Every finding on record at Pomeroy Living Rochester Skilled Rehabilitation

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 04/19/2026 at 8:45 AM initial kitchen/dietary services tour with Dietary Manager/Chef (DM) Q and Corporate Chef (CC) R. On 04/19/2026 at 9:10 AM in the dry storage area observed the floor soiled with debris along perimeter of room at floor/wall juncture and soil build-up on storage shelving. When queried about cleaning frequency of this area, DM Q agreed that noted areas needed cleaning attention.According to the 2022 FDA Food Code section 4-602.13 Nonfood-Contact Surfaces. NonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues.According to the 2022 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean.Observed upright reach-in cooler with a towel full of water in the bottom of the unit and condensate dripping at the top of the unit interior onto packaged single service food items. When queried about the unit, DM Q says the towel is replaced every day to absorb the dripping condensate and that it's been like that since I've been here.According to the 2022 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair .On 04/19/2026 at 9:30 AM in the [NAME] Terrace dining area observed a pump container of food thickener product stored at the handwash sink behind the faucet and near the hand soap dispenser. DM Q said it is in this area as it is used for beverages, specifically coffee service and then they relocated item to the counter area away from handwashing sink. On 04/20/2026 at 12:30 PM during lunch service in [NAME] Terrace (main) dining room observed pump of food thickener product stored in handwash area.According to the 2022 FDA Food Code section 3-305.11 Food Storage. (A) .FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .On 04/19/2026 at 9:45 AM in the [NAME] Dining area observed the ice machine leaking and standing water pooled on the floor under and behind the ice machine. The floor tiles were observed soiled with a black mold-like substance and several floor tiles were loose, damaged and/or missing. The drain lines from the ice machine into the floor drain were soiled with black build up and the ice bin drain line terminated below the flood rim of the floor drain and was not provided with the required air gap. Observed several small flying insects (drain flies) in this area. When queried during this observation DM Q said this concern would be shared to maintenance staff. According to the 2022 FDA Food Code section 5-402.11 Backflow Prevention. (A) .a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. According to the 2022 FDA Food Code section 6-501.11 Repairing. PHYSICAL FACILITIES shall be maintained in good repair.According to the 2022 FDA Food Code section 6-501.111 Controlling Pests. The PREMISES shall be maintained free of insects, rodents, and other pests.On 04/19/2026 at 10:05 AM in the kitchen observed the juice machine nozzles and area around nozzles soiled with dark mold-like substance. When queried, CC R also observed this and indicated they would detail clean this area. According to the 2022 FDA Food Code section 4-602.11 Equipment Food-Contact Surfaces and Utensils. (E) .surfaces of UTENSILS and EQUIPMENT contacting FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cleaned: (4) In EQUIPMENT such as ice bins and BEVERAGE dispensing nozzles.: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold.On 04/19/2026 at 11:55 AM observed bin of clean stored rubber spatulas- 3 of 5 observed with torn/damaged edges. DM Q indicated spatulas are replaced regularly and discarded 1 of the damaged spatulas to the garbage. According to the 2022 FDA Food Code section 4-202.11 Food-Contact Surfaces. (A) Multiuse FOOD-CONTACT SURFACES shall be: (1) Smooth; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections.On 04/19/2026 at 12:45 PM in the [NAME] Terrace (main) kitchenette, observed stacked domed plate covers stored wet and with food contact (interior) portion exposed. As dietary staff pulled a cover to place over plated food, water droplets spilled onto floor. Clean utensils in storage containers located on top of the microwave were observed stored with eating portion of utensils exposed (instead of handles).On 04/20/2026 at 12:30 PM during lunch service in [NAME] Terrace kitchenette observed clean utensils stored on the microwave and stacked and domed plate covers with food contact surfaces exposed. When queried, DM Q said that's how they are usually stored. When asked about air drying of food equipment like the plate covers, DM Q indicated they are usually fully air dried before brought to the kitchenette but acknowledged that may not always be the case.According to the 2022 FDA Food Code section 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD.According to the 2022 FDA Food Code section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) .cleaned EQUIPMENT and UTENSILS . shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted.On 04/20/2026 at 11:15 AM observed pre-set silverware on top of napkins (not covered) in the [NAME] dining room.On 04/20/2026 at 11:30 AM observed the [NAME] Terrace dining room tables were pre-set with uncovered silverware. Residents were using dining room tables for activities at this time. When asked about the multi-purpose use of this room, DM Q confirmed that this room is used for resident activities throughout the day. When queried about pre-setting silverware, DM Q indicated it is how they set the table to create a homelike environment. When asked if there was a policy for dining/table set up, CC R said they would check. CC R reported back that there is no related policy for dining room table set up.According to the 2022 FDA Food Code section 4-904.13 Preset Tableware. (A) Except as specified in (B) of this section, TABLEWARE that is preset shall be protected from contamination by being wrapped, covered, or inverted.

Based on observation and interview, the facility failed to assure medications were safely secure and inaccessible to unauthorized staff and residents, for two of four medication carts observed for medication storage, and observations within two resident rooms (R47, during medication administration and (R39) during initial pool interviews, and environmental observations of the community shower rooms. Findings include.On 4/19/26 at 9:00 AM, during an observation of medication administration with Licensed Practical Nurse (LPN) C for R47, three bottles of Nystatin Powder (a topical antifungal medication) were observed stored on the resident's sink counter. LPN C commented those should not be here and was observed removing from counter. On 4/19/26 at 9:00 AM, Medication Cart #1 was observed was with LPN C for medication storage which revealed in the residential storage drawer one loose white oval pill and one loose round orange pill, not packaged and with no resident identifiers.On 4/19/26 at 10:20 AM, R39 was observed asleep, a brown and silver tube labeled Clear Zinc Barrier Ointment was observed on the bedside tray table. Record review of the Medication Administration Record (MAR) from April, did not document this medication as ordered or to remain at the bedside.On 4/19/26 at 10:50 AM, the [NAME] Unit Shower Rooms were observed with Certified Nursing Assistant (CNA) G. Two packages of skin protectant (product designed to form a protective barrier on the skin) were observed lying amongst multiple bottles of used open shampoo body products. The closet door was opened and a shower caddy revealed storing multiple single use packages of Vitamin A&D ointment (medication used as a moisturizer to treat skin conditions). CNA G was overheard commenting the packages of ointments should not be in the shower room. On 4/20/26 at 3:03 PM, a Medication Cart on the Subacute Rehabilitation labeled Wing B Cart #2 was observed unlocked and no nursing staff were present. Unit Manger Licensed Practical Nurse (LPN) E was informed of the observation and acknowledged the cart should not be unlocked. On 4/21/2026 12:30 PM, the Nursing Home Administrator and Corporate Acting Director of Nursing were informed of the above observations, acknowledged the medications were not stored safely, securely, and properly.

Based on interview and record review, the facility failed to operationalize an effective antibiotic stewardship program to ensure appropriate infection criteria was met, this had the ability to affect multiple residents who were prescribed antibiotics including six [R8, R30, R56, R138, R139 and R140] residents identified. Findings include:On 4/20/26 at 8:26 AM, a request was made for all the infection control surveillance books to review for the Infection Control Task.Review of January 2026 antibiotic surveillance revealed:The line listing for R138 documented UTI [urinary tract infection] with an onset date of 1/13/26, no signs or symptoms were marked no testing was indicated, and Keflex 500 mg [milligrams] twice a day for seven days was ordered. An Individual Infection Investigation for R138 with an onset date of 1/20/26 documented the UTI was facility acquired and the symptoms were, elevated temp [temperature], urine odor and that Hospice declined was written in for the date of the urine culture. The line listing for R8 documented pneumonia with an onset date of 1/14/26, symptoms marked were: cough, sputum and SOB [shortness of breath]. Na [not applicable] was marked for diagnostics and Cefuroxime Axatil 250 mg every 12 hours for seven days was ordered. An Individual Infection Investigation documented the onset date of 1/22/26, facility acquired with no date of x-ray.Review of February 2026 antibiotic surveillance revealed:The line listing for R139 documented UTI with an onset date of 2/7/26, symptoms marked was change in urine. NA: did not meet McGreers [Sic-McGeer's Criteria] and Keflex 500 mg three times a day for five days was ordered. An Individual Infection Investigation documented the UTI as facility acquired with no date of urine culture.The line listing for R140 documented LLE cellulitis [left lower extremity], an onset date of 2/12/26 with symptoms of redness and swelling. Cephalexin 500 mg four times a day for five days was ordered. An Individual Infection Investigation documented no date of onset, no community or facility acquired, no symptoms, and no testing. The treatment orders were Doxycycline Hyclate 100 mg two times a day for five days.Review of March 2026 antibiotic surveillance revealed:The line listing for R30 documented CAUTI [catheter-associated urinary tract infection], an onset date of 3/17/26 and symptoms marked were: fever, flank pain and change in urine. Macrobid 100 mg two times a day for five days was ordered. An Individual Infection Investigation documented the UTI was facility acquired, the date resolved was 3/24/26, Hospice declined the urine culture and that the original antibiotic ordered was Bactrim and was changed to Macrobid.The line listing for R56 documented UTI, an onset date of 3/25/26 and symptoms marked were: flank pain, change in mental status and burning on urination. Rocephin 1 g [gram] IM [intramuscularly] for three days. An Individual Infection Investigation documented the UTI as facility acquired, had sediment written for symptoms and had 3/25/26 for the date of the urine culture with the result as negative. An attached nursing progress note dated 3/25/26 at 5:44 PM read in part, .Writer performed Dip stick testing with negative nitrates and moderate leukocytes. Residents urine clear without sediment, no odor, no pain per resident, no fever noted throughout shift The attached urinalysis and urine culture reports were negative for infection.On 4/20/26 at 1:54 PM, Licensed Practical Nurse [LPN] I, who was serving as the Interim Infection Preventionist, was interviewed and asked about the antibiotic stewardship at the facility. LPN I explained she had only taken over the program three weeks prior, the Director of Nursing [DON] became aware of the lack of antibiotic stewardship by the prior Infection Preventionist [IFP] Q, and had asked her to help re-train IFP Q on McGeer's Criteria and antibiotic stewardship, but IFP Q quit so she was asked to step into the roll until they could hire someone. LPN I was asked about residents on antibiotics that were on Hospice with no cultures or other testing. IFP Q explained that was one of the issues they had noticed. LPN I was asked about the different documentation on the line listings and the Individual Infection Investigation reports. IFP Q explained she could not speak to that as she had not done them. On 4/21/26 at 9:09 AM, the Corporate Director of Nursing [CDON], who was serving as Acting DON, was interviewed and asked about the lack of antibiotic stewardship at the facility. The CDON explained multiple people, including herself, had tried to re-train IFP Q on antibiotic stewardship; however, it does not seem to make any difference.Review of a facility policy titled, Antibiotic Stewardship Program dated 9/12/18 read in part, .To ensure the safe and appropriate use of antimicrobials. a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.

Based on observation, interview, and record review the facility failed to maintain general cleanliness and repair of the central shower rooms. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living affecting residents that use the [NAME] Unit and [NAME] Unit central shower rooms. Findings Include: On 04/20/2026 at 9:15 AM toured central shower/spa rooms with Housekeeping Director (HK) K. Observed the following in the two [NAME] Unit central shower rooms: broken/missing tiles around the shower drains and at wall corners, storage room door threshold surface rusted/deteriorating and no longer smooth and cleanable, multiple storage rooms with debris on the floor surface, including cleaning brushes and bucket, bag of grout. Observed perimeter of showering areas soiled with black mold-like substance on tiles, grout, and caulking. During this time, when queried HK K said these closets would be used by nursing and housekeeping doesn't use or clean these rooms. Observed scouring utility brush in this area, when queried, HK K said that nursing staff uses this to clean resident wheelchairs in the shower rooms on midnight shifts. Observed shower bed support surface and blue shower mat soiled with black substance and the mat discolored and worn and plastic shower chair soiled near the wheel area with black substance. Observed 2 of 4 light bulbs burned out at the hand sink lighting. On 04/20/2026 at 9:30 AM Observed [NAME] unit central shower area (2 showers) with HK K. In the left showering area observed the vinyl shower floor surface stained and cracking and separated from the adjacent tiled surface creating a gap where water can collect. HK K says this area is soon to be resurfaced. In the right showering area observed standing water not draining to the floor drain in a storage room adjacent to shower. Observed long handled utility brush stored in resident showering area. Observed perimeter of both showering areas soiled with black mold-like substance on tiles, grout, and caulking. Observed HealthWeight chair stored in the shared hall area of this spa room soiled around the base. When asked about cleaning responsibilities for spa rooms and equipment, HK K says they do a daily check, re-stock and cleaning early in the day and then will respond to requests as needed and any maintenance needs observed will be put in the electronic request system (TELS) and that nursing staff is responsible for cleaning resident use equipment. On 4/20/2026 record review of Capital Project Approval Request (CPAR) dated 3/25/36 described Brief Description of Request: Replacement of sheet vinyl in the spa bathroom (cracking and aged/dirty appearance) on [NAME] unit. On 04/20/2026 at 11:50 AM Interviewed Unit Nursing Manager (NM) O regarding the policy and protocols for cleaning of resident wheelchairs and was referred to the Nursing Home Administrator (NHA) who indicated that use of central shower area for wheelchair cleaning is a common practice in their experience. The Corporate acting Director of Nursing (staff) A indicated that this task only happens on midnights and that showers are then cleaned ahead of use for resident care. When asked for policy and procedures for this task the NHA indicated they would look for and provide any related polices. On 4/20/2026 the following Records were provided and reviewed: 1) Infection Prevention and Control Manual: Maintaining a Clean Environment dated June 2021 Upon review, it is noted that this policy did not address cleaning of wheelchairs or cleaning of central showers 2) Infection Prevention and Control Manual: Cleaning & Disinfecting Bathing Tubs & Showers dated June 2021 Showers & Shower Chairs 1. Obtain a long-handled brush, and a spray bottle containing a disinfecting solution (diluted per the manufacturer's label specifications). 2. Rinse the shower area and shower chair with clean water to flush out dirt, hair, and body oils. 3. Spray all surfaces of the shower area and chair with the disinfecting solution. 4. Scrub all surfaces of the shower area and shower chair with the long-handled brush. 5. Rinse the shower area and chair thoroughly with fresh water to clean out the disinfecting solution. 6. Allow the shower area, chair, and long-handled brushes to air dry. 7. Repeat step one (immediately above) between each resident. 8. Repeat the procedure steps (1-4) for cleaning and disinfecting between each resident and after the last shower at the end of the day. Upon review, it is noted that this policy does not address: - the storage of cleaning equipment away from residents for safety/infection prevention -shared showering area usage for cleaning of wheelchairs and associated procedures - required contact time for disinfecting solution use (e.g. documented procedure includes use of disinfecting solution followed by scrubbing and rinsing steps) On 4/19/26 at 10:44 AM, during interview and introductions for initial pool selection, a family member commented that the facility shower rooms (specific to [NAME] Shower rooms) were unkempt, unsanitary, specifically the shower equipment used to hold the residents that could not stand. On 4/19/26 at 10:50 AM, the [NAME] Unit Shower Rooms were observed with Certified Nursing Assistant (CNA) G. The shower room on the left was observed storing a long white shower bed stretcher with a blue colored vinyl pad that was observed worn and had a black colored substance in-between the folds of the padding. Both [NAME] rooms were observed storing multiple bottles of half used shampoo/body washes, along with multiple cans of shaving cream, on the counter, and along the support rails in the shower. Razors were on the counters, and the razor cover caps were observed lying on the floor. The closets were opened and were observed with plastic hangers on the floor, gloves, black grime substance, dead insects, and webs. Corners of the room were observed with broken tiles observed with sharps edges, and shards of tile. Two packages of skin protectant (product designed to form a protective barrier on the skin) were observed lying amongst multiple bottles of used open shampoo body products. The closet door was opened and a shower caddy revealed storing capless bottles of shampoo shower products, multiple single use packages of Vitamin A&D ointment (medication used as a moisturizer to treat skin conditions). CNA G was overheard commenting the packages of ointments should not be in the shower room. Storing used and partially opened body wash and shampoos should be disposed of or returned to residents and placed in their room once they are done showering. The [NAME] Shower room was observed storing multiple bottles of half used shampoo/body washes, along with multiple cans of shaving cream. A pink shower basin containing shower products was observed being stored on the back of the toilet and small gnats were observed flying around the toilet. The countertop was observed with three white handled hairbrushes with visible strands of hair, a mini chocolate peanut candy bar, a purple-colored shower loofah, the toilet paper case was observed with packs of artificial sweetener. The closets were opened and were observed with plastic hangers on the floor, gloves, a white trach receptacle half filled with garbage, and wheelchair footrests. On 4/20/26 at 8:55 AM, During observations with Maintenance Director L both [NAME] shower rooms specific to the broken tiles lying on floor were observed. Per Maintenance Director L, tile repairs are on the workorder list and recognized the sharp broken pieces of tiles should have not been left on the floor.

Based on interview and record review the facility failed to transcribe a medication as ordered from the hospital for one resident (R115) of one resident reviewed for admissions. Findings include:On 4/19/26 at 10:32 AM, R115 was interviewed and asked about their stay at the facility. R115 reported that the facility was okay, but they needed to have their staples removed so they could be discharged (back to community).A review of the medical record revealed that R115 was admitted to the facility on [DATE] with the admission diagnosis of Displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, Muscle weakness and other lack of coordination. A further review of the medical record revealed that on R115's discharge paperwork from the hospital provided a reference for staples to be removed and how to care for the incision site as well as listed medications to be continued at the facility.A review of the hospital discharge paperwork revealed that R115 was to start a medication called Lovenox 30 milligrams twice daily for twenty-one days to prevent blood clots. A Review of the facility's transcribed orders showed that the medication was not added to R115's medication regimen.On 4/20/26 at 9:51 AM, an interview with the facility Wound Care Coordinator (WCC) P was completed.They were asked about the removal of the staples for R115. WCC P reported that the staples were not removed because the resident's primary care physician did not want them to remove the staples and wanted to let the surgeon remove them. WCC P was then asked if that conversation was documented because the hospital discharge paper stated to remove the staples in two weeks. WCC P reported that the nurse who spoke with the physician did not record that conversation, but the unit manager was on the phone to schedule the resident with a follow-up appointment with orthopedics. WCC P was then asked about the transcribing of orders and was asked to locate the resident's order for Lovenox 30 milligrams twice daily for twenty-one days. WCC P was unable to locate the order, and they were then asked was the order supposed to be added to the resident's plan of care and who ensures that medication orders are transcribed correctly. WCC P reported that the nurse that admits the resident is responsible for adding orders into the system and then the inter disciplinary team (IDT) will go over the hospital paperwork again to make sure everything is added. WCC P was unsure as to how that medication was missed.There was no additional information provided by the exit of the survey.

Based on interview and record review, the facility failed to complete an annual OBRA (Omnibus Budget Reconciliation Act) Level I evaluation to determine if a Level II Evaluation was needed, or if exemption was identified for one (R12) of one resident reviewed for PASARR (Preadmission Screen and Resident Review). Findings include: A review of R12's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: schizophrenia, dementia, bi-polar disease and post traumatic stress disorder (PTSD). A review of the resident's most recent Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 (cognitively intact). Continued review of R12's clinical record noted a Preadmission Screening (PAS)/Annual Review (ARR) (2/25/25) document that noted the following: .Hospital Exemption Discharge.Patient (R12).Section II-Screening.Yes.The person has a diagnoses of dementia.Yes.The person has received treatment for.Dementia.Yes.The person has routinely received one or more prescribed antipsychotic or medications within the last 14 days.Explain.on Ativan (a anxiety medication). *There were no other PASARR documentation found in R12's record. On 4/21/26 at approximately 10:49 AM, an interview was conducted with Social Worker Director (SW) 'F. SW F was asked about the facility's PASARR protocol and whether R12 needed to be screened as they have been in the facility for over a year with dementia and mental illness diagnoses. SW F reported that they started at the facility several months after R12's admission and noted that residents, including R12 should be screened annually and/or when a significant change is found. A request for the facility's PASARR policy was made on 4/21/26 at approximately 1:00 PM. No policy was provided by the end of the survey.

