shoulder, and right hand contractors. R2 no longer resided at the facility at the time of the onsite investigation. Record review of a facility incident report (FRI) dated 7/5/2022 revealed R2 fell out of bed while being repositioned and sustained a fracture to her right ankle. The FRI revealed R2 was a quadriplegic, was non-verbal, and required two staff members for extensive assistance for bed mobility and care. The report further revealed that on 7/4/2022 R2 fell out of bed while receiving care by Certified Nurse Aid (CNA) C. The FRI revealed that CNA C had not followed R2's care plan regarding her extensive assistance needs by two staff members, and had provided incontinence care and repositioning of R2 by herself. The report revealed that R2 had fallen out of bed when CNA C had rolled R2 towards her which caused CNAC to lose her footing resulting in R2 rolling out of her, and sustaining a fracture to R2's right tibula and fibula (bones of the lower leg). Record review of X-ray results dated 7/5/2022, revealed R2 had a fractured tibula and fibula that was an acute (recently occurred) fracture. Review of R2's care plans revealed R2 had a Focus of .ADL (activities of daily living) self-care performance deficit r/t (related to) respiratory distress syndrome, paraplegia, contractors., dated 7/24/2019. The care plan revealed an intervention that R2 required extensive assist by two staff members for repositioning and turning in bed. The intervention was dated 7/24/2019. In an interview on 3/7/2023 at 1:00 PM, CNA C stated that on 7/4/2023 she went to see R2 before breakfast, CNA C said she had called to get assistance from another staff member but stated no one responded. CNA C said she had washed R2, and then left to get linen and when she had returned R2 had shifted to her left side closer to the left side of the bed. CNA C said she called for help because R2 was to close to the side of the bed, but no staff responded to her call for help so she rolled R2 towards herself, grabbed a draw sheet that was underneath R2 and pulled R2 towards herself. CNA C said that was when she lost her footing and both R2 and herself landed on the floor. CNA C said she knew how to care for a resident by the resident's Kardex (CNA guide to resident specific care and reflects what the resident's care plan states). CNA C then stated that the CNAs were to print out resident's Kardex's at the beginning of each shift and carry the printed Kardex with them. CNA C said she did not look to see what R2's required staff assistance was for bed mobility before she had turned R2. In an interview on 2/7/2023 at 1:45 PM, Licensed Practical Nurse (LPN) D stated that at the time he did not know R2's plan of care. LPN D said he recalled seeing CNA C providing care to R2, and did ask CNAC if she needed help, but CNA C told him no. LPN D also stated that CNA C did not request his assistance with R2's bed mobility either. LPN D said R2 was not able to move the lower half of her body, nor her legs, and was non-verbal. LPN D stated that he responded to R2's room at the time of R2's fall, and upon entering the room R2 was on the floor. LPN D further stated that the CNAs were to print out a copy of resident's Kardex at the start of their shift. In an interview on 3/7/2023 at 2:50 PM, CNA E stated that she was working when the incident occurred, and that the CNAs carried walkie talkies. CNA E said she did received a call from CNA C over her walkie talkie to assist with R2's bed mobility and care. CNA E said she had told CNA C that she would be there in a minute after she finished some charting documentation, but stated that CNA C did not wait for her to get to R2's room. CNA E said an emergency call went out and upon arriving to R2's room she observed R2 on the floor. CNA E said that all the CNAs were required to review all assigned resident's Kardex prior to providing care, and were also required to print the Kardex's at the start of their shift to carry with them. Record review of CNA C's employee file revealed that she was termination from her employment at the facility on 7/12/2022 related to R2's fall out of bed, and failure to follow R2's care plan/Kardex. CNA C's filed had also revealed that she had been signed off on training for the use of a resident's Kardex, and following of a resident's care plan when providing resident care on 5/4/2021. In an interview on 3/9/2023 at 10:25 AM, Director of Nursing (DON) B said that it was her expectation that when a resident's care plan revealed the resident required a two person assist for care then two staff members were to provide the care, and if help was not available then the CNA was not to proceed until help arrived. DON B said a resident's Kardex was what CNAs were to refer to prior to providing care, and had all the resident's care plan information on it. DON B also stated that the CNAs were to print out all their resident's Kardex at the start of every shift and review it.

This citation pertains to intake number MI00131560. Based on interview and record review the facility failed to ensure for two out of six residents (Resident #3 and #4) an incident of resident to resident abuse was reported immediately to the facility's Abuse Coordinator, and the state agency, resulting in the potential for further actual or alleged abuse to not be reported immediately to the facility's Abuse Coordinator and state agency. Findings Included: Per the facility face sheet Resident #3 (R3) was admitted to the facility on [DATE], and Resident R4 (R4) was admitted to the facility on [DATE]. Record review of a facility reported incident (FRI) dated 9/12/2023, revealed that on 8/25/2022, R4 hit R3 on the top off her head out of apparent frustration when R3 decided not to take her medications that Licensed Practical Nurse (LPN) F was attempting to administer to her, and revealed that LPN F witnessed the incident. The FRI also revealed that on 8/25/2022 at 9:30 PM revealed that LPN F had written up an incident report regarding the incident. The FRI revealed LPN F was administering medications to R3, who was sitting in the hall in addition to R4, when R4 told R3 to Take your medicine, in which R3 then threw her pills on the floor, R4 then stood up and Further review of the FRI revealed that Certified Nurse Aid (CNA) G was at the nurses station when she saw LPN F attempting to give R3 her medication when R4 started to argue with R3, because R3 did not want to take the medications, so R4 got mad and hit R3 on the back of her head. The FRI revealed that the incident was discovered on 9/12/2022 while Director of Nursing (DON) B was reviewing incident reports. Further review of the FRI revealed that the incident occurred on 8/25/2022 at 9:30 AM, however was not submitted to the state agency until 9/12/22 at 4:30 PM. Review of LPN F's employee file revealed she was hired on 6/28/2021, but no longer worked at the facility. LPN F had received training on Unusual Occurrence Procedure/State Reportable on 7/2/2021 which also included reporting of allegations of abuse documented. Further review of LPN F's employee file revealed that LPN F had been written up on 9/15/2022 due to not reporting the incident. On 3/8/2023 at 10:04 AM, an attempt was made to contact LPN F, however there was no answer. A voicemail was left for a return call. On 3/9/2023 at 8:21 AM, another attempt was made to make phone contact with LPN F, but there was no answer, and another voicemail message was left for a return phone call. At the time of exit on 3/9/2023 at 11:00 AM, no return phone call was received from LPN F. Review of CNA G's employee file revealed an Employee Orientation Checklist dated 1/19/2016, that CNA G was check off on reporting of abuse, including resident to resident abuse. On 3/8/2023 at 10:06 AM, an attempt was made to make contact with CNA G, but there was no answer, and a voicemail was left for a return call. On 3/9/2023 at 8:25 AM, another attempt was made to make phone contact with CNA G but there was no answer, and a voicemail was left for a return call. At the time of exit on 3/9/2023 at 11:00 AM, no return phone call was received from LPN F. In an interview on 3/9/2023 at 10:25 AM, Director of Nursing (DON) B stated that Administrator A was the Abuse Coordinator, however she stated that her expectation was that any staff member who suspects resident abuse were to call her and Administrator A immediately. In an interview on 3/9/2023 at approximately 10:40 AM, Administrator A stated that herself and DON B were to be contacted immediately with any allegations of resident abuse, and the contact numbers were posted. Record review of the facility's policy and procedure titled, Reporting Abuse to Facility Management Policy Statement, dated 9/19/2022 as last revised, revealed, It is the responsibility of our employees, facility consultants, volunteers, attending physicians, family members, visitors etc., to promptly report any incident or suspected incident of mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property to facility management., under Policy Interpretation and Implementation #3. The administrator and director of nursing services must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the administrator and director of nursing services must be called at home. The person reporting must verbally speak to the administrator and director of nursing services, leaving a voice mail is not adequate. If the administrator or DON are off-duty or unavailable, they each notify staff of who is on call to cover them and who would need to be notified verbally.

Based on observation, interview, and record review, the facility failed to follow the standards of care for one resident (Resident #12) receiving hydration and nutrition via a tube feed, resulting in the potential for choking and aspiration. Findings: Resident #12(R12) Review of an Admission Record revealed R12 was a [AGE] year old female, most recently admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 06/07/22 at 11:50 AM certified nurse aide (CNA) K entered R12's room, shut off the tube feed, and changed the resident's brief. During an observation on 06/08/22 at 8:58 AM, R12's tube feed ([MEDICATION(S)] 1.2) was running and the head of the bed was elevated to 15 degrees. The call light sat over the head board out of reach and out of sight of R12. During an observation on 06/08/22 at 9:05 AM, licensed practical nurse (LPN) J entered R12's room to prepare for med pass, did not adjust the head of the bed, and did not place the call light within reach of the resident. During an interview on 06/08/22 at 9:15 AM, LPN J indicated that the position of R12's head of the bed was very low and it had gone unnoticed when the LPN had been in the room a short time ago. LPN J stated that the head of the bed for tube feeding must be at least 30 degrees. During an observation on 06/08/22 at 9:22 AM, LPN J exited R12's room and the call light remained over the head board out of sight and out of reach of the resident. Review of the facility policy Enteral Tubes, last reviewed on 08/10/20, reflected the following: (16) keep the head of bed at least 30 degrees while tube feed is running .(22) nursing staff is responsible for checking the elevation of the head of bed for tube feed resident's when they are in the room .The CNA role with enteral tubes: (1) The CNA does not unhook a tube feeding, change a tube feed rate, or turn the tube feed on or off at anytime .(7) the proper position for a resident with a tube feed is 30 degrees.

Based on observation, interview, and record review, the facility failed to: 1.) ensure residents remained free from falls, and 2.) thoroughly assess and treat pain, for 1 resident (Resident #91), reviewed for quality of care, resulting in ongoing increased pain that was unassessed and untreated after a fall. Findings: Resident #91 (R91) Review of a Face Sheet revealed R91 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for R91, with a reference date of 4/27/22 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R91 was cognitively intact. Review of the Functional Status revealed that R91 required extensive 2 person assist for transferring. During an interview on 06/06/22 at 02:38 PM, R91 reported that she had recently had a fall and was lowered to the ground. R91 reported she was not transferred the correct way from her wheelchair to the bed. R91 reported that she was to have 2 people assist with transferring and only 1 staff was available which resulted in the fall. R91 reported that the aides needed additional education on how to transfer residents. During an interview on 06/08/22 at 3:25 PM, CNA D reported that she was called in to assist R91 and CNA E. CNA D reported that she believed the nurse was notified that the resident fell prior to assisting R91 to bed. CNA D reported that R91 normally transferred with 2 people and would never self-transfer. CNA D reported that there are 4 CNA's per unit which makes it difficult to assist 2 assist residents especially around breakfast time. During an interview on 6/8/22 at 3:35 PM CNA E reported that on the morning of the fall on 6/1/22 staffing was a [MEDICATION(S)] that morning and CNA E was having difficulty getting staff assistance with resident care. CNA E reported that at the time of the fall R91's care plan reflected that R91 was a 2 person assist for transfers. CNA E reported that later that day she was notified that R91 was now a 1 person assist for transfers. CNA E reported that there's absolutely no way she would be safe to be a 1 person assist for transfers. Review of R91's Incident Report dated 6/1/22 revealed, Was transferring resident, who was trying to self transfer, was lowered to the floor .Per resident report she stood up when aide got here, transferred, was lowered to the floor due to unable to make it to the chair . (no documentation of a comprehensive nursing assessment following the fall was located in the medical record). Review of R91's Root Cause Summary dated 6/1/22 revealed, on 6-1-22 it was report (sic) to (Licensed Practical Nurse (LPN) G) Nurse Supervisor, by (LPN H) that (R91) had been lowered to floor. (LPN H) reported that the resident had reported this to the nurse. (LPN G) Nurse supervisor had (LPN H) assess the resident and obtain witness statements from the CNAs and complete an incident report. (LPN) G then notified ADON (Assistant Director of Nursing) and Nurse educator of the situation. Upon investigation (LPN G) Nurse supervisor along with (Registered Nurse Educator RNE I) found that (Certified Nursing Assistant CNA E) was obtaining a second person to assist the resident and while waiting the resident attempted to self-transfer and the Velcro strap became disengaged and R91was lowered to the floor by (CNA E). (CNA D) did enter the room, however the resident had already been lowered to the floor. Both CNAs then applied a gait belt and assisted the resident off the floor and back into her wheel chair (sic). It was found that the resident had reported the fall to the nurse. The careplan (sic), Kardex (brief overview of patient) and orders were reviewed and it was found that on 5/14/22 therapy had written the order, OT (occupational therapy) initial eval and treat completed on 5-14-22. Pt (patient) to be see 5 (times) a week for 4 weeks for thera act, thera ex, self-care, neuro [NAME], wc management and functional transfers. Pt is to be (one person assist) with (four wheeled walker) and gait belt for functional transfers in her room including bed, wheelchair, toileting, and shower chair. Which was placed into (electronic health record) however not updated on the KARDEX. The resident was assessed for safe transfer utilizing 1 person assist and KARDEX was updated. Resident denied any pain for injury at time of incident. Both (CNA E) and (CNA D) were given formal education on Appropriate Response to Any Fall. Both CNAs verbalized understanding of the education given to them. All transfer orders reviewed from 5-1-22 through 6-1 2022 (sic) to verify that the orders were placed in the orders tab, careplan (sic) and KARDEX and no further issues were found. Review of CNA E's Formal Education: Appropriate Response to Any Fall revealed, On 6/1/22 you were attempting to obtain a 2nd person to assist with transferring resident (R91), when resident stood, despite your encouragement to remain seated. resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . At this time, another aide, (CNA D). entered the room to assist as a second person, when she observed the resident on the floor. At this time, both you and (CNA D) applied the resident's gaitbelt and assisted resident off of the floor and into her chair. Your actions were appropriate up until the time (CNA D) entered and you two made the decision NOT to notify the team of the fall by activating the emergency light. You did not follow protocol and did not give the nurse the opportunity to assess resident for injury or other potential changes in condition, as a nurse is specifically trained to do . Review of CNA D's Formal Education: Appropriate Response to Any Fall revealed, On 6/1/22 you entered the room of (R91) in order to assist as a second person during resident's transfer. Upon entering, you reported that you observed resident on the floor with (CNA E) nearby. At this time, both you and (CNA E) applied resident's gaitbelt and assisted resident off of the floor and into her chair. Neither party alerted the nurse to the fact there was a fall . During an interview on 6/8/22 at 3:35 PM CNA E reported that on the morning of the fall on 6/1/22 staffing was a [MEDICATION(S)] that morning and CNA E was having difficulty getting staff assistance with resident care. CNA E reported that at the time of the fall R91's care plan reflected that R91 was a 2 person assist for transfers. CNA E reported that later that day she was notified that R91 was now a 1 person assist for transfers. CNA E reported that there's absolutely no way she would be safe to be a 1 person assist for transfers. During an interview on 06/09/22 at 08:49 AM, R91 reported that she broke her tailbone when she was in her 20's. R91 reported that after the fall on 6/1, her tailbone pain has increased and would rise to 7/10 which is not manageable for her. R91 reported that the physician has not done an assessment and no xray or other diagnostic testing has been completed. R91 reported that the nursing staff have given her warm blankets to sit on which helps ease the pain. R91 reported ever since falling, the pain has been there. R91 reported she has always been a two person assist and reported that is what she should currently be. R91 reported that she was not involved in recent care plan changes. Review of R91's Care Plan revealed, I have acute and chronic pain r/t (related to) [CONDITION(S)] and gout Date Initiated: 05/17/2019 . my pain is tolerable at a level of 6 . Review of R91's Care Plan revealed, I have an ADL (activities of daily living) self-care performance deficit r/t Activity Intolerance, Limited Mobility, RA ([CONDITION(S)]), Gout, [CONDITION(S)] (hypertension), A-fib ([CONDITION(S)]), [CONDITION(S)] Date Initiated . Transfer Order: I transfer with 2 person assist with gait belt and front wheeled walker. My husband has been trained by therapy to assist as second person with transfers. Date Initiated: 05/16/2019 Revision on: 09/22/2021 . (Note: the care plan was changed to reflect 1 person assist with gait belt after the fall on 6/1/22). Review of R91's Electronic Health Record (EHR) revealed no documentation of the fall or the comprehensive nursing assessment following the fall on 6/1/22. Review of R91's Incident Note dated 6/3/22 revealed, Follow up on witnessed fall-lowered to floor during transfer. Resident states the fall has aggravated old tail bone injury 5/10 pain. Continues with unchanged in weight bearing status and range of motion. Review of R91's Incident Note dated 6/4/22 revealed, Follow up fall .5/10 pain to tail bone . Review of R91's Nurse Note dated 6/8/22 revealed, Resident reports some relief to tailbone with application of warm blanket . (indicating ongoing tailbone pain.) Review of R91's EHR revealed no documentation of physician communication for R91's increased pain nor a physician assessment following the fall on 6/1/22 until 6/9/22 at 10:35 A.M. Review of R91's Communication with Physician note dated 6/9/22 at 10:35 A.M. revealed, Resident had a fall 6/1/22 were (sic) she was lowered to the floor during transfer. She is complaining of 7/10 pain at this time to her coccyx. She states she had an old injury that may have been aggravated. Do you want an xray of this area. Please assess and advise .Recommendations: PCP notified and xray of sacral spine ordered.