Based on observation, interview, and record review, the facility failed to provide treatment and services according to professional standards of practice related to failure to implement treatment according to physician orders and documenting as completed for one (R110) of one reviewed for edema, and treatment and self-administering medication for one (R135) of one reviewed for medication administration. Findings include: R135 On 4/19/26 at 9:39 AM Licensed Practical Nurse (LPN) C was observed entering into room A23 (R135) without donning any personal protective equipment (PPE) (for a contact isolation room) accompanied by a Certified Nursing Assistant (CNA) who was not wearing any PPE as well. LPN C was observed, setting up a respiratory breathing treatment, applying it to the resident's face via mask, started the nebulizer machine and walked out of the room. LPC C on their way out, let the resident in room A23 (R135) know that they would be back to stop the treatment once it was complete. On 4/20/26 a review of the medical record revealed that R135 was admitted to the facility on [DATE] with the diagnosis of Chronic obstructive pulmonary disease, Enterocolitis due to Clostridium difficile (a bacterial infection of the bowel), and Obstructive sleep apnea. The [NAME] data set (MDS) for R135 was not completed (due to being newly admitted ), the Brief interview for Mental Status Score (BIMs) was not available. A Further review of the record revealed that R135 did not have a self-administration (of medications for the resident to have completed their nebulizer treatment alone) assessment completed. A review of the facility Policy titled Medication Pass Guidelines read in part Self-administration Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with the guidelines for self-administration of medication. On 4/20/26 at 10:53 AM, an interview with Corporate Director of Nursing (DON) was completed. DON and informed of the observations from 4/19/26 on the breathing treatment that was self-administered by the resident and if the resident was able to do so. The Corporate DON reported that they would have to investigate the situation being that they have filled in for the DON who was currently out of the facility. On 4/20/26 at 3:44 PM, the DON, followed up on R135 and stated that the facility would correct and assess the resident for appropriateness of self-administration. R110 Clinical Record review revealed R110 was admitted to the facility on [DATE], was a long-term residence of the facility and had a past medical history of Congestive Heart Failure (CHF), required medication and treatment managed with diuretics (medication to remove excess fluid) and treatment for chronic lower extremity swelling. Minimum Data Set (MDS) assessment documented on 1/27/26 documented a Brief Interview Mental Status (BIMS) of 13/15 indicating no cognitive impairment. On 4/19/26 at 11:33 AM, during initial interview and introduction, R110 was observed sitting in a wheelchair dressed appropriate, alert, orientated and voiced concern of increased leg swelling, R110 pointed to two large ace wraps on top of their dresser and was specific to instruction that their legs were to be wrapped at 9:00 AM every day and take off when they go to bed every night. R110 commented it was almost lunch time and they are still not wrapped. R110 pulled up both black pant legs where bilateral knee-high nylon stockings were observed pulled up just below the knees. The top bands of the knee-high nylons were observed rolled, not evenly distributed around top of calf and an indentation of the perimeter of the nylon was evident. Observation of the left leg was observed more swollen than the right and confirmed their concern and said the last time they were wrapped was two days ago, Friday 4/17/26. Record review of order for treatment renewed on 3/27/26 at 10:15 AM documented to wrap feet and legs with ace bandage bilaterally once daily. Apply at 9:00 AM then remove at 9:00 PM or bedtime. Physician Progress Note dated 4/1/26 documented R110 with chronic swelling of lower extremities, .Chronic swelling continue Ace wraps. Record review of the treatment record revealed the ace wrap treatments were applied on Sunday 4/19/26 at 9:00 AM. On 4/20/26 at 12:49 PM, R110 were observed sitting in their wheelchair, ace bandages were not observed wrapped on their legs. When inquired, R110 acknowledged that their legs remained unwrapped. R110 was observed opening the third drawer of their dresser and retrieved two folded ace wraps, and repeated have not having on since Friday and asked if I could please have someone wrap them. Record review of the treatment record revealed the ace wrap treatments were applied on Monday 4/20/26 at 9:00 AM by Registered Nurse (RN) B On 4/20/26 at 12:55 PM, an interview with RN B reviewed the treatment record and confirmed they signed off on providing the leg wrapped treatment. When informed the treatment wraps were not on R110, the ace bandages were tucked into the dresser drawer, RN B said they would reapply. At 1:00 PM, while in R110s room, RN B was observed walking in with new ace bandages. When asked if they had wrapped them earlier, why were they retrieving new wraps, RN B had no comment. On 4/20/26 at 1:10 PM the Corporate Acting Director of Nursing (DON) was informed Nursing treatment was signed off, and treatment was not observed in place on 4/19/26 at 11:45 (signed off 4/19/26) and today 4/20/26. The DON acknowledged the observations and stated they will further follow up. No additional information was given after exit.

Based on observation, interview and record reviews the facility failed to ensure a physician order was implemented for oxygen administration for one (R8) of one resident reviewed for respiratory care. Findings include:On 4/19/26 at 10:38 AM, R8 was observed sleeping in bed with 3 liters of oxygen administered via nasal cannula.A review of the medical record revealed R8 was admitted to the facility on [DATE], with a diagnosis that included systolic and diastolic heart congestive heart failure.A review of the physician orders revealed no order implemented for the oxygen administration.A review of the care plan titled Oxygen Use with an effective date of 3/1/26, documented the following in part . With interventions implemented, my risk for hypoxia/SOB (shortness of breath) will be minimized/reduced through next review. Administer oxygen at 2L (liters)/min (minute) via nasal cannula as ordered. Observe oxygen precaution.On 4/21/26 at 8:04 AM, R8 was observed in bed with 3 liters of oxygen administered via nasal cannula. At this time R8's assigned nurse was asked to come to R8's room. Licensed Practical Nurse (LPN) H was asked to observe the oxygen administration and asked if they could review the orders. At 8:11 AM, LPN H confirmed there were no orders for R8's oxygen administration. LPN H stated they would follow up with the Physician.A review of a facility policy titled Respiratory Care dated October 2011, documented in part . A resident will receive oxygen per physician's orders and facility protocol.

Based on observation, interviews and record reviews the facility failed to prevent the use of an unnecessary antibiotic for one (R11) of five residents reviewed for unnecessary medications. Findings include:On 4/19/26 at 10:43 AM, R11 was observed fully clothed sleeping in bed. A review of the medical record revealed R11 was admitted to the facility on [DATE] with a diagnosis that included dementia.A review of the Physician orders revealed a Nitrofurantoin Macrocrystal (antibiotic) 50 mg (milligram) capsule to be administered once daily for . lower urinary tract calculus.A review of the transferring facility medication list provided to the facility upon R11's admission documented in part . Nitrofurantoin Macrocrystal Capsule 50 mg, one capsule by mouth one time a day for prophylactic UTI (urinary tract infection), Start Date 1/24/25 Recurrent urinary tract infection - Cont (continue) Nitrofurantoin 50 mg po q (every) day prevention and wiping discussed . N39.0: Urinary tract infection, site not specified . A review of the medical record revealed multiple clinician notes that documented the Nitrofurantoin medication for . UTI prophylaxis.Further review of the medical record revealed no documentation on the benefits and/or appropriateness of the resident to receive the antibiotic.A review of a Nursing note dated 3/11/26 at 3:48 PM, documented . START BACTRIM DS (antibiotic) q (every) 12 hours times 5 days after collect urine, writer notified to next shift nurse.A review of the March 2026 Medication Administration Record (MAR) documented the administration of the Bactrim antibiotic for five days for a urinary tract infection. This medication was administered in addition to the Nitrofurantoin antibiotic.On 4/21/26 at 10:22 AM, the interim Infection Preventionist (IP) I accompanied by a third party Nurse that provided palliative care for R11 - RN J was interviewed and asked about R11's prophylactic Nitrofurantoin Macrocrystal antibiotic. IP I said they would look into the record and follow back up. At 11:32 AM IP I returned and stated the family requested that R11 be prescribed the antibiotic prophylactically. IP I was asked about the Bactrim DS prescribed in March 2026 for a UTI, despite the resident to have received the prophylactic antibiotic and IP did not provide a response but acknowledged the concern. RN J stated they had a talk with the family who verbalized concerns of a history with frequent UTI's and requested that the resident have a prophylactic antibiotic. RN J stated the doctor decided to keep the resident on the medication prophylactically after discussing it with the family. RN J was asked to provide the documentation on the rationale from the Physician on why the resident was prescribed a prophylactic antibiotic and RN J stated they did not have the documentation to provide.A review of a facility policy titled Antibiotic Stewardship Program dated 9/12/18, documented in part . ensure the safe and appropriate use of antimicrobials. coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.

Based on observation, interview, and record review, the facility failed to don personal protective equipment (PPE) for one Resident (R135) of one reviewed for isolation. Findings include:On 4/19/26 at 9:39 AM, Licensed Practical Nurse (LPN) C was observed entering into room R135's room. R135's was noted to be in contact isolation. LPN C entered the room without donning any PPE (for contact isolation-an isolation requiring staff to wear PPE upon entering) accompanied by a Certified Nursing Assistant (CNA) who was not wearing any PPE as well. LPN C was observed setting up a respiratory breathing treatment, applying it to the resident's face via mask, started the nebulizer machine and walked out of the room. On 4/20/26 a review of the medical record revealed that R135 was admitted to the facility on [DATE] with the admission diagnosis of Chronic obstructive pulmonary disease, Enterocolitis due to Clostridium difficile (a highly contagious infection of the bowel), and Obstructive sleep apnea. On 4/20/26 at approximately 10 AM, an interview with the facility's acting Infection control preventionist (IP) I was conducted. The IP I was made aware of the observation that took place on 4/19/26 and they reported that they had just taken over the program since the previous IP had quit three weeks prior. IP I also reported that the staff members should have been wearing PPE when entering the room.A review of the facilities policy titled Transmission Precautions: Contact read in part Wear clean, non-sterile gowns upon entering the residents room if you anticipate substantial contact between your clothing and the resident, environmental surfaces or items in the room, wear a gown if the resident is incontinent, has diarrhea ,an ileostomy, a colostomy or has wound drainage not contained by a dressing On 4/21/26 at approximately 9:00 AM, with the Corporate Director of Nursing (DON) and the Administrator a review of the cameras was made, and observed staff members entering the room without PPE on.There was no additional information provided at the exit of the survey.

This citation pertains to the complaint: 2594578. Based on interviews and record reviews the facility failed to timely identify signs/symptoms of a urinary tract infection (uti), failed to consistently inform the Physician/NP (nurse practitioner) of identified signs/symptom, and failed to timely treat a uti for one (R202) of three residents reviewed for a change of condition, resulting in the resident to be hospitalized in the intensive care unit for urosepsis (urinary tract infection spreads to the bloodstream) and ultimately admitted into hospice care. Findings include:A review of a hospital Emergency Medicine consult dated 8/19/25 at 11:55 AM, documented in part . present to the Emergency. for altered mental status and hypotension. they <sic> she is acting worse than baseline. Patient is unable to provide any history at this point in time. They identified that the patient's urine is foul smelling. She does have a Foley catheter in place. Tachycardia present. Respiratory distress present. Laboratory evaluation identifies a significant urinary tract infection and evaluation of the CAT scan identifies that the Foley catheter that was recently placed may not have been completely inserted. When it was removed the area was covered with stool. The patient is dehydrated and initially was hypotensive though that has improved during her emergency department stay. Sepsis. Final Impression: 1)AMS (altered mental status) 2)UTI 3)Sepsis 4) palliative care.A review of the medical record revealed R202 was transferred from another nursing facility and admitted to the facility on [DATE], with a diagnosis of dementia. The resident was documented to have severely impaired cognition and required staff assistance for all activities of daily living.Review of the transferring nursing home documentation provided to the facility staff upon R202's admission revealed no documented behaviors or urinary concerns. A review of a Physician History and Physical dated 8/1/25, documented in part . transferred from (previous nursing home name) for placement, she is seen and examined, laying in bed comfortably, not in distress, no new complaints, no new events over night, and no new issues per nursing staff. Foley catheter. No change in cognition. in no acute distress.A review of the progress notes revealed the following: A nursing note dated 8/2/25 at 1:25 AM, documented in part Observed resident continuingly removing brief and clothes and pulling call light cord out of the wall. Resident is in a very confused mental state at this time. Observed crying and pulling at shirt to remove immediately. Observed thick cloudy urine in foley tubing. Foul odor to urine.There was no documentation of the Physician to have been notified of the abnormal urine findings. A nursing note dated 8/4/25 at 11:01 AM, documented in part residents urine bag was changed due to the old one clogged with sediment.A nursing note dated 8/10/25 at 6:24 PM, documented in part . Resident foley is draining appears very dark in color, unsure if due to dehydration or blood due to resident continuously pulling at indwelling foley. Will leave message in dr (doctor) book regarding issue.A nursing note dated 8/12/25 at 2:54 PM, documented in part . Writer noted cloudy and discoloration to urine, increased confusion and resident presented with back pain. NP (nurse practitioner) in house and ordered for urine dip and if positive to send out. Writer dipped urine with 125++ noted of leucocytes <sic>. Urine placed in total lab book for p/u (pick up). Writer changed Foley catheter bag and irrigated Foley, Labs also placed for CBC (complete blood count) and CMP (comprehensive metabolic profile) for 8/13/25.A nursing note dated 8/13/25 at 11:27 AM, documented in part . Assistance provided with breakfast. stating she did not want any more as she was about to throw up. refuses to consume more than 1 or 2 sips of water, UA (urinalysis) still pending, no results yet.A nursing note dated 8/14/25 at 6:15 PM, documented in part . Foley draining but odd coloring, full of sediment. Still awaiting urinalysis results.A nursing note dated 8/16/25 at 6:38 PM, documented in part . resident was baning <sic> her hand repeatly <sic> on the table and screaming. Family was called to help console the resident.A nursing note dated 8/16/25 at 6:42 PM, documented in part . resident was up the whole night screaming, banging her hand on the table and grabbing her foly <sic> and wrapping it around her head.A nursing note dated 8/17/25 at 12:19 AM, documented in part . observed by nurse laying in bed playing in her stool. Resident with stool all over her hands.A nursing note dated 8/18/25 at 2:07 AM, documented in part . Resident complains of back pain Tylenol provided and norco (controlled pain medication) reordered.A nursing note dated 8/18/25 at 4:41 AM, documented in part . Resident has a pending UA and CS (culture and sensitivity). Lab book states CMP (comprehensive metabolic panel) and CBC (complete blood count) blood specimen pending.A review of a urinalysis, urine culture and sensitivity report collected on 8/12/25 and resulted on 8/18/25, revealed an abnormal UA with an identified organism of > (more than)100,000 of E.Coli present in R202's urine. The report noted the antibiotics the organism was resistant and sensitive to. A review of the medical record revealed no documentation of the identified abnormal UA and C&S results, no notification to the Physician/NP and no treatment implemented for the infection. Further review of the medical record revealed no results or documentation of the CMP and CBC to have been completed. A Physical Medicine and Rehabilitation (PMR) note dated 8/19/25 at 10:51 AM, documented in part . Patient is resting in bed. Not responding to verbal stimuli. ROS (review of systems) unable to assess. pt (patient) with significant decline, unable to participate. Patient was standing CGA (contact guard assist) last week during therapy. D/w (discuss with) RN (registered nurse), states UA sent last week, no result noted at this time. D/w RN regarding purple urine in foley bag. D/w RN agonal breathing (gasping for air), 02 (oxygen) applied, RN called EMS (emergency medical services) and IM (internal medicine) regarding sig. (significant) change in patient condition, to be sent to hospital.Further review of the urinalysis, urine culture and sensitivity report noted on the bottom sent on this AM (clinician's initials) 8/19/25. This indicated the staff failed to report the results to the Physician/NP on 8/18/25 and was delayed a day and sent to the Physician/NP on 8/19/25. The collected date of the urinalysis was noted on the report as 8/12/25 and the resulted date was noted as 8/18/25, a six day delay from the facility's contracted lab to have reported the abnormal urinalysis to the facility and the delay in the reporting of the culture and sensitivity results. A review of a hospital Urology consult dated 8/20/25 at 7:52 AM, documented in part . Chief Complaint: AMS (altered mental status), hypotension. She was found to have urosepsis in ED (emergency department) and was transferred to ICU (intensive care unit) and is <sic> pressors at this time. She does not arouse to verbal or gentle physical stimuli at this time. Foley in place with amber urine now but was red upon exchange. UA positive, Ucx (urine culture) pending. Bcx (blood culture) positive with E. Coli. LA (lactic acid) 8.8. WBC (white blood cells) 17.6 (H- high) 08/20/2025. Impression. Hematuria. UTI, sepsis. PLAN: In ICU. UA positive. Ucx pending. Bcx positive. On zosyn (antibiotic), did get cefepime (antibiotic). ID (infectious disease) consulted. Trend WBC (white blood cells).A review of a hospital Hospitalist consult dated 8/22/25 at 12:14 PM, documented in part . Change in mental status-toxic metabolic encephalopathy. Lactic acidosis due to septic shock, UTI with sepsis, Acute renal failure, multifactorial, Hematuria.Plan -Patient is transferred to inpatient hospice -Remains hypotensive, noted shallow breathing, decreased respiratory rate today. presented to the hospital with septic shock. Patient initially was admitted to the intensive care unit with change in mentation with lactic acidosis urinary tract infection. Received a fluid resuscitation pressor support was evaluated by multidisciplinary team. has had acute renal failure on presentation. Patient has declined to decline despite maximal medical therapy and after meeting with palliative care team patient had a hospice informational visit. Pressors were discontinued patient remained hypotensive, lethargic and was transferred to inpatient hospice. I have discussed during the intensive care unit admission and today with the (R202's family member). is agreeable with plan of care and. understands the grave prognosis. Patient has shallow breathing remains hypotensive with minimal urine output.On 8/27/25 at 8:27 AM, the Director of Nursing (DON) was interviewed and asked about the delayed UA, culture and sensitivity results and the DON stated they were newly employed with the facility and realized coming in that there were issues with the contracted laboratory. The DON stated they started a past non compliance regarding the laboratory services. The DON identified delayed completion and reporting of test results. At 9:02 AM, the DON stated they were trying to find a new laboratory provider for the facility. The DON was asked about R202's clinical signs/symptoms of a UTI that was not initially reported to the Physician/NP, the failure to timely identify and treat R202's UTI and the DON acknowledged the concern, stating they were awaiting the results of the testing before treatment was started. The DON explained that the resident was newly admitted to the facility so the staff was unaware of the change from the resident's baseline. The DON was asked why the CBC and CMP was not ordered/completed. The DON stated they read the note regarding the test pending, however they could not find results. A review of a facility policy titled Acute Change in Condition dated July 2021, documented in part . An Acute Change of Condition (ACOC) is a sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death. Resident's are assessed upon admission to establish Baseline Data. Changes (symptoms) in a resident's condition are communicated by any staff member to nurses. Document in the medical record all interventions to address the change of condition. Changes (symptoms) are communicated to the physician.No further explanation or documentation was provided by the end of the survey.