This citation pertains to MI 505 and MI 016. Based on observation, interview and record review, the facility failed to ensure that residents received treatment/care in accordance with professional standards of practice for R1, resulting in unrecognized weight gains and delays in treatment and hospitalization , and putting an additional 23 facility residents (who were either full code and/or wanted aggressive treatment) with [CONDITION(S)] at risk for delayed treatment and increased risk for hospitalization s and further deteriorations in health. Resident #1 (R1) According to the Minimum Data Set (MDS), dated [DATE], R1 was moderately cognitively impaired, was totally dependent on 2 or more staff for transfers, did not walk and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to MDS data, R1 was discharged to the hospital on 8/09/21 and returned to the facility on [DATE]. Review of R1's End of Life Decisions, dated 12/13/19, revealed she had chosen, hospitalization /No Resuscitation CODE Status: DNR DO NOT provide RESUSCITATION or emergency transportation to the hospital in the event that the resident's heart or breathing stops. Treat all other illnesses aggressively with hospitalization if appropriate. Review of R1's Physician Orders, ordered 3/29/21 and discontinued 8/09/21, revealed, Fluid restriction 2000 cc per 24 hours *Dietary to provide 840 cc *1st shift to provide 500 cc *2nd shift to provide 500 cc *3rd shift to provide 160 cc every shift. In an interview, on 8/25/21 at 3:17 PM, R1's son and power of attorney N reported, (R1) went to the hospital because she gained 31 pounds in three weeks and we had to send her out to the hospital. I finally said we have to do something. I had her sent out because she was getting lethargic. I couldn't let her drown in her own water and die. When she came back, they moved her to a different room . It was neglect, the water issue. In an interview, on 8/23/21 at 10:51 AM, R1's daughter O reported, (R1) was so full of water, it was coming out of her skin . During an observation/interview, on 8/24/21 at 2:02 PM, R1 was sitting in a wheelchair in her room and said, I just got back from the hospital. They took fluid off me. I was gone 17 days. I don't know how it happened (the fluid build up). I had blisters from the fluid. Review of R1's Vital Signs record revealed the following weights between 6/02/21 - 8/20/21: 8/20/2021 5:40 PM - 289.0 Lbs (pounds) Mechanical Lift 8/9/2021 at 9:53 AM - 286.0 Lbs Mechanical Lift 8/8/2021 at 9:39 AM - 314.0 Lbs Mechanical Lift (there was a line drawn through this) 7/14/2021 at 9:14 AM - 253.0 Lbs Mechanical Lift 6/9/2021 at 10:39 AM - 254.0 Lbs Mechanical Lift 6/2/2021 at 8:33 AM - 257.0 Lbs Mechanical Lift According to a Nutrition/Dietary Note for R1, dated Late Entry 6/2/2021 at 10:15 AM, Dietary Administrative Assistant M documented, Note Text: Weights are stable, changing weekly weights to monthly weights. Dietary will continue to monitor. In an interview, on 8/26/21 at 9:54 AM, Dietary Administrative Assistant M reported she was responsible for determining whether a resident would be on daily, weekly, or monthly weights according to the facility Policy and Procedure. Dietary Administrative Assistant M said R1's weights stabilized so she determined she should be a monthly weight and said she had no special orders for residents with CHF. Dietary Administrative Assistant M said, I was called on the 60# wt (weight) gain . There was no indication she had gained so much weight .I see her on a quarterly basis only. According to the facility's Weight Monitoring Policy and Procedure, dated 2/04/20, The weight of all residents will be monitored monthly or more often as indicated by the resident's condition, physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview, on 08/26/2021 at 9:45 AM, Director of Nursing (DON) B stated R1's documented weight on 8/08/21 was not 314.0 Lbs. DON B said, We did a reweight prior to sending her to the hospital on the 8/9/21. The gain was actually 33 pounds. According to a COMMUNICATION - with Physician , dated 7/12/2021 at 3:15 PM, Situation: (Palliative Care Physician T) called and stated that it is recommended to see a Nephrology for her sodium/potassium low levels per lab results . Review of a Nurse Note, dated 7/31/2021 at 6:54 PM, revealed, Note Text: Resident is showing increased in blister size to right arm since yesterday, increase in [CONDITION(S)] to both feet, and had episode of lung congestion with expiratory wheeze post dinner. Duonebs (inhaled medication) given at 1800 (6:00 PM) with relief of wheeze and spo2 remained in the 90's. Review of a Skin/Wound Note, dated 8/2/2021 at 12:59 PM, revealed, Text: right arm, lateral/anterior and posterior aspects are all noted to have intact water blisters from the bicep area to mid forearm, resident denies any pain, no blisters are ruptured at this time, one site is dripping the fluid from a pinhole sized opening, fluid is clear yellow in color, no redness or bruising noted on arm at blister sites at time of assessment, arm is cool to the touch, will continue to monitor and treat. Review of an Orders - Administration Note, dated 8/4/2021 at 11:22 AM, revealed, . pinkness lateral right ankle, right foot with +4 pitting [CONDITION(S)]. Pitting [CONDITION(S)] occurs when excess fluid builds up in the body, causing swelling; when pressure is applied to the swollen area, a pit, or indentation, will remain. Although it can affect any part of the body, pitting [CONDITION(S)] usually occurs in legs, feet, and ankles .+4 [CONDITION(S)]: 8 mm of depression, rebounding in 2-3 minutes . <https://www.osmosis.org/answers/pitting-[CONDITION(S)]> According to a COMMUNICATION - with Family/NOK (next of kin)/POA (power of attorney), dated 8/5/2021 at 12:29 PM, Note Text: Spoke with (Son and durable power of attorney) N, medical decision maker, regarding increase in [MEDICATION(S)] (diuretic) due to [CONDITION(S)] . According to a COMMUNICATION - with Physician , dated 8/8/2021 at 5:46 PM, Situation: Resident's family is requesting resident go to hospital for diuresis due to [CONDITION(S)]. Weight gain of 61 pounds over 3 weeks. She is DNR with hospitalization . Vitals stable, Lungs clear and neuro check baseline. [MEDICATION(S)] increased on 8/5/21. Background: CHF, [CONDITION(S)], HYPO-OSMOLALITY AND [CONDITION(S)], stage 3 kidney disease, obesity, afib, [CONDITION(S)], [CONDITION(S)] AND [CONDITION(S)], [CONDITION(S)] Assessment (RN)/Appearance (LPN): Vitals: T 97.3, P 90, R 16, BP 140/88, spo2 92% on RA, lungs clear/diminished bilateral, A&O x 3, Increased fluid filled blisters multiple right arm, several lower abdomen, one left lower leg, +4 pitting [CONDITION(S)] bilateral lower extremities, weight gain of 61 pounds over last 3 weeks . According to a COMMUNICATION - with Physician , dated 8/25/2021 2:25 PM, Situation: Resident has hx of heart failure, currently on a fluid restriction, and has a hx of [CONDITION(S)]. Background: Assessment (RN)/Appearance (LPN): Recommendations: What is the frequency of weights you would like done? Weekly or Daily. What are the parameter's of the weights taken. Please review and assess. Thank you. Review of a Nurse Note, dated 8/9/2021 at 10:30 AM, revealed, Note Text: Resident transferred to hospital by ambulance per doctor's order for renal failure, recent rapid weight gain of 33lbs. At time of hospital pick up resident is alert and oriented, denies discomfort, VS charted. Awaiting call back from family, who (according to received report) had previously stated that they would like to have her sent to the hospital related to the weight gain. In an interview, on 8/30/21 at 11:27 AM, Registered Nurse (RN) Q reported, (R1) was ordered for monthly weights under tasks in the computer .I investigated it because of the [CONDITION(S)] and the blisters. Family and I decided it would be good to have her go to the hospital. (R1's) [MEDICATION(S)] (diuretic/water pill) was discontinued due to low sodium . The doctor will tweak her diuretics. It is a constant battle because of her CHF. (R1) started having more [CONDITION(S)], so he added a [MEDICATION(S)] (diuretic) dosage. I didn't see any good effects. I got a weight even though she was monthly. Two days later, her weight was down. I do know she had [CONDITION(S)]. I had them repeat the weight that night and it was the same, 314.0 Lbs. I put in the referral .I did the [CONDITION(S)] assessment. The blisters were fuller than usual. (R1's) skin became more fragile due to the [CONDITION(S)] being worse . I was reporting everything to doc; he never ordered weekly weights. I weighed her anyways. I am full time and she is on my section. I can't answer why she wasn't being weighed every three - five days . her legs were weeping . the blisters were getting bigger after [MEDICATION(S)] was discontinued. (R1) is a mechanical lift and they weigh her with the mechanical lift with a weight scale; she gets up everyday. It would be no big deal to weigh her daily, but it would have to be ordered though . She was on a liberal fluid restriction when she went out to the hospital. Always drank all and wanted more . She had no problem staying with the restriction. She can't fill it up herself and move herself to the sink. On 8/30/2021 at 11:34 AM, DON B reported there were 36 residents residing in the facility that had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Treat all other illnesses aggressively with hospitalization if appropriate. In an interview, on 8/30/21 at 12:16 PM, Nurse Aide R reported R1 was compliant with her fluid restriction and said, I never heard her complain about it. About obtaining R1's weights, Nurse Aide R said, Its basically, just lifting her up with the Hoyer to weigh her. In an interview, on 8/30/21 at 3:37 PM, DON B said, I believe that is the best practice for residents with CHF. DON B was unable to say which residents would need weight monitoring more often as indicated by the resident's condition. DON B agreed, the facility was R1's home. In an interview, on 9/01/21 at 12:14 PM, R1's Physician/Medical Director S, reported, (R1) is an [AGE] year-old woman on palliative care. I always look for comfort. (R1) was not on a fluid restriction . One day the nurse called me said she gained 60 #. I said reweigh and it was 30 #. It was a difficult family, so I sent her to the hospital because of the difficult family. I insisted because of the difficult family. No signs of decompensation at the hosp (hospital) either but they kept her. They couldn't diuresis her. She looks better . My main thing is that she was on palliative care with hospitalization . I didn't see any puffiness or swelling, only +1 [CONDITION(S)]. I did not see a reason to send her except because of the family. Keep in mind she is a palliative care patient . Yes, I want to know when she is gaining weight. Mostly they are looking for symptomology. Because of the palliative care and no fluid restriction, monitoring the weight is not going to change the outcome. We just changed for CHF for weekly weights. I put (R1) on weekly weights. Because she was palliative care, I didn't think we need to weigh her every week. Going forward, we will be doing weekly weights on our CHF patients. According to a Hospital Nephrology Consult, dated 8/15/21, .We will switch to P.O. (oral) [MEDICATION(S)] 2 mg twice daily along with [MEDICATION(S)] 5 mg daily. Can be continued at the time of discharge .follow-up with us in 2 weeks. Monitor renal function with diuresis. Cardiology following (afib MV/mitral valve clip). Strict I/O (intake and output), daily weights . Review of R1's Hospital Discharge History and Physical, dated 8/20/21, revealed, Reason for consultation . (8/16/21) Consult to Neurology .Reason for consultation: lethargy, confusion . (8/18/21) Consult to Infectious Diseases .[CONDITION(S)] (urinary tract infection), possible pneumonia XXX[AGE] year old female with history of chronic heart failure with preserved ejection fraction .mitral valve replacement (on [MEDICATION(S)]), [CONDITION(S)], [CONDITION(S)] who is a nursing home resident .who presented because the physician at the nursing home was concerned about her acute weight gain and lower extremity [CONDITION(S)] and intermittent shortness of breath. Patient was admitted for possible heart failure exacerbation and for IV diuretics . initially under observation for diuresis and eventually she required many days of IV diuretics . With aggressive diuresis she did have good urine output and respiratory status improved .She was requiring nocturnal oxygen as well as 1 to 2 L (liters) of oxygen during the day . a chest x-ray on 8/18/21 due to increased cough showed .she was thought to have healthcare associated pneumonia due to the prolonged hospitalization she was started on [MEDICATION(S)] (antibiotic) .she will be treated with [MEDICATION(S)] at the time of discharge for another 5 more days to complete the course of a 7-day antibiotic therapy .She was also found to have a urinary tract infection and urine cultures from 8/17/21 showed Pseudomonas aeruginosa (bacteria) which was also sensitive to [MEDICATION(S)] . hence she will be discharged on [MEDICATION(S)] .Foley catheter was removed prior to discharge .Also patient's [MEDICATION(S)] (hormone) was weaned down to 5 mg daily as of 8/11/21 and has been getting that since then and hence at the time of discharge I greatly do not think that the patient really needs [MEDICATION(S)] . According to Mayo Clinic, Dec. 16, 2020, Corticosteroids carry a risk of side effects, some of which can cause serious health problems . Because oral corticosteroids affect your entire body instead of just a particular area, this route of administration is the most likely to cause significant side effects. Side effects depend on the dose of medication you receive and may include: Fluid retention, causing swelling in your lower legs High blood pressure Problems with mood swings, memory, behavior, and other psychological effects, such as confusion or [CONDITION(S)] Upset stomach Weight gain, with fat deposits in your abdomen, your face and the back of your neck When taking oral corticosteroids longer term, you may experience: Elevated pressure in the eyes ([CONDITION(S)]) Clouding of the lens in one or both eyes ([CONDITION(S)]) A round face (moon face) High blood sugar, which can trigger or worsen diabetes Increased risk of infections, especially with common bacterial, [CONDITION(S)] and fungal microorganisms Thinning bones ([CONDITION(S)]) and fractures Suppressed adrenal gland hormone production that may result in a variety of signs and symptoms, including severe fatigue, loss of appetite, nausea and muscle weakness Thin skin, bruising and slower wound healing Side effects of inhaled corticosteroids . <https://www.mayoclinic.org/steroids/art- 692> According to the National Institute for Health, May 14, 2021, Palliative care is specialized medical care for people living with a serious illness, such as cancer or heart failure. Patients in palliative care may receive medical care for their symptoms, or palliative care, along with treatment intended to cure their serious illness. Palliative care is meant to enhance a person's current care by focusing on quality of life for them and their family. <https://www.nia.nih.gov/health/what-are-palliative-care-and-hospice-care> According to an American Heart Association article entitled Heart Failure Management in skilled Nursing Facilities, dated May 2015, Morbidity and mortality rates are significantly increased for hospitalized older adults with HF (heart failure) discharge to SNFs (skilled nursing facilities) compared with those discharged to other sites.long-term care residents sent to the emergency department are at increased risk for hospital admission and death .General concepts of management of decompensated HF, or volume overload resulting in worsening HF symptoms in SNFs, are similar to those for management of outpatients. Decompensation is usually recognized by a gain in weight . Absence of symptoms at rest does not necessarily indicate stable HF status . According to the U.S. National Library of Medicine, 6/25/20, Heart failure - home monitoring .You will get to know what weight is right for you. Weighing yourself will help you know if there is too much fluid in your body . Weigh yourself every morning on the same scale when you get up -- before you eat and after you use the bathroom. Make sure you are wearing similar clothing each time you weigh yourself. Write down your weight every day on a chart so that you can keep track of it .Call your provider if your weight goes up by more than 3 pounds (about 1.5 kilograms) in a day or 5 pounds (2 kilograms) in a week. Also call your provider if you lose a lot of weight. According to another article from the American Heart Association, entitled Physical Changes to Report for Heart Failure, dated May 31, 2017, Heart failure requires you and your caregivers to pay close attention to any changes in symptoms. If you notice something new, or a sudden worsening of a current symptom, notify your healthcare professional immediately .Watch for: Rapid weight gain - Ask your doctor about the amount of weight gain you should report to him or her. It ' s so important for people with heart failure to weigh themselves every day - preferably every morning, before breakfast and after urinating. Try to weigh yourself daily with the same type of clothes on, without shoes, on the same scale and in the same spot . <https://www.heart.org/en/health-topics/heart-failure/living-with-heart-failure-and-managing-advanced-hf/physical-changes-to-report-for-heart-failure>

This citation pertains to intakes MI 181 and MI 5[AGE] Based on interview and record review, the facility failed to thoroughly investigate allegations of abuse/neglect and misappropriation for 6 residents (Residents #3, #6, #7, #8, #9 and #10) of 11 reviewed for abuse/neglect and misappropriation, resulting in allegations of abuse that were not thoroughly investigated and the potential for further allegations of abuse to not be thoroughly investigated. Findings include: Resident #3 Review of the medical record and Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed that Resident #3 had clear speech, was understood, understands and was cognitively intact. Review of the Facility Reported Incident which was reported to the State Agency on 1/2/20 revealed, (Resident #3) states she took her wedding band off on 1/1/2020 at/around 1300 (1:00 p.m.) and sat it on a puzzle box in her room. She noticed later that evening at 1[AGE]0-1945 (7:30-7:45 p.m.), that it was no longer there but she did not report it until early 1/2/2020 in the morning. It was reported to the supervisor who then contacted the Director of Nursing that a ring was missing that belonged to the resident. A night shift supervisor reviewed cameras on the night it was reportedly missing. At 1430 (2:30 p.m.) on 1/2/2020, the resident asked to speak to the supervisor on duty to report the ring as stolen. During the onsite survey, the facility's investigation file was reviewed. Part of this file was an email that was sent to Director of Nursing (DON) B on 1/2/20 at 4:44 p.m. Review of this email revealed that Shift Supervisor E had completed a camera review and observed the following, From 1305 (1:05 p.m.) till 1415 (2:15 p.m.) she (Resident #3) left with therapy her door was closed and no one entered her room. I was unable to see her leave at any other time she says she left around 1[AGE]0 (6:30 p.m.). I did not see anyone enter besides (Maintenance Staff Q), (Registered Nurse (RN) R), (RN S) and a dietary person I believe (she was delivering a tray). She says that she seen it b4 (before) therapy and reports that she realized it was lost at 715 pm. Further review of the investigation file revealed that as a part of the investigation/follow up action, Staff interviews and witness statements are being obtained for all staff that worked on all shifts for 1/1/2020 and 1/2/2020. Further review of the investigation file failed to reveal any staff interviews. There were witness statements which asked two questions, Did you see or hear of anyone stealing a wedding ring from (Resident #3) on 1/1/2020 or 1/2/2020? and Did you see anyone who was in her room on those dates, who should not have been? For example, a resident, visitor, vendor, etc. Review of the investigation file failed to reveal any witness statements or interviews for the staff members that were seen on video going into Resident #3's room, RN R and RN S. In the investigation file, there was no documentation as to the identification of the dietary person who was seen on the video. During an interview on 2/26/20 at 1:20 p.m., DON B was notified by this surveyor that there were no witness statements from RN R or from RN S. When asked who the dietary person was that was viewed in the video, DON B stated that she did not know and would have to look through the statements and try go see who the dietary person was. DON B further stated that she would have to go back and look to see who was on the schedule that day and see who would have had a reason to go into Resident #3's room, and then see if we have a statement from them. This surveyor confirmed with DON B, that the dietary person was not readily identified, and that DON B was going to compare the statements that were provided as part of the investigation with the dietary staff that were scheduled to work that day to determine who it was. On 2/26/20 DON B sent this surveyor an email which stated, There are three witness statements for dietary staff that you had in the file and I confirmed with the dietary team that these were the people working on that floor that day. They are (Dietary Staff T, U and V). It is common that dietary staff would deliver her tray as she is independent. Review of the Witness Statement dated 1/3/20 and signed by Dietary Staff V revealed that the two questions, Did you see or hear of anyone stealing a wedding ring from (Resident #3) on 1/1/2020 or 1/2/2020? and Did you see anyone who was in her room on those dates, who should not have been? For example, a resident, visitor, vendor, etc. were not answered. This witness statement simply had the date and Dietary Staff V's name and signature. Review of the investigation file failed to reveal where any of the staff that were witnessed to go into Resident #3's room during the time that it was thought Resident #3's wedding band came up missing, were ever interviewed. During an interview on 2/26/20 at 1:20 p.m., when asked if she was interviewed for or provided a witness statement for Resident #3's missing wedding band, RN S stated, No, I did not even know she had a ring. RN S confirmed that she did work on 1/1/20 from 7: 00 a.m.-7:00 p.m., and that Resident #3 was a part of her assignment. RN S further stated that she was not made aware of Resident #3's missing ring until her next work day. RN S confirmed that nobody interviewed her about the missing ring and that she did not write a statement. Residents #6, 7, 8, 9, 10 Review of the medical records and Minimum Data Set Assessments revealed the following: Resident #6 was a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] revealed that Resident #6 was totally dependent of 2 people for transfers and required extensive assistance of 2 people for most other Activities of Daily Living (ADLs). Review of Resident #6' care plan revealed, I prefer to eat my meals in the dining room. Refer to my dietary orders.Try to have me up daily. Resident #7 was a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #7 had clear speech, usually understood, usually understands, was severely impaired cognitively, required extensive assistance of 2 staff for transfers, and extensive assistance of 1-2 staff for most other ADLs. Resident #8 was a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #8 had clear speech, rarely/never understood, rarely/never understands, vision highly impaired, was severely impaired cognitively, requires extensive assistance of 2 staff for transfers and extensive assistance of 1-2 staff members for all other ADLs. Review of Resident #8's care plan revealed, I am on half an hour rounding at this time, please make sure my brief is checked and offer to toilet me regularly.Offer to get me up by 0[AGE]0 (6:00 a.m.) for breakfast. I may refuse and if I do notify the nurse. Resident #9 was a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #9 had unclear speech, was rarely/never understood, rarely/never understands, was severely impaired cognitively, required extensive assistance of 2 staff for transfers, and required extensive assistance of 1-2 staff for most other ADLs. Review of Resident #9's care plan revealed, Offer to get me up 0630 before breakfast I may refuse and if I do notify the nurse Date Initiated: 01/26/2018.Transfer Order: I transfer with 2 person assist Hoyer lift only with green sling Date Initiated: 06/28/2017.BED MOBILITY: Dependent assist of 2 staff, I cannot have a slide sheet on my bed. Date Initiated: 07/06/2017. Resident #10 was a [AGE] year old resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident discharged from the facility on [DATE]. Review of the MDS dated [DATE] revealed that Resident #10 had clear speech, was understood, understands was severely impaired cognitively, required extensive assistance of 2 staff for transfers and requited extensive assistance of 1-2 staff for most other ADLs Review of Resident #10's care plan revealed, Transfer Order: I am a 2 person assist hoyer with a yellow sling. I use a broda chair for facility mobility. Date Initiated: 10/26/2019.I need extensive assistance by 1 staff to turn and re-position in bed as necessary. Date Initiated: 10/26/2019. Review of a Staff/Visitor/Resident Witness Form dated 12/22/19 and signed by Certified Nursing Assistant (CNA) H revealed, (CNA D) was mandated to stay over she had section 2. She did not perform cares on any residents. The few people she got up she only dressed, did not wash. When she left at 11 am (CNA J) took over and I helped her to go through and get everyone done. Rooms of: (Room of Resident #6), (Room of Resident #10), (Room of Resident #7) and (Room of Resident #8) and (Room of Resident #9) were all completes (unable to care for themselves). (CNA D) never asked anyone for help with cares. When she needed help with transfers, we helped. She also had a rude and unapproachable attitude during the shift when we asked a question or for help, she would scoff at us or completely ignore us. During an interview on 2/26/20 at 2:45 p.m., when asked if these allegations of not providing care to these residents was reported to the State Agency, Director of Nursing (DON) B stated no, because it was one CNAs opinion of another CNA not performing their duties. During a telephone interview on 2/26/20 at 2:18 p.m., when asked about the statement she wrote on 12/22/19, CNA H stated that she wrote it out of concern for the residents, We thought (CNA D) had done everything and I was irate because of the way her residents were left. I went to the office and talked to the supervisor (Shift Supervisor I) and she told me to write a statement. I turned it into my supervisor, it was the weekend so the DON or the Administrator were not here. The supervisor said she would take care of it. When asked if she wrote the statement because she felt the residents were neglected, CNA H stated, Yes, I feel so. CNA H continued that the residents were all soaked in their own urine, not just their briefs, but through their clothing onto the bed. When asked if any of the residents would be able to recall these events, CNA H stated, No, they have dementia and they would not be able to remember or tell you about it. During a telephone interview on 2/26/20 at 3:35 p.m. when asked about the morning of 12/22/19 when the concern of residents not being cared for by CNA D occurred, CNA J stated that CNA D was mad because she had to stay and said she was not going to do anything. When it was my turn to take over the schedule (at 11:00 am) there were people that were soaking in pajamas and not washed, they were not pulled up in their beds and were not taken care of, and this was at 11:00 am, so this went from 7:00 a.m. until 11:00 a.m. Residents were not turned, they weren't changed or dressed, they were not washed up, they were soaked, soaked right through to their beds. When asked if she felt the residents were neglected, CNA J stated, Yes. CNA J stated that she had told the supervisor. When asked if she remembered any of the residents that were left this way, CNA J stated that it was a long time ago and she could not remember all of them. CNA J stated she remembers (Resident #6) and (Resident #7), but stated there were others, she just couldn't remember. When asked if she had these types of encounters with CNA D before, CNA J stated that she did not because she does not take over shifts very often. CNA J stated that this particular morning, CNA D, Stood at the circle bench and told us she was not going to take care of anyone. CNA J stated that she had written and provided the supervisor (Shift Supervisor I) a statement. This surveyor asked for this statement during the survey, but the facility was not able to provide it. Multiple attempts to interview CNA D were made with no success. This surveyor asked to review the investigation file for this incident and was provided a one page, two paragraph Inhouse Investigation document completed by Shift Supervisor I and dated 12/22/19 which stated the following: In house investigation was started after a statement was made by (CNA H) regarding cares not completed by (CNA D). The witness statement made stated that (CNA D) did not perform cares on any residents in her assigned section. Statement included that (CNA D) did not help get the residents washed up for the day. Five of the residents in the section are dependent for care. They did require care after (CNA D) left but the was due to preference of the residents at the time. The investigation process began with the witness statement along with video review and a call light audit. The investigation did not result in determining a lack of care to the residents. Video review was performed for the residents on (CNA D's) assigned section. The video review established that (CNA D) did enter resident rooms timely. Throughout the video review, (CNA D) can be seen working and at times wandering but not overly busy. A call light audit was performed for the five residents that were allergy (sic.) not provided cares as stated in the statement. The review did not support or prompt concern of a lack of care. The residents will continue to monitored for any concerns. Review of the medical records revealed that 4 of the 5 residents' cognitive status was severely impaired. During an interview on 2/26/20 at 3:48 p.m., when asked about this investigation, Shift Supervisor I stated, I do recall the concern about the lack of care, and I called (DON B) and I went down and looked at and spoke to the residents. And I went on to look at camera reviews and in this incident we did not find anything wrong. When asked if she had any other witness statements, or interview documentation pertaining to this incident, Shift Supervisor I stated, I don't have any other documentation. When asked if she would had talked to staff as a part of this investigation, Shift Supervisor I stated, I would have spoke with (CNA D). When asked if she talked to anyone else? Shift Supervisor I stated, I can't recall. Shift Supervisor I further stated, that when she visually looked at the residents she did not have any concerns that the residents were not taken care of. Shift Supervisor I further stated that she did not have any other statements from staff telling me that cares were not provided, It was just (CNA H) telling me this. Shift Supervisor I stated she had no other documents pertaining to her investigation because there was nothing out of the ordinary of what she looked at. Shift Supervisor I stated she looked at video and checked all of the residents, and they were clean. This surveyor asked Shift Supervisor I how she could ask the resident about their cares if 4 of the 5 residents were severely impaired cognitively, Shift Supervisor I was not able to answer. Furthermore, Shift Supervisor I stated that when she went down and checked on the residents, they were all clean and cared for. This would have been after CNAs H and J took care of these residents. Review of Residents #6, 7, 8, 9, 10 medical charts failed to reveal any documentation that these residents were assessed on 12/22/19, with the exception of Resident #10 who had a weekly skin assessment completed later in the day. Further review of these medical records failed to reveal any documentation that would indicate any of these residents refused to be turned, cleaned or gotten up for the day.

This citation pertains to intake MI 5[AGE]. Based on interview and record review, the facility failed to immediately report allegations of neglect/abuse for 6 (Resident #6, #7, #8, #9, #10, #11) of 6 residents reviewed for neglect, resulting in allegations of neglect/abuse that were not reported to the State Agency timely and the potential for further allegations of neglect to go unreported, and not thoroughly investigated. Findings Include: Residents #6, 7, 8, 9, 10 Review of the medical records and Minimum Data Set Assessments revealed the following: Resident #6 was a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] revealed that Resident #6 was totally dependent of 2 people for transfers and required extensive assistance of 2 people for most other Activities of Daily Living (ADLs). Review of Resident #6' care plan revealed, I prefer to eat my meals in the dining room. Refer to my dietary orders.Try to have me up daily. Resident #7 was a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #7 had clear speech, usually understood, usually understands, was severely impaired cognitively, required extensive assistance of 2 staff for transfers, and extensive assistance of 1-2 staff for most other ADLs. Resident #8 was a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #8 had clear speech, rarely/never understood, rarely/never understands, vision highly impaired, was severely impaired cognitively, requires extensive assistance of 2 staff for transfers and extensive assistance of 1-2 staff members for all other ADLs. Review of Resident #8's care plan revealed, I am on half an hour rounding at this time, please make sure my brief is checked and offer to toilet me regularly.Offer to get me up by 0[AGE]0 (6:00 a.m.) for breakfast. I may refuse and if I do notify the nurse. Resident #9 was a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #9 had unclear speech, was rarely/never understood, rarely/never understands, was severely impaired cognitively, required extensive assistance of 2 staff for transfers, and required extensive assistance of 1-2 staff for most other ADLs. Review of Resident #9's care plan revealed, Offer to get me up 0630 before breakfast I may refuse and if I do notify the nurse Date Initiated: 01/26/2018.Transfer Order: I transfer with 2 person assist Hoyer lift only with green sling Date Initiated: 06/28/2017.BED MOBILITY: Dependent assist of 2 staff, I cannot have a slide sheet on my bed. Date Initiated: 07/06/2017. Resident #10 was a [AGE] year old resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident discharged from the facility on [DATE]. Review of the MDS dated [DATE] revealed that Resident #10 had clear speech, was understood, understands was severely impaired cognitively, required extensive assistance of 2 staff for transfers and requited extensive assistance of 1-2 staff for most other ADLs Review of Resident #10's care plan revealed, Transfer Order: I am a 2 person assist hoyer with a yellow sling. I use a broda chair for facility mobility. Date Initiated: 10/26/2019.I need extensive assistance by 1 staff to turn and re-position in bed as necessary. Date Initiated: 10/26/2019. Review of a Staff/Visitor/Resident Witness Form dated 12/22/19 and signed by Certified Nursing Assistant (CNA) H revealed, (CNA D) was mandated to stay over she had section 2. She did not perform cares on any residents. The few people she got up she only dressed, did not wash. When she left at 11 am (CNA J) took over and I helped her to go through and get everyone done. Rooms of: (Room of Resident #6), (Room of Resident #10), (Room of Resident #7) and (Room of Resident #8) and (Room of Resident #9) were all completes (unable to care for themselves). (CNA D) never asked anyone for help with cares. When she needed help with transfers, we helped. She also had a rude and unapproachable attitude during the shift when we asked a question or for help, she would scoff at us or completely ignore us. During an interview on 2/26/20 at 2:45 p.m., when asked if these allegations of not providing care to these residents was reported to the State Agency, Director of Nursing (DON) B stated no, because it was one CNAs opinion of another CNA not performing their duties. During a telephone interview on 2/26/20 at 2:18 p.m., when asked about the statement she wrote on 12/22/19, CNA H stated that she wrote it out of concern for the residents, We thought (CNA D) had done everything and I was irate because of the way her residents were left. I went to the office and talked to the supervisor (Shift Supervisor I) and she told me to write a statement. I turned it into my supervisor, it was the weekend so the DON or the Administrator were not here. The supervisor said she would take care of it. When asked if she wrote the statement because she felt the residents were neglected, CNA H stated, Yes, I feel so. CNA H continued that the residents were all soaked in their own urine, not just their briefs, but through their clothing onto the bed. When asked if any of the residents would be able to recall these events, CNA H stated, No, they have dementia and they would not be able to remember or tell you about it. During a telephone interview on 2/26/20 at 3:35 p.m. when asked about the morning of 12/22/19 when the concern of residents not being cared for by CNA D occurred, CNA J stated that CNA D was mad because she had to stay and said she was not going to do anything. When it was my turn to take over the schedule (at 11:00 am) there were people that were soaking in pajamas and not washed, they were not pulled up in their beds and were not taken care of, and this was at 11:00 am, so this went from 7:00 a.m. until 11:00 a.m. Residents were not turned, they weren't changed or dressed, they were not washed up, they were soaked, soaked right through to their beds. When asked if she felt the residents were neglected, CNA J stated, Yes. CNA J stated that she had told the supervisor. When asked if she remembered any of the residents that were left this way, CNA J stated that it was a long time ago and she could not remember all of them. CNA J stated she remembers (Resident #6) and (Resident #7), but stated there were others, she just couldn't remember. When asked if she had these types of encounters with CNA D before, CNA J stated that she did not because she does not take over shifts very often. CNA J stated that this particular morning, CNA D, Stood at the circle bench and told us she was not going to take care of anyone. CNA J stated that she had written and provided the supervisor a statement. This surveyor asked for this statement during the survey, but the facility was not able to provide it. Resident #11 Review of a grievance form that was completed by Resident #11's grandson and dated 1/15/19 (error, should be 1/15/20) revealed, On two separate occasions (CNA D) denied (Resident #11) assistance during evening hours. (CNA D) told (Resident #11) to take care of himself in a disrespectful tone and left my grandfather to tend to himself. According to the investigation file that was provided to this surveyor, Assistant Director of Nursing (ADON) C was responsible for addressing this grievance. During an interview on 2/27/20 at 2:25 p.m., when asked if this concern of CNA D denying Resident #11 was reported to the State Agency, ADON C stated that NHA A and DON B would have known about this during morning meeting. When asked what the definition of neglect is ADON C stated, Someone requesting something, and they are not giving it to them. Or not doing something for someone when they ask. When asked if this grievance was an allegation of neglect ADON C stated, It could be construed as neglect. During an observation and interview on 2/27/20 at 2:10 p.m., Resident #11 was observed to be sitting on the side of his bed. He invited this surveyor into his room and stated that the is not supposed to get up without someone being in his room. Resident #11 then began to stand up and using his foot, was reaching for his shoes that were just out of reach. This surveyor explained to Resident #11 that help could not be provided by the surveyor and suggested that the resident use his call light for assistance. Resident #11 was able to bring his shoes closer to him, sat back down on the side of the bed, and then put his shoes on. When asked about the incident of CNA D not providing him assistance, Resident #11 stated, Yes, it was just one girl. I had asked her for help on two different occasions. The first time my covers were all tangled up and I asked her to help me untangle my covers and cover me up. (CNA D) said, 'What? I am not helping you untangle your covers; you can untangle them yourself' and then she walked out. Just the attitude alone was enough to scare me. The second time, I just asked her to cover me up, and again she said, 'I'm not doing that' She was not going to help me with my covers and 'I could do it myself'. After that I just stopped asking for help. Both times it was between 3-4 a.m., and there wasn't much going on. I wasn't asking for much. After the second time, I would ask who was taking care of me and if it was her (CNA D), I just wouldn't ask for help. When asked how this made him feel, Resident #11 stated, Just her attitude alone was scary, it was very intimidating. She is the only one, all the other staff have been great. Review of Resident #11's ADL, self-care deficit related to [MEDICAL CONDITION], initiated on [DATE] revealed the following intervention, BED MOBILITY: I require extensive assistance by 1 staff member for bed mobility. Date Initiated: [DATE]19. Multiple attempts to interview CNA D were made with no success.

This citation pertains to intakes MI 181 and MI 5[AGE] Based on observation, interview, and record review, the facility failed to provide an environment free from neglect and verbal abuse for 6 (Residents #6, #7, #8, #9, #10 and #11) of 11 reviewed for abuse and neglect resulting in residents #6, 7, 8, 9, 10 being left soiled and Resident #11 feeling scared and intimidated. Residents #6, 7, 8, 9, 10 Review of the medical records and Minimum Data Set Assessments revealed the following: Resident #6 was a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] revealed that Resident #6 was totally dependent of 2 people for transfers and required extensive assistance of 2 people for most other Activities of Daily Living (ADLs). Review of Resident #6' care plan revealed, I prefer to eat my meals in the dining room. Refer to my dietary orders.Try to have me up daily. Resident #7 was a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #7 had clear speech, usually understood, usually understands, was severely impaired cognitively, required extensive assistance of 2 staff for transfers, and extensive assistance of 1-2 staff for most other ADLs. Resident #8 was a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #8 had clear speech, rarely/never understood, rarely/never understands, vision highly impaired, was severely impaired cognitively, requires extensive assistance of 2 staff for transfers and extensive assistance of 1-2 staff members for all other ADLs. Review of Resident #8's care plan revealed, I am on half an hour rounding at this time, please make sure my brief is checked and offer to toilet me regularly.Offer to get me up by 0[AGE]0 (6:00 a.m.) for breakfast. I may refuse and if I do notify the nurse. Resident #9 was a [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed Resident #9 had unclear speech, was rarely/never understood, rarely/never understands, was severely impaired cognitively, required extensive assistance of 2 staff for transfers, and required extensive assistance of 1-2 staff for most other ADLs. Review of Resident #9's care plan revealed, Offer to get me up 0630 before breakfast I may refuse and if I do notify the nurse Date Initiated: 01/26/2018.Transfer Order: I transfer with 2 person assist Hoyer lift only with green sling Date Initiated: 06/28/2017.BED MOBILITY: Dependent assist of 2 staff, I cannot have a slide sheet on my bed. Date Initiated: 07/06/2017. Resident #10 was a [AGE] year old resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident discharged from the facility on [DATE]. Review of the MDS dated [DATE] revealed that Resident #10 had clear speech, was understood, understands was severely impaired cognitively, required extensive assistance of 2 staff for transfers and requited extensive assistance of 1-2 staff for most other ADLs Review of Resident #10's care plan revealed, Transfer Order: I am a 2 person assist hoyer with a yellow sling. I use a broda chair for facility mobility. Date Initiated: 10/26/2019.I need extensive assistance by 1 staff to turn and re-position in bed as necessary. Date Initiated: 10/26/2019. Review of a Staff/Visitor/Resident Witness Form dated 12/22/19 and signed by Certified Nursing Assistant (CNA) H revealed, (CNA D) was mandated to stay over she had section 2. She did not perform cares on any residents. The few people she got up she only dressed, did not wash. When she left at 11 am (CNA J) took over and I helped her to go through and get everyone done. Rooms of: (Room of Resident #6), (Room of Resident #10), (Room of Resident #7) and (Room of Resident #8) and (Room of Resident #9) were all completes (unable to care for themselves). (CNA D) never asked anyone for help with cares. When she needed help with transfers, we helped. She also had a rude and unapproachable attitude during the shift when we asked a question or for help, she would scoff at us or completely ignore us. During a telephone interview on 2/26/20 at 2:18 p.m., when asked about the statement she wrote on 12/22/19, CNA H stated that she wrote it out of concern for the residents, We thought (CNA D) had done everything and I was irate because of the way her residents were left. I went to the office and talked to the supervisor (Shift Supervisor I) and she told me to write a statement. I turned it into my supervisor, it was the weekend so the DON or the Administrator were not here. The supervisor said she would take care of it. When asked if she wrote the statement because she felt the residents were neglected, CNA H stated, Yes, I feel so. CNA H continued that the residents were all soaked in their own urine, not just their briefs, but through their clothing onto the bed. When asked if any of the residents would be able to recall these events, CNA H stated, No, they have dementia and they would not be able to remember or tell you about it. During a telephone interview on 2/26/20 at 3:35 p.m. when asked about the morning of 12/22/19 when the concern of residents not being cared for by CNA D occurred, CNA J stated that CNA D was mad because she had to stay and CNA D said she was not going to do anything. When it was my turn to take over the schedule (at 11:00 am) there were people that were soaking in pajamas and not washed, they were not pulled up in their beds and were not taken care of, and this was at 11:00 am, so this went from 7:00 a.m. until 11:00 a.m. Residents were not turned, they weren't changed or dressed, they were not washed up, they were soaked, soaked right through to their beds. When asked if she felt the residents were neglected, CNA J stated, Yes. CNA J stated that she had told the supervisor. When asked if she remembered any of the residents that were left this way, CNA J stated that it was a long time ago and she could not remember all of them. CNA J stated she remembers (Resident #6) and (Resident #7), but stated there were others, she just couldn't remember. When asked if she had these types of encounters with CNA D before, CNA J stated that she did not because she does not take over shifts very often. CNA J stated that this particular morning, CNA D, Stood at the circle bench and told us she was not going to take care of anyone. CNA J stated that she had written and provided the supervisor (Shift Supervisor I) a statement. This surveyor asked for this statement during the survey, but the facility was not able to provide it. Review of a Staff Witness Form dated 12/22/19 completed by CNA L revealed, I came on her (CNA D's) hallway. She asked me did she have to get (Resident #9) up. I said I believe we need to get everyone up. She said, 'well her (Resident #9's) care plan says preferred to eat in dinning not must. I'm not getting anyone up' and walked away. During a telephone interview on 2/27/20 at 9:50 a.m., when asked about the staff witness statement, CNA L stated that she normally does not work 1st shift, so she was not that familiar with what needed to be done. CNA L stated that CNA D came up to her and asked about having to get Resident #9 up. CNA L stated that CNA D first asked the nurse if she had to get Resident #9 up, to which the nurse said yes, then she asked CNA L. CNA L stated that during the morning CNA D told everyone that she was not getting anyone up. CNA L further stated that CNA D was mad about being mandated, she told me she was not happy about it. When asked if CNA D helped her during the morning, CNA L stated, Every time I looked for her she was nowhere to be found.All I can say is that when I was looking for her, I was unable to find her to include looking in the rooms she was responsible for. CNA L further stated that the Supervisor did come and talk with her and that she told the supervisor that that she could not find (CNA D) to help her. CNA D no longer worked at the facility. Multiple attempts to interview CNA D were made with no success. This surveyor asked to review the investigation file for this incident and was provided a one page, two paragraph Inhouse Investigation document completed by Shift Supervisor I and dated 12/22/19 which stated the following: In house investigation was started after a statement was made by (CNA H) regarding cares not completed by (CNA D). The witness statement made stated that (CNA D) did not perform cares on any residents in her assigned section. Statement included that (CNA D) did not help get the residents washed up for the day. Five of the residents in the section are dependent for care. They did require care after (CNA D) left but the was due to preference of the residents at the time. The investigation process began with the witness statement along with video review and a call light audit. The investigation did not result in determining a lack of care to the residents. Video review was performed for the residents on (CNA D's) assigned section. The video review established that (CNA D) did enter resident rooms timely. Throughout the video review, (CNA D) can be seen working and at times wandering but not overly busy. A call light audit was performed for the five residents that were allergy (sic.) not provided cares as stated in the statement. The review did not support or prompt concern of a lack of care. The residents will continue to monitored for any concerns. Review of the medical records revealed that 4 of the 5 residents' cognitive status was severely impaired. During an interview on 2/26/20 at 3:48 p.m., when asked about this investigation, Shift Supervisor I stated, I do recall the concern about the lack of care, and I called (DON B) and I went down and looked at and spoke to the residents. And I went on to look at camera reviews and in this incident we did not find anything wrong. When asked if she had any other witness statements, or interview documentation pertaining to this incident, Shift Supervisor I stated, I don't have any other documentation. When asked if she would had talked to staff as a part of this investigation, Shift Supervisor I stated, I would have spoke with (CNA D). When asked if she talked to anyone else? Shift Supervisor I stated, I can't recall. Shift Supervisor I further stated, that when she visually looked at the residents she did not have any concerns that the residents were not taken care of. Shift Supervisor I further stated that she did not have any other statements from staff telling me that cares were not provided, It was just (CNA H) telling me this. Shift Supervisor I stated she had no other documents pertaining to her investigation because there was nothing out of the ordinary of what she looked at. Shift Supervisor I stated she looked at video and checked all of the residents, and they were clean. This surveyor asked Shift Supervisor I how she could ask the resident about their cares if 4 of the 5 residents were severely impaired cognitively, Shift Supervisor I was not able to answer. Furthermore, Shift Supervisor I stated that when she went down and checked on the residents, they were all clean and cared for. This would have been after CNAs H and J took care of these residents. Review of Residents #6, 7, 8, 9, 10 medical charts failed to reveal any documentation that these residents were assessed on 12/22/19, with the exception of Resident #10 who had a weekly skin assessment completed later in the day. Further review of these medical records failed to reveal any documentation that would indicate any of these residents refused to be turned, cleaned or gotten up for the day. Resident #11 Review of a grievance form that was completed by Resident #11's grandson and dated 1/15/19 (error, should be 1/15/20) revealed, On two separate occasions (CNA D) denied (Resident #11) assistance during evening hours. (CNA D) told (Resident #11) to take care of himself in a disrespectful tone and left my grandfather to tend to himself. According to the investigation file that was provided to this surveyor, Assistant Director of Nursing (ADON) C was responsible for addressing this grievance. During an interview on 2/27/20 at 2:25 p.m., when asked if this concern of CNA D denying Resident #11 was reported to the State Agency, ADON C stated that NHA A and DON B would have known about this during morning meeting (which would have been the following day). When asked what the definition of neglect is ADON C stated, Someone requesting something, and they are not giving it to them. Or not doing something for someone when they ask. When asked if this grievance was an allegation of neglect ADON C stated, It could be construed as neglect. During an observation and interview on 2/27/20 at 2:10 p.m., Resident #11 was observed to be sitting on the side of his bed. He invited this surveyor into his room and stated that the is not supposed to get up without someone being in his room. Resident #11 then began to stand up and using his foot, was reaching for his shoes that were just out of reach. This surveyor explained to Resident #11 that help could not be provided by the surveyor and suggested that the resident use his call light for assistance. Resident #11 was able to bring his shoes closer to him, sat back down on the side of the bed, and then put his shoes on. When asked about the incident of CNA D not providing him assistance, Resident #11 stated, Yes, it was just one girl. I had asked her for help on two different occasions. The first time my covers were all tangled up and I asked her to help me untangle my covers and cover me up. (CNA D) said, 'What? I am not helping you untangle your covers; you can untangle them yourself' and then she walked out. Resident #11 further stated, Just the attitude alone was enough to scare me. The second time, I just asked her to cover me up, and again she said, 'I'm not doing that' She was not going to help me with my covers and said that I could do it myself. After that I just stopped asking for help. Both times it was between 3-4 a.m., and there wasn't much going on. I wasn't asking for much. After the second time, I would ask who was taking care of me and if it was her (CNA D), I just wouldn't ask for help. When asked how this made him feel, Resident #11 stated, Just her attitude alone was scary, it was very intimidating. She is the only one, all the other staff have been great. Review of Resident #11's ADL, self-care deficit related to [MEDICAL CONDITION], initiated on [DATE] revealed the following intervention, BED MOBILITY: I require extensive assistance by 1 staff member for bed mobility. Date Initiated: [DATE]19. Multiple attempts to interview CNA D were made with no success.

Based on interview, and record review, the facility failed to implement interventions to prevent the development of a deep tissue injuries on the heels and coccyx of one resident (#324) out of two residents reviewed for pressure ulcers resulting in Resident #324 developing 3 unstageable pressure ulcers (deep tissue injury). Findings include: Review of the medical record and Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #324 was a [AGE] year old female resident admitted to the facility on [DATE], from the hospital where she as treated for [REDACTED]. Review of the MDS revealed that Resident #324 had clear speech, was understood, understands, was moderately impaired cognitively, required extensive assistance of two staff for bed mobility and transfers. Further review of the MDS revealed Resident #324 had 2 Stage 2 unhealed pressure ulcers that were not present upon admission. Review of the Wound-Weekly Observation Tool dated 10/21/19 for Wound #1 revealed Resident #324 acquired a pressure ulcer on the left heel which was staged as SDTI (Suspected Deep Tissue Injury). The wound measured 30x30 mm (millimeters) and had necrotic tissue present. The extent of the necrosis was describe as 75% of the wound bed. Further review of the medical record revealed that this wound was first observed on 8/19/19 and measured 50x60 mm. Review of the Wound-Weekly Observation Tool dated 10/21/19 for Wound #2 revealed Resident #324 acquired a pressure ulcer on the right heel which was staged as SDTI (Suspected Deep Tissue Injury). The wound measured 10x13 mm (millimeters) and had necrotic tissue present. The extent of the necrosis was describe as 15% of the wound bed. Further review of the medical record revealed that this wound was first observed on 8/19/19 and measured 40x45 mm. Review of the Wound-Weekly Observation Tool dated 10/21/19 for Wound #3 revealed Resident #324 acquired a pressure ulcer on the coccyx which was staged as SDTI (Suspected Deep Tissue Injury). The wound measured 10x3 mm (millimeters) and had necrotic tissue present. The extent of the necrosis was describe as 100% of the wound bed. Further review of the medical record revealed that this wound was first observed on 10/2/19 and measured 15x10 mm. Review of the admission assessment dated [DATE] failed to reveal any documented pressure wounds for Resident #324. Review of the admission Braden scale assessment dated [DATE] revealed that Resident #324 was a Moderate Risk for developing pressure ulcers. Review of Resident #324's baseline care plan revealed that it was created on 8/13/19, four days after Resident #324 was admitted to the facility. Further review of this care plan failed to reveal any interventions that would address Resident #324's Moderate Risk for developing pressure ulcers. Review of Resident #324's Skin Observation Tools revealed the following: --8/16/19, skin breakdown bilateral inner ankles/feet. Treatment dressing intact. Wound nurse notified . --8/23/19, wounds bilateral heels. Coccyx dark red scabbed in middle. Surrounding skin thin with sign of breakdown' Review of Resident #324's comprehensive care plan revealed the Focus area of, I am at risk for skin breakdown related to femur fracture, non weight bearing to left but this care plan was not initiated until 8/20/19, after Resident #324 developed the two ulcers on her heels. During an interview on 10/30/19 at 1:50 PM when asked about Resident #324's pressure wounds, Unit Manager, Registered Nurse (RN) K agreed that the three wounds were acquired in the facility. When asked what interventions were put in place to prevent the development of the pressure wounds, RN K stated, She is semi-immobile, we try to get her boots and other interventions in place upon admission (but in this case these interventions were not put in place upon admission). Resident #324 was a little malnourished and dehydrated and not moving well. While looking at the medical chart, RN K commented on the that the Braden scale assessment dated [DATE], She scored as a moderate risk. When asked about Resident #324's baseline care plan, RN K looked in the medical chart and agreed that it was not completed in the required time frame, I can attest to that. During this same interview, when asked what interventions were in place prior to the development of these heel wound, RN K looked in the medical record and stated that only the standard of practice interventions like turn every two hours were in place. RN K agreed that there were no additional interventions in place to prevent development of pressure wounds. When asked what type of interventions would be expected to be put into place after the Braden Scale Assessment completed upon admission scored Resident #324 as being a Moderate Risk, RN K stated, She was a severe risk because of that hip (Resident #324 was admitted with a [MEDICAL CONDITION]). With her and the hip and the immobility would want to see air mattress, blue boots, wedges. RN K confirmed that these interventions were not in place prior to Resident #324 developing the heel wounds. During the survey, Resident #324 declined request for nurse surveyor to observe her wounds.

Based on observation, interview and record review, the facility failed to follow their policy for the storage of refrigerated medications in 2 of 4 medication rooms observed resulting in the likelihood that there would be a decrease in efficacy of medication and a loss of potency so residents receiving the medications would not receive the total action of the medication. Findings include: On 10/30/19 at 9:16 AM, in the presence of Licensed Practical Nurse (LPN) F, the Harbors B side refrigerator was observed. The inside door of the fridge was smooth so that no medications would be stored there. There was no freezer compartment noted. The outside of the fridge had an electronic thermometer attached. A record review of the temperature log for (MONTH) 2019 revealed that temperatures were not consistently documented three times a day, as noted on their facility policy, on the am, pm' and noc (night) columns of the temperature logs. No temperatures were noted for the AM, PM and N[NAME] shifts for (MONTH) 2, 3, 4, 10, 11. The pm and noc temperatures were not documented on (MONTH) 7th. The noc temperature was not documented for (MONTH) 15th and the am temperature was not documented for (MONTH) 16th. In (MONTH) 2019, the following dates and times were missing temperature documentation: 9/3 - no temperatures, 9/5 - ''am'' and ''pm'', 9/6 ''pm'', 9/7 - ''noc'', 9/8 - ''noc'', 9/9 - no temperature documentation for any of the 3 times, 9/10 - ''noc'', 9/14 - ''pm'' and ''noc'', 9/15 to 9/20 - no temperatures documented, 9/22 - ''noc'' missing, 9/23 - no temperatures documented, 9/24 - ''noc'', 9/26 - ''noc'', 9/27 - ''noc'', 9/28 - ''noc'', 9/30 - ''pm'' and ''noc'' missing and 9/31 - no temperatures documented. The temperature logs for April, May, (MONTH) (MONTH) and (MONTH) 2019 were reviewed and the same pattern of missing temperatures was noted. The Harbors refrigerator contained the following medications: [REDACTED]. On 10/30/19 at 9:26 AM, in the presence of Registered Nurse (RN) G, the medication refrigerator on Safe Havens unit was observed. An electronic thermometer was noted on the outside of the refrigerator door. The (MONTH) 2019 Vaccine Storage Temperature Log was reviewed and revealed there were no temperatures documented for the month of (MONTH) until pm on (MONTH) 23rd. An interview with the Infection Control RN (IC) J indicated the refrigerator was out of service from 9/27/19 until 10/23/19. No temperatures were documented for the following dates and shifts: 10/23-noc, 10/24 - pm and noc, 10/25 - pm, 10/26 - am, pm, noc; 10/27 - noc, 10/28 - noc and 10/29 - noc. The (MONTH) 2019 log indicated the following missing temperatures: ''am'' temperatures were not documented for 9/1, 9/2, 9/4, 9/5, 9/8, 9/11, 9/14, 9/21, 9/22; ''pm'' temperatures were not documented on9/5, 9/6, 9/12, 9/19, 9/24, 9/27, 9/29; and ''noc'' temperatures were not documented for 9/2, 9/4, 9/10, 9/11, 9/12, 9/13, 9/14, 9/15, 9/17, 9/18, 9/19, 9/23, 9/24; and no temperatures for any of the three time categories were documented for 9/3, 9/7, 9/9, 9/25, 9/26, 9/28, 9/30, and 9/31. The same pattern was noted in April, May, (MONTH) (MONTH) and (MONTH) 2019. The Safe Havens Refrigerator contained the following medications: [REDACTED]. On 10/30/19, a record review of the Vaccine Storage policy and procedure with a revised date of 10/29/19 indicated All refrigerators will remain in the range of 35 degrees Fahrenheit to 46 degrees Fahrenheit. On 10/30/19 at 11:30 AM, in an interview with Infection Control (IC) RN J was done. When IC J was shown the 6 months' of refrigerator logs she indicated that the facility policy was to check the temperatures three times a day. When asked who reviewed the logs at the end of the month, she stated the logs were sent to a secretary and IC J was not sure if anyone clinically reviewed them. In addition, a discussion about the correct temperature range for refrigerated medications as indicated by the Centers for Disease Control (CDC) determined the documentation on the refrigerator logs and in their vaccine storage policy and procedure was incorrect. According to the Centers for Disease Control (CDC), the temperature range for storing immunizations and biologicals is 36 degrees Fahrenheit to 46 degrees Fahrenheit. The temperature range documented on the facility's policy and procedure for vaccine storage and on the temperature log indicated the range to be 35 degrees Fahrenheit and not 36 degrees as noted by the CDC.