This citation pertains to the complaint: 2594578. Based on interviews and record reviews the facility failed to order laboratory tests as directed by the Physician/Nurse Practitioner, ensure timely/efficient laboratory services, ensure promptly notify the Physician of abnormal results and failed to develop a policy and/or procedure for ordering laboratory test, obtaining & reporting abnormal values to the Physician for one (R202) of three residents reviewed for a change in condition. Findings include: A review of the medical record revealed R202 was admitted to the facility on [DATE], with a diagnosis of dementia. The resident was documented to have severely impaired cognition and required staff assistance for all activities of daily living.A review of a nursing note dated 8/12/25 at 2:54 PM, documented in part . Writer noted cloudy and discoloration to urine, increased confusion and resident presented with back pain. NP (nurse practitioner) in house and ordered for urine dip and if positive to send out. Writer dipped urine with 125++ noted of leucocytes <sic>. Urine placed in total lab book for p/u (pick up). Writer changed Foley catheter bag and irrigated Foley. Labs also placed for CBC (complete blood count) and CMP (comprehensive metabolic panel) for 8/13/25. care updated.A review of a nursing note dated 8/18/25 at 4:41 AM, documented in part . Resident has a pending UA (urinalysis) and CS (culture and sensitivity) <sic>. Lab book states CMP and CBC blood specimen pending.A review of the medical record revealed the CBC and CMP order was never implemented as directed. Further review of the medical record revealed no results of a CBC or CMP. A review of a urinalysis, urine culture and sensitivity report collected on 8/12/25 and resulted on 8/18/25, revealed an abnormal UA with an identified organism of > (more than)100,000 of E.Coli present in R202's urine. The report noted the antibiotics the organism was resistant and sensitive to. Review of the medical record revealed no documentation of the identified abnormal UA and C&S, no notification to the Physician/NP and no treatment implemented for the infection. Further review of the urinalysis, urine culture and sensitivity report noted on the bottom sent on this AM (clinician's initials) 8/19/25. This indicated the staff failed to report the results to the Physician/NP on 8/18/25 and was delayed a day and sent to the Physician/NP on 8/19/25. The collected date of the urinalysis was noted on the report as 8/12/25 and the resulted date was noted as 8/18/25, a six-day delay from the facility's contracted lab to have reported the abnormal urinalysis to the facility and the delay in the reporting of the culture and sensitivity results. Review of a nursing note dated 8/19/25 at 11:16 AM, documented in part . Resident was sent to (hospital name) for evaluation vis <sic> EMS (emergency medical services), resident urine appeared dark emesis in color, Resident was experience <sic> mental status change without following command.On 8/26/25 at 9:27 AM, the Administrator was asked to provide the facility policy on the ordering and report of lab results. At 10:08 AM, the Administrator replied the facility did not have a policy regarding the ordering and reporting of lab results. On 8/27/25 at approximately 8:27 AM, the Director of Nursing (DON) was interviewed and asked about the facility's protocol regarding implementing and ordering the labs as directed by the Physician/NP and the DON replied the facility staff put in the orders into the laboratory website and the lab worker would come to the facility in about two days, stat (immediate) right away if needed. The DON was asked the facility's protocol in how the staff identify and report abnormal lab findings to the Physician. The DON stated the lab results are emailed to them (DON) and faxed to the facility. The DON explained Monday through Fridays the unit ward clerk would obtain the faxed laboratory reports and provided them to the staff. The DON stated on the weekends the Nursing supervisor would obtain the reports and provide it to the staff. The DON was asked about the CBC and CMP that was supposed to be ordered for R202. The DON stated they saw that it was documented and noted to be pending, however the facility did not have the results. The DON stated they had identified issues/concerns with the facility's contracted lab services and was working toward a solution. The DON was then asked about R202's abnormal UA and C&S results to have been reported on 8/18/25, however not reported to the Physician until 8/19/25. The DON stated they recognized the long processing times with the third-party laboratory to have been problematic and stated the nurse should have followed up on 8/18/25 when the abnormal UA & C&S was completed to report it to the Physician. The DON stated they had started education with the nursing staff regarding the concern. No further explanation or documentation was provided.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: On 2/25/25 between 8:35 AM-9:15 AM, during an initial observation of the kitchen, the following items were observed: In the walk-in cooler, there was dried up milk on the floor underneath the milk crates. The inside bottom shelf of the Victory freezer was soiled with food spills and food debris. On 2/25/25 at 9:00 AM, Corporate Chef Y confirmed the soiled flooring in the walk-in cooler and inside the Victory freezer, and stated they would be cleaned right away. According to the 2017 FDA Food Code section 4-602.13 Nonfood-Contact Surface, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. The ceiling vent located near the ice machine was coated with dust. According to the 2017 FDA Food Code section 6-501.14 Cleaning Ventilation Systems, Nuisance and Discharge Prohibition, (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. The flooring underneath and behind the ice machine was observed with a heavy buildup of trash debris and a black, mold-like substance on the floor tiles. At the hand sink located next to the Southbend skillet, there was a hose hanging on the wall, with a continuous flow of dripping water onto the floor. The floor was wet with a black mold-like substance on the surface of the floor tiles. The flooring underneath the 3 compartment sink was wet, with a black mold-like substance observed on the surface of the tiles. There was a buildup of food debris on the floor underneath the racks in the dry storage room. On 2/25/25 at 12:00 PM, Corporate Chef X stated they haven't had a porter in the kitchen for a while, so while they do mop the floors, they don't get deep cleaned as often as they should. According to the 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A) Physical facilities shall be cleaned as often as necessary to keep them clean. The trash can for the hand sink located next to the Southbend skillet was heavily soiled on the exterior with black and brown stains. According to the 2017 FDA Food Code section 5-501.116 Cleaning Receptacles, .(B) Soiled receptacles and waste handling units for REFUSE, recyclables, and returnables shall be cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming attractants for insects and rodents. The floor drain located underneath the soiled drainboard of the dish machine was observed with numerous small drain flies. According to the 2017 FDA Food Code section 6-501.111 Controlling Pests, The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: .2. (B) Routinely inspecting the PREMISES for evidence of pests; 3. (C) Using methods, if pests are found, such as trapping devices or other means of pest control as specified under SS 7-202.12, 7-206.12, and 7-206.13; and 4. (D) Eliminating harborage conditions. On 2/25/25 at 12:15 PM, Dietary Staff Z was observed measuring the internal temperatures of the food items on the steam table in the [NAME] kitchenette. Staff Z retrieved a thermometer from inside a binder. Staff Z did not sanitize the thermometer probe, and began measuring the internal temperatures the food items on the steam table. Staff Z then took the temperatures of all the food items on the steam table, without ever using a probe wipe to clean the thermometer probe. On 2/25/25 at 12:20 PM, Chef X was queried about the expectation from staff when taking the temperature of food items, and confirmed that the thermometer should have been cleaned with a probe wipe initially as well as in-between each food item.

Based on interview and record review the facility failed to ensure the facility assessment was reviewed and revised in accordance with current regulatory requirements. This has the potential to affect all 117 residents. Findings include: According to the Centers for Medicare & Medicaid Services (CMS) memo: QSO (Quality Safety & Oversight)-24-13-NH, dated 6/18/2024, revised Facility Assessment requirements effective 8/8/2024 included: .In conducting the facility assessment, the facility must ensure .Active involvement of the following participants in the process: (i) Nursing home leadership and management, including but not limited to, a member of the governing body, the medical director, an administrator, and the director of nursing/ and (ii) Direct care staff, including but not limited to, RNs (Registered Nurse), LPNs (Licensed Practical Nurse)/LVNs (Licensed Vocational Nurse), NAs (Nurse Aide), and representatives of the direct care staff, if applicable. (iii) The facility must also solicit and consider input received from residents, resident representatives, and family members . On 2/26/25 at 11:10 AM, review of the documentation provided for the Facility Assessment Tool revealed this had last been updated on 1/10/25. Review of the section that identified Persons (names/titles) involved in completing assessment included only the following staff: the Administrator, Director of Nursing, Assistant Director of Nursing, Infection Preventionist, Social Services Director, Dietary manager, Housekeeping/Laundry Manager, and Maintenance Director. There was no documentation included within this facility assessment that identified the facility had obtained active involvement with the Medical Director, direct care staff, and obtained input from residents, resident representatives, and family members. On 2/27/25 at 8:23 AM, an interview was conducted with the Administrator regarding the facility assessment documentation provided and some areas that had questions marks within the document itself. They reported they may have provided a working copy and would submit a revised copy. When asked if they had included any resident and family input into the facility assessment, the Administrator reported they had not yet. When asked if they were aware of the requirements to the facility assessment effective 8/8/24, the Administrator did not give a definitive response but reported that was around the time they started in their role and would have to work on that. When asked if they might have attended any resident council meetings to obtain input, the Administrator reported they had not due to having simultaneous other meetings when resident council was held. On 2/27/25 at 9:00 AM, the Administrator provided an updated facility assessment last updated 1/10/25 which included additional details of the number of direct care staff in their staffing plan. There was no additional documentation provided to address the concerns identified above.

Based on observation, interview and record review the facility failed to ensure enhanced barrier precautions (EBP)policies and protocols were followed and maintained for three residents (R48, 53, & and 78), maintain linen carts, as well as a system of surveillance that consistently documented signs and symptoms of infections and consistently tracked and trended infections, this had the ability to affect all 117 residents residing at the facility. Findings include: Review of the facility's Infection Control program revealed the following: The program revealed no consistent documentation of signs and symptoms and laboratory (Lab) data results for residents with infections that were listed for the months of January 2025 and February 2025. On 2/27/25 at 10:25 AM an interview with the facility's infection control preventionist (ICP) and the Director of clinical services was asked about the missing Lab data and signs and symptoms for the line listing for the months for January and February, and who was responsible for ensuring that all items are completed to finish the monthly surveillance. The ICP nurse replied that they were responsible for ensuring that the surveillance was completed and that required labs were documented and completed. The ICP also stated that for signs and symptoms that they rely on the floor nurse's documentation but if there were not any signs documented then they had nothing to go by. A review of a facility policy titled Surveillance for Infections (Revision date May 2021) documented in part, . Surveillance of infections occurring will be conducted on a regular basis by the infection control preventionist Conditions which meet the McGeer's criteria of infection are considered an infection . The infection preventionist should evaluate each set of signs and symptoms of potential infection . the Infection Preventionist should utilize a facility schematic to assist in identifying facility trends. This will enable the infection control team to identify potential issues of cross contamination from all sources . No addition information was provided by the exit of survey 38271 R53 On 2/25/25 at approximately 10:19 a.m., R53 was observed in the common area, up in their wheelchair. R53 was observed to have a catheter bag hanging from the wheelchair. R53's room was observed to not have any signage for EBP (enhanced barrier precautions). On 2/26/25 at approximately 8:32 a.m., R53 was observed in their room, laying in their bed. R53's room door was still observed to not contain any signage indicating R53 should be provided enhanced barrier precautions while providing direct care or to ensure hands were disinfected prior to entering R53's room. On 2/26/25 between 8:32 a.m., and 8:36 a.m., three facility staff members were observed entering R53's room without sanitizing their hands prior to entering the room. At that time, the staff members were observed providing direct care to R53. On 2/27/25 at approximately 8:33 a.m., R53's room was still observed without any signage indicating R53 was to be provided EBP while providing care. On 2/27/25 at approximately 11:36 a.m., R53 was observed in their wheelchair by the Nursing station. R53 was observed to have their catheter tubing dragging on the facility floor. On 2/25/25 the medical record for R53 was reviewed and revealed the following: R53 was last admitted to the facility on [DATE] and had diagnoses including Parkinson's disease and Chronic kidney disease. A review of R53's MDS (minimum data set) with an ARD (assessment reference date) of 1/17/25 revealed R53 needed assistance from facility staff with most of their activities of daily living. R53's BIMS score (brief interview for mental status) was three indicating severely impaired cognition. A review of R53's comprehensive plan of care revealed the following: With interventions implemented by the facility, my risk for urinary tract infection due to use of catheter will be reduced through next review Interventions-EBP as ordered .Effective 2/25/2025 . On 2/27/25 at approximately 9:07 a.m., during a conversation with the Infection Control Preventionist (ICP)/ADON, was interviewed pertaining to EBP for R53. The ICP reported that R53 should have had EBP signage on their door indicating staff should be donning EBP while providing care and should be sanitizing their hands prior to entering their room. 30675 R48 On 2/25/25 at 9:10 AM, an interview was conducted with the resident. R48 reported they had been at the facility for about four weeks, but recently had been hospitalized . There was a bandage to their right lower extremity and an urinary catheter drainage bag was secured to the left side of the bed. There was no Enhanced Barrier Precaution (EBP) signage posted on the door, nor was there any personal protective equipment (PPE) available for use. When asked about their wound and urinary catheter, they reported they had those for about four weeks now. Additional observations from 9:15 AM to 12:00 PM revealed staff entering in/out of R48's room without cleaning hands. On 2/25/25 at 11:53 AM, an interview was conducted with Certified Nursing Assistant (CNA 'T') who was assigned to R48. When asked about whether R48 had an indwelling urinary catheter or utilized any infection control precautions, CNA 'T' reported only that the resident was discharging today (which was R48's roommate). When asked if they were sure R48 was discharging today and if it could be their roommate, CNA 'T' reported they needed to go talk with their supervisor. Review of the clinical record revealed R48 was initially admitted into the facility on [DATE], readmitted on [DATE] with diagnoses that included: diabetes due to underlying condition with diabetic neuropathy, Extended spectrum beta lactamase (ESBL) resistance, cellulitis of right and left lower limb, chronic respiratory failure, and lymphedema. According to the MDS assessment dated [DATE], R48 had no communication concerns, had intact cognition, and had an indwelling urinary catheter. On 2/25/25 at 12:04 PM, Unit Manager (UM 'M') approached and stated they were available to answer any questions. When asked about who was in the bed occupied by R48 (as R48 was not included in the documentation provided to the survey team to be in their current room), UM 'M' reported the resident admitted yesterday (the clinical record showed R48 readmitted on [DATE]) and was a readmission. UM 'M' confirmed the resident had a urinary catheter and when asked about the wounds, they reported the resident has cellulitis and has wounds on her legs. When asked if the resident should be on EBP, UM 'M' reported Yes, they should be. They were unable to explain why they had not been implemented. R78 On 2/25/25 at 9:51 AM, R78 was observed lying in bed. There was a urinary catheter drainage bag secured to the side of the bed. The signage posted on the door identified the room was on Enhanced Barrier Precautions and further instructed, .EVERYONE MUST: Clean their hands, including before entering and when leaving the room . There was a cart in the hallway just outside the room that contained several disposable gowns, two N-95 masks and two face shields. There were no disposable gloves, hand-sanitizer, or hand-wipes in the cart, and there was no hand sanitizer on the walls or in the hallway available for use. On 2/25/25 at 9:52 AM, Certified Nursing Assistant (CNA 'S') was observed exiting the room next to R78 and entered into R78's room without cleaning hands (using hand sanitizer, wipes, etc). CNA 'S' was observed to go over to R78's bedside and began moving their bedside tray table around and removed R78's meal tray to return to a cart near the nursing desk. CNA 'S' then re-entered R78's room without cleaning their hands before and upon exiting the room. On 2/25/25 at 10:04 AM, Staff was observed placing a container of Sani-Hands in the top drawer of the cart outside R78's room. Linens: On 2/25/25 at 10:49 AM, the linen cart in the hallway outside of room C54 was observed with scattered candy wrappers and there was a thick white creamy substance spilled directly on top of linen cart material that consisted of a thick mesh-like plastic covering. The inside of this linen cart was observed to have various linens (towels, bed sheets, blue pads, and gowns). Additionally, there were other non-linen items stored directly touching and scattered about which included pink basins, several boxes of disposable gloves that were opened, and various personal care supplies (shampoo, lotion). On 2/25/25 at 10:55 AM, the linen cart across from room A32 was observed to have various linens stored directly touching other non-linen supplies which included clear trash bags, disposable briefs, pink basins, and various personal care items. On 2/25/25 at 10:57 AM, the linen cart across from room A43 was observed to have various linens stored directly touching other non-linen supplies which included a pink basin with personal care items, several bottles of perineal cleanser, and an opened box of disposable gloves. On 2/25/25 at 11:02 AM, the linen cart across from room A62 was observed to have various linens stored directly touching other non-linen supplies which included disposable briefs, skin repair cream, and two opened boxes of disposable gloves. On 2/25/25 at 11:15 AM, a staff member (wearing maroon colored scrubs) was observed accessing the linen cart outside of room A63, while holding towels, gowns and linens in their arms directly pressed against and in contact with their upper body and proceeded to walk down the hallway. On 2/26/25 at 9:31 AM, a staff member (wearing maroon colored scrubs) was observed exiting the clean utility room and entering room D61 with clean linens that were held directly pressed against and in contact with their upper body. On 2/26/25 at 12:13 PM, an interview was conducted with the Assistant Director of Nursing (ADON) who was currently acting as the interim DON while the DON was out sick. The ADON was also the facility's Infection Preventionist. When asked about the storage of linens, and how they should be transported/held when staff obtained clean linen, the ADON reported all staff were in-serviced upon hire that linens should be held away from them and to consider anything else they might come into contact with as contaminated. The ADON was informed of the concerns with the observations and reported that should not have occurred. When asked what should be stored on/within the linen carts, the ADON reported various linens and mentioned at times the staff might use pink basins that had individual shampoos and things like that. The ADON was informed of the multiple observations of the linen carts from 2/25 - 2/26/25 and was asked to observe a few of the linen carts. Upon observation of the linen cart on [NAME] unit, the ADON confirmed there were various items other than linens, including gloves, pink basin with toiletries, and garbage bags stored within the linens. The ADON reported those would be removed immediately. Upon observation of the [NAME] unit, the ADON confirmed the linen cart contained various items that should not have been stored with the linens, including trash bags and disposable gloves and confirmed those items should not have been stored with the linens.

Based on observation, interview, and record review, the facility failed to ensure medications were stored appropriately for one resident (R367) of one resident reviewed for medication storage as well as properly stored, labeled, and dated in five of five medication carts reviewed. Findings include: R367 On 2/25/25 at 12:06 PM, R367 was observed lying on their back in bed. An interview was conducted with the resident at that time. Observed on their bedside table was a tube of Triad ointment. A review of the medical record revealed no documentation or assessment of R367 to be able to self-administer the Triad ointment. On 2/27/25 at 12:26 PM, the Assistant Director of Nursing (ADON) A (who covered the medical care/questions as the facility's Director of Nursing (DON) was not present for the survey) was interviewed and asked about the Triad ointment observed by R367's bedside and ADON A replied that R367 is unable to apply the ointment to themselves and that the ointment should have been stored in the treatment cart. Medication Carts On 2/27/25 at 8:19 AM, a request for a policy for medication administration was made via e-mail, however; it was not provided by the end of the survey. On 2/26/25 at 12:45 PM, an observation of the [NAME] Hall medication cart #1 was conducted. It was observed the lock was engaged but the top left drawer and the second right drawer were ajar and could be opened without unlocking the cart. At that time, Nurse 'U' came to the cart and was asked to unlock the cart, secure all drawers tightly and re-engage the lock. After doing so, it was observed the right second drawer was then not able to be opened, but the top left drawer could still be opened with the lock engaged. Further review of the cart revealed a Humalog flex pen (generic insulin lispro) with an open date of 12/1/24 and a Lantus (generic insulin glargine) flex pen with no open date. It was also discovered food items (applesauce cups and hot cocoa packets) were stored in the bottom drawer of the cart with medications and the liquid drug disposal system. On 2/26/25 at 1:00 PM, a review of the medication cart #2 on the [NAME] unit was completed with Nurse 'E'. The cart revealed a Novolog flex pen (generic insulin aspart) and a Lantus flex pen with no dates they were placed in the cart. The cart further revealed six cups of applesauce, four cups of pudding and a cup of prune juice stored in the bottom left drawer with resident's oral medications. On 2/26/25 at 1:15 PM, an observation of medication cart #1 on the [NAME] unit was conducted with nurse 'V'. The cart revealed three open tubes of diclofenac gel (topical pain relief) stored alongside oral medications in the bottom right drawer. The bottom left draw revealed two cups of applesauce stored with resident's oral medications. On 2/26/25 at 1:20 PM, an observation cart of medication cart #2 on the [NAME] Unit was conducted with Nurse 'W' and the following was observed: a Humalog (generic insulin lispro) flex pen with no date it, had been placed in the cart, two Humalog flex pens in a plastic zipper bag with a green label that read, REFRIGERATE UPON ARRIVAL with neither pen containing a date it had been placed in the cart, a second zipper bag with the green refrigeration label containing an insulin glargine (trade name Lantus) flex pen, a Lantus flex pen, and a Novolog flex pen, none with dates when they had been placed in the cart, and an insulin lispro (trade name Humalog) flex pen with no patient name or date when it had been placed in the cart. At that time, Nurse 'W' said the cart being reviewed was not their usual cart. They were then asked if insulin pens should be labeled and dated and said they should. On 2/27/25 at 9:18 AM, an interview was conducted with the facility's Assistant Director of Nursing and they were asked if the insulin pens should be dated and said they should be refrigerated until they are placed in the cart for use and contain a date of when they were placed in the cart. A review of drug manufacturer's recommendations for insulin storage was conducted and revealed the following: Humalog (generic insulin lispro), Novolog (generic insulin aspart) and Lantus (generic insulin glargine) unopened should be refrigerated at 36-46 degrees Fahrenheit and once opened should be discarded after 28 days. On 2/27/25 at 10:26 AM, Nurse 'K' was requested to observe their medication cart. Upon observation of the medication drawer that contained multiple medication cartridges (with foil backing), there were several loose pills stored on the bottom of the drawer that were green, yellow, blue, and white in color. When asked if they could identify the pills, or who they were for, Nurse 'K' stated I have no idea. They removed the pills with their bare hands, then placed the pills into a clear medication cup and took to the medication room to dispose in a container labeled drug disposal. On 2/27/25 at 2:32 PM, an interview was conducted with the Assistant Director of Nursing (DON). When informed of the concern with the observation of the medication cart with Nurse 'K', they reported that was a frequent problem (with medications in the cartridges) but the carts should be reviewed upon starting to ensure those were maintained.

Based on observation, interview, and record review, the facility failed to ensure water was provided and kept within resident's reach for one resident, (R33) of one resident reviewed for accommodation of needs. Findings include: On 2/25/25 at 9:39 AM, R33 was observed sleeping in their bed. It was further observed R33 had no water for drinking at their bedside. An observation of their bedside table situated parallel to the bed on the left side revealed a typed note taped to the top that read, PLEASE place this tray table above her abdomen so she can reach her drink! .She is often dehydrated as table & water is out of reach . Further review of the room revealed a chalkboard on the bathroom door that read, Keep my water within my limited reach of Rt (right) hand. On 2/25/25 at 2:32 PM, 2/26/25 at 8:48 AM, 10:05 AM, and 2:30 PM, R33 was observed in their bed. The tray table with water for drinking was observed to the left side of the bed, out of reach from their right hand. A review of R33's care plan was conducted and read, .ADL (activities of daily living)-Decreased ability to self care .Interventions .Keep my call light and my frequently used personal item within my reach. Encourage and remind me to use call light for assistance . On 2/27/25 at 9:02 AM, the observations of R33's water not placed in reach were shared with the Assistant Director of Nursing and they acknowledged the concern. On 2/27/25 at 8:19 AM, a policy regarding accommodation of needs was requested via e-mail, however; it was not provided by the end of the survey.