Based on interview and record review, the facility failed to ensure a baseline care plan that included information to properly care for 1 (Residents #324) of 25 residents reviewed for care plans was developed and implemented, resulting in the potential for unmet care needs, and the development of multiple deep tissue injuries. Findings include: Review of the medical record and Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #324 was a [AGE] year old female resident admitted to the facility on [DATE], from the hospital where she as treated for [REDACTED]. Review of the MDS revealed that Resident #324 had clear speech, was understood, understands, was moderately impaired cognitively, required extensive assistance of two staff for bed mobility and transfers. Further review of the MDS revealed Resident #324 had two Stage 2 unhealed pressure ulcers that were not present upon admission. Review of the Wound-Weekly Observation Tool, dated 10/21/19, for Wound #1 revealed Resident #324 acquired a pressure ulcer on the left heel which was staged as SDTI (Suspected Deep Tissue Injury). The wound measured 30x30 mm (millimeters) and had necrotic tissue present. The extent of the necrosis was describe as 75% of the wound bed. Further review of the medical record revealed that this wound was first observed on 8/19/19 and measured 50x60 mm. Review of the Wound-Weekly Observation Tool, dated 10/21/19, for Wound #2 revealed Resident #324 acquired a pressure ulcer on the right heel which was staged as SDTI (Suspected Deep Tissue Injury). The wound measured 10x13 mm (millimeters) and had necrotic tissue present. The extent of the necrosis was describe as 15% of the wound bed. Further review of the medical record revealed that this wound was first observed on 8/19/19 and measured 40x45 mm. Review of the Wound-Weekly Observation Tool dated 10/21/19 for Wound #3 revealed Resident #324 acquired a pressure ulcer on the coccyx which was staged as SDTI (Suspected Deep Tissue Injury). The wound measured 10x3 mm (millimeters) and had necrotic tissue present. The extent of the necrosis was describe as 100% of the wound bed. Further review of the medical record revealed that this wound was first observed on 10/2/19 and measured 15x10 mm. Review of the admission assessment dated [DATE] failed to reveal any documented pressure wounds for Resident #324. Review of the admission Braden scale assessment dated [DATE] revealed that Resident #324 was a Moderate Risk for developing pressure ulcers. Review of Resident #324's baseline care plan revealed that it was created on 8/13/19, four days after Resident #324 was admitted to the facility. Further review of this care plan failed to reveal any interventions that would address Resident #324's Moderate Risk for developing pressure ulcers. During an interview on 10/30/19 at 1:50 PM, when asked about Resident #324's pressure wounds, Unit Manager, Registered Nurse (RN) K agreed that the three wounds were acquired in the facility. When asked what interventions were put in place to prevent the development of the pressure wounds, RN K stated, She is semi-immobile, we try to get her boots and other interventions in place upon admission (but in this case these interventions were not put in place upon admission). Resident #324 was a little malnourished and dehydrated and not moving well. While looking at the medical chart RN K commented that the Braden scale assessment dated [DATE], She scored as a moderate risk. When asked about Resident #324's baseline care plan, RN K looked in the medical chart and agreed that it was not completed in the required time frame, I can attest to that. During the survey, Resident #324 declined request for nurse surveyor to observe her wounds.

Based on observation, interview and record review the facility failed to log and resolve grievances in a timely manner brought forth by the Resident Council members and for one resident (#65). Resulting in feelings of frustration and concerns related to care not being addressed. Findings include: On 1/08/2019 at 10:00 am, during the Resident Council meeting 8 of the 12 council participants reported their call light response time frequently exceeds 45 minutes, particularly on second shift. Resident Council members further stated they have brought this concern forward in their Resident Council meetings, care conferences and on an individual basis but have not had their concerns addressed or provided any type of response. Review of the Resident Council meeting minutes dated 12/04/18 reflected in part, .residents stated that 2nd shift call lights are not being answered in a timely fashion Review of the facility grievance log reflected the last entry was 11/27/2018. On 01/09/2019 at 4:10 PM, during an interview with Activity Director AA she reported she conducted resident council meeting and after each meeting sent concerns to all department managers and the Administrator, at this time each department manager was to address whatever concern pertains to them and, make an effort to resolve the issue, log it on the grievance log and report back to Activity Director AA in writing so that she can provide responses back to the Resident Council at their next meeting. When Activity Director AA was asked to provide the resolution and or response provided to the resident council from the 12/04/2018 meeting. Activity Director AA stated she did not have any responses from that meeting. On 1/10/19 at 10:15 AM, during an interview with Director of Nursing (DON) B , she reported the process was to be handled as explained by Activity Director AA. DON B offered no explanation as to why she had not logged the concern related to staffing/call light response time or had provided a written response back to Resident Council. On 1/10/19 at 11:10 AM, during an interview with Administrator A she reported she was aware of call light response times being a concern for residents, but was not able to explain why the grievance log was not maintained or why there was no response to the concern. Review of the undated facility policy related to grievances reflected: 4. The resident, or person acting in the behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within 30 days of the filing the grievance or complaint. 9. Upon receipt of the complaint (written or verbal) an investigation will begin. Within 5 working days of receiving the complaint, a written report of findings will be created. The person filing the will be notified of the findings of the investigation and corrective action within 30 days of filing the complaint. Resident #65 (R65) According to R65's Minimum Data Set, dated dated [DATE], R65 was cognitively intact and had [DIAGNOSES REDACTED]. During an observation/interview, on 01/07/19 at 10:48 AM, R65 was lying in bed and stated the facility was responsible for ruining his personal cell phone when they ran it through the laundry with his clothes, he had complained to the facility and they said they were working on replacing it but he had heard nothing and he had been without his cell phone for months. R65 also said, I want to get my hair cut. I signed up at the desk a long time ago and haven't heard a thing about when it will happen. I look a mess. I look terrible. I want my hair cut. I complained. I think I've done everything . I need to have my teeth looked at. They need to be cleaned. I signed the paper to have it done when I first got here, but I haven't heard anything about that either. Review of a Dental Consent form revealed R65 signed it on 11/16/18. According to a Social Work Progress Note, dated 12/3/2018 at 13:36, (R65's) mobile phone was sent to laundry and it was put through the washer. Laundry put it in rice over the weekend. However, it no longer works. He is furious. He said somebody better pay for that sh*t. It's not my fault. Inquired of Administration will replace it. In the meantime, this writer requested IT enable the service on the landline in his room. He's not happy about that being his only way to communicate . In an interview, on 01/09/19 at 11:08 AM, Social Worker (SW) GG reported, R65's phone, it went through the wash. I talked to his brother about it. Facility does his laundry. Talked to the Nursing Home Administrator (NHA A) about what steps he could take. We gave him a phone in his room. When we were addressing that (replacing his cell phone), he went out to the hospital. I sent emails (to NHA A). I did not make out a concern form. No form was made out . Last met with (R65) on 12/03/18 to talk about his phone. (R65) went to the hospital on [DATE] and came back on 12/17/18. I forgot about it. SW GG said she would look into why R65 had not had his hair cut or made aware of when his dental appointment is scheduled to be done.

This citation pertains to intake MI 461. Based on observation, interview and record review, the facility failed to ensure supervision for 1 (Resident #2) of 8 residents reviewed for falls of a total sample of 21, resulting in acute subdural hemorrhages (brain bleed), pain, discomfort and admission to the hospital. Findings Include: Review of the Face Sheet, Minimum (MDS) data set [DATE], physician and nurses note's dated 7/26/17 through 9/19/17, Medication Administration Record and Hospital note's dated 8/2/17 through 8/4/17, revealed Resident #2 was a [AGE] year old female admitted to the facility on [DATE], had a BIMS of 8 (cognitive assessment score of 8 indicates cognitive impairment), confused with behaviors and not able to make her own healthcare decisions with a power of attorney in place; she was being weaned off of hospice medications and was waking-up. Resident #2 was totally dependent on staff for all Activities of Daily Living (ADL's) and safety needs due to decreased safety awareness. Facility staff member M (Physician Assistant/PA) had discontinued the resident's hospice ordered medications she was admitted on and the results of the resident became more alert and active. The resident's [DIAGNOSES REDACTED]. Observation of Resident #2 was done on 9/19/17 at 9:23 a.m., during the initial tour. The resident was sitting in her wheelchair, confused and unable to be interviewed due to decreased cognitive ability. The resident had a large light blue/green bruise on the right side of her face under her eye down toward her lower cheek area. Review of the facility Five Day Investigation dated 8/8/17, revealed on 8/2/17 at approximately 2:45 p.m., Resident #2 was found by staff (staff member Y Nursing Assistant/CNA) face down on the floor in her room, next to her bed. The facility Incident Report dated 8/2/17, stated Resident was found in her room lying on her left side. Resident's feet were facing towards the foot of her bed. Resident was facing towards the wall at the head of her bed. It appeared that resident stood without staff assist, and fell , hitting on the wall at the head of her bed. Resident then fell to the ground, hitting her left arm on the floor. The resident was transferred to the hospital and admitted due to a intracranial bleed (brain bleed) and readmitted to the facility on [DATE]. The resident was moved to a room closer to the nurse's station and fall preventive measures were put in place after her fall on 8/2/17. Review of the facility Incident Report dated 8/2/17, stated Remedial measures to prevent incident reoccurring, Resident made falling leaf, perimeter mattress obtained and resident room change. Staff educated on being aware if resident is with family where the resident is when family leaves. Review of the hospital note's dated 8/2/17 to 8/4/17, stated Patient was seen on 8/2/17 at (hospital) Cognition: Impulsive, Poor judgement, Poor safety awareness, Poor attention/concentration. The patient is a 80 y.o. female s/p fall from standing (mechanical). Pt (patient) with Alzheimer's had unwitnessed fall at nursing home today. She has been bedridden for last several weeks as she was recently taken off hospice. She has been somnolent since the fall. Her family says she has was talking much more before. She is not on any anticoagulation (blood thinner medication) anymore as her family took it off for frequent falls several months ago. The patient was found on the edge of her head with blood coming from a laceration on her head. The patient was sent to ER (emergency room ) for further evaluation where she was found to have a subdural hematoma and subarachnoid hemorrhage (brain bleed) resulting in current admission. Since admission patient has remained somnolent and has continued to be dependent on assistance with all ADL's. (BB Family Member #1/Power of Attorney) reports that she suffered a closed head injury so she knows that it will take time to heal and get the patient back to her baseline. Review of the hospital Imaging, CT (CAT scan) report dated 8/3/17, stated Small acute subdural hemorrhages are noted along LEFT temporal lobe adjacent to the area of parenchymal contusion and also anteriorly within the RIGHT middle cranial fossa. Osseous structures (the major structural and supportive connective tissue of the body).: A non-depressed fracture is present along the RIGHT frontal bone, just anterior along the coronal suture (connective tissue joint that separates the frontal and parietal bones of the skull). Review of Resident #2's fall assessment dated [DATE] (prior to fall on 8/2/17), revealed the facility had assessed her to have a score of, 75 (a score of 45 or higher=high risk for falls). Review of Resident #2's fall assessments dated 7/26/17 (prior to fall on 8/2/17) and 8/2/17 (post fall), revealed the same score of 75. The residents fall risk did not increase after her fall on 8/2/17, she was a high risk for falls prior to fall on 8/2/17 and post fall. During an interview done on 9/20/17 at 10:45 a.m., staff member DD (Medical Records and Admissions) stated, we thought she might have been dying so we gave her that room (on C-Hall upon admission). The nurse's station is not in sight of the room (on C-Hall), it's around the corner. Review of Physician note's dated 8/2/17 at 3:58 p.m., stated The resident is examined today in response to some finding on head CT (Cat Scan) and incidental finding of high riding right humeral head. Concern is for an occult injury (brain bleed). Extensive bruising over facial area, tenderness with palpation, poor nasal airflow which may chronic or may be secondary to swelling over the bridge of the nose. During an interview done on 9/20/17 at 2:42 p.m., staff member Y (CNA) stated I just came on (on 8/2/17) to do my rounds (meaningful rounds-resident rounds to give report with shift change), they started the rounds about 3 or 4 months ago. She (the resident) was in bed when I did my rounds, she was awake. I went to get the Hoyer (mechanical lift) to get her up. I saw her face down with blood around her head, she was moaning, she was lying face down. I don't believe she had a mat (floor mat beside the resident's bed). During an interview done on 9/20/17 at 2:50 p.m., staff member Z (CNA) stated (staff member YCNA) asked me to come and help him get her (the resident) up. She was face down on the floor, there was no mat. She was in a puddle of blood and she was moaning. During an interview done on 9/20/17 at 3:00 p.m., staff member S (Nursing Assistant/CNA) stated, I was assigned to her when she fell (on 8/2/17), she was with her (family members, not POA) eating in the main dining room. He (family member, not POA) put her (the resident) to bed, left and he did not tell me. I had C-Hall at the time (the resident was on C-Hall at the time of her fall on 8/2/17), there's a lot going on (on C-Hall); she should have been on A-Hall, that's for resident who fall. I didn't get any education on this lady and her fall's (fall prior to admission), just after (after the fall on 8/2/17) they (management) told me to watch her more. Now she moved closer to the nurse's station on A-Hall, she was on C-Hall, they moved her closer to the nurses' station. The aides (CNA's) were confused why she was on put on C-Hall. The fall could have been prevented by putting her on A-Hall so we could watch her better, by watching her closer, by better communication with aides, nurses and family members. Review of the typed memo from staff member B (Director of Nursing) dated 8/3/17 (after the residents fall on 8/2/17), stated The aide on a schedule needs to buddy up with on-coming aide and TOGETHER you need to go room-to-room checking resident needs. As a team dedicated to providing excellent care, we cannot be satisfied with a quick report in the hall or checking needs from a distance. During an interview done on 9/20/17 at 9:30 a.m., staff member H (Nurse Coordinator, RN) revealed after Resident #2's fall on 8/2/17, the facility put the following fall preventive measures in place: -The facility added the Falling Leaf protocol in all resident admission packets. -Resident #2 was put on the Falling Leaf program (identifying her as a fall risk). -A perimeter mattress was added to Resident #2's bed. -Resident #2 was moved from C-Hall to A-Hall, near the nurse's station for closer monitoring. -An anti-fatigue mat was placed on the floor next to the resident's bed for safety. -The resident's bed was put in the lowest position. -Chime alarms were added to the resident's bed to alert staff if she was attempting to get out of bed. -Staff were to keep the resident in sight when she was in her Broda chair (therapeutic chair). A phone interview was done on 9/21/17 at 8:40 a.m., with BB (Family Member #1, Power of Attorney of Resident #2). BB stated, she (Resident #2) has not been one to sit, I told them that when she was admitted , she fell 6 times at (the assisted living agency the resident was living at prior to admission to the facility). I told them when she woke-up, she will want to walk and they said they won't let her walk alone, I talked to different nurses. We (BB and another family member's) showed them (nursing staff on the locked unit) pictures on our phone of mom's face when she fell (at the assisted living agency), it was black and blue. Review of the facility Post Fall Huddle record dated 8/2/17, revealed Resident #2 had a recent fall risk score of 75, had muscle wasting, loss of balance, altered mental status, pain and impaired communication prior to her fall on 8/2/17. Interventions put in place post fall included, a perimeter mattress, room change and she was put on the Falling Leaf program (a fall prevention program). Review of the resident's facility fall care plan initiated on 7/30/17 and up-dated on 9/13/17, revealed interventions including being put on the Falling Leaf program, given a perimeter mattress, anti-fatigue mat, chime alarms to bed, to keep resident in sight of staff when in broad chair and having her bed in the lowest position where not put into place until 8/5/17 (after her fall on 8/2/17). During an interview done on 9/20/17 at 11:20 a.m., staff member O (Charge Nurse, RN) stated meaningful rounds (staff rounding as they give the on-coming shift report on residents) was not done, it came out in an email after her fall it was put into effect. We could have had bed alarms (chime alarms on bed) in place before she fell . During an interview done on 9/20/17 at 11:25 a.m., staff member N (Medication Nurse, LPN) stated she (the resident) came from assisted living, she was receiving hospice prior to this facility. She could have been closer to the nurse's station, we could of moved her closer to the nurses station and had more frequent checks as she woke up (as the resident was taken off her hospice prescribed medications), it could have been prevented. During an interview done on 9/20/17 at 11:40 a.m., staff member P (Case Manager, RN) stated we had an issue with (a family member), we have had to remind him of safety issues. The meaningful rounds weren't done until after her fall. We should have had a talk with family and moved her (when the resident was taken off hospice medications), we may have been able to prevent this when she started moving. We should of moved her and when (family member) left (left the residents room just prior to her fall on 8/2/17), it should of triggered staff to check on her. During an interview done on 9/20/17 at 12:50 p.m., staff member M (Physician Assistant/PA) revealed the resident was admitted from an assisted living home and heavily medicated due to receiving hospice medications and stated, she woke-up, she was still real confused (prior to fall on 8/2/17). Review of the social service note's dated 8/15/17, stated The resident was admitted to the facility for LTC (long term care) due to dementia, Alzheimer's type. BIMS score was 8/15 (8 out of 15 possible score), which is suggestive of moderate impairment. The resident has difficulty with recall, judgement and safety awareness and requires cues and supervision. She is also inattentive in her thinking at times. Staff need to anticipate needs as the resident does not always make her wants/needs known. Review of the facility Falls Management Protocol Program dated 6/1/17, revealed the Fall Risk Committee meetings where part of the Quality Assessment and Assurance Committee and identified residents who had risks for falls which included the following: -Experienced an injury from a fall within past 6 months. -Experienced 1 plus falls within past 30 days. -All newly admitted residents for the first 30 days. -Residents at risk for future falls. Review of the Falls Management protocol Program dated 6/1/17, stated Prioritize residents who need to be assessed immediately, and develop a schedule for accomplishing assessments for all residents on the list. Develop a method for communicating when new residents need to be added to the list, especially residents who undergo a significant change of condition.

This citation refers to intake # MI 743. Based on observation, interview and record review, the facility failed to transfer one resident (#301) safely using a Hoyer lift out of 4 residents (#301 - 304) reviewed for transfers using a Hoyer lift, out of a total sample of 4 residents, resulting in bodily injury for Resident #301 and the potential for injury, up to and including death, for residents who need to be transferred using a Hoyer lift. Findings include: Resident #301 was an eighty-two year old female who was admitted to the facility on [DATE], according to her undated face sheet. Her [DIAGNOSES REDACTED]. On 10/11/2015, Resident #301 fell from a Hoyer lift and sustained a 5 centimeter laceration to the left occipital area of the head. Three sutures were needed to close the wound. While in the emergency room at a local hospital, a CT scan was done and reveal no abnormal findings. Resident #301 was observed during the initial tour on 10/14/2015 sitting in a Broda chair in the hall by the nurse's station. She was clean and dressed and there were no odors to her person. Resident #301 did not respond to any questions asked by the surveyor. On 10/14/2015 at 1:00 PM, a record review of the annual Minimum Data Set ((MDS) dated [DATE], indicated Resident #301 was totally dependent of facility staff for all activities of daily living. There was no score for the Brief Interview for Mental Status (BIMS) test as the resident was non-verbal and could not respond appropriately to questions. On 10/14/2015 at 1:30 PM, an observation of a re-enactment of the incident involving Resident #301 occurred with Director of Nursing (DON) B and Assistant Director (ADON) of Nursing K. ADON K represented Resident #103 and was sitting in the same Broda chair used by Resident #301 at the time of the incident. DON B demonstrated how the sling straps were attached to the lift, how the plastic inserts were to be placed in the back portion of the sling to support the neck and spine, and how the legs of the lift became entangled with the legs of the Broda chair. In an interview with DON B, on 10/11/2015 at 1:50 PM, DON B stated Certified Nursing Assistant (CNA) L approached Resident #301 while she was sitting in a Broda chair (a tilting wheelchair) and prepared to transfer Resident #301 using a Hoyer lift. According to the DON B, CNA L began to raise Resident #301 from the Broda chair using the electric lift when the legs of the lift became tangled with the Broda chair. CNA L returned Resident #301 down to the Broda chair and untangled the legs of the lift from the legs of the Broda chair. Once that was complete, CNA L began lifting Resident #301 again, not noticing the left leg strap of the sling, which supported the right side of Resident #301's body, was no longer connected to the lift. When Resident #301 began to fall from the lift, CNA L grabbed Resident #301's left leg and Resident #301 slipped out of the sling, fell to the floor, hit the back of her head and sustained a laceration to the back of the head requiring three stitches to repair. On 10/14/2015 at 2:00 PM, a record review of the manufacturer's information sheet for the Maxi Move (Hoyer) lift stated the lifts are designed for safe usage with one caregiver. It is the responsibility of each facility or medical professional to determine if a one or two person transfer is more appropriate . On 10/14/2015 at 2:15 PM, a record review of the facility's archived Hydraulic Lift (Hoyer) policy and procedure, dated 3/1/2010 and revised on 1/27/2011, indicated the purpose of the document was to enable one individual to lift from bed and move a resident safely. A record review of the policy and procedure, which was revised on 10/12/2015, stated two people must be present with all Hoyer transfers. The following items, which were not in the archived policy and procedure, indicated staff were to verify that the plastic stays (inserts) are in place in the sling. Before lifting resident, verify that all our plastic attachments are secure to the Hoyer on the metal knobs. On 10/14/2015 at 3:00 PM, a record review of the interview notes with CNA L were reviewed. The interview took place via phone immediately after the incident where Resident #301 fell from a Hoyer lift during a transfer. The following information was documented: CNA L hooked Resident #301 to the Hoyer lift using the Hoyer sling which was under Resident #301's body. CNA L verified the sling was secure to the Hoyer lift then lifted the resident up. When CNA L tried to move the Hoyer lift away from the Broda chair, the legs of the Hoyer were stuck to the Broda chair. Resident #301 was lowered to the Broda chair and CNA L separated the lift from the chair. Resident #301 was lifted up into the air. When CNA L went to move the resident away from the Broda chair, the left leg of the sling came off the Hoyer. CNA L said she instinctively grabbed out to the leg of the resident and the resident fell backwards out of the sling. DON B asked CNA L if the plastic inserts (stays) which are placed in the back portion of the sling to support the neck and back areas, were used when the transfer occurred. CNA L said she did not use them as she could not locate any. Follow up by charge nurse/Registered Nurse (RN) J regarding the location of any plastic stays indicated that RN J checked Resident #301's room immediately after the phone interview with CNA L and found the plastic stays lying on the sink in Resident #301's room. On 10/14/2015 at 3:45 PM, observation of transfers using a Hoyer lift took place on the closed unit (1 East) on the first floor with Licensed Practical Nurse (LPN) H. Two resident transfers were observed, Resident #303 at 3:50 PM and Resident #301 at 4:05 PM. Both transfers were done with two staff members providing the transfer under the direction of LPN H. No issues or concerns were noted during the transfers. On 10/14/2015 at 4:15 PM, a record review of the termination letter to CNA L, dated 10/12/2015, documented you did not have the plastic inserts (stays) in the sling. You confirmed that you understood they were supposed to be in place with transfers. After careful review of the situation, it was determined that you failed to follow the facility expectations of safe Hoyer transfers. You were trained on the expectations and failed to followed them. These actions are intolerable, therefore you are terminated today 10/12/2015. DON B reported CNA L's license to the Licensing board at the State of Michigan.