Based on observation, interview and record review, the facility failed to follow end of life wishes for one of one resident (R417) reviewed for advance directives. Findings include: On [DATE] at 1:43 PM, during and interview, R417 was asked about their end of life wishes. R417 reported, they did not want to receive Cardiopulmonary resuscitation (CPR) because R417 did not want their chest to be cracked open and be placed on a breathing tube. R417 was then asked who was responsible for making medical decisions for them, R417 stated that they would be in control of decision making until they were unable to do so. R417 reported, they signed a paper the day before to become a Do Not Resuscitate (DNR). A review of the record revealed that R417 was admitted to the facility on [DATE] with the diagnoses of depression, anxiety and COVID-19. The most recent Minimum Data Set (MDS) indicated a Brief Interview for Mental Status score of 15, which indicated no cognitive impairments. The record also revealed that R417 was a full code, indicating an attempt of full resuscitation if the resident's heart were to stop beating. On [DATE] at 1:48 PM, Nurse N was interviewed and asked, in the event R417 was to become unresponsive, what would the facility do for them. Nurse N replied that R417 was a full code so they would start CPR. On [DATE] at 3:07 PM, the social work department, Social Work Director AA and Social Services BB was interviewed about the code status of R417 as to why they were still a full code even though R417 requested to become an DNR. Social service BB reported that when they gave R417 the paperwork (to change from a full code to a DNR) they explained that it can take ,d+[DATE] hours to have the physician sign and the status be changed in the medical record. The Social Work Director AA was then asked, why could a verbal order not be taken to honor the resident's wishes. Social Work Director AA reported that it was not in their scope to transcribe verbal orders. Social Work Director AA was asked could the nurse take verbal orders until the physician can physically come in and sign the orders and the Social Work Director AA responded that nurses can take verbal orders but the advanced directives were not done this way, that they would wait the ,d+[DATE] hours until the physician came in to change someone's code status. On [DATE] the Director of Clinical Services was interviewed and asked could Nurses take verbal orders from physicians for code status. Director of clinical services explained that the nurses could take verbal orders. A review of the facility's policy Advance Directive Policy dated [DATE] revealed the following: .Do-Not-Resuscitate Order-A do-not-resuscitate (DNR) order is a written document in which the resident expresses their wish that if their breathing and heartbeat cease, they do not want anyone to attempt to resuscitate them .DNRs may .be requested by the resident themselves. Becomes effective upon signature .Procedure: .Complete DNR .Place copies of all paperwork in chart .Review advance directives at least annually . No addition information was provided at the exit of survey.

This citation pertains to intake #MI00148138. Based on observation, interview and record review, the facility failed to follow nursing professional standards of practice related to medication administration for two (R29 and R368) of two residents reviewed for professional standards. Findings include: R29 Review of the clinical record revealed R29 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: type 2 diabetes mellitus with diabetic neuropathy. According to the Minimum Data Set (MDS) assessment dated [DATE], R29 had intact cognition, had orders for insulin and received insulin injections for seven of the last seven days. Review of the physician orders identified R29 was to have their blood sugar (BS) level checked at 7:30 AM and parameters were in place to administer insulin depending on what the BS result was. On 2/26/25 at 9:45 AM, review of R29's Medication Administration Record (MAR) revealed the was no documentation (blank) for if this had been completed as ordered. On 2/26/25 at 9:47 AM, Nurse 'E' who was assigned to R29 was asked about where they documented BS results. Nurse 'E' reported that should be on the MAR. When asked about R29's lack of documentation on the MAR, Nurse 'E' reported they had obtained the resident's BS earlier, but did not document it and further stated, I'll do that right now. When asked when that should be documented, Nurse 'E' reported when it's (the blood sugar) obtained. On 2/26/25 at 12:13 PM, an interview was conducted with the Assistant Director of Nursing (ADON). When asked about the facility's practice for monitoring and documenting BS's for diabetic residents, the ADON reported the physician orders should be followed. The ADON was informed about the concerns with R29 and discussion with Nurse 'E' and they reported the nurse should've documented that immediately. The ADON further reported staff were educated if it was documented, it wasn't completed. The ADON reported the BS's should've been documented at the time it was obtained, in accordance with the physician orders and entered on the MAR. 41415 R368 On 2/25/25 at 10:19 AM, an interview was conducted with R368 who was observed sitting in a wheelchair in their room. R368 stated they were concerned because the staff had not taken their vital signs yet or administered their blood pressure medications. R368 stated they were concerned because they were having problems with their blood pressure. On 2/25/25 at 10:21 AM, Registered Nurse (RN) D (the assigned nurse for R368) was interviewed and asked how many residents they were responsible for and RN D replied approximately 15 residents. RN D was asked if they were late in administering the resident medications for the morning and RN D stated they were not. RN D was then asked about obtaining R368's blood pressure and the administration of R368's blood pressure medications. RN D then stated that R368's medications are a little late, however RN D stated they would administer the medications to R368 next. A review of the Physician orders and Medication Administration Record (MAR) for February 2025 revealed the following: Nifedipine ER (extended release) 30 mg (milligrams) tablet by oral route once daily for hypertension. This was scheduled for 9:00 AM. Metoprolol Succinate ER 50 mg tablet by oral route once daily for hypertension. This was scheduled for 9:00 AM. A review of the administration times of R368's blood pressure medication revealed the Nifedipine ER was documented as administered at 10:32 AM and the Metoprolol was documented as administered at 10:32 AM. On 2/27/25 at 12:23 PM, the Assistant Director of Nursing (ADON) A (who covered the medical care/questions as the facility's Director of Nursing (DON) was not present for the survey) was interviewed and informed of the interviews with R368 and RN D. ADON A was asked about the normal protocol for medication administration in the facility was and ADON A replied the nurses have an hour before or after (the prescribed time) to administer medications. ADON A stated if the nurse was running late they should have called the doctor to inform them and let management know so that we can help out. No further explanation or documentation was provided by the end of the survey.

Based on observations, interviews and record reviews the facility failed to consistently provide assistance for oral care for a dependent resident, one (R58) of three residents reviewed for Activities of Daily Living (ADLs). Findings include: On 2/25/25 at 11:00 AM, R58 was observed in the community room playing a game with their daughter. R58 was asked if they had any concerns with the facility's care. R58's daughter replied that their dad always made sure their hygiene was up to par and they had concerns with the staff not assisting R58 with brushing their teeth. R58's daughter explained that R58 can brush their own teeth if staff set up their tooth brush and tooth paste and handed R58 their toothbrush, however staff were not ensuring the assistance was being provided. R58 was asked if staff assisted with brushing their teeth this morning and R58 replied No. A review in the medical record revealed R58 was admitted to the facility on [DATE], with diagnoses that included: traumatic subdural hemorrhage encounter, muscle weakness, and dysphagia. R58 required staff assistance for all ADLs. A review of a care plan titled ADL- Decreased ability to self care included the following intervention, . Provide me assistance for ADL, bathing, toileting, dressing, transferring, grooming, hygiene as needed. Encourage me to participate in self care as I can tolerate . On 2/27/25 at 11:56 AM, R58 was observed sitting in their wheelchair in the community room talking to a peer. R58's teeth was noted to be visibly dirty with plaque. R58 was asked if the staff provided assistance for them to brush their teeth and R58 responded No. R58 confirmed their teeth had not been brushed this morning. On 2/27/25 at 11:58 AM, Certified Nursing Assistant (CNA) P (the CNA assigned to R58) was interviewed and asked why they had not assisted R58 with brushing their teeth this morning and CNA P stated R58 was already up and dressed when they got on duty this morning. CNA P stated since the midnight CNA had gotten R58 up for the day, they assumed the midnight CNA assisted R58 with their oral care. On 2/27/25 at 12:21 PM, the Assistant Director of Nursing (ADON) A (who covered the medical care/questions as the facility's Director of Nursing (DON) was not present for the survey) was interviewed and asked about the responsibility and coordination of care regarding R58's oral care and ADON A responded that R58's oral care should have been completed when they were provided assistance with getting out of bed and dressed for the day. ADON A stated they would follow up on the concern. No further explanation or documentation was provided by the end of the survey.

This citation pertains to Intake Number: MI00135098. Based on interview and record review, the facility failed to respond to a change in condition in a timely manner for one (R801) of two residents reviewed for changes in condition, resulting in the resident being transferred and admitted into the hospital after they refused medications, decreased food intake, and refused nursing care for four to five days. Findings include: Review of a complaint submitted to the State Agency revealed allegations that R801 suffered a decrease in physical and cognitive function due to his lack of food, water, and meds (medications) .There are concerns that (R801) should have been sent to the hospital sooner .he is now on hospice . On 4/27/23, an unannounced onsite investigation was conducted. Review of R801's clinical record revealed the following: R801 was admitted into the facility on [DATE] and discharged to the hospital on 1/29/23 with diagnoses that included: COVID-19 (Coronavirus Disease 2019), cardiomyopathy (a disease of the heart muscle that makes is harder to pump blood to other parts of the body), chronic right heart failure, viral pneumonia, hypertension (high blood pressure), atrial fibrillation (an irregular heart rhythm that can lead to blood clots in the heart), hyperlipidemia (high cholesterol), unstable angina (chest pain), insomnia, constipation, congestive heart failure, and anxiety disorder. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R801 had intact cognition, required extensive physical assistance with all activities of daily living besides eating, bed mobility, and transfers, and had experienced weight loss. Review of R801's progress notes revealed the following: On 1/19/23, a Social Services progress note documented R801 had a history of being non-compliant with taking medication. On 1/24/23, a Medical progress note written by Physician 'D' documented, completed isolation .comfortable .no pain or discomfort .cooperative . On 1/24/23, a Dietary progress note documented, CBW (current body weight): 125.6 # (pounds). Weight is down from 134# x 5 days .Patient tells this writer that he just can't get hungry. Patient appears down and depressed to writer. Writer notes that patient was dx (diagnosed ) with depression while in the hospital per doctor's note .Writer spoke with IDT (interdisciplinary team) regarding appetite and mood .Writer notified doctor of weight change . On 1/26/23 at 11:44 AM, a Nursing progress note documented, Resident displays very combative behavior, refused to take medications, and consistently pulling out nasal cannula, when writer attempts to put O2 (oxygen) supply back in place resident pushes writer hands away. NP (Nurse Practitioner) 'E' alerted of behavior and ordered to continue to monitor and report any changes in behavior . On 1/26/23 at 2:32 PM, a Physical/Rehab progress note documented, .Nursing reports that patient was combative last night, pulled call light out of wall, is refusing medications and basic ADL care and refusing oxygen .Currently will not verbally answer questions. RN (registered nurse) states that she was just in the room and was told to get out of the room .Currently has his oxygen off .RN reports oxygen was 94% .Oral mucosa is dry .combative behavior .Psych consult placed .Patient refusing medications and oxygen .(NP 'E') notified of behavior: refusing medication, and oxygen. Nursing to continue to monitor . On 1/27/23 at 2:51 AM, a Nursing progress note documented, .Resident refused all his medications, writer explained to resident the importance and danger of not taking medications, which resident verbalized understanding, but still refused . There was no indication that a medical provider was contacted about R801 refusing their medications. On 1/27/23 at 1:40 PM, a Nursing progress note documented, .Noncompliant with medication administration. Resident refused meals and was noted to be physically aggressive . There was no indication that a medical provider was contacted about R801 refusing their medications, meals, or physically aggressive behavior. On 1/28/23 at 3:39 AM, a Nursing progress note documented, .non compliant with all nursing care. Resident refused medication and adl care. Resident became combative and aggressive . There was no indication that a medical provider was contacted about R801 refusing their medication and care or their combative and aggressive behaviors. On 1/29/23 at 2:07 AM, a Nursing progress note documented, .refused writer to get VS (vital signs) or give medications as ordered. Explained to resident the need for taking medications, continues to refuse .resists care . There was no indication that a medical provider was contacted about R801 refusing their medication. It should be noted that this was the fourth day it was documented R801 refused their medications. On 1/29/23 at 11:41 AM, a Nursing progress note documented, Resident has been, for days refusing to allow vitals to be taken, refused to eat and drink, refusing his medications. EMS (emergency medical services) called . Review of R801's Physician's Orders and Medication Administration Record (MAR) revealed R801 refused the following medications and treatments on the following dates and times: Entresto (a medication used to treat heart failure) 97 mg (milligrams)-103 mg tablet give 1 tablet two times a day was not administered on 1/25/23 at 9:00 AM and 9:00 PM, 1/26/23 at 9:00 AM and 9:00 PM, 1/27/23 at 9:00 AM and 9:00 PM, 1/28/23 at 9:00 AM and 9:00 PM, and 1/29/23 at 9:00 AM. R801 missed a total of nine doses. It was documented that R801 refused to take the medication at those times. Atorvastatin (a medication used to treat high cholesterol) 40 mg once daily at bedtime was not administered on 1/25/23, 1/26/23, 1/27/23, and 1/28/23. R801 missed a total of four doses. It was documented that R801 refused to take the medication at those times. Aspirin (a medication used to prevent blood clots) 81 mg daily was not administered on 1/26/23, 1/27/23, 1/28/23, and 1/29/23. R801 missed a total of four doses. It was documented that R801 refused to take the medication at those times. Lasix (a medication used to treat fluid retention in people with CHF) 20 mg once daily was not administered on 1/26/23, 1/27/23, 1/28/23, and 1/29/23. It was documented that R801 refused to take the medication at those times. Metoprolol tartrate (a medication used to treat high blood pressure) 25 mg two times a day was not administered on 1/25/23 at 9:00 AM and 9:00 PM, 1/26/23 at 9:00 AM and 9:00 PM, 1/27/23 at 9:00 AM and 9:00 PM, 1/28/23 at 9:00 AM and 9:00 PM, and 1/29/23 at 9:00 AM. It was documented that R801 refused to take the medication at those times. Norvasc (a medication used to treat high blood pressure) 10 mg once daily was not administered on 1/26/23, 1/27/23, 1/28/23, and 1/29/23. It was documented that R801 refused to take the medication at those times. Plavix (a medication used to prevent heart attacks, strokes, and blood clots) 75 mg once daily was not administered on 1/26/23, 1/27/23, 1/28/23, and 1/29/23. It was documented that R801 refused to take the medication at those times. Zoloft (a medication used to treat depression and anxiety) 50 mg once daily was not adminstered on 1/25/23, 1/26/23, 1/27/23, 1/28/23, and 1/29/23. It was documented that R801 refused to take the medication at those times. Further review of R801's clinical record revealed there was no documentation that indicated a medical provider was contacted regarding the missed medications mentioned above, their combative behaviors, or their refusal of ADL care and nutrition. There was no indication in R801's clinical record that they were seen by behavioral health services. On 4/27/23 at 3:23 PM, the Director of Nursing (DON) was interviewed. When queried about when a medical provider should be notified if a resident refused significant medications, the DON reported the nurse should attempt to offer the medication to the resident a few times and if they continued to refuse they would document it as a refusal. The DON reported it should be no more than a couple days before the medical provider was contacted about a resident missing their medications. When queried about R801's missed doses of medications for four to five days and the eventual transfer to the hospital, the DON reported the medical provider should have been contacted at the most two days and should have also been notified of the changes in behavior that included combativeness, poor nutrition, and refusal of ADL care. On 4/27/23 at 4:09 PM, a policy regarding medication refusals and/or refusal of care was requested. According to the DON, the facility did not have a policy.

This citation pertains to Intake MI 346 and MI 074. Based on observation, interview and record review, the facility failed to ensure a resident who required a two person assist using a lift for transfers was transferred per the resident's plan of care for one (R#904) of two residents reviewed for accidents, resulting in the resident experiencing pain and a hospital visit due to a left femur fracture requiring surgical repair. Findings include: Review of a Facility Reported Incident (FRI) submitted to the State Agency revealed on 10/10/20, Certified Nursing Assistant (CNA) A transferred R#904, alone, using a turn and pivot method of transfer knowing R#904 required the use of a mechanical lift for transfers. On 3/3/21 at 12:35 PM, R#904 was observed sitting in a wheelchair with an elevated foot cradle pad. On the wall above R#904's bed a sign was observed that had a picture of a penguin with the words Happy Feet at the top and EZ Stand (a type of mechanical lift) at the bottom. R#904 was asked how their leg was broken in October 2020. R#904 stated, The aide was waiting for a lift, and it was a long time, and she (CNA A) said, 'Do you want me to move you', I thought about it and then said yes. My leg didn't move and it broke. I had to go to the hospital and have surgery. Review of the clinical record revealed R#904 was admitted into the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment dated [DATE], R#904 scored 12/15 on the Brief Interview for Mental Status (BIMS) exam, indicating moderately impaired cognition. The MDS assessment also indicated R#904 required the Extensive assistance of Two+ (two staff members plus a mechanical lift) for transfers. Review of R#904's ADL (activities of daily living) care plan dated 2/19/19 read in part, .I have weakness and decreased mobility . I transfer with E-Z stand and 2 person staff assist . Review of an Unusual Occurrence Report with an incident date of 10/10/20 for R#904 read in part, .Resident (R#904) states the CENA transferred her from the w/c (wheelchair) to the bed w/o (without) the sit-to-stand as ordered because she asked the CENA to because she had a BM (bowel movement), was tired of being soiled and the sit-to-stand was on (another unit) being used and while pivoting to the left, resident said, My leg did not move, then I felt great pain. The Resident Outcome had Fracture circled. Review of (Name Redacted - local hospital) discharge paperwork dated 10/15/20 read in part, .Your primary [DIAGNOSES REDACTED]. Procedures(s)/Surgeries during current admission: Left - OPEN REDUCTION INTERNAL FIXATION LEFT PERIPROSTHETIC FEMUR FRACTURE (surgical placement of a metal device to hold a bone in place) . Surgical date 10/12/2020 . On 3/3/21 at 1:43 PM, CNA A was interviewed by phone and asked about the incident that happened on 10/10/20 with R#904. CNA A explained it happened in the evening and R#904 wanted to go to bed and get changed because she had a BM. CNA A explained to R#904 the lift was being used for another resident, but she would bring it as soon as she could, and R#904 told her OK. CNA A further explained that R#904 put her light on again about 30 minutes later so she went back in and told R#904 the lift was still being used, but that R#904 did not want to wait any longer, she wanted to be cleaned up, that she was tired of being soiled and to just transfer her. CNA A stated, I think I made the wrong decision, I take full responsibility for that, but there was nothing malicious about it, I was just trying to help her, I did not do it to hurt her, you could smell that she had messed on herself, I really wanted to help her. CNA A was asked how she transferred R#904. CNA A explained she put the wheelchair next to the bed and used a gait belt to assist R#904 to stand and then did a turn and pivot to the bed. CNA A continued to explain after R#904 was in the bed, R#904 complained her leg hurt, so she went and told the nurse. CNA A was asked if she continued to work at the facility. CNA A explained she was an agency CNA and was not allowed back at the facility. On 3/3/21 at 4:04 PM, the Director of Nursing (DON) was interviewed and asked how many sit-to-stand lifts were in the building. The DON explained there were four lifts, one for each unit. The DON was asked how many lifts were in the building in October 2020. The DON explained there had been four lifts at that time.

This deficient practice pertains to MI 291: Based on observation, interview, and record review the facility failed to prevent the development and worsening of avoidable pressure ulcers, promptly identify and obtain treatment for [REDACTED].#803 and R#805) of three residents reviewed for wounds, resulting in an Immediate Jeopardy when R#803 developed multiple facility acquired stage 3 (full thickness skin loss) pressure ulcers and R#805 developed of a stage 4 (full thickness skin and tissue loss) facility acquired pressure ulcer which required antibiotic treatment for [REDACTED]. Findings include: The Immediate Jeopardy started on 5/22/20. The Immediate Jeopardy was identified on 6/29/20. The Administrator was notified of the Immediate Jeopardy on 6/29/20 at approximately 2:20PM and a plan to remove the immediacy was requested. The immediacy was verified onsite 7/1/20 as being removed 6/29/20. Although the immediacy was removed, the facility remained out of compliance at the scope of pattern and a severity of potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency. Resident #803: Review of a complaint received by the State Agency expressed, in part, that R#803 had bedsores on their bottom. On 6/25/20 at 10:36AM R#803 was observed in bed in the resident's room. R#803 was queried in regard to wounds, and explained they had wounds on their back and butt that were acquired at the facility. The resident was queried as to why they felt the wounds had developed, and explained they guessed it was from laying in urine, however they were not sure. On 6/29/20 at 1:37PM an observation was made of R#803's right buttock wound with Licensed Practical Nurse (LPN) 'A'. The resident was observed to be in bed and was observed to have their feet resting directly on the mattress. A dressing dated 6/29 was observed on the resident's right buttock. The resident's dressing was peeled back to observe the wound bed. LPN 'A' was queried as to a description of the wound, and explained the wound bed was pink with slough with a necrotic base. Review of the clinical record for R#803 was reviewed and revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of the resident's admission minimum data set (MDS) assessment dated [DATE] it was revealed the resident scored 14 out of 15 on a brief interview for mental status exam, which indicated the resident was cognitively intact. Per this assessment R#803 required the extensive assistance of one person for bed mobility and required the total dependence of two plus persons for transfers. Also, per the assessment it was noted the resident was at risk for pressure ulcer development and had no unhealed pressure ulcers. Review of a Nursing-Admission Nursing Assessment for R#803 dated 4/21/20 documented, in part, that R#803 was cooperative with no recent memory changes, and was oriented to person, place, and time. Per the Wound Location section of the assessment, two areas were noted to the resident's skin. Bruising was noted to the resident's left arm, and an Old scar was noted to the resident's front lower left leg. No other areas were indicated on the body diagram present on the assessment. Per a Nursing-Weekly Skin Assessment-Friday form created on 4/24/20 and completed on 4/25/20 it was documented that the resident had five wound locations on the resident's skin. Per the body diagram redness was noted to the resident's front lower torso area, redness was noted to the front left chest, a bruise was noted to the left front arm, discoloration was noted to the front right arm, and redness and scabs were noted to the left lower leg. It was noted that no areas had been identified/documented on the back view of the body diagram. Review of R#803's Treatment Administration Record (TAR) for May 2020 revealed the resident was to receive skin assessments twice per week, scheduled to be completed on Tuesdays and Fridays. It was not signed off on the resident's TAR to indicate the resident's scheduled skin assessment had been completed on 4/28/20. Review of a Nursing-Weekly Skin Assessment-Friday form created 5/1/20 and completed 5/2/20 was not noted to include a body diagram. A question was left unchecked which documented, Skin Intact? If NO indicate abnormalities on diagram. The assessment indicated Yes per the comments section of the assessment to Previously identified area . Per a Weekly Skin Assessment-Friday form created 5/8/20 and completed on 5/9/20 four areas were documented to the resident's skin, including a circled area on the right buttock area on the back section of the diagram. The description of the wound documented, open area, under treatment. Per a consultation progress note written by Nurse Practitioner (NP) 'B' dated 5/8/20 at 7:03PM it was documented R#803 had a right buttock pressure ulcer. Per the consultation note was the following: Wound #1 Right Buttock is a Stage 2 Pressure Injury Pressure ulcer and has received a status of Not Healed. Initial wound encounter measurements are 7cm (centimeters) length x 4cm width x 0.01cm depth .There is a moderate amount of sero-sanguineous (yellowish with small amounts of blood) drainage noted . Also, per this consultation was the following: Wound Orders: Wound #1 Right Buttock TREATMENT RECOMMENDATIONS (Brand Name Dressing) Q3D (every three days) and PRN (as needed). Per a Nursing-Weekly Skin Assessment-Friday form dated 5/15/20 completed on 5/17/20 it was noted, in part, that one area was identified on the resident's buttocks, more towards the right side on the body diagram. The description documented was as follows: open area with dressing. No additional areas were marked on the diagram to indicate additional wounds to the buttocks. Review of a consultation progress note authored by NP 'B' dated 5/15/20 at 1:51PM documented, in part, the following: HPI (History of Present Illness) .Location: R (right) Buttock, L (left) Buttock Context: Pressure Ulcer, Deep Tissue Injury (persistent non-blanchable deep red, maroon or purple discoloration) .Wound #1 Right Buttock is a Stage 2 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 9cm length x 5cm width x 0.01cm depth .There is a moderate amount of serosanguineous drainage noted .Wound #2 Left Buttock is a Deep Tissue Injury and has received a status of Not Healed .Initial wound encounter measurements are 6cm length x 2cm width .Wound bed has Dark Maroon Base [MEDICATION NAME] It was noted treatment recommendations included orders for a dressing every three days and as needed to the right and left buttock. Review of the resident's Treatment Administration Record (TAR) for May 2020 did not reveal changes to treatment orders to reflect recommendations by NP 'B'. Review of R#803's TAR for May 2020 revealed the following order with a start date of 5/11/20: Cleanse Right Buttocks with NSS (normal saline solution), and pat dry, apply (Brand Name Dressing) . This treatment was documented as having been completed on 5/11/20, 5/14/20, was not signed off as administered on 5/17/20, and was completed on 5/20/20. The resident's treatment order was noted to change on 5/22/20 to address the bilateral buttocks. Review of (Pressure Ulcer Risk) assessments for R#803 dated 4/28/20, 5/5/20, and 5/12/20 were reviewed and were all noted to have been completed on the date of 5/20/20. Scores on the assessments documented the following: 4/28/20 (completed 5/20/20): 16 Mild Risk, 5/5/20 (completed 5/20/20): 16 Mild Risk, 5/12/20 (completed 5/20/20): 15 Mild Risk. Review of a Nursing-Weekly Skin Assessment-Wednesday form dated 5/20/20 and completed on 5/21/20 documented the following in part: Per review of a back view of the body diagram on the skin assessment a circle had been drawn to include the resident's left and right buttocks. Per the description of the area it was documented, pressure sore on buttocks. This assessment indicated yes to the question as to whether the skin assessment noted a previously identified area. Review of a consultation progress note dated 5/22/20 at 3:30PM authored by NP 'B' documented, in part, the following: HPI .Location: R Buttock, L Buttock Context: Pressure Ulcer . Wound #1 Coccyx/R Buttock is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 9.5cm length x 8 cm width x 0.2cm depth . There is a moderate amount of sero-sanguineous drainage noted which has no odor. Wound bed has Necrotic Base [MEDICATION NAME] . Wound #2 Left buttock is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 5.5cm length x 2cm width x 0.2cm depth . There is a moderate amount of sero-sanguineous drainage noted which has no odor. Wound bed has Necrotic (death of body tissue) Base [MEDICATION NAME] . Wound #3 Right, Proximal Buttock is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed .Initial wound encounter measurements are 1.5cm length x 1.5 cm width x 0.2cm depth . There is a small amount of sero-sanguineous drainage noted which has no odor. Wound bed has Yellow Necrotic Base [MEDICATION NAME] . Wound #4 Right, Distal Buttock is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 2.5cm length x 0.5cm width x 0.2cm depth . There is a small amount of sero-sanguineous drainage noted which has no odor. Wound bed has Yellow Necrotic Base [MEDICATION NAME] . Wound #5 Right, Lateral Buttock is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 5cm length x 1cm width x 0.2cm depth .There is a moderate amount of sero-sanguineous drainage noted which has no odor. Wound bed has Yellow Necrotic Base [MEDICATION NAME] .Diagnosis 1.: Pressure Ulcer Stage III Coccyx/R Buttock, R Proximal Buttock, R Distal Buttock, R Lateral Buttock, L Buttock . Per a Nursing-Weekly Skin Assessment-Friday form dated 5/22/20 completed on 5/22/20 it was noted, in part, that one circle was present on the back portion of the body diagram section of the skin assessment. This circled area included the left and right buttocks. The description documented was as follows: sore, under treatment. No additional descriptions had been documented to describe wounds present to the resident's buttocks. It was noted per NP 'B's consultation notes that staff had reported R#803 to not be compliant with repositioning. A plan of care to address Non-Adherence with receiving treatments and getting up to a chair related to shortness of breath and pain had been input in the resident's record on 5/27/20. All interventions per the plan of care were dated 5/27/20. It was noted this plan of care was in place after the development of the resident's wounds noted above. Review of a plan of care for skin for R#803 dated 4/23/20 documented, in part, the following: SKIN-at Risk for Skin Breakdown I am at risk for skin breakdown related to decreased mobility, obesity, weakness, pain, depression. Interventions per the plan of care included, in part, the following: 4/23/20- Report any signs of skin breakdown (sore, tender, red, or broken area). Notify physician as needed, 4/29/20-(Pressure Ulcer Risk Assessment) per protocol, 4/29/20-Skin assessment 2 x weekly. pay particular attention to the bony prominences. Review of an Actual skin breakdown plan of care dated 5/13/20 was noted to have the following options for etiology: admitted with Right Buttock (wound), cognitive impairment, DM (diabetes mellitus), [MEDICAL CONDITION], immobility, incontinence, use of steroid medication, [MEDICAL CONDITION] ([MEDICAL CONDITION]/PAD (peripheral artery disease) diagnosis. Marked per the etiology on the plan of care were [MEDICAL CONDITION], immobility, and incontinence. The resident's goal per the plan of care was dated 5/13/20, and all interventions per the plan of care were also dated 5/13/20. On 6/29/20 at 10:19AM LPN 'A', who functioned as a wound care nurse at the facility, was queried in regard to wound care. LPN 'A' was queried as to what staff were to do if they identified a skin issue, and explained that they were supposed to notify the doctor and put something in place for a change in skin condition. LPN 'A' explained they would look at what was put into place to see if it would need to be changed. LPN 'A' explained that if staff observed a reddened area, they were to start a (barrier cream name) and let LPN 'A' know. When queried as to whether staff were to document a progress note if they observed an abnormal skin area, LPN 'A' acknowledged they were to do so. When queried in regard to skin assessments, LPN 'A' acknowledged they were to be completed two times per week in the computer. LPN 'A' explained that the facility had quality of life meetings weekly where wounds would be discussed. When queried as to whether there had been an increase in wounds since the pandemic, LPN 'A' acknowledged there had been an increase. LPN 'A' also explained that they attended the facility's quality assurance meetings. LPN 'A' was queried in regard to staging of wounds at the facility and explained that NP 'B' staged wounds. When queried in regard to implementation of interventions, LPN 'A' explained that they or the interdisciplinary team would address interventions on the plans of care. R#805 On 6/25/20 at 11:22 am, R#805 was observed in their room, laying on their back in bed. The resident requested a cup of ice water and staff was notified of the resident's request. On 6/29/20 at 1:47 pm, R#805 was observed laying on their back in bed. Wound Nurse (WN) A attempted to awake R#805 with verbal and touch stimuli, however, was unsuccessful. The resident remained asleep. On 7/1/20 at 11:13 am, R#805 was observed laying on their back with oxygen administered via nasal cannula. When asked how they were doing, R#805 responded ok. A Review of the records revealed R#805 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 0 (indicating severely impaired cognition) and requiring staff assistance for all Activities of Daily Living (ADL's). A review of the resident's clinical record documented the following: An Admission Nursing assessment dated [DATE] documented four abnormal skin areas observed upon admission. Two areas were documented as discoloration to the back of the left and right lower arms. The third area was documented as redness to the coccyx/buttocks area and the fourth area documented redness to the frontal groin area. There was no documentation of the physician, wound nurse practitioner (WNP) B being notified of the redness on the coccyx/buttocks area or treatment being started. An Admission Braden Scale (assessment tool for predicting the risk of pressure ulcer) documented a total score of 18 Mild Risk. A review of March 2020 Treatment Administration Record documented no treatments for the coccyx/buttock area. A physician order [REDACTED]. Further review of the records revealed no documentation that a skin assessment was completed on the dates of May 8th, 15th, 19th, 22nd or June 2nd and 26th. The Director of Nursing (DON) was queried on the missing skin assessments and asked to provide the assessments for review, however no further assessments were provided by the end of survey. Additional skin assessments dated April 1st, 7th, 8th, 10th and 17th documented redness on the buttock/coccyx area, however no notification was documented of the physician, WNP B or WN A being notified. A Nursing note dated 4/24/20 at 7:42am, documented Observed the resident's buttocks redness developed. Treatment order in place. Sent msg (message) to unit manager and wound care nurse. A wound care consultation report dated 4/24/20 at 2:58 pm, documented in part Context: Pressure Ulcer . Wound #1 Coccyx/ L Buttock is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 4 cm length x 1.5 cm width x 0.2 cm depth, with an area of 6 sq. (square) cm and a volume of 1.2 cubic cm. There is a moderate amount of sero-sanguineous drainage (yellowish with small amounts of blood) noted which has no odor. Wound bed has Necrotic Base [MEDICATION NAME] . TREATMENT RECOMMENDATIONS- [MEDICATION NAME] (THIN LAYER) DAILY AND PRN - Coccyx/ L Buttock . Additional Orders . LOW AIR LOSS MATTRESS OR LOW AIR LOSS BED, FREQUENTLY REPOSITION . PRESSURE RELIEF / OFFLOADING RECOMMENDATIONS DISCUSSED WITH NURSING STAFF . The DON was asked to provide documentation of the start/delivery of the low air loss mattress or low air loss bed, however, was unable to provide documentation of the start or delivery of the ordered mattress. A review of the April 2020 Resident Treatment Administration Record revealed the following: Reposition patient side to side- no signature of completion for the following dates and times: 25th - 6 pm & 10 pm, 26th - 2 am, 6 am & 2pm, 28th- 2 am, 6 am, 10 am and 2 pm. Cleanse Left Buttock with wound cleanser, pat dry and apply [MEDICATION NAME] on 4x4, and cover with dry dressing- no signature of completion for the 28th. A wound care consultation report dated 5/15/20 at 1:24 pm, documented in part . There is a moderate amount of sero-sanguineous drainage noted which has a strong odor . TREATMENT RECOMMENDATIONS- CRUSHED [MEDICATION NAME] (500 MG milligram) + HYDROGEL DAILY AND PRN X 14 DAYS . Review of the nursing notes revealed no documentation of the WNP B or a physician being notified of the wound having a strong odor prior to this consultation. A Nursing note dated 5/21/20 at 8:37 pm, documented in part wound needed addressed <sic> foul odor noted with yellow exudate. Treatment done as ordered. Wound consult ordered. A Nursing note dated 5/23/20 at 4:23 pm, documented in part wound is 9.1 cm x 4.8 cm x 0, irregular edges, black soft filled base, mild odor, moderate serosanguineous drainage. Wound cleaned with NSS (normal saline solution), applied [MEDICATION NAME] and Solosite covered with gauze and secured with Bordered gauze . Further review of the progress notes revealed no documentation to the physician or WNP B of the worsening of the wound. A wound care consultation report dated 5/29/20 at 6:36 pm, documented in part Wound #1 Coccyx/ L Buttock is a Stage 4 Pressure injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 9cm length x 6cm width x 3.5cm depth, with an area of 54 sq. cm and a volume of 189 cubic cm. Undermining has been noted at 11:00 and ends at 2:00 with a maximum distance of 3.5cm . Diagnosis 1. Pressure Ulcer Stage IV Coccyx/ L Buttock . Please note change in diagnosis . TREATMENT RECOMMENDATIONS- HYDROGEL IMPREGNATED GAUZE DAILY AND PRN . Review of the residents clinical record revealed no prior documented notification to the physician or WNP B of the worsening of the Coccyx/ Buttock wound before this consultation. A review of the skin assessment documentation revealed no documented assessments for the dates of May 19th & 22nd. The May 26th skin assessment did not identify any worsening of the wound or any documented notification to the physician. The DON was asked to provide documentation of the skin assessments for May 19th and 22nd and no further documentation was provided by the end of survey. A review of the May 2020 Resident Treatment Administration Record revealed the following: Reposition patient side to side- no signature of completion for the following dates and times: 6th - 10 am and 2 pm, 7th - 10 am, 2 pm, 6 pm & 10 pm, 10th - 10 pm, 16th 2 am and 6 am, 18th- 2pm, 20th- 2pm, 22nd - 2 pm and 30th- 10 am and 2 pm. Cleanse Left Buttock with wound cleanser, pat dry and apply [MEDICATION NAME] on 4x4, and cover with dry dressing- no signature of completion for the May 6th treatment. A Hospice note dated 6/15/20 at 1:13 pm, documented in part . Wound has progressively worsened since last visit (5/27/20), called placed to MD (medical doctor) for new orders and awaiting call back. The facility's skin assessments completed by the nursing staff was reviewed for the dates of May 29th, June 2nd-none, 5th, 9th, 12th and 16th revealed no documentation of worsening of the wound or notification to the physician, until the above hospice nurse note. Further review noted no documentation of the physician returning the nurses phone call regarding the worsening of the wound or further treatment implemented. A Hospice note dated 6/18/20 at 11:02 am, documented in part . wound on coccyx assessed, (Doctor's name redacted) notified, new order to place Foley catheter for wound progression . A wound care consultation report dated 6/19/20 at 1:54 pm, documented in part . Wound #1 Sacrococcyx/ Bilateral Buttock is a Stage 4 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 9cm length x 7.7cm width x 3.2cm depth, with an area of 69.3 sq. cm and a volume of 221.76 cubic cm. Bone is exposed. Undermining has been noted at 11:00 and ends at 2:00 with a maximum distance of 4.6cm. There is a large amount of sero-sanguineous drainage noted which has a strong odor. Wound bed has Necrotic Base [MEDICATION NAME]. The wound is deteriorating . Please note change in wound site . TREATMENT RECOMMENDATIONS- DAKINS SOLUTION ¼ STRENGTH BID (twice a day) AND PRN X14 DAYS - (lightly packed), SECONDARY DRESSING- COVER WITH SECONDARY DRESSING . ORAL ANTIBIOTIC - [MEDICATION NAME] 100mg PO (by mouth) BID X 14 DAYS A review of June's skin assessments and nursing notes revealed no identification or documentation of the worsening of the wound by the facility's nursing staff and no notification to the physician or WNP B until the hospice nurse attempted to notify the physician on 6/15/20 and on 6/18/20 when the hospice nurse obtained a foley catheter placement for wound progression. A review of the June 2020 Resident Treatment Administration Record revealed the following: Reposition patient side to side- no signature of completion for the following dates and times: 4th - 10 am & 2 pm, 6th- 6 pm & 10 pm, 7th- 2 am, 6 am, 6 pm & 10 pm, 8th - 2 am & 6 am, 11th- 6 pm, 17th- 2 pm, 6 pm & 10 pm. Cleanse Left Buttock with wound cleanser, pat dry, apply Hydrogel Impregnated gauze, cover with 4x4, dry dressing- no signature of completion for the 2nd, 8th or 17th. A care plan titled SKIN- At Risk for Skin Breakdown dated 3/13/20 documented in part . Report any signs of skin breakdown (sore, tender, red, or broken area). Notify physician as needed . Skin assessment 2 x weekly. Pay particular attention to the bony prominences . A care plan titled Actual skin breakdown, Etiology: I have a stage 4 on coccyx . dated 4/24/20 documented in part, . Assess the pressure ulcer location, stage, size (length, width, depth), presence/absence of granulation tissue and epithelization per protocol, Apply treatment as ordered, Wound care consult and follow up as ordered/ needed, Weekly wound round and measurements and prn . A care plan titled INFECTION- infected non healing wound (dated 6/22/20) documented in part . Assess the site for a decrease of redness, swelling . Document and report abnormals . A review of the care plans revealed no interventions for the resident's air mattress or turning and repositioning directive. On 6/29/20 at 10:17 am, WN A was queried on if a resident is admitted with redness on their skin what are the nurses expected to do? WN A replied They would notify the doctor and put something in place. They will notify me, and we would start a topical for prevention . If the nurse discovers any skin issues, they should do a progress note . When asked how often skin assessments were completed, WN A stated in part .Twice a week . When asked how often the residents were seen by the wound nurse practitioner, WN A stated in part, . I keep a list of any concerns and have a list ready every Friday when the wound nurse practitioner comes. Hospice residents are seen once a month, if it worsens, we see them before that . When asked about the monitoring of the worsening of the residents' wounds and the follow up wound care of residents with wounds, WN A explained that staff should be notifying them and the doctor. Any concerns they observed or that was reported would require a resident to be added to the list for the wound NP to assess when they returned to the facility. When asked if they noted an increase in the facility acquired pressure ulcers since the pandemic, WN A stated yes. On 6/29/20 at 10:35 am, WN A and the DON were queried on the skin assessments not found for the dates of April 28th , May 8th, 15th, 19th & 22nd and June 2nd and 26th and why the resident's care plans were not modified to reflect the current interventions. The DON stated they would follow up and get back to the surveyors. The DON was able to provide further documentation, however, none of the information was relevant to the requested information. On 6/29/20 at 5:39 pm the Administrator documented in part (Resident #805's name redacted) wound care plan has been reviewed and deemed appropriate with no changes needed . On 7/1/20 at 12:28 pm, the DON provided an updated/modified wound care plan for R#805. On 7/1/20 at 11:30 am, WNP B was queried on if staff observed a wound worsening between their visits what should the nurses do and replied in part . If they have concerns before that they call me or one of my team members. Yes, they should contact me if it worsens . When asked how they follow up with the resident's wound care they stated in part, . the weekly visits is based off the roster that (WN A name redacted) gives to me . A facility policy titled Pressure Ulcer & Skin Care Management dated May 2015 documented in part, A resident who enters the facility without pressure ulcers does not develop pressure ulcers . A licensed nurse checks the resident's body for the presence of pressure ulcers, wounds, and other skin conditions . The licensed nurse documents that the body check was completed on the resident's weekly head to toe skin record. The presence of any pressure ulcer, wound, or other skin condition is documented weekly on pressure ulcer or skin report forms . The interdisciplinary team will develop a care plan addressing risk factors and periodically review and update the care plan as needed to minimize risk and promote healing . A licensed nurse completes a Wound/skin healing record or a Non pressure skin report: When a pressure ulcer, wound or other skin condition is identified, and Weekly until healed. The interdisciplinary team will review residents with skin conditions regularly to monitor treatment and support effectiveness and recommend changes as needed . Documentation on the weekly head to toe skin check for the presence of pressure ulcers, wounds, and other skin conditions. Record the description of ulcers on the Wound/skin healing record or the Non pressure skin report. Assessment of risk for pressure ulcers is documented. Document approaches and interventions to prevent and/or treat pressure ulcers in the care plan. The Quality of Life meeting is documented in the nurse's notes. A facility policy titled Braden Scale with Interventions dated 5/13 documented in part, . A Braden Scale evaluation must be completed on each new patient upon admission and if it has been determined that the patient is moderate or low risk a Braden Scale will be completed at least weekly for the first month following admission . Daily skin check by CENA (CENA to report any changes in resident's skin. Nurse to document if more redness, pain, or drainage is noted with a current wound. Or if a new pressure ulcer is found . Turning schedule (if not being done with CENA rounds) to meet the patient's needs if unable to move independently . Elevate heels off bed if partially or totally immobile. Heel and sacrum checks daily (CENA to notify nurse of any breakdown, redness, or tenderness . The facility submitted the following accepted plan of removal: Plan for IJ Removal F686 Failure to Prevent Pressure Ulcers 1. Residents 805 and 803 remain in the facility and continue to receive care and treatment as ordered. Both residents continue to be followed by wound care physician and wound care Nurse Practitioner. 2. Resident 805's wound care plan has been reviewed and deemed appropriate with no changes needed. 3. Resident 803's wound care plan has been reviewed and updated with minor changes. 4. 6 of 6 residents with pressure ulcers have had their wound care plans reviewed. 3 of 6 required minor changes. 5. A facility-wide completion of skin assessments was done 6/29/20 to ensure all residents have current skin assessments. 6. Facility-side (Pressure Ulcer Risk Assessment) scales were completed 6/29/20 to ensure all residents have a current (Pressure Ulcer Risk Assessment) scale documented. 7. The Skin Management policy has been reviewed and deemed appropriate. 8. Beginning 6/29/2020 nurses are being educated on skin assessment and {Pressure Ulcer Risk Assessment) process and frequency to ensure compliance with the Skin Management Policy. Effective 6/30/2020 nurses are not being allowed to provide care until the education is received. Effective 6/29/2020 the facility has validated that no residents are at risk for harm related to the alleged deficient practices.