This citation pertains to intake number MI 248. Based on interviews and record review, the facility failed to follow Primary Care Provider's (PCP) orders to maintain 1 of 4 sampled residents (#101) who received enteral feedings (feedings given through a feeding tube) as nothing by mouth (NPO), from a total sample of 22 residents reviewed for Physician orders [REDACTED].#101 being provided orally administered medication in applesauce, inhaling the mixture into his lungs, experiencing respiratory distress (shortness of breath, inability to maintain adequate air exchange to oxygenate his body, and altered breath sounds), requiring emergent transfer to a local hospital for evaluation, and subsequent treatment with antibiotics. Findings include: The professional standard of quality for physician orders [REDACTED]. The face sheet revealed Resident #101 was an [AGE] year old man who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Care Plan dated 5/9/2014, and revised 3/24/2015, Resident #101 had potential for increased risk of aspiration for which he had presence of a gastrostomy tube; the care plan specified Resident #101 was to have no oral intake. According to the Minimum Data Sets ((MDS) dated [DATE], Resident #101 was dependent on facility staff for assist with feeding related to strict use of a feeding tube; he was to receive no oral foods, fluids, or medications. The Physician orders [REDACTED].#101 was NPO, tube feed all meds via PEG tube (feeding tube), AM (morning), PM (afternoon), and HS (bedtime). Review of the Medication Administration Record [REDACTED]. According to the Medication Occurrence form dated 5/30/2105 at 4:44 PM, Resident #101 received administration of a [MEDICATION NAME] capsule (medication used to treat constipation), by an Agency nurse (nurse contracted by the facility to provide care to residents when facility staffing was insufficient) mixed in applesauce; administration was intended for another resident who resided at the facility. Resident #101 had no order for the administered [MEDICATION NAME] capsule or for oral administration of foods/fluids; he was strictly NPO. Review of the Nurses Notes dated 5/30/2015 at 4:44 PM, revealed Resident #101 received, by mouth, administration of a [MEDICATION NAME] capsule mixed in applesauce. According to the Nurses Note dated 5/30/2015 at 6:22 PM, Resident #101 experienced coughing, wheezing, patient given meds by mouth when he is NPO; patient aspirated applesauce and medication. According to the Nurses Note dated 5/30/2015 at 7:27 PM, Resident #101 experienced increasing respiratory distress, difficulty breathing, cough, and sudden congestion. Assessment was documented as respirations irregular and labored, productive cough producing large amounts of sputum, and congestion was heard, upon auscultation of all lobes. Patient found in room noted to have difficulty breathing and coughing up large amounts of sputum. This nurse sat patient up in bed, instructed patient to take slow deep breaths. Instructed staff to ask charge nurse to call 9-1-1. Patient sent to ER (emergency room ) for evaluation as lung sounds were very wet upon ausculation and patient continued to be in distress. Review of the Emergency Department assessment dated [DATE] at 1835 (6:35 PM), Resident #101 presented to the hospital with a foreign body in his throat, difficulty breathing and front of his gown saturated with saliva and sputum. He was documented to have required administration of 2 liters of oxygen, via nasal canula and initiation of antibiotic therapy for aspiration pneumonia. During a phone interview on 9/3/2015 at 2:29 PM, Resident #101's sister, and legal guardian, said the Resident was returned to the facility for continued care, despite a request made by hospital staff to hospitalize the Resident due to his need for intravenous antibiotic therapy. The Resident's guardian said his return to the facility was made by the family, since he was a Do Not Resuscitate (DNR), elderly, and severely intellectually impaired. Resident #101 was returned to the facility on [DATE] at 2239 (10:39 PM). During a phone interview on 9/2/2015 at 12:40 PM, Registered Nurse (RN) A, an agency nurse, acknowledged he had made a mistake when he administered an unordered [MEDICATION NAME] capsule in applesauce, orally, to Resident #101 on 5/30/2015 at approximately 4:30 PM. RN A acknowledged he had not followed the physician's orders [REDACTED]. RN A said he had received an orientation, at the facility, which included medication pass as well as policies/procedures related to the task. During an interview on 9/3/2015 at 9:35 AM, the Director of Nursing said, This Resident (#101) had a doctor's order that he was strictly NPO; no food, drinks, or meds. If a resident has an order to be NPO, I expect the staff, agency nurses as well, to follow the doctor's orders. I feel that giving the Resident (#101), who was strictly NPO, an oral medication given with applesauce, put this resident in danger. He (Resident #101) had just completed antibiotics within the past 2 weeks for pneumonia. During an interview on 9/3/2015 at 9:35 AM, Physician C (Resident #101's attending physician), said, He (Resident #101) was strictly NPO due to dysphagia. He's severely impaired since birth. He has been strictly tube fed for over [AGE] years. He frequently gets pneumonia. He had just completed antibiotic therapy about 2 weeks ago for pneumonia. He has drooling; he's unable to swallow. He's not able to effectively protect his own airway due to his mental [MEDICAL CONDITION]. He's very high risk for aspiration pneumonia. I expect my orders to be followed. I ordered that he be strictly NPO; I expected that this order was to be followed. This put him in danger. On 9/3/2015 at 9:35 AM, the Director of Nursing provided the State Surveyor, a copy of the facility Employee Orientation Checklist for RN A, the skills checklist was signed by RN A and an instructor's name that as of 5/11/2015 RN A was able to perform skill (medication pass) without assistance according to policy. ( )

This citation pertains to intake number MI 248. Based on interviews and record review, facility staff failed to follow policy and procedures related to medication administration to ensure the prevention of medication errors, when 1 of 4 residents (Resident #101) with a gastrostomy tube and orders to receive nothing by mouth (NPO), from a total of 22 residents reviewed, received oral administration of medication (intended/ordered for another resident who did not have a gastrostomy tube and was not NPO), mixed in applesauce, inhaling the mixture into his lungs, experiencing respiratory distress (shortness of breath, inability to maintain adequate air exchange to oxygenate his body, and altered breath sounds), requiring emergent transfer to a local hospital for evaluation, and subsequent treatment with antibiotics. Findings include: The face sheet revealed Resident #101 was an [AGE] year old man who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Care Plan dated 5/9/2014, and revised 3/24/2015, Resident #101 had potential for increased risk of aspiration for which he had presence of a gastrostomy tube; the care plan specified Resident #101 was to have no oral intake. According to the Minimum Data Sets ((MDS) dated [DATE], Resident #101 was dependent on facility staff for assist with feeding related to strict use of a feeding tube; he was to receive no oral foods, fluids, or medications. The Physician orders [REDACTED].#101 was NPO, tube feed all meds via PEG tube (feeding tube), AM (morning), PM (afternoon), and HS (bedtime). The Physician orders [REDACTED].#101 should receive administration of [MEDICATION NAME] capsules. Review of the Medication Administration Record [REDACTED]. According to the Administering Medications Policy Statement revised 10/17/2013, and provided to the State Surveyor on 9/2/2015 at 8:50 AM by the Director of Nursing as the current policy/procedure in use by the facility, it states, #3) Medications must be administered in a timely manner and in accordance with the attending physician's written/verbal orders, #5) Should the resident's identity be questionable, the individual administering the medication must verify the resident's identity before administering the medication (see policy entitled Resident Identification), #8) The individual administering the medication must ensure that he right medication, the right dosage, the right time, and the right method of administration are verified before the medication is administered. According to the Resident Identification Policy Statement revised 4/29/2013, and provided to the State Surveyor on 9/2/2015 at 8:50 AM by the Director of Nursing as the current policy/procedure in use by the facility, it states, #1) If there is any doubt about a resident's identity, medications or treatments shall not be administered until positive identification has been made, #2) The person administering the medication(s) must verify the resident's identity by checking the resident's photo identification card, wrist band, or other established means of identification before administering the medication. According to the Medication Occurrence form dated 5/30/2105 at 4:44 PM, Resident #101 received administration of a [MEDICATION NAME] capsule (medication used to treat constipation), by an Agency nurse (nurse contracted by the facility to provide care to residents when facility staffing was insufficient) mixed in applesauce; administration was intended for another resident who resided at the facility. Resident #101 had no order for the administered [MEDICATION NAME] capsule or for oral administration of foods/fluids; he was strictly NPO. Review of the Nurses Notes dated 5/30/2015 at 4:44 PM, revealed Resident #101 received, by mouth, administration of a [MEDICATION NAME] capsule mixed in applesauce. According to the Nurses Note dated 5/30/2015 at 6:22 PM, Resident #101 experienced coughing, wheezing, patient given meds by mouth when he is NPO; patient aspirated applesauce and medication. According to the Nurses Note dated 5/30/2015 at 7:27 PM, Resident #101 experienced increasing respiratory distress, difficulty breathing, cough, and sudden congestion. Assessment was documented as respirations irregular and labored, productive cough producing large amounts of sputum, and congestion was heard, upon auscultation of all lobes. Patient found in room noted to have difficulty breathing and coughing up large amounts of sputum. This nurse sat patient up in bed, instructed patient to take slow deep breaths. Instructed staff to ask charge nurse to call 9-1-1. Patient sent to ER (emergency room ) for evaluation as lung sounds were very wet upon ausculation and patient continued to be in distress. Review of the Emergency Department assessment dated [DATE] at 1835 (6:35 PM), Resident #101 presented to the hospital with a foreign body in his throat, difficulty breathing and front of his gown saturated with saliva and sputum. He was documented to have required administration of 2 liters of oxygen, via nasal canula and initiation of antibiotic therapy for aspiration pneumonia. During a phone interview on 9/3/2015 at 2:29 PM, Witness K (Resident #101's sister, and legal guardian), said the Resident was returned to the facility for continued care, despite a request made by hospital staff to hospitalize the Resident due to his need for intravenous antibiotic therapy. The Resident's guardian said his return to the facility was made by the family, since he was a Do Not Resuscitate (DNR), elderly, and severely intellectually impaired. Resident #101 was returned to the facility on [DATE] at 2239 (10:39 PM). During a phone interview on 9/2/2015 at 12:40 PM, Registered Nurse (RN) A, an agency nurse, acknowledged he had made a mistake when he administered an unordered [MEDICATION NAME] capsule in applesauce, orally, to Resident #101 on 5/30/2015 at approximately 4:30 PM. RN A acknowledged he had not followed the physician's orders [REDACTED]. RN A said he had received an orientation, at the facility, which included medication pass as well as policies/procedures related to the task. During a phone interview on 9/3/2015 at 10:13 AM, RN B said she had worked with RN A, an agency nurse, on the evening shift (3 PM through 11 PM) on 5/30/2015. RN B said, He (RN A) told me he had given the resident (identified as Resident #101) [MEDICATION NAME] by mouth mixed in applesauce. I assessed the Resident. The Resident's ID bracelet was on; I saw it. His (Resident #101) MAR indicated [REDACTED]. During an interview on 9/3/2015 at 9:35 AM, the Director of Nursing said, The procedure for med pass is to check each resident's bracelet, and armband, for the resident's identity, and to verify with the picture on the MAR; it's on the computerized MAR. The Agency nurse (RN A) went into the wrong room. Our investigation found that the Resident (#101) was wearing an armband. The MAR indicated [REDACTED]. If staff are unsure of a resident's identity, they're supposed to check the ID bracelet, check the picture of the resident on the MAR, and then confirm the identity of the resident with another staff member. This Resident (#101) had a doctor's order that he was strictly NPO; no food, drinks, or meds. If a resident has an order to be NPO, I expect the staff, agency nurses as well, to follow the doctor's orders. I feel that giving the Resident (#101), who was strictly NPO, an oral medication given with applesauce, put this resident in danger. He (Resident #101) had just completed antibiotics within the past 2 weeks for pneumonia. During an interview on 9/3/2015 at 9:35 AM, Physician C (Resident #101's attending physician), said, He (Resident #101) was strictly NPO due to dysphagia. He's severely impaired since birth. He has been strictly tube fed for over [AGE] years. He frequently gets pneumonia. He had just completed antibiotic therapy about 2 weeks ago for pneumonia. He has drooling; he's unable to swallow. He's not able to effectively protect his own airway due to his mental [MEDICAL CONDITION]. He's very high risk for aspiration pneumonia. I expect my orders to be followed. I ordered that he be strictly NPO; I expected that this order was to be followed. This put him in danger. On 9/3/2015 at 9:35 AM, the Director of Nursing provided the State Surveyor, a copy of the facility Employee Orientation Checklist for RN A, the skills checklist was signed by RN A and an instructor's name that as of 5/11/2015 RN A was able to perform skill (medication pass) without assistance according to policy. ( )

THIS CITATION PERTAINS TO MI 277 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO PREVENT A FALL FOR 1 RESIDENT (#103) OF 3 RESIDENTS REVIEWED FOR FALLS FROM A TOTAL SAMPLE OF 3 RESIDENTS. RESULTING IN A FRACTURED PELVIS, POST TRAUMATIC ILEUS AND A HEAD LACERATION WITH 3 STAPLES PLACED. FINDINGS INCLUDE: ACCORDING TO THE UNDATED FACILITY FACE SHEET RESIDENT #103 WAS A [AGE] year OLD MALE admitted to the facility on [DATE]. THE RESIDENT [DIAGNOSES REDACTED]. ACCORDING TO THE INCIDENT AND ACCIDENT REPORT DATED 8/23/2013 ON 8/22/2013 AT 11:16 P.M., RESIDENT #103 WAS AMBULATING IN HIS ROOM WITH THE ASSISTANCE OF 1 CERTIFIED NURSE AIDE STAFF #8. RESIDENT #103 fell AND SUSTAINED A FRACTURED PELVIS AND A LACERATION TO THE RIGHT POSTERIOR SIDE OF HIS HEAD. THE FACILITY 5 DAY REPORT DATED 8/23/2013 REFLECTED RESIDENT #103 WAS CARE PLANNED TO BE AMBULATED WITH A GAIT BELT, WHEELED WALKER AND 2 STAFF MEMBERS. A WRITTEN STATEMENT DATED 8/22/2013 FROM STAFF #8 REFLECTED HE AMBULATED RESIDENT #103 WITHOUT ASSISTANCE FROM OTHER STAFF AND RESIDENT #108 fell TO THE RIGHT. ON 8/29/2013 AT 9:55 A.M., DURING AN IN PERSON INTERVIEW WITH STAFF MEMBER #8 HE DEMONSTRATED THE INCIDENT. STAFF MEMBER #8 DEMONSTRATED THAT HE WAS ON RESIDENT #103 LEFT SIDE, ALONG WITH THE GAIT BELT AND SHOES. THE WALKER WAS IN FRONT OF RESIDENT #103. STAFF MEMBER #8 HAD HIS RIGHT ARM WRAPPED IN RESIDENT #103 ARM, AS IN A BRIDE AND GROOM FASHION. STAFF MEMBER #8 STATED HIS LEFT ARM WAS ON THE WALKER. STAFF MEMBER #8 REPORTED HE WAS AWARE THAT HE SHOULD HAVE ASKED FOR ASSISTANCE FROM ANOTHER NURSE AIDE AS WRITTEN IN THE RESIDENTS CARE PLAN AND WALKED BEHIND RESIDENT #8 HOLDING ONTO THE GAIT BELT. STAFF MEMBER #8 REPORTED THAT HE DID NOT ASK FOR HELP BECAUSE HE HAD REMEMBERED MULTIPLE OTHER NURSE AIDES TAKING RESIDENT #103 TO THE BATHROOM ALONE. ACCORDING TO THE Minimum Data Set, dated dated dated DATED 8/28/2013 RESIDENT #103 HAD A BRIEF INTERVIEW MENTAL STATUS SCORE OF 15, INDICATING NO COGNITIVE IMPAIRMENT. ON 8/28/2013 DURING AN INTERVIEW WITH RESIDENT #103 HE REPORTED STAFF MEMBER #8 WAS WITH HIM DURING THE FALL WITH NO OTHER STAFF PRESENT. "I DON'T REMEMBER ANYTHING ABOUT A GAIT BELT." A REVIEW OF RESIDENT #103 NURSE AIDE CARE GUIDE THAT WAS IN PLACE ON 8/22/2013 READ: "AMBULATE ASSIST OF 2 FULL WEIGHT BEARING ASSISTIVE DEVICE: FRONT WHEELED WALKER GAIT BELT MODERATE ASSIST TO TOLERANCE." THE FACILITY POLICY ON AMBULATION DATED 12/31/1999 PAGE 2. BULLET POINT 7. "APPLY GAIT BELT" BULLET POINT 15. GRASP THE GAIT BELT WITH ONE HAND AND SUPPORT THE RESIDENT AS NEEDED WITH THE OTHER HAND. DO NOT LET GO OF THE GAIT BELT." ON 8/29/2013 AT APPROXIMATELY 12:00 P.M., DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING, SHE REPORTED THAT IT WAS HER EXPECTATION THAT FACILITY PROTOCOL WAS TO ALWAYS UTILIZE A GAIT BELT AND THAT CERTIFIED NURSING ASSISTANCE WERE TO NOT PRINT A COPY OF THEIR ASSIGNED RESIDENTS CARE GUIDES BUT THE EXPECTATION IS THAT THE CARE GUIDE BE READ AND ADHERED TO PRIOR TO INITIATING CARE ( ) This citation pertains to intake number MI 277.

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION FOR 1 OF 6 RESIDENTS (#7) REVIEWED FOR FALL WITH AND WITHOUT FRACTURES FROM 23 TOTAL SAMPLED RESIDENTS RESULTING IN LEFT ORBITAL WALL FRACTURE WITH ACCOMPANYING PAIN AND DISCOMFORT. FINDINGS INCLUDE: ACCORDING TO HOSPITAL HISTORY AND PHYSICAL (H &P) DATED 11/6/12 RESIDENT #7 WAS A [AGE] year OLD FEMALE WITH MULTIPLE FALLS AND HER PAST MEDICAL AND SURGICAL HISTORY INCLUDED THE FOLLOWING Diagnoses: [REDACTED]. THE H &P CONTINUED TO STATE RESIDENT #7 " ...fell AND HURT HER LEFT FOREHEAD ...EVIDENCE OF MODERATE LEFT PERIORBITAL SOFT TISSUE SWELLING CONSISTENT WITH EDEMA AND HEMATOMA ...CAT SCAN/ FACIAL BONES REVEALED LEFT INFERIOR ORBITAL WALL FRACTURE ... " THE physician's orders [REDACTED]. (THE FACILITY HAD NO FACE SHEET, AND THE admitted S WERE EXTREMELY DIFFICULT TO DETERMINE. MOST OF THE UNIT STAFF WERE UNABLE TO ACCESS THESE DATES FROM THE ELECTRONIC MEDICAL RECORD SYSTEM). THE MINIMUM DATA SET (MDS) assessment dated [DATE] REFLECTED RESIDENT #7 HAD A BIM (BRIEF INTERVIEW FOR MENTAL STATUS) SCORE OF 5 (SEVERELY IMPAIRED) OUT OF POSSIBLE 15 POINTS. THIS BIM IS USED TO DETERMINE THE LEVEL OF ORIENTATION AND COGNITION. UNDER THE FUNCTIONAL STATUS, RESIDENT #7 WAS CODED AS 1, NEEDING SUPERVISION WITH HER TRANSFER, AMBULATION, DRESSING AND PERSONAL HYGIENE. UNDER THE BALANCE DURING TRANSITIONS AND WALKING RESIDENT #7 WAS AGAIN CODED AS 1, MEANING SHE WAS NOT STEADY, BUT ABLE TO STABILIZE WITHOUT ASSISTANCE FOR MOVING FROM SEATED TO STANDING POSITION, WALKING, TURNING AROUND AND MOVING ON AND OFF THE TOILET. UNDER THE BOWEL AND URINARY CONTINENCE SECTION, RESIDENT #7 WAS CODED AS 0 MEANING SHE WAS ALWAYS CONTINENT. THE " FALL ASSESSMENT: PREDISPOSITION FOR FALLING " DATED 12/23/11 THROUGH 11/8/12, REFLECTED RESIDENT #7 HAD SCORED 12 (A SCORE OF TEN OR ABOVE INDICATES A HIGH RISK FOR FALLING) AND REFLECTED ON THE FOLLOWING DATES: 1/2/12, 3/15/12, 6/10/12, 9/15/12, 9/17/12, 9/20/12, 11/6/12 AND 11/8/12. RESIDENT #7 SCORED 15 ON 10/14/12 AND 19 ON 10/22/12. THE CLINICAL CONDITIONS USED TO DETERMINE THESE POINTS INCLUDED AGE, MENTAL STATUS, LENGTH OF STAY, ELIMINATION, IMPAIRMENT, BLOOD PRESSURE, GAIT AND MOBILITY AND CURRENT MEDICATIONS. RESIDENT #7 WAS CONSISTENTLY GIVEN 4 POINTS FOR CONFUSION, 3 POINTS FOR ELIMINATION, 1 POINT FOR VISUAL IMPAIRMENT, 1 POINT FOR USING ASSISTIVE DEVICES AND 2 POINTS USING ANTIHYPERTENSIVE AND CATHARTICS. IN ADDITION RESIDENT #7 had a history of [REDACTED]. THE CARE PLAN REGARDING FALLS DATED 8/16/12 REFLECTED RESIDENT #7 WAS AT RISK FOR FALLS RELATED TO "WEAKNESS, AUDITORY IMPAIRMENT, COGNITIVE DIFFICULTIES AND ADVANCED AGE". THE INTERVENTIONS WITH IMPLEMENTATION DATE OF 8/16/12, INCLUDED, "EVALUATE FOR NEED OF PROTECTIVE DEVICES, TEACH AND OBSERVE PROPER USE OF WALKER, IDENTIFY CONTRIBUTING FACTORS, VERIFY A SECURE AND SAFE ENVIRONMENT, IDENTIFY AND ELIMINATE POTENTIAL SAFETY HAZARDS BASED ON RESIDENT ASSESSMENT, MONITOR RESIDENT TO ENSURE SAFETY". THE NEXT INTERVENTION, ADDED ON DATE 11/6/12 REFLECTED, "SAFETY DEVICE: WANDERGUARD, CHIME ALARM, BED ALARM, CHAIR ALARM". THE MOST RECENT INTERVENTION DATED 11/6/12 (DATE OF MOST RECENT FALL) REFLECTED, "WHEN RESIDENT IS AGITATED, HAVE RESIDENT SITTER. THIS INCLUDES WHEN IN BED AFTER EPISODES OF AGITATION". REVIEW OF INCIDENT REPORTS FOR THE PAST 6 MONTHS DATED 5/11/12 THROUGH 11/6/12 REFLECTED RESIDENT #7 HAD 7 FALLS : 5/11/12, 7/12/12, 9/15/12, 9/20/12, 10/14/12, 10/22/12 AND 11/6/12 WITH VARIOUS SKIN INJURIES AND 2 FRACTURES (LEFT HAND FRACTURE: DISCOVERED ON 8/14/12 AS A LATE CONSEQUENCE RELATED TO A FALL FROM 7/12/12), AND LEFT ORBITAL FRACTURE OCCURRED ON 11/6/12. THE INCIDENT REPORT DATED 5/11/12 REFLECTED, "RESIDENT #7 GOT DOWN HER HANDS AND KNEES TO LOOK FOR SOMETHING UNDER THE BED, WAS UNABLE TO GET BACK UP SO SHE CRAWLED TO THE CHAIR TO HELP HERSELF UP". FOLLOW UP REPORT STATED THE RESIDENT HAD NO INJURY, SHE WAS INTERMITTENTLY CONFUSED AND THE CARE PLAN WAS UPDATED FOR BED ALARM. THE INCIDENT MAY HAVE BEEN RELATED TO THE RESIDENT'S VISUAL AND PERCEPTUAL IMPAIRMENT. THE INCIDENT REPORT DATED 7/11/12 REFLECTED, " ...IN THE DINING ROOM RESIDENT #7 ATTEMPTED TO GET UP FROM HER CHAIR WITHOUT STAFF ASSISTANCE BY REACHING FOR HER WALKER AND fell TO HER LEFT SIDE ONTO THE FLOOR NEXT TO HER CHAIR. STAFF NURSE WHO WAS ATTENDING OTHER RESIDENT WAS NOT ABLE TO STOP RESIDENT #7 FROM FALLING". THE FOLLOW UP REPORT STATED, "THE RESIDENT HAD A PAINFUL BRUISED SWOLLEN LEFT HAND AND PAIN IN HER LEFT LEG". THE CARE PLAN WAS UPDATED FOR BED ALARM AND REMINDING RESIDENT TO ASK FOR ASSISTANCE FROM STAFF BEFORE TRANSFERRING. THE X-RAY OF THE RESIDENT'S LEFT HAND WAS NEGATIVE FOR FRACTURE AT THIS TIME, BUT THE REPEAT X-RAY ON 8/14/12 REVEALED A FRACTURE. THE INCIDENT MAY HAVE BEEN RELATED TO THE RESIDENT'S VISUAL, PERCEPTUAL IMPAIRMENT AS WELL AS ENVIRONMENTAL FACTORS. THE INCIDENT REPORT DATED 9/15/12 REFLECTED, " ...RESIDENT #7 WAS AT DINING ROOM, SHE TRIED TO SIT DOWN FOR LUNCH WHERE THERE WAS NO CHAIR ... " THE FOLLOW UP REPORT STATED THAT THE RESIDENT HAD NO INJURY AND MEASURES TO PREVENT SIMILAR INCIDENTS INCLUDED HAVING A STAND- BY ASSIST WHEN TRANSFERRING AND AMBULATING. THE INCIDENT AGAIN MAY HAVE BEEN RELATED TO THE RESIDENT'S VISUAL AND PERCEPTUAL IMPAIRMENT. THE INCIDENT REPORT DATED 9/17/12 REFLECTED RESIDENT #7, "FOUND SITTING ON FLOOR ON HER BUTTOCK BY ROOM MATE, BACK TO CLOSET, FACING BED". THE FOLLOW UP REPORT STATED THE RESIDENT WAS TRYING TO WIPE UP SOME WATER ON THE FLOOR AND fell . THE CARE PLAN WAS UPDATED TO APPLY "CHIME ALARM". THE INCIDENT MAY HAVE BEEN RELATED TO THE RESIDENT'S VISUAL IMPAIRMENT OR ENVIRONMENTAL FACTORS. THE NURSING NOTE DATED 9/18/12 REFLECTED, "WHEN RESIDENT WAS STANDING AT SINK WASHING HER HANDS AFTER TOILETING SHE BECAME WEAK AND 'ALMOST fell BACKWARDS' CNA (CERTIFIED NURSING AIDE) WAS ASSISTING AND PREVENTED ANOTHER FALL. CNA REPORTS SHE NOTICED RESIDENT HAD INCREASED WEAKNESS. BLOOD PRESSURE IS A LITTLE LOWER THAN NORMAL". THE INCIDENT REPORT DATED 9/20/12 REFLECTED RESIDENT #7, "SLID OFF BED ATTEMPTING TO PUT DIFFERENT SHOES IN HER ROOM". THE FOLLOW UP REPORT STATED RESIDENT HAD 1.5 CM IN DIAMETER LUMP ON HER POSTERIOR (BACK) HEAD. THE MEASURES TO PREVENT SIMILAR INCIDENT INCLUDED PLACING A FLOOR MAT AT HER BEDSIDE. THE INCIDENT MAY HAVE BEEN RELATED TO THE RESIDENT'S MEDICATION ADVERSE EFFECT. THE NURSING NOTE DATED 10/4/12 REFLECTED RESIDENT #7 HAD A SHORT EMERGENCY TRIP DUE TO HER LEFT SIDED DROOP AND LEFT SIDED WEAKNESS. AT 10:00 P.M. ON THE SAME DAY, THE RESIDENT HAD GONE TO THE BATHROOM ALONE, TWICE, WITHOUT ASSISTANCE. THE INCIDENT REPORT DATED 10/14/12 REFLECTED RESIDENT #7 " ... WAS FOUND SITTING UP RIGHT ON THE MAT ADJACENT TO HER BED WITH BILATERAL LOWER EXTREMITIES EXTENDED OUT IN FRONT OF HER. HER WALKER WAS TIPPED OVER NEAR HER. RESIDENT WAS GETTING UP TO TOILET AND TRIPPED ON 'THAT DAMN FLOOR MAT'. SHE CAUGHT HERSELF ON THE EDGE OF HER BED AND fell OVER CATCHING HER LEFT CHEST ... " THE FOLLOW UP REPORT STATED THAT THE RESIDENT HAD NO VISIBLE INJURIES BUT ICE PACK WAS APPLIED TO HER LEFT CHEST/RIB FOR PAIN. THE MEASURES TO PREVENT SIMILAR INCIDENT INCLUDED FREQUENT CHECKS AND EDUCATE (CALL FOR STAFF ASSISTANCE PRIOR TO GETTING UP) PATIENT ON SAFETY. THE INCIDENT WAS CLEARLY RELATED TO THE ENVIRONMENTAL FACTOR (FLOOR MAT). THERE WAS NO EVALUATION OF THE CONTINUED USE THE FLOOR MAT. THE INCIDENT REPORT DATED 10/22/12 REFLECTED RESIDENT #7 "GOT UP OUT OF BED AND fell on HER BOTTOM ON THE FLOOR". THE FOLLOW UP REPORT STATED THAT ACCORDING TO THE RESIDENT'S FAMILY, THE RESIDENT WAS VERY INDEPENDENT AND LIKED TO DO THINGS FOR HERSELF. THE REMEDIAL MEASURES TO PREVENT SIMILAR INCIDENTS INCLUDED MOVING RESIDENT #7 CLOSER TO THE NURSING STATION AND TO CHECK HER EVERY COUPLE OF HOURS TO SEE IF RESIDENT NEEDED TO BE TOILETED. THE INCIDENT MAY HAVE BEEN RELATED TO THE RESIDENT'S IMPAIRED COGNITION AS WELL AS HER GAIT AND BALANCE IMPAIRMENT. THE NURSING NOTES DATED 11/2/12 REFLECTED RESIDENT #7 " WAS COMPLAINING OF VAGINAL ITCHING AND BURNING WITH URINATION. ALSO COMPLAINS OF URGENCY". NURSING NOTES DATED 11/4/12 REFLECTED THE RESIDENT #7 WAS STARTED ON AN ANTIBIOTIC FOR URINARY TRACT INFECTION. THE MOST RECENT INCIDENT REPORT DATED 11/6/12 AT 8:09 P.M., REFLECTED RESIDENT #7 "FOUND BY STAFF LAYING ON HER LEFT SIDE AT THE FOOT OF HER BED. RESIDENT HAD TRANSFERRED HERSELF WITHOUT STAFF ASSISTANCE ...NOTED HAVING LACERATION ON HER LEFT EYEBROW. LEFT EYE NOTED SWOLLEN SHUT WITH A PURPLE DISCOLORATION ...RIGHT HAND NOTED HAVING EDEMA AND PAINFUL WITH MOVEMENT ..." AN INTERVIEW ON 11/8/12 AT 11:00 A.M. WITH REGISTERED NURSE, (STAFF "K") STATED THAT SHE WAS TOLD THE RESIDENT HAD BEEN LAID DOWN IN BED TO SLEEP AROUND 7:00 PM. THE STAFF HEARD AN ALARM AND FOUND HER AT THE FOOT OF HER BED BY THE TIME THE STAFF ENTERED ROOM. STAFF "K" ADDED THE RESIDENT AMBULATED WITH A WALKER, BUT SHE IS VERY QUICK ON HER FEET AND SHE THOUGHT SHE COULD DO THINGS ON HER OWN. THE INCIDENT MAY HAVE BEEN RELATED TO A COMBINATION OF PREVIOUS RISK FACTORS SUCH AS VISUAL IMPAIRMENT, ENVIRONMENTAL FACTOR, GAIT AND BALANCE IMPAIRMENT, MEDICATION USE AND BEHAVIOR THAT HAD CAUSED THE PREVIOUS FALLS. ON 11/9/12 AT 10:45 A.M., DIRECTOR OF NURSING (DON) WAS ASKED WHAT MAY HAVE BEEN THE CAUSES FOR RESIDENT #7'S REPEATED FALLS. THE DON STATED, "THE RESIDENT WAS CONFUSED AND DID NOT ASK FOR ASSISTANCE". HOWEVER, RESIDENT #7 HAD MULTIPLE OTHER CAUSES FOR HER FALLS AS LISTED IN THE INCIDENT REPORTS. SHE WAS UNSTEADY (COULD ONLY WALK WITH A WALKER), HAD VISUAL AND HEARING IMPAIRMENT ([DIAGNOSES REDACTED]. THE DON WAS ASKED WHETHER THE RESIDENT COULD BE EXPECTED TO USE A CALL LIGHT FOR ASSISTANCE AS THE CARE PLAN REPEATEDLY STATED. THE DON STATED, "NO". THE DON ALSO STATED, "AD HOC MEETINGS ARE HELD BY THE ASSISTANT DIRECTOR OF NURSING, STAFF NURSE AND THE NURSING AIDE WHO WERE INVOLVED WITH THE INCIDENT. NO OTHER DISCIPLINES ATTENDED THIS AD HOC MEETINGS TO DETERMINE CAUSES OR ANALYZE THE CAUSES OF FALLS". THE DON WAS ASKED WHETHER RESIDENT #7 COULD HAVE BENEFITED HAVING A VIDEO CAMERA IN HER ROOM TO INCREASE DIRECT SUPERVISION SINCE SHE REPEATEDLY fell WITHOUT CALLING FOR ASSISTANCE. (A VIDEO CAMERA WAS WAS AVAILABLE FOR OTHER RESIDENTS). THE DON STATED, " I HAD JUST INSTALLED ONE YESTERDAY AFTER THE RESIDENT CAME BACK FROM HOSPITAL". ON 11/9/12 AT 11:15 A.M., RESIDENT #7 WAS OBSERVED LYING IN HER BED, MOANING CONSTANTLY WITH HER EYES CLOSED. BOTH EYES WERE COVERED WITH DARK BLACK PURPLE BRUISE IN CIRCLES. THE RESIDENT WAS SLIGHTLY RESTLESS AND WAS ATTEMPTING TO PULL OFF THE STERI-STRIP THAT HAD BEEN APPLIED ON THE EYE BROW ABOVE HER LEFT EYE. RESIDENT #7 APPEARED TO BE IN PAIN AND UNCOMFORTABLE WITH HER INJURY. THE FALLS FOR RESIDENT #7 WERE PREVENTABLE. THE CARE PLAN DID NOT REFLECT THE RESULTS OF AN ONGOING ASSESSMENT, INTEGRATION OF THE CAUSES OF THE FALLS AND A MONITORING AND EVALUATION OF THE INTERVENTION. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT DEVELOPMENT OF PRESSURE ULCERS FOR 2 OF 7 RESIDENTS (#1, AND 18) REVIEWED FOR PRESSURE ULCERS FROM A TOTAL 23 SAMPLED RESIDENTS, RESULTING IN THE DEVELOPMENT OF PAINFUL UNSTAGEABLE (TISSUE DESTRUCTION COVERED BY NECROSIS OR ESCHAR) RIGHT HEEL ULCER FOR RESIDENT #1 AND UNSTAGEABLE LEFT HEEL ULCER FOR #18. FINDINGS INCLUDE: THE physician's order [REDACTED]. THE EARLIEST DATE THE CARE PLAN HAD BEEN WRITTEN WAS RECORDED AS 7/12/2008. THE CARE PLAN INDICATED RESIDENT #1 HAD [DIAGNOSES REDACTED]. ON 11/7/12 AT 10:00 A.M., DURING AN INITIAL TOUR, THE LICENSED PRACTICAL NURSE, (STAFF " B " ) STATED RESIDENT #1 HAD A PRESSURE ULCER ON HER RIGHT HEEL DUE TO HER SHOES. STAFF "B" ADDED THE RESIDENT WOULD NOT TAKE OFF SHOES EVEN IN BED. STAFF "B" COULD NOT CLEARLY EXPLAIN HOW THE RESIDENT'S SHOE COULD HAVE CONTRIBUTED TO THE DEVELOPMENT OF THE PRESSURE ULCER. THE CARE AREA ASSESSMENT (CAA) DATED 4/26/12 REFLECTED RESIDENT #1 HAD A BIM (BRIEF INTERVIEW FOR MENTAL STATUS) SCORE OF 10 (MODERATELY IMPAIRED) OUT OF 15. UNDER THE PSYCHOSOCIAL WELL-BEING AND MOOD RESIDENT #1 WAS DESCRIBED AS A LONER, EASILY IRRITATED, HAVING FREQUENT CONFLICTS WITH HER ROOM MATES AND A DEPRESSED CLIENT WHO REFUSED TO GET HELP. UNDER THE PRESSURE ULCER CATEGORY RESIDENT #1 HAD NO PRESSURE ULCERS BUT WAS AT RISK FOR DEVELOPING ONE DUE TO FREQUENT URINARY INCONTINENCE, CONFINED TO CHAIR MOST OF THE TIME AND REQUIRED STAFF ASSISTANCE TO MOVE IN BED ALTHOUGH SHE COULD REPOSITION HERSELF IN BED. THE CARE PLAN INITIATED ON 9/19/12 REFLECTED RESIDENT #1 HAD A PROBLEM WITH POOR TISSUE INTEGRITY (UNSTAGEABLE) RELATED TO " DIABETES MELLITUS AND DECREASED SAFETY AWARENESS ". THE INTERVENTIONS DEVELOPED ON 9/19/12 FOR NURSES INCLUDED, " ASSESS SKIN CONDITION DAILY AND NOTE ANY CHANGES, MONITOR USE OF SKIN PROTECTIVE DEVICES, INSTRUCT ON THE IMPORTANCE OF GOOD SKIN CARE, MONITOR DIET INTAKE ". THE INTERVENTIONS DEVELOPED FOR THE NURSE AIDES INCLUDED, " ASSIST WITH HYGIENE AND GENERAL SKIN CARE, KEEP SKIN CLEAN AND DRY, ENCOURAGE RESIDENT TO REMOVE SHOES WHILE IN BED, WEAR PRAFO BOOT ON RIGHT FOOT WHILE IN BED, NOT TO WEAR SHOE ON RIGHT FOOT UNTIL WOUND HEALED ". THE WOUND NOTE DATED 9/19/12 REFLECTED RESIDENT #1 WAS IDENTIFIED AS HAVING 4.0 CM LONG AND 4.0 CM WIDE PURPLE UNSTAGEABLE PRESSURE ULCER ON HER RIGHT HEEL. THE PRESENCE OF THIS RIGHT HEEL ULCER HAD NEVER BEEN DOCUMENTED BEFORE AND THE DATE OF 9/19/12 WAS REGARDED AS THE DATE OF ONSET. THE WOUND TYPE WAS ASSESSED AS A SUSPECTED DEEP TISSUE INJURY (SDT). THE MEASUREMENTS OF RESIDENT #1'S RIGHT HEEL WOUND AND CHARACTERISTICS WERE DESCRIBED AS FOLLOWS: DATE SIZE (LENGTH X WIDTH X DEPTH IN CENTIMETERS) 9/19/12 4.0 X 4.0 X 0.0 PURPLE 9/26/12 2.8 X 2.6 X 0.0 BROWN 10/3/12 2.8 X 2.6 X 0.0 BROWN 10/10/12 2.7 X 2.6 X 0.0 NECROTIC/ESCHAR BROWN 10/17/12 3.5 X 2.8 X 0.0 BROWN 10/25/12 2.8 X 2.4 X 0.0 BROWN 10/31/12 3.3 X 2.8 X 0.0 BROWN 11/7/12 3.0 X 2.8 X 0.0 BROWN ON 11/8/12 AT 9:30 A.M., THE DRESSING CHANGE BY THE REGISTERED NURSE, (STAFF " A " ) TO RESIDENT #1'S RIGHT HEEL WOUND WAS OBSERVED IN HER ROOM. STAFF "A" REMOVED THE EASY BOOT REFERRED TO AS A PRAFO BOOT IN THE CARE PLAN. THIS PRAFO BOOT IS A THICKLY PADDED CLOTH COVERED BOOT WITH THE HEEL PART OPEN USED ON THE RESIDENT'S RIGHT FOOT. A" MOON BOOT WHICH HAS LESS PADDING THAN THE EASY BOOT WAS ON THE RESIDENT'S LEFT FOOT. STAFF "A" TOOK OUT A PAIR OF SCISSORS FROM HER POCKET AND CUT THROUGH THE KERLIX WRAP ON THE RESIDENT'S RIGHT FOOT. THE TOP OF THE RESIDENT'S RIGHT FOOT WAS COVERED WITH NUMEROUS RED PETECHIAL ( DOTTED) SPOTS. THE RIGHT HEEL WOUND HAD A HARD BROWN OVAL SHAPED SCAB AND MEASURED APPROXIMATELY 3 CM LONG AND 2.5 CM WIDE. STAFF "A" CLEANSED THE WOUND WITH SALINE PAD, APPLIED [MEDICATION NAME] DRESSING AND WRAPPED IT WITH KERLIX. THERE WAS NO [MEDICAL CONDITION] ON EITHER FEET AND ANKLE. STAFF "A" STATED THE WOUND WAS A BLACK SCAB WHEN SHE FIRST SAW IT BUT WAS BECOMING BROWN IN COLOR. STAFF "A" ADDED THAT THE WOUND HAD NEVER OPENED. STAFF "A" STATED THAT RESIDENT #1 WAS NOT AMBULATORY, COULD TURN HERSELF SOME IN BED AND WOULD NOT TAKE OFF HER REGULAR TENNIS SHOES EVEN AT NIGHT. STAFF "A" SUSPECTED THAT THE FAILURE TO REMOVE THE TENNIS SHOES CAUSED RESIDENT #1'S RIGHT HEEL PRESSURE ULCER. ON 11/8/12 AT 10:00 A.M., STAFF "A" WAS ASKED WHETHER RESIDENT #1 HAD ANY ABNORMAL OR NEGATIVE FINDINGS DURING THE SKIN ASSESSMENTS BEFORE 9/19/12 SINCE THE RESIDENT ' S RIGHT HEEL PRESSURE ULCER WAS AN ABRUPT UNEXPECTED FINDING. STAFF "A" COULD NOT PRESENT ANY SKIN ASSESSMENT DOCUMENTATION OTHER THAN WOUND NOTES. THE FACILITY POLICY TITLED, " PRESSURE ULCER, CARE AND PREVENTION OF " DATED 12/31/99 AND REVISED 2/7/12, DID NOT REFLECT ANY GUIDELINES ABOUT PERFORMING REGULAR OR PERIODIC SCHEDULED SKIN ASSESSMENTS. THE CENTER FOR MEDICARE AND MEDICAID'S (CMS) AGENCY FOR HEALTH CARE POLICY AND RESEARCH HAS PUBLISHED THE CLINICAL PRACTICE GUIDELINES FOR "PRESSURE ULCERS IN ADULTS: PREDICTION AND PREVENTION" WHICH STATED ON P. 15, " ALL INDIVIDUALS AT RISK SHOULD HAVE A SYSTEMATIC SKIN INSPECTION AT LEAST ONCE A DAY, PAYING PARTICULARLY ATTENTION TO THE BONY PROMINENCES. RESULTS OF SKIN INSPECTIONS SHOULD BE DOCUMENTED". THE NURSING NOTES DATED 9/1/12 THROUGH 11/7/12 REFLECTED RESIDENT #1 WAS REPEATEDLY DESCRIBED AS HAVING ANKLE [MEDICAL CONDITION] (THE LEFT MORE SWOLLEN COMPARED TO THE RIGHT) AND FEELING RIGHT FOOT PAIN WHEREIN THE RIGHT HEEL ULCER DEVELOPED. THE NURSING NOTES DATED 9/20/12 REFLECTED, " SOFT TISSUE RIGHT FOOT PAIN AT SCALE OF 5" FROM A SCALE OF 0-10, 10 BEING THE MOST INTENSE PAIN. THE NOTE DATED 9/23/12 REFLECTED " SEVERE RIGHT FOOT PAIN AT SCALE OF "7". THE NOTE DATED 10/19/12 REFLECTED, "COMPLAINS OF SEVERE PAIN RIGHT FOOT THIS AM. NO REDNESS OR OPEN AREAS SEEN". ON 11/8/12 AT 11:00 A.M., RESIDENT #1 WAS OBSERVED SITTING IN HER WHEEL CHAIR IN FRONT OF THE NURSING STATION. SHE WAS WEARING WHITE TENNIS SHOES ON BOTH FEET WITH REGULAR WHITE SOCKS, ALTHOUGH THE CARE PLAN STATED THE RESIDENT WAS TO WEAR KNEE HIGH TED HOSE ON BOTH LEGS (DATED 8/8/12). ON 11/9/12 AT 11:30 A.M., RESIDENT #1 WAS AGAIN OBSERVED SITTING IN HER WHEEL CHAIR, EATING HER LUNCH IN HER ROOM. THE RESIDENT WAS WEARING THE SAME WHITE PAIR OF TENNIS SHOES WITH REGULAR WHITE SOCKS. THE RESIDENT APPEARED IRRITABLE AND STATED THAT SHE ONLY HAD ONE PAIR OF SHOES THAT FITTED PROPERLY. WHEN RESIDENT #1 WAS ASKED WHETHER SHE HAD PAIN ON HER RIGHT HEEL WOUND, SHE SAID, " NATURALLY ". THE RESIDENT'S RIGHT HEEL ULCER WITH ACCOMPANYING PAIN WAS PREVENTABLE. THE FACILITY'S LACK OF CONSISTENT IMPLEMENTATION OF INTERVENTIONS AND HOW THESE INTERVENTIONS WERE BEING MONITORED LED TO THE DEVELOPMENT AND EXACERBATION OF THE RIGHT HEEL PRESSURE ULCER. IT WAS UNCLEAR HOW THE FACILITY WAS PROACTIVE IN PREVENTING THE PRESSURE ULCER DEVELOPMENT WHEN THE RESIDENT WAS IDENTIFIED AS AT RISK FOR SKIN ULCERATION AS EARLY AS 4/2012. ( ) THE physician's orders [REDACTED]. BOTH MINIMUM DATA SET ((MDS) dated [DATE] AND 10/3/12 REFLECTED RESIDENT #18 COULD NOT BE DETERMINED FOR HER LEVEL OF MENTAL STATUS OR ORIENTATION CAPABILITY. UNDER THE FUNCTIONAL STATUS RESIDENT #18 WAS CODED AS REQUIRING EXTENSIVE TO TOTAL DEPENDENCE ON STAFF FOR ALL OF HER ACTIVITIES OF DAILY LIVING (ADL). THE CARE PLAN, WITH INITIATION DATES OF 2/24/10 TO 9/30/12, REFLECTED RESIDENT #18 HAD A SEVERE COGNITIVE IMPAIRMENT, RESISTANT AND COMBATIVE TO CARE, UNABLE TO FOLLOW INSTRUCTIONS, INCONTINENT OF BOWEL AND BLADDER AND HAD DISRUPTIVE BEHAVIORS. THE BRADEN RISK ASSESSMENT SCALE, USED TO PREDICT THE RISK OF DEVELOPING PRESSURE ULCER, DATED 4/3/12 REFLECTED A TOTAL SCORE OF 14 OUT OF POSSIBLE SCORE OF 16, REPRESENTING MODERATE RISK (12 OR LESS = HIGH RISK). THE SKIN OBSERVATION DATA BETWEEN 6/12/12 AND 7/30/12 REFLECTED RESIDENT #18 HAD INTACT SKIN EXCEPT FOR A RED AREA ON HER LEFT FOOT ANKLE ON 7/31/12. RESIDENT #18 HAD THE PROBLEM WITH SKIN INTEGRITY DATED 7/20/12. THE SKIN BREAKDOWN WAS IDENTIFIED AS UNSTAGEABLE PRESSURE ULCER ON HER LEFT HEEL. THE RISKS INCLUDED WERE " URINE AND BOWEL INCONTINENCE, BEDFAST, DIABETES MELLITUS AND SENSORY PERCEPTION". THE INTERVENTIONS, STARTED ON 7/20/12, INCLUDED " TREATMENT AS PRESCRIBED, ASSESS SKIN CONDITION DAILY AND NOTE ANY CHANGES, BANDAGE AS APPROPRIATE, DEVELOP AND MONITOR TURNING SCHEDULE, KEEP CLEAN AND DRY AND MEASURE AREA ". INTERVENTIONS DATED 9/30/12, FOR THE NURSE AIDES INCLUDED, " REPOSITION EVERY 2 HOURS, MINIMIZE PRESSURE ON BONY PROMINENCES ". THE NURSES NOTES DATED 7/11/12 STATED, " REFERRAL TO PHYSICIAN: PLEASE ASSESS LARGE FLUID FILLED BLISTER ON LEFT HEEL ...BOOTS MAY BE CAUSING MORE PRESSURE. MAY WE FLOAT THE HEELS"? THE NEXT ENTRY IN THE NURSES NOTES DATED 7/18/12 REFLECTED, "LEFT HEEL, MEDIAL ASPECT, BLOOD FILLED BLISTER MEASURES 5 CM IN CIRCUMFERENCE, 2 CM IN DEPTH ...THERE IS NO ADDITIONAL CHARTING ON THIS, NO UPDATES TO THE CARE PLAN OR CNA (CERTIFIED NURSING AIDE) CHARTING, ALTHOUGH THIS RN (REGISTERED NURSE) WAS INFORMED IN REPORT THAT THE RESIDENT HAD A SMALL BLISTER ON HER LEFT HEEL (SOMETIME LAST WEEK) AND AGAIN TODAY IN REPORT FROM SECOND SHIFT, THIS FINDING IS MUCH LARGER AND MORE COMPLICATED AT THIS POINT. RESIDENT IS WEARING HEEL BOOTS ON BOTH FEET, THIS IS NOT CARE PLANNED EITHER, NOR IS THERE ANY CHARTING ON THIS. BOOTS REMOVED FOR PROTECTION, HEELS FLOATED". THE WOUND NOTES DATED 7/11/12 THROUGH 11/7/12 REFLECTED THE FOLLOWING MEASUREMENTS AND CHARACTERISTICS OF RESIDENT #18'S LEFT HEEL ULCER: DATE SIZE (LENGTH X WIDTH X DEPTH IN CENTIMETERS) 7/18/12 5 CM IN CIRCUMFERENCE, 2 CM DEEP, and BLOOD FILLED BLISTER, RED PURPLE SUSPECTED DEEP TISSUE (SDT) INJURY 7/25/12 4.5 X 5.5 X 0.0, SUSPECTED DEEP TISSUE, NECROTIC/ESCHAR 8/1/12 5.0 X 5.2 X 0.0, BLACK NECROTIC/ESCHAR, SDT WORSE 8/8/12 4.5 X 4.5 X 0.0, BLACK NECROSIS 8/15/12 4.4 X 4.0 X 0.0, BLACK SDT 8/22/12 4.0 X 3.0 X 0.0, BLACK NECROSIS, UNSTAGEABLE SDT 8/29/12 2.8 X 3.2 X 0.0, BECOMING SMALLER 9/5/12 1.4 X 2.2 X 0.0, IMPROVING 9/12/12 1.8 X 1.5 X 0.0, IMPROVING 9/18/12 1.8 X 1.4 X 0.0, LIGHT DRAINAGE 9/26/12 0.8 X 1.0 X 0.0, DARK SCAB CAME OFF WITH SMALL OPEN AREA 10/3/12 HEALED STAGE 2 LEFT HEEL 10/7/12 MUSHY LEFT HEEL 10/17/12 2.4 X 3.0 X 0.0, PURPLE SDT 10/25/12 2.4 X 3.5 X 0.0, PURPLE 10/31/12 2.0 X 3.4 X 0.0, HEALING SDT 11/7/12 2.0 X 2.8 X 0.0, PURPLE SDT ON 11/9/12 AT 9:30 A.M., A DRESSING CHANGE PERFORMED BY THE REGISTERED NURSE, (STAFF "C" ) TO RESIDENT #18'S LEFT HEEL PRESSURE ULCER WAS OBSERVED IN HER ROOM. STAFF "C" REMOVED THE EASY BOOT AND STOCKINET DRESSING FROM THE RESIDENT'S LEFT FOOT. THE LEFT HEEL WOUND HAD AN IRREGULAR SHAPE DARK SCAB SURROUNDED BY PINK TISSUE. STAFF "C" CLEANSED THE WOUND WITH SALINE PAD, APPLIED A & D OINTMENT AND 4 X 4 GUAZE FOLLOWED BY A TUBULAR STOCKINET COVER DRESSING. ON 11/9/12 AT 9:45 A.M., STAFF "C" WAS ASKED HOW RESIDENT #18'S BOOTS COULD HAVE CAUSED THE SKIN BREAKDOWN, SINCE THE RESIDENT WAS NON-AMBULATORY AND THE BOOTS NORMALLY WERE USED TO RELIEVE THE PRESSURE WHILE IN BED RATHER THAN APPLYING PRESSURE. STAFF "C" WAS NOT SURE WHAT TYPE OF BOOTS THE RESIDENT HAD OR WHEN THE RESIDENT HAD STARTED WEARING THE BOOTS. STAFF "C" WAS ASKED HOW THE NURSES DOCUMENTED THEIR FINDINGS RELATED TO THEIR SKIN ASSESSMENTS. STAFF "C" STATED THAT THE LICENSED NURSES WERE SUPPOSED TO DOCUMENT SKIN CONDITIONS WEEKLY ON THE RESIDENT'S BATH DAY. HOWEVER THERE WAS NO SKIN ASSESSMENT DOCUMENTATION OTHER THAN THE WOUND NOTES. STAFF "C" WAS ASKED WHAT COULD HAVE BEEN THE DIRECT CAUSE OF RESIDENT #18'S LEFT HEEL PRESSURE ULCER DEVELOPMENT. STAFF "C" STATED, " PROBABLY THE RESIDENT WAS NOT TURNED OFTEN ENOUGH AND HER HEELS WERE NOT FLOATED". RESIDENT #18 DEVELOPED A PREVENTABLE PRESSURE ULCER IN HER LEFT HEEL RELATED TO A LACK OF A PERSON CENTERED CARE PLAN REFLECTING HER CURRENT NEEDS AND STATUS, LACK OF MONITORING OF THE ULCERATION DEVELOPMENT AND IMPLEMENTING PROACTIVE INTERVENTIONS. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE NECESSARY TREATMENT TO PROMOTE HEALING OF EXISTING STAGE 2 COCCYX ULCER FOR 1 OF 3 RESIDENTS (#17) REVIEWED FOR PRESSURE ULCERS FROM A TOTAL SAMPLE OF 24 RESIDENTS, RESULTING IN A NON-HEALING STAGE 4 COCCYX PRESSURE ULCER WITH ACCOMPANYING PAIN. FINDINGS INCLUDE: RESIDENT #17 WAS AN [AGE] year OLD MALE admitted to the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. ON 1/27/12 AT 9:15 A.M., RESIDENT #17 WAS OBSERVED SITTING UP WITH THE KNEE GAUGES ELEVATED HIGH, DOZING IN HIS BED. ON 1/27/12 AT ABOUT 9:30AM, THE RESIDENT STATED, "I DID NOT SLEEP WELL LAST NIGHT". RESIDENT #17 SOUNDED IRRITABLE AND ADDED, "I STAYED UP LATE, NOTHING WAS COMFORTABLE AROUND HERE. THE BED WAS UNCOMFORTABLE AND CHAIR WAS ALSO UNCOMFORTABLE". RESIDENT #17 WAS ASKED IF HE HAD ASKED TO BE REPOSITIONED. HE STATED, "IF I ASK THEM TO TURN ME AT NIGHT THEY MIGHT NOT DO THAT". THE NURSING NOTES DATED 8/12/11 (REadmitted ) REFLECTED RESIDENT #17 HAD 4 CM LONG AND 1 CM WIDE OPEN AREA ON COCCYX (TAIL BONE) AREA. THE WOUND HAD RED EXUDATE (DRAINAGE) AND "LUBE" AND "[MEDICATION NAME]" DRESSING HAD BEEN PLACED PER STANDING ORDER. THE NOTE ALSO INDICATED RESIDENT #17 HAD 2.5 CM ROUND OPEN AREA ON HIS LEFT BUTTOCK. THE NURSING NOTE 8/14/11(2 DAYS AFTER ADMISSION) REFLECTED RESIDENT #17 'S COCCYX WOUND WAS RED AROUND EDGES AND PAINFUL TO TOUCH. THE NOTE CONTINUED TO STATE THAT THE RESIDENT'S RIGHT BUTTOCK (UNCLEAR IF THIS IS REFERRING TO THE LEFT BUTTOCK WOUND THAT HAD BEEN IDENTIFIED ON ADMISSION OR THIS RIGHT BUTTOCK WAS A NEW AREA) WOUND WAS CIRCULAR AND LOOKED LIKE "RED POPPED BLISTER". THE NEXT ENTRY OF SKIN DOCUMENTATION COULD BE FOUND ON 8/16/11. THE COCCYX PRESSURE ULCER WAS DESCRIBED AS A STAGE 3 (FULL THICKNESS OF SKIN LOSS, EXPOSING THE SUBCUTANEOUS TISSUES-PRESENTS AS A DEEP CRATER) WITH RED SURROUNDING AREA AND GRANULATION SLOUGH TYPE OF TISSUE. THE RIGHT LOWER BUTTOCK PRESSURE ULCER WAS DESCRIBED AS A STAGE 2 (PARTIAL THICKNESS SKIN LOSS) WITH RED SURROUNDING TISSUE. ALTHOUGH THE COCCYX WOUND WAS CLASSIFIED AS A STAGE 3 AND THE RIGHT BUTTOCK WOUND WAS DEFINED AS A STAGE 2, THERE WAS NO MEASUREMENT ON BOTH WOUNDS. THIS WAS INDICATIVE OF INADEQUATE ASSESSMENT. THE NURSING NOTE DATED 8/16/11 AT 3:30 P.M., RESIDENT #17 WAS SENT TO THE emergency room DUE TO LOW HEMOGLOBIN 7.5 G/DL (NORMAL RANGE: 13.5-18.0) AND HAVING BLACK STOOLS. HE WAS RETURNED NEXT DAY AFTER THE TREATMENT. THE SKIN assessment dated [DATE] (10 DAYS FROM THE PREVIOUS ASSESSMENT DATE) REFLECTED THE COCCYX PRESSURE ULCER WAS NOW A STAGE 2 (IT WAS A STAGE 3 FROM THE 8/16/11 NOTES), DESPITE THE STATUS OF THE WOUND THAT WAS DESCRIBED AS WORSENING AND THE SIZE HAD GOTTEN LARGER (7 CM X 2 CM X 0.2 CM). NO ASSESSMENT OF THE RIGHT BUTTOCK WOUND COULD BE FOUND. THE NOTES DATED 8/16/11 INDICATED THE PRESSURE ULCER TO BE A STAGE 3. THE NURSING NOTES DATED 8/30/11 REFLECTED THE RIGHT BUTTOCK WOUND REMAINED A STAGE 2 WITH MEASUREMENT OF 1.6 CM X 0.4 CM. THE COCCYX WOUND HOWEVER, HAD WORSENED WITH MEASUREMENT OF 7 CM X 0.3 CM X 0.3 CM. THE WOUND WAS NOW IDENTIFIED BACK TO A STAGE 3 AND THE WOUND LOOKED DEEPER. THE NEXT DAY (8/31/11) THE COCCYX WOUND MEASURED 7 CM X 0.4 CM X 0.4 CM. BOTH THE NURSING NOTES AND THE SKIN ASSESSMENT NOTES DATED 9/9/11 REFLECTED RESIDENT #17'S COCCYX PRESSURE ULCER HAD WORSENED WITH SIZES OF 5.5 CM X 2 CM X 1.25 CM (SIGNIFICANT INCREASE WITH DEPTH) ALTHOUGH THE WOUND WAS DESCRIBED AS NOT HAVING ANY DRAINAGE OR SIGNS OF INFECTION. THE FOLLOWING SKIN ASSESSMENT WITH MEASUREMENT COULD BE FOUND ON 9/21/11 (12 DAYS LATER). THE WOUND HAD BEEFY RED BASE WITH SEROSANGUINOUS DRAINAGE AND MEASURED 5.0 CM X 2.0 CM X 1.5 CM. THE TREATMENT STILL CONSISTED OF APPLYING "LUBE" AND "[MEDICATION NAME]" DRESSING. THE LISTED INTERVENTIONS INCLUDED PRESSURE RELIEVING GEL CUSHION, ALTERNATING LOW AIR MATTRESS, TURNING/POSITIONING, HYDRATION AND NUTRITION. THE RESIDENT WAS SEEN FOR A WOUND CARE CONSULTATION ON 9/23/11. THE WOUND CARE NOTE DATED 9/28/11 REFLECTED RESIDENT #17'S COCCYX WOUND REMAINED AT A STAGE 3 WITH BEEFY RED WOUND BASE AND SMALL AMOUNT OF SEROSANGUINOUS DRAINAGE. THE NEW TREATMENT CONSISTED OF APPLYING "[MEDICATION NAME] AG" AND ABSORBANT COVER DRESSING. RESIDENT #17'S SUBSEQUENT COCCYX PRESSURE WOUND MEASUREMENTS (10/5/11, 10/19/11, 10/26/11) REFLECTED THE STATUS OF WOUND REMAINED UNCHANGED EXCEPT THE DEPTH WAS GETTING WORSE. THE WOUND MEASUREMENT OF COCCYX PRESSURE ULCER ON 11/7/11 WAS 5 CM X 1.5 CM X 3.0 CM. THE PHYSICIAN'S PROGRESS NOTE DATED 11/10/11 REFLECTED THE RESIDENT HAD A STAGE 4 (FULL THICKNESS SKIN LOSS WITH EXTENSIVE DESTRUCTION, OR DAMAGE TO MUSCLE, BONE, OR SUPPORTING STRUCTURES) SACRAL PRESSURE ULCER. THE NURSING NOTES DATED 11/10/11 REFLECTED RESIDENT #17 HAD BEEN discharged TO HOME AND RETURNED ON 11/18/11 WITH [MEDICAL CONDITION] ON HIS LEFT ARM. NEITHER THE NURSING NOTE NOR THE WOUND NOTE HAD ANY COMPREHENSIVE SKIN ASSESSMENT ON REadmitted . THE NOTE SIMPLY STATED, "NO NEW SKIN CONDITIONS NOTED." THE WOUND CARE NOTE DATED 12/8/11 (20 DAYS AFTER REadmitted ) REFLECTED RESIDENT #17'S COCCYX WOUND WAS A STAGE 3 (ANOTHER INCONSISTENT STAGING SINCE THE PHYSICIAN HAD CALLED IT A STAGE 4 ON 11/10/11) AND MEASURED 4 CM X 2 CM X 3 CM WITHOUT SLOUGH BUT SMALL AMOUNT OF BLOODY DRAINAGE. THE WOUND WAS DRESSED WITH SALINE SOAKED GAUZE PACKING AND "ABD." THE LAST PRESSURE ULCER ASSESSMENT NOTE HAD BEEN DOCUMENTED ON 1/2/12. THE WOUND MEASURED 4 CM X 2 CM X 1.6 CM. NO FURTHER DOCUMENTATION OF ANY PRESSURE ULCER MEASUREMENTS AND THE SKIN ASSESSMENTS COULD BE FOUND. THE NURSING NOTES DATED 11/18/11 THROUGH 1/27/12 REFLECTED RESIDENT #17 HAD FREQUENT EPISODES OF PAIN RELATED TO THE COCCYX WOUND. (HIS RANGED BETWEEN 7-9 POINTS FROM 1-10 INTENSITY SCALE WITH 10 BEING THE WORST PAIN). HE WAS ALSO DESCRIBED AS BEING NON-COMPLIANT WITH POSITIONING AND INTAKE OF PROTEIN SUPPLEMENTS. HOWEVER, NO RESIDENT-DIRECTED CARE PLANS; PREFERENCES, REEVALUATION OF CURRENT INTERVENTIONS RELATED TO PRESSURE REDISTRIBUTION DEVICES OR NUTRITIONAL SUPPLEMENTS COULD BE FOUND TO ADDRESS THESE ISSUES. ON 1/27/12 AT 9:30 A.M., THE DRESSING CHANGE TO RESIDENT #17'S COCCYX WOUND WAS OBSERVED IN HIS ROOM. THE UNIT NURSE, STAFF "U" ASSISTED BY THE NURSE AIDE, STAFF "V" CLEANSED THE WOUND WITH THE DIAL SOAP AND WATER AND PACKED WITH "[MEDICATION NAME] AG", WET "[MEDICATION NAME]" BY SQUIRTING APPROXIMATELY 10 ML SALINE SOLUTION FROM 60 ML SYRINGE AND COVERED WITH "ABD," A LARGE GAUZE DRESSING. STAFF "U" THEN APPLIED 'CALMOSEPTIC" CREAM ON THE SURROUNDING AREAS. THE "ABD" DRESSING WAS NOT SECURED WITH TAPE BUT HELD BY THE RESIDENT'S BRIEF. THE COCCYX WOUND WAS LOCATED RIGHT AT THE CRACK BETWEEN THE BUTTOCKS CLOSE TO THE RECTUM. THE ENTIRE WOUND BASE LOOKED BEEFY RED WITH SCANT AMOUNT OF BLOODY DRAINAGE. THE SURROUNDING TISSUE WAS ALSO RED. ALTHOUGH THE SIZE OF THE WOUND LOOKED LARGE, MEASURING APPROXIMATELY 6 CM LONG, 3 CM WIDE AND 3 CM DEEP, THE WOUND LOOKED CLEAN. THE RESIDENT COMPLAINED OF PAIN WHENEVER THE WOUND WAS TOUCHED AND ALSO COMPLAINED OF DISCOMFORT FROM LYING TOO LONG ON HIS LEFT SIDE WHILE THE DRESSING WAS BEING DONE. THE CARE PLAN DATED 11/18/11 REFLECTED RESIDENT #17'S IMPAIRED SKIN INTEGRITY WAS RELATED TO HIS POOR NUTRITIONAL STATE. THE INTERVENTIONS INCLUDED MONITORING FOOD INTAKE, HYDRATION, TURNING/REPOSITIONING EVERY TWO HOURS, KEEPING SKIN CLEAN AND DRY, DAILY SKIN CHECKS AND WEEKLY MEASUREMENT OF WOUND. THE ADDED NURSING INTERVENTION DATED 12/10/11 INCLUDED NOT GETTING RESIDENT UP FOR GREATER THAN AN HOUR AND A HALF AT A TIME. ON 1/27/12 AT 12 NOON, THE ASSISTANT DIRECTOR OF NURSING/INSERVICE DIRECTOR, STAFF "Q" CONFIRMED THAT THE FACILITY DID NOT HAVE A CONSISTENT WOUND MANAGEMENT SYSTEM WHEREIN THE NURSING STAFF DO SKIN ASSESSMENTS INCLUDING MEASUREMENTS ON A REGULAR BASIS INCLUDING EACH READMISSION; REVISE AND IMPLEMENT CARE PLANS THAT WERE CONSISTENT WITH THE RESIDENT'S NEEDS, GOALS AND ROOT CAUSE; AND EVALUATE THE INTERVENTIONS BY THE INTERDISCIPLINARY TEAM FOR IT'S EFFECTIVENESS OR LACK OF. RESIDENT #17'S WORSENED COCCYX PRESSURE ULCER TO A STAGE 4 ACCOMPANIED BY PAIN WAS PREVENTABLE. A HEALING OR NON-HEALING STAGE 3-4 PRESSURE ULCER COULD RESULT IN MORE SERIOUS COMPLICATIONS SUCH AS OSTEO[DIAGNOSES REDACTED]. ( )