Based on interview and record review, the facility failed to initiate cardiopulmonary resuscitation (CPR) and call 911 for one (R#119) of four residents reviewed for advance directives, resulting in an Immediate Jeopardy (IJ) when staff failed to provide CPR to R#119 who had a documented full code status, and was found unresponsive with no pulse or respirations. R#119 was pronounced dead at the facility. Findings include: The IJ started on [DATE] at approximately 9:15 PM. The IJ was identified on [DATE] at approximately 4:22 PM. The Administrator was notified of the IJ verbally and electronically on [DATE] at 4:32 PM. The immediacy was removed on [DATE] at approximately 11:15 AM based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed, the facility remained out of compliance at the scope of isolated and severity of actual harm. According to the Fundamentals of Nursing (Potter and Perry, 6th ed., 2005), [MEDICAL CONDITION] is characterized by an absence of pulse and respiration. If the nurse determines that the client has had a [MEDICAL CONDITION], cardiopulmonary resuscitation (CPR) must be initiated. CPR is a basic emergency procedure of artificial respirations and manual external cardiac massage. On [DATE], a review of R#119's closed record revealed R#119 was admitted into the facility on [DATE], readmitted on [DATE], signed onto hospice as a full code on [DATE], and died on [DATE] in the facility. [DIAGNOSES REDACTED]. According to the significant change Minimum Data Set (MDS) assessment dated [DATE], R#119 had mildly impaired cognition and received hospice services. Further review of the clinical record revealed R#119 did not have a legal guardian, medical power of attorney, or living will upon readmission to the facility on [DATE]. There was a Physician Determination of Decision Making Capability form which had an X marked next to I certify that the resident IS NOT capable to understand the Bill of Rights and participate in Medical Treatment Decisions. R#119's attending physician signed this form on [DATE], and a licensed psychologist signed the second portion of the form on [DATE], which determined R#119 was incompetent. According to the face sheet, there was no legal guardian or medical power of attorney in place at the time of the resident's death. Review of the interdisciplinary progress notes and physician orders [REDACTED]. Documentation included: A hospice physician order [REDACTED].Admit to (name of local hospice company) .no labs, no x-rays, no physical therapy, Full Code . An entry by Nurse AA dated [DATE] read, .Resident is full code until tomorrow and no lab need to draw per son will continue to monitor . An entry by Social Worker (SW I) on [DATE] at 4:51 PM read, .(Name of R#119) is expected to be admitted to (name of local hospice company) as a full code. (Name of R#119) does not have POA (power of attorney) papers assigning anyone to make medical decisions and she was deemed not competent . An entry by Social Worker I on [DATE] at 10:11 AM read, (Name of R#119) was admitted to Hospice services effective [DATE] .(Name of R#119) will remain a full code until emergency guardian can be obtained by family, SS (social services) to assist. An entry by Hospice Social Worker Z on [DATE] at 1:37 PM read, .Patient's son .is working on guardianship currently . An entry by Licensed Practical Nurse (LPN V) on [DATE] at 9:31 PM read, .Writer entered room @ approximately 9:15 pm and observed the resident lying on her side with no signs of life. Writer performed auscultation of breath sounds and heart, absent heart and lung sounds. Manager notified. Hospice notified. On [DATE] at 3:34 PM, an phone interview was conducted with LPN 'V'. When queried about R#119, LPN 'V' explained that the resident was a declining patient, and reported that she entered the room and the resident was lying there with their eyes in a fixed position. LPN 'V' further explained that when they started on the shift they had been told that R#119 was actively dying. LPN 'V' was further queried in regard to R#119's code status, and reported there was a book at the nurses station. LPN 'V' explained that there was a question about the resident's code status, and said the resident had two different things (code status forms). LPN 'V' explained that the resident was a hospice resident, full code, and the family was in the process of making the resident a DNR. When asked about R#119's code status, LPN 'V' acknowledged CPR was not completed for R#119. LPN 'V' explained they had followed direction from the supervisor. On [DATE] at approximately 3:50 PM, the facility's Director of Nursing (DON) was queried in regard to the facility's code status policy. The DON explained that if staff were unsure of code status, if there was not an order, or staff could not find it in the advance directive book or record, the resident would be considered a full code. On [DATE] at 4:11 p.m., an interview was conducted with LPN/Supervisor 'U'. When asked about the events surrounding R#119's death, first she stated, I was not here. When shown a picture of R#119, LPN/Supervisor 'U' stated, I can't remember. The nurse told me that she had passed away. On [DATE] at 9:22 AM, LPN/Supervisor 'U' provided a clarification of their previous statement and explained that she had two different residents in mind. LPN/Supervisor 'U' then explained a clinical history for R#119, and explained that she did not know R#119 had been a full code. LPN/Supervisor 'U' further explained a nurse had informed her of the status of R#119. LPN/Supervisor 'U' entered the room and noted R#119 had labored breathing, and LPN/Supervisor 'U' could tell the resident was active (dying) and left the room with the daughter. Per LPN/Supervisor 'U', the nurse called again and told LPN/Supervisor 'U' that the resident had expired. When queried about CPR, LPN/Supervisor 'U' explained that CPR had not been done because it was not known the resident was a full code. LPN/Supervisor 'U' was queried as to the process to follow if it was not known if a resident was a full code, and explained that they would not do CPR, would dial 911, and would check the records. LPN/Supervisor 'U' then acknowledged that she should have checked the record and had not done so. LPN/Supervisor 'U' then acknowledged that 911 had not been called for R#119. On [DATE] at 9:50 AM, an interview was conducted with Social Worker (SW I). When asked to recall the events following R#119's readmission into the facility on [DATE], SW I reported, She was deemed incompetent and was in and out of the hospital multiple times. When asked about who was legally authorized to sign the resident onto hospice services and consent to withhold treatment including x-rays, labs and therapy, SW I stated, That was one of my questions to hospice. They were saying they wanted to honor the DNR (do-not-resuscitate) in the hospital, but as you can see my note was she (R#119) was admitted to hospice as a full code. There was no one able to legally sign a DNR. I assisted the son with a petition for legal guardianship. I believe he was getting a note from a doctor in the community. He never got to probate (court) to have (legal guardianship papers) filed before she passed. When asked what the facility's process was to verify a resident's code status in the event a resident was found unresponsive, without vital signs, SW I stated, (Code Status Forms) are kept in binders on the units. Normally if someone passed on a full code, the facility would call the Sheriff's office, but under the hospice umbrella I'm not sure. I believe everyone said she was hospice. Would typically initiate CPR immediately. That's happened here and a lot of times the Sheriff comes with EMS (Emergency Medical Services). On [DATE] at approximately 10:15 AM, the Administrator was requested to provide the actual code status sheet that was on the nursing unit at the time of R#119's death, any additional hospice documentation, and who pronounced the resident's death as there was no such documentation in the resident's clinical record of these events. On [DATE] at 10:47 AM, a phone interview was conducted with the hospice nurse case manager that had been assigned to R#119 (Nurse X). At that time, when asked to discuss R#119's end of life care, Nurse X reported that she would investigate further and get back with any details. On [DATE] at 10:27 AM, Nurse X left a detailed voicemail message which stated, We spoke yesterday and I was going to try and get back with you .I was able to look her (R#119) up and she was in the facility, and what I was able to read was that she died after hours. While one of our nurses (Nurse BB ) went out, patient had expired by the time (name of Nurse BB) got there. Apparently the patient was a full code and it was not called. That's all I know about it. On [DATE] at approximately 11:20 AM, the Administrator reported, There is no additional hospice documentation other than what's available in the electronic records. We are not able to provide an actual code status form for (R#119) since she was a full code. We don't do them (code status form) if full code. That's the problem. Review of the facility's undated Advance Directives Policy provided for review, documented, in part: .This facility also intends to encourage communication between its residents and their health care providers and to ensure that the resident's final days are meaningful and dignified .Full Code: In the event of respiratory and/or [MEDICAL CONDITION], 911 will be called, and the resident will receive all resuscitative measures, including but not limited to CPR until EMS arrives. In the absence of a DNR order, a resident will be considered a full code .RESIDENT WITHOUT CAPACITY TO MAKE MEDICAL DECISIONS WITH NO ADVANCE DIRECTIVES .Resident is a full code unless or until a guardian requests a DNR and/or clear and convincing evidence is produced for making life-sustaining treatment decisions . The facility submitted the following plan of removal: Plan for Removal of IJ Related to F678 Failure to Follow Physician order [REDACTED].>1. Resident is deceased . 2. An audit on [DATE] was completed to ensure all hospice residents have a current code status. Reviewed 5 residents are signed up for hospice and all 5 residents have DNR paperwork on hand, correctly documented in the medical record and wristbands to indicate DNR code status. 3. Initiated Licensed nurse's re-education on Advance Directive Policy and Procedure and how to identify a resident's code status on [DATE]. Employees scheduled to work on [DATE] were educated prior to returning to the units. (Facility Name Redacted) employs 69 licensed nurse which includes 20 RNs and 49 LPNs. Out of the 69 nurses 19 have been reeducated which includes 7 RNs and 12 LPNs. By 8pm on [DATE] 4. Staff is being re-educated on how to identify resident code status quickly and correctly. 5. Involved employee (LPN 'V') LPN has been suspended pending investigation. Involved RN Supervisor (Supervisor 'U') has been suspended pending investigation. 6. An investigation surrounding this occurrence is underway. 7. 121 of 121 residents advance directive and code status were reviewed and updated as necessary (all found current and in place). 8. Facility is doing daily testing of staff staring immediately to ensure they are knowledgeable about identify code status and are able to verbalize their knowledge.

This citation pertains to Intake #MI 890 Based on observation, interview and record review the facility failed to ensure one resident (R#709) remained free from injury and pain out of two residents reviewed for injuries of unknown origin/falls/accidents resulting in extreme pain, fracture to the left tibia/fibula and a two day stay in the hospital. Findings include: The facility reported to the State Agency that on 1/25/19, R#709 was observed grimacing and wincing in pain. R #709's left leg was swollen and tender. An x-ray noted a fracture to the tibia and fibula (tib/fib). R#709 was then sent to the Hospital. A review of the Facility Investigation Summary documented, in part, the following: The assignment nurse C (name redacted) was the nurse on duty when R#709 began screaming and assessed the resident .the resident was unable to be interviewed or explain what occurred .results of the x-ray were she had a left tibia and fibula fracture .resident was sent to the hospital .she is to be transferred with two person assist with a hoyer lift .R#709 had a history of [REDACTED]. 2-24-15 from a fall. A skin assessment was completed 2-23-19 and no issues noted .The facility reviewed camera footage .prior to the fracture and the staff were interviewed Conclusion: The facility is unable to identify the event that led to the [MEDICAL CONDITION] tibia and fibula .R#709 does have age related [MEDICAL CONDITION] [DIAGNOSES REDACTED]. All staff interviewed were unable to recall anything unusual that occurred . On 3/13/19 at approximately 1:00 PM a review of R#709's clinical record documented that the resident was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R#709's Minimum Data Set (MDS) assessment (1/8/19) documented that the resident was severely cognitively impaired and required two person assistance for all transfers. Further review of R#709's Fall Care Plan (active 3/3/15) .interventions: Hoyer lift for safe transfers .Fall precautions due to balance disturbances .(effective 3/3/15). Continued review of R#709's clinical record documented, in part, the following progress notes: 1/22/19 (medical): Monthly evaluation visit .patient is sitting in activity room no acute concerns . 1/23/19: Weekly Skin Assessent- Wednesday: Skin Intact . 1/24/19 11:17 PM (nursing): Writer summoned to resident room by aide assigned to resident with c/o (complaints of ) resident grimacing and screaming out in pain. Upon assessment resident LLE (left lower extremity) appears [MEDICAL CONDITION] with discoloration .oncoming nurse notified and made aware . 1/25/19 12:02 AM (nursing): Received resident from ongoing nurse. Resident unable to flex left leg screaming out in pain. Writer will notify physician for stat X-ray of LLE. 1/25/19 2:56 AM (nursing): Spoke with NP (nurse practitioner) in regards to X-Ray results stated to send resident to hospital. A review of the patient report x-ray (s) dated 1/25/19 documented the following: Procedure: Left Tibia-Fibula, Two views .Findings: .Proximal fibular and distal tibia oblique fractures are noted . Procedure: .Left Femur .Findings: The alignment is normal .There is no fracture or dislocation of fracture . A review of R#709's Hospital records documented, in part, the following: Date of Admission 1/25/19 .Date of Discharge: 1/27/19 .Diagnosis: [REDACTED].left leg splinted .the fibula and tibia are 2 bones in your lower leg that go from your knee to your ankle ED (emergency department) nurse notes .PT (patient) is from a nursing home and was brought in .for LLE pain. PT is deaf and blind, pt appears alert .but does not verbally respond when name is called .Per nurse from nursing home, the afternoon shift nurse noticed pt was c/o (complaining of) LLE pain and they did an x-ray that revealed a spiral tib/fib fracture (a spiral fracture is a type of complete fracture. It occurs due to a rotation or twisting force) .Nursing home .they do not know what happened to cause her pain and deny any falls .LLE is bruised through out and is swollen .Abrasion noted to right shoulder Tibia and Fibula Left 2 views .1/25/19 4:54 AM .Findings: Spiral fracture through the distal tibia metaphysis .no additional fractures are seen .Medical Decision Making .Patient .who presents .after sustaining a left spiral tib/fib fracture with unknown mechanism of injury .on exam, the patient is non-verbal .She has an obvious deformity to the distal left leg and an abrasion to the right shoulder .X-ray of the left tib/fib and ankle reveal a spiral [MEDICAL CONDITION] left tibia .Case was discussed with trauma services .requests the patient to be placed in a posterior long splint .Care Plan note (RN) Goal: will remain free from falls . On 3/13/19 at approximatley 3:30 PM, R#709 was observed. The resident was alert, but unable to answer questions asked. On 3/13/19 at approximately 4:30 PM an interview and record review was conducted with the Director of Nursing (DON) and the Administrator/Abuse Coordinator. When queried as to R#709 and the facility's conclusion as to the cause of the tib/fib fracture, the DON reported that the resident was unable to speak and could not provide information. The DON indicated that R#709 did have a prior fracture to the hip and [MEDICAL CONDITION]. The Administrator reported that two nurses were interviewed, but there were no observations of a fall or an in-proper transfer. The Administrator was queried as to whether the Hospital records noted any indication that the tib/fib fracture was the result of [MEDICAL CONDITION] or the prior [MEDICAL CONDITION] that occurred on 2-24-15. The DON and Administer were also queried as to the Hospital records that indicated an abrassion to the right shoulder. The Administrator reported that a complete review of the Hospital documents was not completed prior to reporting the incident to the State. The Administrator was asked to provide any documents that would suggest [MEDICAL CONDITION] and/or prior fracture history led to the tib/fib fracture. On 3/13/19 at approximately 5:00 PM a phone interview was conducted with Nurse C. Nurse C was queried as to the incident pertaining to R#709. Nurse C reported that she worked the evening of 1/25/19 and was informed by another staff member that R#709 was screaming in pain. Nurse C reported that screaming in pain was not the resident's usual baseline and after completing an assessment she noted the resident could not flex her left leg and notified the physician for a stat x-ray. Nurse C stated, I recall that when the resident was x-rayed at the Facility it was noted that the resident had a spiral fracture. Nurse C reported that she looked at the x-ray and stated, It looked like a twist. When queried as to her opinion as to the cause of the fracture, Nurse C stated, It could have been from a transfer, the resident never attempts to get up out of bed on her own. The Administrator was asked to provide any documentation related to [MEDICAL CONDITION] as the cause of the tib/fib fracture as well as any facility policy pertaining to injuries of unknown origin and/or falls. The Administrator provided a one page document included in the Hospital record that related to the Pelvis, that documented: No acute fracture surgical hardware is seen in the left femur. The pelvis is intact. There is diffuse osteopenia . On 3/13/19 at approximately 6:00 PM a review of the facility's policy titled, Unusual Occurrences was conducted and documented, in part, the following: Overview: The facility will take the measures necessary to provide residents .with a safe and incident free environment .unusual negative occurrences will be documented .Fundamental information .An incident is an unusual occurrence that happens within the facility that results in .resident .injury or harm .Examples of Unusual Occurrences include, but is not limited to .bruises .abrasions .suspected abuse .Etc

This citation pertains to intake MI 209 Based on interview and record review, the facility failed to ensure one (#801) of 3 residents reviewed for abuse was not involuntarily secluded in their room, resulting in the resident becoming tearful, yelling out and screaming in emotional distress. Findings included: On 7/3/18 at 10:00 AM, a review of the clinical record revealed that Resident #801 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], indicated that Resident #801 was cognitively intact and required extensive assistance from staff to complete activities of daily living. On 7/3/18 at 10:16 AM, Resident #801 was interviewed in her room with the Director of Nursing (DON). Resident #801 was asked about the incident where she was placed in her room and left against her will. Resident #801 stated, She Certified Nurse Aide (CNA) said I had to go to bed at 6:00 (PM). I said I'm not ready. Since I wouldn't go to bed at 6, she let me stay up late (past when she wanted to go to bed) .She said 'I don't have time for you'. Resident #801 revealed the (CNA) A left her in the chair, turned off the lights in the room, and closed the door. On 7/3/18 at 11:17 AM, during a telephone interview, CNA A was asked about the above incident. CNA A stated, She (Resident #801) was upset. She was screams and hollers a lot. She asked me to put her to bed at 10 o'clock. It was 10:15. They (nurses) tell me to put her in her room and turn off the lights and close the door and that calms her down. So that is what I did. The person that told me to do that was the nursing supervisor (Nurse F) and the nurse (Nurse D). The supervisor hasn't been there for a few month .I was trying to put her night clothes on and she was screaming and got louder. She was still in her chair .I ended up turning off the light, leaving her in her chair, and closing the door. CNA A was asked if Resident #801 was screaming and yelling when she took her to her room. CNA A stated, She started screaming after I got her in the room, not while I was taking her to her room. I've had to do it before (leave her in the room, turn off the lights, and close the door) . CNA A revealed she thought her assignment was heavy and stated, It's a lot. I have to start immediately after dinner, 6:30-7:00 PM putting residents in the bed in order to get done. On 7/3/18 at 12:30 PM, a review of the facility's investigation file revealed the following statements: Resident #801 - She (CNA A) brought me into my room and left me in my room with the light off and the door closed. I was scared .I don't like her .I was not ready for bed and they didn't get me ready for bed. I don't like her .I just want to be happy. CNA A doesn't even smile at me. (CNA A) said, I cannot take this anymore. I felt really said; I don't want to be treated like this . The statement revealed staff person I came when I screamed and yelled. CNA A puts me to bed at 6:30 PM, but I always want to go to bed at 9:00 PM. This makes me sad. I just want to be happy. On 7/3/18 at 12:11 PM, during a telephone interview, Nurse F, former nursing supervisor, was asked about the above incident. Nurse F stated, I was not there. I was off from (MONTH) 12th to (MONTH) 25th (2018). Nurse F was asked if Resident #801 displayed behaviors where she had to be placed in the dark with the door closed. Nurse F stated, She is very happy go lucky. She screamed if something was wrong and it was out job to find out what was wrong. She is very loving to everyone. On 7/3/18 at 2:18 PM, the Staffing Scheduler I was asked about the above incident. Staff person I stated, I was here that night. I happened to run over there to check in with the supervision. I heard this scream. Her door was shut and the CNA (A) was coming towards me. The CNA didn't look mad, she looked aggravated. When I opened the door, the over head light was out, Resident #801 was facing the window, which put her back to the door. She was trying to turn her head to see who was coming into the room. The aide looked frustrated. I continued into the room. She (Resident #801) was mad. I went in to ask her why she was sitting in the dark. She had told the aide (A) she wanted to go to bed at 9 o'clock and here it was 10 PM. She was not crying. she was ticked. In her statement, Staffing Scheduler I reported, Resident #801 reported to me that CNA A came into her room and left her in there with not lights on and left the door closed .I went to the room because (Resident #801) was yelling out, screaming .She was crying and stating that she was upset. On 7/3/18 at 2:25 PM, during a telephone interview, Social Worker (SW) H was asked about the above incident. SW H stated, She was tearful, especially the first time I talked to her. She said she was put in her room with the lights off. She said 'I want to be happy. I don't want to be treated like that'. She was really tearful and really sad. SW H was asked of Resident #801 displayed behavior where she would have to be place in a dark room with the door closed. SW H stated, No She is the sweetest person. There's been no screaming or yelling reported and they tell me everything. On 7/3/18 at 3:07 PM, during a telephone interview, Nurse D was asked about the above incident. Nurse D stated, CNA A' told me she was going to put Resident #801 in the bed. I heard her (Resident #801) screaming and she was upset. The lights were off and CNA A had closed the room and left .When she is awake she doesn't like that (being in the room with the lights out when she's awake). She was sad. After we talked to her, she was okay. Nurse D was asked if Resident #801 would display behaviors that made it necessary for her to be put in her room with the lights out and the door closed when she was up in her wheelchair. Nurse D said, No. On 7/3/18 at 3:30 PM, a review of the facility's Abuse and Neglect Policy, dated 11/2017, stated, Each resident has the right to be free from abuse, neglect, exploitation, involuntary seclusion .Involuntary Seclusion is defined as the separation of a resident from other residents or from her/his room or confinement to her/his room (with or without roommates) against the resident's will, or the will of the resident's legal representative. (Note: it does not include temporary separation, for a limited time, as a therapeutic intervention until a care plan can be developed to meet the resident's needs).