This citation pertains to intake numbers MI 470. Based on observation, interview, and record review, the facility failed to provide adequate supervision for 1 of 9 sampled residents (Resident #106) resulting in an Immediate Jeopardy when the facility failed to replace an expired Wanderguard bracelet on Resident #106 who eloped from the facility without staff knowledge, putting her at high risk of serious injury, harm, impairment, or death, and placing 15 additional residents, who were assessed as risk of elopement, at a high risk of serious injury, harm, impairment, or death. Findings Include: "Documentation of assessment for hypothermia includes temperature (below normal body temperature), assessment of any change in the level of consciousness, increased confusion, blood pressure and/or heart rate changes, appearance of the skin on the tip of the nose, fingers, toes, and change in sensation." (Fundamentals of Nursing 6th Edition, Potter-Perry) An unannounced survey was conducted [DATE]-[DATE]. Per the MDS (Minimum Data Set) dated [DATE], Resident #106 was admitted to the facility on [DATE], needed no help or oversight with ambulation, had no signs of wandering behavior, and had a [DIAGNOSES REDACTED]. Per Resident #106's ECS (electronic charting system) nursing progress notes, dated [DATE] at 3:05 PM, Resident #106 had an "Incident Type: elopement...no apparent injury...left main building wanderguard not functioning...Physician review: notified per rounds...family notified 12:00 (PM)..XXX[DATE]-11:38 AM (the day after the incident), Reviewed by Physician..." Resident #106's nursing progress notes dated [DATE], stated, "Referral to physician: very restless and requiring one to one supervision at this time please assess for restlessness". Resident #106's behavioral tracking record dated [DATE], stated, "Night behavior record: Wandered x 2 (two times) standing in doorway of bedroom with pants down uncertain of what she was doing..." Resident #106's "Wandering Assessment", dated [DATE] stated, "Is this resident a new admission? NO. Is this resident ambulatory? YES. Is resident able to walk alone? YES. Is resident able to walk with walker or other device or use wheelchair? YES. Is the resident resistant to being placed in long term care facility? NO. does the resident have a history of wandering? YES. Is the resident currently taking medication which may cause confusion of disorientation? NO. Are there any indications of dementia? YES. Conclusion: Will reapply wanderguard". In the presence of administrative assistant #35, on [DATE] at 12:35 PM, Surveyor viewed surveillance video tapes, dated [DATE], that revealed Resident #106 left the East hall she resided on at 11:13 AM, turned left and walked the length of front hall of the building, entered the South resident hallway, walked to the end of the South hall and exited the egress door at 11:15 AM, unattended and without winter outerwear. Surveillance video revealed nurse aide #27 began searching for Resident #106 at 11:44 AM and Resident #106 reentered the building, accompanied by nurse aide #28 at 12:00 PM. In an interview on [DATE] at 1:25 PM, the ADON #24 (Assistant Director of Nursing ), she said she had been the facility Inservice Instructor since [DATE]. ADON #24 stated the facility surveillance video tapes confirmed Resident #106 exited the building at around 11:15 AM on [DATE]. ADON #24 stated that Resident #106 was found outside with, "a blanket over her head", and was returned back to the facility at 12:00 PM by nurse aide #28. In an interview, on [DATE] at 11:40 AM, with nurse aide #28, (a different nurse aide), he took this Surveyor outside and showed her where he found Resident #106 on [DATE]. Nurse aide #28 stated it was cold and windy outside and there was snow on the ground on [DATE], when he observed Resident #106's walker on it's side on the cement in front of the shed on the South Patio (an area behind the facility). He stated he found Resident #106 sitting on the ground beside the shed, with a shawl (not a blanket) over her head. He said her nose was "runny" and she told him she was very cold. Nurse aide #28 stated did not know if she fallen or not but he stated he did not see any scrapes or injuries on her hands or face and she did not have observed difficulty ambulating after he helped her to her feet. The outside air temperature between 11:00 AM-12:00 PM on [DATE] was 25 degrees Fahrenheit with "Max Gust Speed 24 mph" , for the city where the facility was located. (http://www.wunderground.com//history/airport/KRNP/[DATE]/DailyHistory.html?req). In an interview, on [DATE] at 11:27 AM, nurse aide #27 (the nurse aide assigned to Resident #106 at the time of the incident), stated, "(Resident #106's) Wanderguard was on her walker at the time (when she exited the building on [DATE])." Nurse aide #27 reported after entering the building at 12:00 PM on [DATE] Resident #106 was immediately taken to her room where he wrapped her in blankets because she was cold and changed her footwear because her feet were wet. In an interview on [DATE] at 10:00 AM, Resident #106 reported she remembered the day she went outside and said, "I just walked outside. I don't remember why. I started walking and just kept on going. It was cold". Resident #106 was dressed and ambulating in her room with her her walker. This surveyor did not observe any discolorations of skin or injury and Resident #106's hands or face and her arms and legs were observed to be functional. Review of the ECS nursing notes dated, [DATE] at 2:25 PM stated, "[DATE] (the day after the incident/no time recorded) late entry for vital signs taken after elopement BP (blood pressure) ,[DATE], P (pulse) 76, T (temperature) 98.2, R (respirations) 18, SpO2 (oxygen level) 94% on room air". There was no documentation of a head to toe assessment of Resident #106 to assess for any injuries or hypothermia. Per Resident #106's ECS vital signs record, "[DATE] - 2:00 PM Blood Pressure: ,[DATE]". There was no documentation of temperature or heart rate to monitor or assess any potential hypothermia from the outside exposure. In an interview, on [DATE] at 11:21 AM, LPN (Licensed Practical Nurse) #26 (the nurse assigned to Resident #106 at the time of the incident) stated she notified the family of Resident #106's elopement at 12:00 PM on [DATE] but did not call the physician. LPN #26 said, "He (the physician) would have reviewed the incident report in the morning". This Surveyor asked LPN #26 why there was no record of a head to toe assessment or monitoring of vital signs for Resident #106 after the incident on [DATE]. LPN #26 told this Surveyor she "did not need to" because Resident #106 looked "just fine". Per Resident #106's physician progress notes [REDACTED]. Her Wanderguard was not working...continue to monitor...". There was no documentation of an assessment for any injuries by the physician. During the survey, this Surveyor interviewed nine staff members that were working at the time of the incident with #106 on [DATE]. LPN #26 and nurse aide #27 (both assigned to Resident #106), and 7 other staff members (nurse aide #28, #29, #30, #32, #33 and #34 and RN #31) all denied seeing Resident #106 leave the building unattended or recalled hearing any alarms sound around the time Resident #106 exited the building. Review of Resident #106's TARs (Treatment Administration Records) with the exception of [DATE]-[DATE], between [DATE]-[DATE] there were no nurses' signatures to indicate that the Resident #106's Wanderguard had been tested . Review of TARS for Resident #107 and Resident #108's (also assessed as at risk for elopement and wore Wanderguard bracelets) showed, that between [DATE]-[DATE], nurses had not recorded they had checked their (either Resident #107's or Resident #108's) Wanderguards to ensure they were in working order. In an interview on [DATE] at 2:20 PM, ADON #24 told this Surveyor that she discovered the reason the Wanderguarded door Resident #106 exited did not alarm was because the midnight nurses had not been checking to see if the residents' Wanderguards were working (the door that Resident #106 exited on [DATE] had a Wanderguard sensor but did not alarm). ADON #24 said Resident #106's Wanderguard bracelet expired on [DATE] (seven days before she eloped from the building on [DATE]) and it was not working when she tested it. ADON #24 said that Wanderguard bracelets were to be replaced every 90 days, "even if it is working". ADON #24 also stated she had sent a "memo" (e-mail message) to staff indicating that they were going to be trained and tested on the new Wanderguard Universal Testers, but the training of staff had not been done yet. This surveyor accompanied ADON#24 and observed her test all Wanderguards in use. All the Wanderguards tested to be functioning properly. Review of an "Employee Discipline Report", signed and dated [DATE] by RN #7 and DON #20 stated, "Written Warning...The treatment record representing the Wanderguard check for (Resident #106) is blank for [DATE] (2010). You worked that evening. Did you not check this important piece of safety equipment? The Wanderguard was determined not to be working when the resident eloped from the facility...It is your responsibility to check the wanderguard device for working order, replace when not working to prevent resident elopement. we must take obvious and protective measures to ensure resident safety". Accompanied by the maintenance #16, on [DATE] at 3:45 PM, this Surveyor observed that all facility Wanderguarded doors alarmed when a Wanderguard device was present. Review of the "Wanderguard" Policy and Procedure" revealed an original date of [DATE] with a revised date of [DATE]. The revised "Wanderguard Departure Alert System "Policy read, "...Hold the Universal Tester (new Wanderguard battery and transmitter testing devices) within one foot from the bracelet, pointing the (Universal) tester towards the bracelet..." There was no evidence on the document that the policy had been reviewed by the medical director, or anyone else, between the origination date in [DATE] and it's revision on [DATE]. The DON #20 was unable to provide any evidence of a facility policy or procedure regarding hypothermia assessment. The DON #20 was unable to provide any proof of elopement prevention/Wanderguard system or hypothermia in-servicing for any of the nursing staff during their employment at the at the facility and the facility. On [DATE] at 2:47 PM, this Surveyor asked the DON #20 about whether Resident #106's elopement had been reported to the state agency. DON #20 stated the facility did not report the incident to the state agency and presented a "Memorandum" regarding "24-Hour Emergency Hotline" dated [DATE] that read, "...your facility has the responsibility to call the BHS (Bureau of Health Systems) Emergency Hotline ....after the occurrence of ...A resident missing for more than two (2) hours (less where there is a strong potential to become an immediate threat to life, e.g., either because of inclement weather conditions or known hazards outside the facility...)" On [DATE] at 3:45 PM, the DON (Director of Nursing) #20 gave this Surveyor the facility "Elopements" Policy, ("Revised" date [DATE] and "Last printed" date [DATE]), that stated, "...Upon return of the resident to the facility, the Director of Nursing Services or Charge Nurse should...Examine the resident for injuries; Contact the Attending Physician and report what happened...Make appropriate notations in the resident's medical record...Notify the Michigan Bureau of Health Systems per the 24-Hour Emergency Hotline ([DATE]-8484) when a resident has been missing or eloped into an unsafe area..." On [DATE] at 8:10 AM, the DON #20 presented a second "Elopements" policy (Revised" date [DATE] and "Last printed" date [DATE]) that contained the wording, "...Notify the Michigan Bureau of Health Systems pert the 24-Hour Emergency Hotline ([DATE]-8484) when a resident has been missing for more than 2 hours (less where there is a strong potential to become an immediate threat to life, e.g. either because of inclement weather conditions or known hazards outside the facility.) This 2 hour limit applies also to residents who have not returned from a Leave of Absence". The dates were the same as the "Elopements" policy presented on [DATE] but the wording was changed. When this Surveyor asked the DON #20 why the policies had the same dates but the words were different, DON #20 said she (DON #20) changed the wording to "...make it right for you (Surveyor)". To re-clarify, this Surveyor asked DON #20 if she had changed the document to include the "2 hour" information from the "Memorandum" dated [DATE], and she stated, yes she had changed the wording but did not change the "Revised" or "Last printed" dates. There was no indication the Medical Director had reviewed and approved the revised policies. DON #20 stated she did an in-service the same morning to the nursing staff on the revised "Elopements" policy and procedure. When this Surveyor asked DON #20 if the Medical Director #36 had approved the changes in the policy and DON #20 stated he had not. DON #20 stated she had the right to go into the computer and make changes. On [DATE] at 3:30 PM, the DON #20 presented a third version of the "Elopements" policy (Revised" date [DATE] and "Last printed" date [DATE]) that read, "...Upon return of the resident to the facility, the Director of Nursing Services or Charge Nurse should...Contact the Attending Physician and report what happened...Make appropriate notations in the resident's medical record...Notify the Michigan Bureau of Health Systems per the 24-Hour Emergency Hotline ([DATE]-8484) when a resident has been missing or eloped into an unsafe area..." On [DATE] at 12:00 PM, this Surveyor was present when office manager #25 printed the "Elopements" Policy and Procedure, that showed a "Last printed" date of [DATE]. This document had no "Revised" date and read, "...Upon return of the resident to the facility, the Director of Nursing Services or Charge Nurse should...Contact the Attending Physician and report what happened...Make appropriate notations in the resident's medical record...Notify the Michigan Bureau of Health Systems per the 24-Hour Emergency Hotline ([DATE]-8484) when a resident has been missing or eloped into an unsafe area..." This Surveyor presented the document to the administrator # 21 and asked why there was no "Revised" date on it. Administrator #21 stated she removed the wording from the bottom of the document that contained the "Revised" date. Administrator #21 stated that she and the DON #20 had the right to change policies in the computer. There was no indication the Medical Director had reviewed and approved the revised policy and the Administrator #21stated that he had not. On [DATE] at 2:00 PM, the Administrator #21 was notified of the Immediate Jeopardy that began on [DATE] as a result of the facility's failure to provide supervision to prevent elopement and ensure the safety of one resident (Resident #106), who had been identified at risk for elopement, when she eloped from the facility for 45 minutes on [DATE] without staff knowledge, and was found outside alone, in below freezing weather, without protective winter clothing, sitting on the ground beside a shed on the facility property. The facility failed to monitor Wanderguard devices for functionality (it was expired), placing 15 additional residents, who were assessed to be at high risk of elopement, at a high risk for elopement with the potential for serious injury, harm, impairment and or death. On [DATE], the Surveyor confirmed that the facility implemented the following to remove the Immediate Jeopardy: 1). On [DATE] a new Wanderguard device was activated and placed on Resident #106's wrist. 2). On [DATE] the ADON #24 began checking all Wanderguard devices and the facility's 14 egress doors in use and accessible to residents. All 8 Wanderguarded doors alarmed properly when tested . One egress door was alarmed with a Nurse Call alarm that alarmed whenever the door was opened, and 5 additional egress doors were opened only with employee badges. 3). On [DATE], the ADON #24 directed that all Wanderguard bracelets have the expiration date written on the bracelet. In addition, the facility will maintain a log of all Wanderguard devices in use with the date they were put in service along with the expiration date. The Treatment Administration Record (TAR) located in the electronic chart will also indicate the expiration date. 4). On [DATE], 3 members of the Quality Assurance Committee, the Administrator #21, ADON #24, and the Director of Maintenance #19, reviewed Resident #106's elopement and began a plan and process utilizing root cause analysis to assure this type of incident does not occur again. 5). On [DATE], Wanderguard devices, doors and testers were checked again, all were in working order. During these checks, it was discovered there various manufactured testers in use and facility management decided to order all similar types of testers for consistency. The maintenance supervisor ordered new (Universal) testers . The manufacturer was contacted to do an onsite visit for recommendations and a representative of the company is expected on [DATE]. 6). On [DATE], the DON #20 educated RN #on her responsibility to check and document (on the TAR) Wanderguard devices on her assigned unit. 7). On [DATE], the ADON #24 and Administrator reviewed the the "Wanderguard" and "Elopements" policies and made revisions as needed. Based on review of the manufacturer's recommendations for the Universal Testers, Wanderguarded door checks were changed from daily to weekly, to be done on Fridays by all 3 shifts. This change was communicated to the Maintenance staff, who are assigned the door checks. Maintenance staff will maintain a log showing the door checks. 8). On [DATE] the DON #20 and the ADON #24 began in-servicing nursing staff on the "Wanderguard" Policy and Procedure. As of [DATE], 25 out of 40 nurses received in-service on the Wanderguard device and using the Universal Tester. As of [DATE], 49 out of 88 nurse aides received in-service on checking Wanderguard device for the location and the integrity of the bracelet. All licensed staff who had not received the in-service will be in-serviced before going on duty upon returning to work. 9). On [DATE] the DON #20 changed the "Elopements" Policy and Procedure and removed the "2 hour" information. DON #20 and ADON #24 began in-servicing staff on the "Elopements" Policy and Procedure. As of [DATE], 135 out of 239 facility staff members had received in-service on the newly revised policy. Those who did not attend will be required to receive the in-service prior to their next scheduled shift. 10). On [DATE], the Quality Assurance committee recommended that I Com (nurse call system vendor), be contacted to order buzzer alarms on all egress doors accessible to residents to alert staff when a person exits the building (in addition to the Wanderguard system). The maintenance Supervisor #19 contacted I Com to install the buzzer system and to have it connected to the nurse call system. The front entrance (main entry) door will continue to have a Wanderguard alarm on 24 hours a day, 7 days per week. The front entrance will also be set to the I Com buzzer alarm between 8:30 PM and 8:00 AM daily. 11). On [DATE], the Administrator #21 established a quality assurance study to monitor compliance. The DON #20, or designee, will make random checks weekly to ensure nurses are documenting the wanderguard checks nightly on the TAR, that maintenance is checking the wanderguard doors weekly and on all 3 shifts, and that nurse aides are documenting in ECS the presence and integrity of the Wanderguard device on their assigned residents. The DON #20, or designee, will conduct random weekly audits on four residents, observing if the device check was done correctly and according to policy and will then verify that the Wanderguard device is properly applied in accordance with nursing care plan. Audits will be recorded in a log. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity of no actual harm but the potential for more than minimal harm due to all staff had not been in-serviced and the State agency had not verified sustained compliance.

This citation pertains to MI 260. Findings include: Based on observations, interviews and records review, the facility failed to provide adequate supervision and assistive devices for 4 of 5 sampled residents who were identified at high risk for falls and had pressure alarms on their beds, resulting in a fractured hip for Resident #101 (sustained during a unsupervised fall) and the potential for falls and potential for serious injuries for Residents #102, #103 and #105. Resident #101: Per a Minimum Data Set, dated dated [DATE], Resident #101 had severely impaired cognitive skills for daily decision-making, wandered (moved with no rational purpose, seeming oblivious to needs or safety) and walked independently in the corridor on unit. Per Incident reports, Resident #101 fell on [DATE] and 9/25/10. Per a care plan, dated 9/18/10, Resident #101 had an identified, "Problem: Potential for Trauma-Falls...fall (or near fall) in past 180 days ...Safety Device(s): Bed alarm on when in bed ...)". Per an incident report, dated 10/15/10, Resident #101 sustained a fall on 10/14/10 at 5:15 AM. The report stated, "Nurse aide responded to loud sound from down the hall ...Bed alarm was not sounding ... Physician notified 5:25 AM, orders received. Family notified 5:30 AM ...Report from ER (emergency), Hip is fractured ..." In an interview with LPN #4, on 11/05/10 at 6:00 AM, she told surveyor she was a floor nurse the night of 10/14/10 and after the ambulance took Resident #101 to the hospital, she checked the pressure alarm on Resident #101's bed and found that it was not functioning. LPN #4 stated she thought the reason the alarm did not sound was due to a faulty pressure pad and the pressure pad was removed and replaced with a new one. In an interview with LPN #2, on 11/05/10 at 6:45 AM, she told Surveyor she helped LPN #4 assess Resident #101 after she fell on [DATE]. LPN #2 stated she suspected that Resident #101 pressed the "big button on the box" (shutting off the Sensatec pressure alarm on the bed) because it was not alarming the night of 10/14/10, when Resident #101 fell . LPN #2 stated, "She (Resident #101) was a resident who played with them (alarm boxes) herself ...she will shut it off if it alarms". In an interview with the nurse aide #3, on 11/08/10 at 9: 30 AM, she stated she had taken Resident #101 to the bathroom, toileted her and returned her to bed 15 minutes prior to when she was found on the floor in the bathroom on 10/14/10 by nurse aide #1 at 5:15 AM. In an interview with nurse aide #1, on 11/08/10 at 10:00 AM, regarding Resident #101's fall on 10/15/10, nurse aide #1 stated she was in another resident's room when, "I heard a loud boom". Nurse aide #1 stated she went into Resident #101's room and found her on the floor in the bathroom. Nurse aide #1 stated that no alarms were sounding. Nurse aide #1 said she turned the bathroom alarm on and two nurses (LPN #2 and LPN #4) came immediately. Nurse aide #1 stated, she watched the two nurses (LPN #2 and LPN #4) try to pick up Resident #101 by her arms, without the assistance of a transfer belt or the mechanical lift, while Resident #101 was,"screaming and crying", in a "very agonizing" voice, "my hip is hurting". Per a facility "Ergonomics" documents, use of "Gait belts/transfer belts", "When to Use: ...assisting after a fall ...Portable lift device (sling type), When to Use: ...after a resident fall ..." In a telephone interview with nurse aide #3, she told Surveyor she had worked at the facility for [AGE] years. On 10/15/10, according to nurse aide #3, the unit where Resident #101 resided had, " ...more than enough staff " the night of 10/14/10. Nurse aide #3 stated she responded to the sound of Resident #101's bathroom alarm and stated she observed LPN #2 and LPN #4 lift Resident #101 by her armpits and attempt to encourage Resident #101 to walk. Nurse aide #3 told Surveyor, "...they stood her up but she wouldn't bear weight on her leg. She pulled her legs up and crossed her ankles". Nurse aide #3 stated (LPN #4) was telling Resident #101 to stand up, take a step and try to walk. Nurse aide #3 also stated, "I think they should have left her on the floor instead of trying to make her walk". In a telephone interview with nurse aide #6, on 11/08/10 at 10:20 AM, she told Surveyor she worked at the facility for at least [AGE] years and was at the nurse's desk when she saw nurse aide #1 run into Resident #101 ' s room and call for help. Nurse aide #6 stated she saw two nurses (LPN #2 and LPN #4) enter Resident #101's room and she subsequently followed them. Nurse aide #6 stated she watched LPN #2 and LPN #4 lift Resident #1 by her arms (without a gait belt). Nurse aide #6 said, "I don't think they were supposed to (lift her that way). Our (previous) director of nursing told us to us a Hoyer (mechanical lift) when someone falls. Nurse aide #6 stated, "I didn't like the way they (LPN #2 and LPN #4) stood her (Resident #101) in the bathroom. Nurse aide #6 continued, saying she offered the the 2 nurses a wheel chair and they placed Resident #101 in the wheel chair, and pushed it up to the side of Resident #101's bed. "They told me to transfer her (Resident #101). I put my arms around her (Resident #101) and she said 'No, no". Nurse aide #6 told the nurses (LPN #2 and LPN #4) she was not comfortable transferring Resident #101 and asked how she should perform the transfer of Resident #101 from the wheel chair to the bed. According to nurse aide #6, the transfer was performed with nurse aide #3 standing behind Resident #101, putting her hands under Resident #101's "bottom", "I (nurse aide #6) was on the left (of Resident #101) and LPN #4 was on the right (we did not use a gait belt or a mechanical lift). "Nurse aide #6 also stated, "I always wondered why they had her (Resident #101) so far away from the (nurse's) desk ...she would get up a lot on her own ...she gets up all different times ..." In a telephone interview with LPN #4, on 11/08/10 at 10:51 AM, she told Surveyor she had worked at the facility for [AGE] years. LPN #4 stated when she arrived in Resident #101's room, on 10/14/10, the light on Resident #101's pressure alarm box, on her bed, was flashing orange. When asked what a flashing orange light meant, LPN #4 stated, "I'm not sure. I think it means pause". Then Surveyor asked LPN #4 what color the light would be if the battery had low power, LPN #4 stated, "Not sure what color ...I think orange". LPN #4 stated she tried to assess Resident #101 in the bathroom but could not because Resident #101's, "legs were around the toilet and it was impossible to do range of motion". LPN #4 said, "We' re not supposed to move them at all but she was in a cramped corner. No matter what you did, she kept screaming ...I don't think we could have gotten the Hoyer into the position she was in". When Surveyor asked if a transfer belt was used, LPN #4 stated, "No". When Surveyor asked her how long it usually takes an ambulance to arrive o the facility after it is called, she stated, "Five-ten minutes". When Surveyor asked LPN #4 how long it took to transfer Resident #101 from the bathroom to her bed on 10/15/10, the night she fell in the bathroom", she stated, "Ten minutes". In an interview with nurse aide #11, on 11/08/10 at 2:10 PM, she told Surveyor she had worked at the facility for [AGE] years. Nurse aide #11 told Surveyor that a yellow flashing light on the alarm boxes meant pause. When asked what would happen if the battery was low on the alarm box, nurse aide #11 stated, "I think it flashes red, I believe". In an interview with RN #23, on 11/08/10 at 1:55 PM, she told Surveyor she had worked at the facility for 7 years. RN #23 accompanied Surveyor to Resident #101's room and observed Resident #101 lying quietly in bed and a pressure alarm box (Sensatec control unit) was attached to the enabler bar (grab bar) on the top side of the bed within reach of Resident #101. RN #23 told Surveyor the pressure alarm box was the same type that was on Resident #101's bed on 10/14/10 and showed Surveyor a yellow light on the box. RN #23 said, " Yellow means it 's activated". When nurse #23 tried to demonstrate whether the alarm was working properly, she depressed the on/off/silence button on the face of the box but was unable to get the light to turn green, stating, "If it's green, its turned on". Surveyor observed the connector plug from cord of the sensor bed pad was loose fitting in the sensor jack of the alarm control box. RN #23 stated, "I need to get a new box. It's loose in there but it worked before ...it was blinking green this morning". Per the Sensatec Fall Alert system In-service Manual, "It is the responsibility of the facility to implement structured training procedures for all employees using the system. Only users who have received adequate training on the use of the system should use the system. Failure to adequately train employees may cause equipment failure do to user error. In addition, incorrect use of the equipment may also result in equipment failure ...It is the responsibility of the facility to establish and facilitate a regular maintenance schedule ...includes regular inspection, testing, and cleaning. Failure to provide regular maintenance to these products may result in equipment failure ...Using the nylon strap and side release buckles, hang the Control Unit on the bed, out of reach of the resident. (Illustrations showed the "Silence" button on the face of the unit and proper positioning of the box, on the bed frame) ...Check to see that the battery is properly connected and operational; the green LED should be flashing rapidly ...Sensatac System will be free from defects in material and workmanship for a period of one year from date of sale and title ...Warranty coverage does not include ...any design, specification, or instruction changed by Buyer, its employees ...failure to comply with any applicable instructions or recommendations of Seller, including installation procedures..." Per a "Safety and Supervision of Residents" facility document, "...Implementing interventions to reduce accident risks and hazards shall include the following: ...providing training, as necessary; ensuring that interventions are implemented ...Monitoring the effectiveness of interventions shall include the following: ensuring that interventions are implemented correctly and consistently, evaluating the effectiveness of interventions, modifying or replacing interventions as needed, and evaluating the effectiveness of new or revised interventions". Resident #102 Per an incident report, Resident #102 fell in the bathroom, without staff assist, on 10/31/10. Surveyor reviewed the current CNA (nurse aide) Quick Reference, for Resident #102 on 11/09/10. Per the CNA Quick Reference, "Nurse Aide - check alarm to make sure it is operating correctly before each use". In an interview with central supply staff #22, on 11/09/10 at 10:45 AM, she told Surveyor she was responsible for ordering the Sensatec pressure alarms for the facility, maintaining and cleaning of the alarms' control boxes and educating staff on proper operation and testing of the units. She stated she did not maintain a log of when units were purchased or when batteries were changed. Staff #22 stated she trained staff upon hire and not thereafter. Staff #22 told Surveyor, "If they (staff) have any questions, they can ask". Staff #22 stated the Control boxes are cleaned when they are returned to her, if they aren't working properly or if residents no longer need them. Surveyor told staff #22 that she observed, while accompanied by nursing staff on 11/09/10, 7 resident's pressure alarm boxes blinking green only every 8-9 seconds (Resident #102, Resident #103 and off sample residents #17, #18, #19, #20 and #21). Staff #22 said, "I would check it if it were flashing every 8 seconds (not flashing rapidly). Something isn't right". Resident #103 Per an incident report, Resident #103 fell in her room, without staff assist, on 8/18/10 and fell again on 9/03/10 when she got up without staff assist. Surveyor reviewed the current CNA (nurse aide) Quick Reference, for Resident #103 on 11/09/10. Per the CNA Quick Reference, "Nurse Aide - check alarm to make sure it is operating correctly before each use". In an interview with central supply staff #22, on 11/09/10 at 10:45 AM, she told Surveyor she was responsible for ordering the Sensatec pressure alarms for the facility, maintaining and cleaning of the alarms' control boxes and educating staff on proper operation and testing of the units. Surveyor told staff #22 that she observed, while accompanied by nursing staff, alarm boxes on enabler bars (within residents' reach) , on 6 other residents' beds (Resident #103 and off sample residents #17, #18, #19, #20 and #21). Staff #22 stated, voiced concern over the placement of the boxes on the enabler bars, saying if the boxes were placed on the enabler bars, a resident could reach them and turn them off and if the enabler bars were released, the boxes could hit the ground and potentially be broken. Resident #105 On 11/08/10 at 2:19 PM, Surveyor accompanied RN #23 to Resident # 105's bedside and observed Resident #103 lying quietly in bed. An alarm box, attached to the bed, was blinking red but not making any sound. RN #23 told Surveyor a flashing red light means the device needed a new battery. In an interview, on 11/08/10 at 2:11 PM, with nurse aide #13, (the nurse aide assigned to Resident #105) Surveyor asked him how he knew when an alarm box is working properly and he responded, "I just listens for the beep. If the battery is low it will beep". When Surveyor told nurse aide #13 that she had just come from Resident #105's room and observed the alarm box blinking red but not beeping, nurse aide #13 responded, "Oh, it's red?"