This citation pertains to MI 066 and MI 226: Based on interview and record review the facility failed to consistently transfer residents per the resident's plan of care for two (#802, #803) of two residents reviewed for falls/accidents from a total sample of four, resulting in Resident #802 sustaining fractures of both malleoli of the right ankle, Resident #803 experiencing a fracture of the left humerus, and both Residents #802 and Resident #803 experiencing increased pain and transfer to the hospital. Findings include: Resident #802: On 11/14/17 at approximately 11:00am the clinical record for Resident #802 was reviewed and revealed the resident was admitted into the facility on [DATE] with diagnoses which included, in part, primary generalized osteoarthritis, muscle weakness, other depressive disorders, hematuria, anxiety disorder, and pathological fracture of the right ankle. Per review of the resident's MDS assessment dated [DATE], Resident #802 required the extensive assistance of two persons for transfers. Per a physician order [REDACTED].#802 was a (brand name sit to stand) for transfers. On 11/15/17 review of an Unusual Occurrence Report (UO) dated 8/31/17 for Resident #802 revealed the following: Assigned CNA (certified nursing assistant) reported to nurse that pt (patient) has a bruise to R (right) ankle. Pt is complaining of pain to R ankle. Pt unable to state what may have happen to R ankle d/t (due to) confusion observed that pt (patient) shoes fit tight around ankle, and sole of shoe is damaged. Per this report, Resident #802 was noted to have a bruise present, and an x-ray had been ordered for the right foot and right ankle. On 11/14/17 at 11:58am review of a Summary of findings of residents injury dated 9/8/17 for Resident #802 provided by the facility as part of a facility reported incident revealed, in part, the following: The nurse was made aware that resident had pain in her right ankle on 8/31/7. Upon assessing the ankle the nurse noticed a discoloration to the ankle. The physician ordered an x-ray to the right ankle due to the discoloration and right ankle pain The x-ray showed moderate degenerative joint disease and an ankle fractures of two malleoli with slight displacement When interviewing staff, two CNAs stated that she complained of pain after a transfer on 8/29/17. The facility believes that this is when the fracture occurred due to her prior [DIAGNOSES REDACTED]. On 11/14/17 at 12:03pm review of a radiology report dated 8/31/17 revealed, in part, the following: Ankle AP (anteroposterior) and Lat (lateral) 2V(view), Right Results: There are fractures involving both malleoli with slight displacement. The joint alignment is maintained. There is associated soft tissue swelling. Conclusion: Ankle fractures as described above. On 11/14/17 at 12:17pm FRI interview statements were reviewed and documented the following: Documentation of an interview with CNA 'F' dated 9/1/17 revealed, in part, the following: 1. Did you work on 8-29-17? yes . 4. Did you have interaction with (Resident #802)? yes 5. Did she complain of pain? Yes 6. Where did she complain of pain? When I was taking her shoe and socks off she said ouch and I asked her did it hurt and she said yes 7. Where was she when you took her shoes and socks off? In bed 8. Was she complaining of pain when you were putting her in bed? No 9. How did you transfer her? 2 person but she has short arms and when lifting her up on the easy stand she lets go of the (brand name)-stand 10. Who help you with the transfer?(CNA 'E') 11. Who did you report it to? the nurse (Nurse 'G') Documentation of an interview with CNA 'E' dated 9/5/17 revealed, in part, the following: 1. Did you work on 8-29-17? yes 4. Did you have interaction with (Resident #802)? Yes 5. What was the interaction? Putting (Resident #802) in the bed 6. How did you transfer her? With two people using a gait belt 7. Do you know what her transfer status was? Two person 8. How do you know she was a two person? I transferred her with other's and that's how we always transferred her 9. When was the last time you checked? A week or so ago . 11. Did she complain of pain? Yes 12. When did she complain of pain? As we were transferring her 13. Where did she complain of pain? Not alert didn't say anything when we took off the socks she had bruise and I reported it to the nurse 14. Who was the nurse? (Nurse 'G') Documentation of an interview with Nurse 'G' dated 9/5/17 revealed, in part, the following: 1. Did you work on 8-29-17? yes . 4. Did you have interaction with (Resident #802)? Check on her and gave her meds but I didn't assess her at all 5. Did the cena's report anything to you about (Resident #80)? No 6. Did the resident complain of pain? No Documentation of an interview with Staff 'N' dated 9/1/17 revealed, in part, the following: 1. Did you work 8-30-17? yes 4. Did you have interaction with (Resident #802)? yes when I touched rt (right) leg she started screaming in the morning I went and told the nurses 5. Did she complain of pain? Yes in the morning 6. Did you notice any discoloration to there ankle? Nothing was there 7. Is there anything else you would like to tell me? When I touched her leg she complained of pain I told all four nurses so one can take action 8. When you reported it did any nurses go down to the room? I took care and dressed up and I thought nurse took care of it On 11/14/17 at 1:14pm review of work performance/work rules disciplinary action records for CNA 'E' and CNA 'F' were reviewed and revealed that both staff members had their employment terminated related to an infraction of work rules which occurred on 8/29/17. Per the disciplinary action form for both CNAs, it was documented, On 8/2917 you did a 2 person transfer on Resident (identifier number) and her transfer statys was an (brand name sit-to-stand). Continued review of Resident #802's clinical record on 11/15/17 from 8:00am to 12:00pm revealed the following: Review of a Nursing-Pain assessment dated [DATE] revealed Resident #802 had a pain assessment completed due to a bruise to the right ankle. Per the assessment, the resident had a STAT x-ray ordered due to right foot pain. Per this assessment, Resident #802 was noted to have increased pain with movement, had no diagnoses which would indicate the resident would be in pain, and had a change in the intensity of discomfort in the last 7 days. Per this assessment Resident #802 had aching pain, was expressing pain via facial expressions, and had changes in her activities of daily living related to pain. Review of a Medical progress note dated 8/31/17 at 11:40am documented that Resident #802 was seen at the request of the nursing department related to right ankle pain and bruising. Per the history of present illness (HPI) section of the progress note, it was documented that per a report from nursing, the resident had been complaining of pain and was unable to bare weight on her ankle. This note also documented that the resident appeared to be in pain, and documented that the nursing department was unaware of any recent injuries that the resident may have sustained. Per the Acute Impression section of the progress note, the following was documented: 1. Acute pain with swelling to right ankle. 2. Hemotoma to right ankle. Review of a Medical Progress note dated 9/5/17 at 10:29am documented that Resident #802 had been seen for a follow-up visit related to the resident's right ankle fracture. Per the HPI section of the progress note the following was documented: Pt was seem/examined by me on 8/31/17 for acute sever(e) right ankle pain with unknown reason. Per the Impression section of the progress note the following was documented: 1. Right ankle fracture ? etiology 2. Prro oral intake 3. Recurrent UTIs (urinary tract infection) 4. Advanced dementia with decline, new 5. Need for assistance with personal care. On 11/15/17 at 11:41am the facility's Director of Nursing (DON) was queried in regards to the facility reported incident for Resident #802. When queried in regards to the resident's transfer status, the DON said that Resident #802 was changed to a (brand name sit to stand) on 7/19. Per the DON, both staff members were terminated as they did not follow policy, which is to follow the transfer order for residents. Resident #803: On 11/14/17 at approximately 11:00am the clinical record for Resident #803 was reviewed and revealed the resident had been admitted into the facility on [DATE] with diagnoses which included, in part, an unspecified fracture of the upper end of the left humerous, diabetes mellitus type two, hypertension, chronic obstructive pulmonary disease, and schizoaffective disorder. Per review of Resident #803's quarterly MDS assessment dated [DATE], Resident #803 required the extensive assistance of two persons for transfers. On 11/14/17 at 2:52pm review of Summary of findings for injury of unknown origin for Resident #803 dated 8/1/17 was reviewed and revealed, in part, the following: Per the nurse not On 7/26/17 the resident's roommate told the nurse that (Resident #803's) (family member) told her that On 7/25, two aids were transferring resident to bed and dropped her on the floor, resident stated to her (family member) that they dropped her on her left arm. (Family member) never reported the incident to the charge nurse. 7/26/17 resident was complaining of left arm pain when aid was getting her dress for the day. Writer observed the arm, and there were no bruises nor redness. Writer tried to move arm and resident screamed A stat x-ray order was placed .Multiple X-rays were done they concluded Mild degenerative joint disease on the left shoulder; otherwise no acute definite acute fracture seen. Possible modest displaced fracture of the humeral head. Old fixated healing elbow fracture as described. Hairline left humerous fracture as described. Old ulna fixation noted. Physician then requested to send resident out for a CT (computerized tomography) due to some x-rays stating they were old fractures and other not having a time frame on them. The CT scan concluded that There is a minimally displaced acute fracture through the surgical neck of the humerus. The gap is approximately 2mm(millimiters) On 11/14/17 at 3:04pm review of Final Report for Resident #803's CT scan was reviewed and revealed the following: Indication: Left shoulder injury. Left shoulder pain. Technique: Nonenhanced CT of the Left shoulder was performed. Comparison: There is a minimally displaced acute fracture through the surgical neck of the humerus. The gap is approximately 2mm Continued review of the resident's clinical record and Interview statements revealed the following: Documentation of an interview with Resident #803's family member on 7/26/17 was reviewed and revealed, in part, the following: 1. Did you visit (Resident #803) on 7-25-17? Yes 2. Did she report anything to you? I touched her arm and she spoke to me in our language and she said don't touch me it hurts,she said one person I know Im really heavy the girl to skinny and she dropped me Documentation of an interview with CNA 'D' dated 7/26/17 revealed, in part, the following: 1. Did you work 7-25-17? Yes 4. Did you take care of (Resident #803)? Yes . 6. What is her transfer status? Pivot with 2 people and a gait belt 7. How did you transfer her? 2 person transfer with cena (name redacted) 8. Did you drop her? No 9. Is there any thing else you would like to tell me? Before dinner I went in and changed her and I tried to transfer her from the bed to the wheelchair and I couldn't so I put her back on the bed and she was yelling something in Chinese 10. How did you transfer her before dinner? By myself with a gait belt and then I went to get another aid (name redacted) 11. Did you drop her? No her legs where bent and she couldn't stand and I had to put her back in bed. Documentation of an interview with Resident #803's roommate dated 7/26/17 was reviewed and revealed, in part, the following: 1. (Name redacted) is there something you would like to report? Yes, last night the (family member) of (Resident # 803) told me that (Resident #803) told her that the aids dropped her. I told her she needed to tell the nurses so they could get an x-ray 8. Did you tell anyone what about the (family member) told you? I did this morning after I heard them trying to get (Resident #803)up. She was screaming very loudly so I told the aids in the room what the (family member) told me last night Review of an UO report dated 7/26/17 for Resident #803 was reviewed and revealed, in part, the following to prevent the incident from reoccurring Ensure that resident is getting transferred properly, two person transfer with gait belt. On 11/15/17 at 11:58am the facility's DON was queried in regards to the facility reported incident for Resident #802. Per the DON, at no point could it be substantiated that the resident had been dropped. When queried as to the cause of the acute left humerus injury, the DON responded that the facility could not substantiate how the resident's fracture had occurred. On 11/15/17 at approximately 12:00pm a facility policy titled Transfer Between Surfaces dated December 2008 and updated 8/2011 was reviewed and did not discuss transfer status per established plan of care.

This citation pertains to MI 907 Based on observation, interview and record review, the facility failed to transfer a resident based on her accessed needs for a two person transfer assist for one (#703) of two residents reviewed for falls from a total sample of six, resulting in an ankle injury, a decline in mobility and a decline in her ability to participate in rehabilitation services and pain. Findings include: According to the electronic medical record (emr) that was reviewed on 2-08-2017 at 11:00 a.m., it was revealed Resident # 703 was a [AGE] year old female with [DIAGNOSES REDACTED]. According to the Minimum Data Set ((MDS) dated [DATE] resident #703 had a brief interview status score of 15, which indicated no cognitive impairment. The MDS further revealed she required the assistance of 2 staff for transfers. The care plan dated 11-12-2016 reflected 2 person assist for transfers. The nurses note dated 1-24-2017 reflected Resident #703 reported the incident to the nurse and had complained her pain was at an 8. Pain medication was administered, the physician was notified and an x-ray to left ankle was ordered. The radiology report dated 1-24-2017 reflected The ankle mortise is preserved without fracture or dislocation. There is ankle soft tissue swelling. The physician progress notes [REDACTED]. Pt c/o pain in the left ankle, which is swollen, skin is intact. Impression: Ankle sprain Motrin IB 200 milligram 2 tablets every 8 hours for 3 days was ordered. A review of the facility form titled Unusual Occurrence Report dated 1-24-2017 reflected Resident reported to writer stating my left ankle got caught underneath the bed when I was being transferred to bed last night and the girl proceeded to transfer me anyway's. A review of the facility investigation dated 1-27-2017 reflected that Certified Nursing Assistant (CNA) F was the CNA that transferred resident to bed on the evening of 1-23-2017. According to the facility investigation CNA F reported on 1-24-2017 that CNA G assisted with the transfer. The facility interview with CNA G on 1-24-2017 reflected he denied assisting with the transfer. An attempted to contact both CNA F and G was made via telephone on 2-08-2017 at approximately 11:35 a.m., both were left voicemail's, neither CNA returned Surveyors telephone call. The facility investigation that included an interview with Resident #703 on 1-24-2017 reflected CNA F transferred her to bed without the assistance of another staff member. On 2-08-2017 at 1:15 p.m., Resident #703 reported clearly and concisely that her left foot got turned and stuck under the bed during the transfer at bed time on January 23, 2017. It hurt so bad, I yelled and told her to stop. Resident #703 was queried about having any type of therapy and reported Yes, I go. On 2-08-2017 at 2:15 p.m., during an interview with the Restorative Nurse/Wound Nurse H reported up until 1-23-2017 resident #703 walked 15 feet with a rolling walker with restorative therapy, but since the left ankle sprain Resident #703 has not walked at all with Restorative Therapy. When queried if Resident #703 had been evaluated by Physical therapy Restorative Nurse/Wound Nurse H replied No. When queried on the restorative walking schedule for Resident #703, Nurse H reported It is suppose to be 5 times a week, but when we have call ins, restorative aides are the first ones to get pulled to the floor. A review of the restorative nursing notes dated 1-26-2017 reflected Resident was very eager to do the exercise today. She only complained of pain with her left ankle that was bothering her today she had received a pain pill before I came so she would be ok to finish the B-LE she refused to walk because of the constant pain in her ankle, we did 15mins LE therapy. Restorative Nursing notes dated 1-31-2017 Resident was feeling better than the last time I saw her to do exercises. She still refused to walk due to the fact of her ankle and stuff so we just did the B-LE exercises in the room and she really did not show any signs of pain. On 2-08-2017 at 3:40 p.m., during an interview with the facility's Rehabilitation Director I was queried if after an ankle sprain would a physical therapy evaluation be appropriate? Rehab director I reported Yeah, defiantly, she should've been evaled by PT for sure. We recently had another case just like this and they are on our case load. A review of the facility investigation further reflected CNA F was given a Suspension/Termination notice for the infraction on 1/23/2017, and is no longer employed at the facility. On 2-08-2017 at 4:35 p.m., during an interview with the Director of Nursing and Assistant Administrator E she offered no explanation as to why CNA F transferred Resident #703 without assistance per the care plan. When queried why Resident #703 had not been referred to Physical Therapy the Assistant Administrator reported that Resident #703 frequently refused Restorative therapy, even prior to the ankle sprain. Documentation to support Resident #703 refused Restorative Therapy was requested. At the exit interview Resident #703's participation graph for January and February 2017 was provided. The graph reflected 8 days in January that Resident #703 received restorative therapy, and 1 day in February the remaing dates were marked NP. The graph legend reflected x not scheduled and NP not performed the graph did not offer a reason for not performed i.e.; resident refused or Restorative staff not available. According to facility policy titled Lifting Policy-No tolerance safety with a release date of March 2011 reflected It is the policy of this facility to reposition, and/or lift residents safely and according to the resident care guide. The facility has a zero tolerance for employees that do not follow the resident's care guide. Employees who do not follow the resident's care guide related to repositioning, transfers and/or lifting will be terminated.

This citation refers to Intake #M 1504 Based on interview and record review, the Facility failed to provide saftey intevention measures to prevent falls based on the Resident's assessed needs that included frequent monitoring and toileting for one (#901) of two Resident's reviewed for falls and at risk for falls, from a total of five sampled Resident's, resulting in Resident #901 sustaining a closed intertrochanteric fracture of the left femur requiring surgery, skin tears and decrease in mobilization. Findings include: This was a Facility reported incident. On 8/15/16 the Facility reported to the State Agency that Resident #901 had fractured his hip. On 9/29/16 an abbreviated survey was conducted. Resident #902 no longer resided in the Facility. On 9/29/16 at 11:30 a.m., Resident #902's clinical record was reviewed and documented that the Resident was initiallly admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Resident's Minimum Data Set ((MDS) dated [DATE] revealed that the Resident had a Brief Interview for Mental Status (BIMS) score of 9 (Moderately Intake) and required extensive one person assist with Activities of Daily Living (ADLs) including transfers. ( An MDS dated [DATE] documented that the Resident's ADL needs increased to a two person assist.) Further review of the resident's medical record revealed [REDACTED]. On 9/29/16 at 12:20 p.m., a review of the Facility's Unusual Occurrene Reports was conducted and revealed the following: Incident Date: 8/4/16 (9:50 a.m.) Description: Observed lying on floor in front of bathroom. What did you do to try and prevent the inciddent from happening again? timely toileting No further investigation information was provided by the Facility. Incident Date: 8/6/16 (4:20 p.m.) Describe the Incident: Resident states was trying to pull his pants up and his bad leg gave out, Resident Outcome: Skin Tear Laceration What did you do to prevent the incident from happening again: Re educated pt to ask for help when wanting to transfer. Toilet Q 1 . No further investigation information was provided by the Facility. Incident Date: 8/7/16 ( 1:50 a.m.) Describe the incident: Resident observed on the floor of his bathroom in sopine position (blood noted to gown and floor ). Staff used gait belt to transfer resident from floor to chair for evaluation. Skin tears cleansed and dressed. Weeping noted to bilateral LE (lower extremety), writer wraped legs. Resident is in excrutiating pain. MD notified. What did you do to prevent the incident from happening again? MD notified immediately due to suspected fracture. Note to unit manager. Resident needs sitter in case of return. New order to get Geri sleeves. On 9/29/16 at 2:00 p.m., an interview and record review was conducted with the Administrator and Director of Nursing (DON) regarding the Fall Incidents pertaining to Resident #901. The DON was queried as to the interventions used by the Facility to prevent Resident #901, who was a high risk fall patient upon admission. The DON stated, Yes, we knew that he was a high fall risk prior to admission. His initial care plan dated 8/2/16 was a basic fall plan and we added that the Facility was to provide toileting assistance upon rising, AC, PC meals (prior to meals/after) at HS (before sleeping), during bed check and PRN along with general fall risk interventions. We did increase his toileting after his first fall. We do not use fall alarms at the Facility. When further queried as to whether 1:1 monitoring was considered prior to the third fall in five days resulting in a fractured hip the Administrator stated, We did not implement a sitter, we did increase the toileting program. The DON and Administrator provided documents pertaining to the investigation following the incident on 8/7/16 resulting in the Resident's hip fracture. A review of the Resident's Scheduled Toileting Program (8/6/16-8/7/16) documented as follows: Offer:Toilet/bedpan/urinal at the specified time listed when resident is awake and document response by placing an x in the appropriate box. Document T (toileting) B (Bedpan), U (Urinal) , N/A if none. Time 5:30 a.m.- 6:00 a.m 9:00 a.m.- 9:30 a.m 11:00 a.m.- 11:30 a.m. 1:00 p.m.- 1:30 p.m. 4:00 p.m.- 4:30 p.m. ( A check was noted in the Continent/Dry portion of the document) 6:30 p.m. - 7:00 p.m. 9:00 p.m. - 9:30 p.m. 12:00 a.m. - 1:00 a.m. ( A check was noted in the Incontinent portion of the document.) A document authored by the DON documented the following: Camera footage viewed for 8/7/16 from 12:00 mn (midnight) until 1:15 a.m.: No one entered the resident's room (-) until 1:06 a.m. 1:06 a.m. Janitor enters the room and exits quickly towards the nurse's station. On 9/29/16 at 3:00 p.m., both the DON and Administrator were queried as to the whether Resident #901 received toileting as documented on Scheduled Toileting Document between the hours of 12:00 a.m. and 1:06 a.m. when the camera footage indicated that no staff had entered the resident's room between the hours of 12:00 a.m. and 1:00 a.m The Administrator stated, I guess not, maybe the Aide was in earlier. On 9/29/16 at 3:25 p.m., an interview was conducted with Physician B regarding Resident #902's fall history and subsequest fall with fracture. Physician B was queried as to his progress note dated 8/5/16 that documented the followng: 3. Fall Risk - Continue Monitoring-discussed with PT and Nursing. Physician B stated, It is hard to keep a Resident like this patient from falls without constant monitoring. He had a history of [REDACTED]. They can keep his bed low, provide a mat, but that will not always help a Residents with this type of fall risk. I agree that the only thing that generally helps in this situation is constant 1:1 monitoring, but that does not always happen. On 9/29/16 at 4:00 p.m., a review of the Facility's policy titled, Fall Management Guidelines (revised date January 2013) revealed, in part, the following: Overview: Each Resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequated supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls . Fundamental Information: When a Resident is observed on the floor, the facility is obligated to investigate to determine how he or she got there and put into place an intervention to minimize it from reocurring . Practice Guidelings: The IDT will review all resident falls at the next morning meeting to evaluate/investigate the circumstances and root cause of the fall. ( )

This citation has four deficient practices Deficient Practice #1 Based on observation, interview, and record review, the facility failed to adequately administer prescribed pain medications for one resident (Resident #910) out of eight residents reviewed for pain, out of a total sample of 25 residents resulting in avoidable and unresolved moaning, grimacing, wincing, reaching, and crying out during care. Findings include: On 8/9/16 at 9:20 am, Resident #910 was observed seated in her Geri-chair in her room. Resident #910's family was present, as well as the facility's Wound Care Nurse (WCN), and Licensed Practical Nurse (LPN) 'D' who was assigned to Resident #910's care. Resident #910 was observed to be moaning with tightened facial muscles and was fidgeting in her Geri-chair. Resident #910's family member asked Resident #910 if she was in pain, and Resident #910 continued to moan, and nodded her head in a manner indicating that she was in pain. The facility's WCN, requested LPN 'D' to medicate Resident #910 for pain prior to the planned wound care treatment. On 8/9/16 at 10:30 am, wound care provided by the facility's WCN to Resident #910's pressure ulcer was observed. During the positioning of Resident #910 in preparation for wound care, Resident #910 was observed with facial grimacing, tightened facial muscles and was moaning in pain. Throughout the treatment and re-positioning of the resident and after the conclusion of the treatment, Resident #910 continued to moan, grimace, and fidget. On 8/9/16 at 4:30 pm, a review of Resident #910's electronic MAR (medication administration record) was conducted. It was noted that Resident #910 had an as needed order of [MEDICATION NAME] (a narcotic pain reliever) and the following was documented by LPN 'D' Document time: 8/9/16 11:00a (am), Type: Not Administered, Order: [MEDICATION NAME] ([MEDICATION NAME]) (20 mg (milligrams)/5 mL (milliliters) oral solution .give .by oral route every 4 hours as needed, Monitoring: Other: n/a. On 8/9/16 at 4:35 pm, a review of the narcotic control log sheet for Resident #910 was conducted. The narcotic control log sheet for Resident #910 was blank and did not indicate a dose given, a date, a time, a beginning amount of the [MEDICATION NAME], or an ending amount of [MEDICATION NAME]. At this time an interview with LPN 'D' was conducted. LPN 'D' reported that she gave the Resident the [MEDICATION NAME]. An observation of the [MEDICATION NAME] was conducted and the bottle indicated there were 30 ml of [MEDICATION NAME] remaining, which was to total beginning amount of [MEDICATION NAME]. When asked what time it was given, she reported around 11:00 am, which would have been after wound care was performed at 10:30 am. When asked if she gave the medication prior to wound care, she indicated she did, when asked why the time reflected on the MAR indicated [REDACTED]. On 8/10/16 at 9:05 am, Resident #910 was observed in bed. Resident #910 was moaning, wincing, grimacing, fidgeting, and had tightened facial muscles. When asked if she was in pain, Resident #910 did not respond but continued to moan. On 8/10/16 at 11:10 am, catheter and perineal care for Resident #910 was conducted with Certified Nursing Assistant's (CNA) 'F' and 'P'. Prior to positioning Resident #910 for care, Resident #910 was observed to be continually moaning and wincing, with a frown on her face. CNA 'F' and CNA 'P' proceeded to position Resident #910 for care, performed care, and re-positioned Resident #910 after care. Through the care from 11:10 am, until 11:20 am, Resident #910 moaned, winced, grimaced, and squirmed in her bed. At the conclusion of care, CNA 'F' stated to CNA 'P', She's been in a lot of pain. On 8/10/16 at 12:25 pm, an interview with the facility's Director of Nursing (DON) was conducted. She indicated that CNA 'F' and CNA 'P' should not have performed the care if Resident #910 was exhibiting signs and symptoms of pain, and they should have reported it to her nurse. On 8/10/16 at 11:30 am, a review of Resident #910's electronic MAR indicated [REDACTED]. On 8/10/16 at 1:45 pm, Resident #910 was observed in her bed. She was continually moaning, her facial muscles were tightened, her lips curled back, she was reaching out, and twisting in bed. When asked if she was in pain, She did not respond, but moaned louder. On 8/10/16 at 3:00 pm, a final review of Resident #910's MAR printed from the electronic MAR indicated [REDACTED]. On 8/8/16 at 2:40 pm, a review of Resident #910's medical record was conducted and revealed a re-admission date of [DATE] with [DIAGNOSES REDACTED]. A review of Resident #910's Minimum Data Set assessment conducted 6/6/16 indicated impaired cognition and she was an extensive to total assist of one to two staff members for transferring, bed mobility, wheelchair mobility, dressing, eating, hygiene, and bathing. It was noted that Resident #910 was also on Hospice services effective 7/30/16. A review of her care plans at that time indicated a care plan for pain with the intervention to administer pain medications as ordered by the doctor and a care plan for activities of daily living with an intervention that read, Monitor for presence of pain/intolerance during self care offer pain medication before therapy/care . On 8/10/16 at 3:05 pm, a review of the facility's Resident Guide read, You have the right to: .Adequate management of pain . The facility was asked if they had any additional information concerning Resident #910, and none was provided by the end of the survey. ( ) Deficient Practice #2 Based on observation, interview, and record review the facility failed to assess and monitor one resident (Resident #39) who received a nebulizer treatment, out of one resident observed to receive a nebulizer treatment, out of a total of seven residents observed during the medication pass observation, resulting in the to potential for inappropriate administration of the medication. Findings include: On 8/9/16 at 9:55 am, Licensed Practical Nurse (LPN) 'G' was observed passing medications to Resident #39. Among the medications was an [MEDICATION NAME] and [MEDICATION NAME] nebulizer medication (a combination medication converted by a machine from a liquid to a fine mist and inhaled into the lungs for various respiratory conditions). LPN 'G' prepared the medication by pouring the liquid into the nebulizer mask's reservoir and turned the machine on. She placed the mask containing the mist over Resident #39's mouth and face. It was noted that the resident's family member was present in the room at the time of the treatment. LPN 'G' then exited the room and entered another Resident's room to prepare their medications. LPN 'G' was not observed to assess Resident #39's lung sounds, heart rate, respiratory rate, or oxygen saturation prior to the administration of the treatment. On 8/10/16 at 11:50 am, an interview with the facility's Director of Nursing (DON) was conducted. During the interview the DON was asked if nurses should be performing any type of assessment prior to administering a nebulizer treatment, and the DON indicated that there should be an order in the computer to assess a resident's lung sounds, heart rate, respiratory rate, and oxygen saturation prior to administering the treatment. The DON also indicated that if a resident is not able to administer the medication themselves, the nurse should remain present. When asked if it would be appropriate for a family member to remain with the resident instead of the nurse she indicated that they would need to be assessed and educated and a determination on whether it would be appropriate could be made. On 8/10/16 at 12:15 pm, a review of Resident #39's medical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #39's Minimum Data Set assessment dated [DATE] indicated severely impaired cognition. On 8/10/16 at 3:30 pm, a review of the facility's Nebulizer Therapy policy released October 2011, read, .Procedure .7. For the first treatment of [REDACTED].(complete assessment pre/post administration of medication) .14. Assess therapy for efficacy . Monitoring the resident for adverse reactions such as [MEDICAL CONDITION](increased heart rate), sudden [MEDICATION NAME], nausea and vomiting .18. Licensed professional must stay at bedside if it is determined that the resident is unable to complete treatment as ordered, independently . The facility was asked if they had any additional information to provide regarding the concern and none was given by the end of the survey. Deficient Practice #3 Based on observation, interview, and record review, the facility failed to appropriately dilute medications and flush a percutaneous endoscopic gastrostomy (PEG) tube (a tube passed into a stomach through the abdominal wall commonly used for nutrition and medication administration) for one supplemental sampled resident (Resident #39) out of one resident observed to receive medications via a PEG tube, out of a total of seven residents observed during the medication pass observation, resulting in the potential for complications with the PEG tube such as clogging. Findings include: On 8/9/16 at 9:55 am, Licensed Practical Nurse (LPN) 'G' was observed passing medications to Resident #39. LPN 'G' prepared multiple medications, including five pills and a liquid suspension of potassium chloride. At the time of the preparation, the label on the bottle of potassium chloride was reviewed, and read, Dilute prior to administration. LPN 'G' crushed the pills and placed them in pill cups. LPN 'G' entered the room and diluted the pills with water, but was not observed to dilute the potassium chloride. LPN 'G' then unclamped the PEG tube and poured the first water diluted pill into the tube. LPN 'G' was not observed to flush the tube prior to administering the medications. LPN 'G' then administered each of the four remaining pills and the un-diluted potassium chloride. She was not observed to flush in between the medications. On 8/10/16 at 12:15 pm, a review of Resident #39's medical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #39's Minimum Data Set assessment dated [DATE] indicated severely impaired cognition. A review of Resident #39's physician's orders [REDACTED]. On 8/10/16 at 11:50 am, an interview with the facility's Director of Nursing (DON) was conducted, and she indicated that the PEG tube should have been flushed before medication administration, and after each medication. On 8/10/16 at 4:10 pm, a review of the facility's policy titled, Enteral Feeding: Tube Flushing with a release date of December 2008 read, .Tubes should be irrigated before and after administration of medications . The facility was asked if they had any additional information to provide regarding the concern, and none was provided by the end of the survey. ( ) Deficient Practice #4 Based on observation, interview and record review, the facility failed to notify the physician, obtain a physician's orders [REDACTED].#905) of 14 residents reviewed for quality of care, from a total sample of 25, resulting in a delayed investigation into the cause of a skin tear with the potential for infection or worsening of the skin tear due to delayed treatment. Findings include: On 8/8/16 at 12:10 P.M., Resident #905 was observed in the(NAME)Dining Room, eating lunch with a family member. An undated bandage was observed on the top of the resident's left hand. On 8/9/16 at 8:45 A.M., Resident #905 was observed sitting on the side of his bed after eating breakfast. An undated bandage with visible red drainage soaked through the guaze underneath the adhesive bandage was observed on Resident #905's hand. When asked what happened to his hand, Resident #905 stated, It hit the wall when I was in the wheelchair trying to go to the bathroom. I cut it or something. Resident #905 was asked if staff were helping him in the wheelchair and Resident #905 stated, It's tight to move around. It happens a lot. When asked when Resident #905 injured his hand, he stated, It was a few days ago. One day they changed this bandage three times and nobody has touched it since. I'm going to ask them to change it. At this time, Resident #905 pressed the call light. Nurse D entered the room and Resident #905 asked to go to the bathroom and to have the bandage changed on his hand. At 9:08 A.M., Nurse D was asked what happened to Resident #905's hand and stated, I don't know what happened. Nurse D reviewed physician's orders [REDACTED].#905 and reported that there was no documentation of any changes to Resident #905's hand. An observation of Resident #905's hand was made with Nurse D at this time. Nurse D was asked if there was a date on the bandage and stated, It looks like something might be written on there, but it's all folded over so I can't see. Nurse D attempted to remove the bandage and stated, It's stuck to it from all the dried up blood. I don't want to just pull it off because I don't know what's under there. I'm going to get some normal saline and call the doctor. Nurse D was asked if she was made aware that Resident #905 had a skin alteration on his left hand and stated, I really didn't have a clue. At this time, Nurse D returned with Nurse Practitioner (NP) V. NP V removed the bandage from Resident #905's left hand and revealed an approximately 2 centimeter (cm) skin tear. NP V asked Resident #905 what happened and Resident #905 reported that he hit it when he was in the wheelchair about a week ago, but he wasn't sure. NP V stated, It looks pretty new. At 9:40 A.M. on 8/9/16, NP V reported that although Resident #905 appeared to be cognitively intact, he was quite confused. NP V reported that the skin tear on Resident #905's hand appeared to be fairly new and that she did not think it happened a week ago. When asked if anyone notified her of the skin tear, NP V stated, I just found out about it today, just now. Incident and Accident Reports (I&As - Unusual Occurrence Reports) were requested for Resident #905 since the last annual survey. No I&As were received regarding Resident #905's skin tear on the left hand. The Director of Nursing (DON) was interviewed on 8/10/16 at 1:00 P.M. regarding the process for new skin alterations such as skin tears. The DON reported that an unusual occurrence form (I&A) would be completed and the nurse would start an investigation to try to determine what happened by reviewing the environment or any recent events. The DON further explained that all I&As were reviewed in morning meetings each day to look into it further to make sure no abuse occurred. When asked if there should be documentation in the clinical record of a skin tear, the DON reported that the nurses should document in the clinical record and also notify the physician. The DON stated, We were not aware of it and don't know how it happened. We have an incident report now and are looking into it. Resident #905's clinical record was reviewed on 8/9/16 at 10:05 A.M. and 8/10/16 at 2:30 P.M. and revealed the following: Resident #905 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 5/5/16, documented that Resident #905 had moderately impaired cognition, required extensive physical assistance for activities of daily living, and had severely impaired vision. physician's orders [REDACTED].M. documented, Cleanse left hand with normal saline apply xeroform 4 X 4 and Kerlix every other day The facility's policy titled, Unusual Occurrences with a revision date of January 2013, was reviewed on 8/10/16 at 3:00 P.M. and documented the following: .Unusual occurrences will be documented, reported, assessed, and care planned, investigated when warranted by the interdisciplinary team to minimize repeat incidents . .Examples of Unusual Occurrences include .skin tear . .If an unusual occurrence occurs: .If the incident involves a resident, notify the following individuals as soon as practicable after the incident occurs .physician . .After the resident/visitor has been treated, an Unusual Occurrence Report will be completed by the nurse on the unit . .The nurse will write an objective note in the nursing notes about the incident and place a notation on the 24-Hour Report Sheet . .The IDT should review resident incidents at the next morning meeting to evaluate/investigate circumstances and root cause for the incident .( )

The Past non-compliance documents were accepted on [DATE] after review of the facility's interventions put in place on [DATE] as verified onsite on [DATE]. On [DATE] the surveyor verified that on [DATE] the facility implemented the following to remove the immediate jeopardy: Although the immediate jeopardy was removed, the facility's deficient practice remained at the isolated actual harm with potential for more than minimal harm that was not immediate jeopardy with past non-compliance: Findings include: On [DATE] the facility reported an incident to the State agency involving resident 701 and licensed practical nurse (LPN) ' A ' . The final report submitted by the facility summarized, on [DATE], LPN ' A ' discovered resident 701 not breathing and without a pulse and LPN ' A ' contacted the hospice agency, notified the family and tended to the resident believing her to be hospice and a no code (DNR status, do not resuscitate). This report indicated approximately ,[DATE] minutes later, after finding resident 701 without vital signs, LPN ' A ' reviewed resident 701 ' s chart and discovered the resident was a full code. This report indicated, at that point, it was too late to call a code because resident 701 ' s family was at the bedside. This report indicated hospice nurse ' D ' pronounced resident 701 dead on [DATE] at 8:50 PM. This report indicated LPN ' A ' believed (resident 701) to be a no code hospice resident who she found with no pulse, not breathing and believed she had already expired . During interviews with the administrator (ADM) on [DATE] at 9:55 am and 10:40 am, the ADM said there are three areas available for staff to confirm the resident code status, the physical chart located at the nursing station, the electronic medical record, and the resident ' s wristband. The ADM said resident 701 was a full code even though she was a hospice patient. The ADM said resident 701 ' s responsible parties never signed or provided any paperwork to the facility agreeing to make resident 701 ' s code status a DNR (do not resuscitate). The ADM said the hospice nurse as well as facility RN ' s can pronounce resident death. The ADM said LPN ' A ' should have called emergency medical services and initiated cardiopulmonary resuscitation (CPR) when resident 701 was discovered unresponsive and absent of vital signs. During an interview with licensed practical nurse (LPN) ' A ' on [DATE] at 11:30 am, LPN ' A ' said, on [DATE] at approximately 7:30 PM she observed resident 701 reclined in geriatric chair in the facility hallway and the resident appeared to be sleeping and was pale in color. LPN ' A ' said she received no prior report before beginning her work shift indicating resident 701 ' s condition was declining or that a significant change occurred. LPN ' A ' said on [DATE] at approximately 7:50 PM, in preparation to place resident 701 into bed, she assessed resident 701 further and discovered she had no signs of life, further described as (701) was not breathing, had no pulse, no blood pressure, was pale and cold to the touch . LPN ' A ' said she did not call a code at that time because she believed resident 701 to have DNR status since she received hospice services. LPN ' A ' said she notified nursing supervisor ' C ' , the resident ' s family and hospice nurse ' D ' of resident 701 ' s condition on [DATE] at approximately 8:00 PM. LPN ' A ' said hospice nurse ' D ' arrived at the facility approximately 30 minutes later and spoke with resident 701 ' s family who were already present at the bedside. LPN ' A ' said, on [DATE] at approximately 8:30 PM, upon reviewing the electronic medical record to determine resident 701 ' s funeral home information, she discovered that resident 701 was a full code. LPN ' A ' said it was too late to call a code because the family was present at the bedside speaking with hospice nurse ' D ' . LPN ' A ' said hospice nurse ' D ' pronounced resident 701 dead on [DATE] at 8:50 PM. LPN ' A ' said she did not call a code, did not call 911 and did not initiate CPR for resident 701. During an interview with physician (DO) ' B ' on [DATE] at 11:50 am, DO ' B ' said resident 701 was a full code despite receiving hospice services. DO ' B ' said resident 701' s overall medical condition and prognosis were very poor and her life expectancy was expected to be six months or less. DO ' B ' said resident 701 ' s responsible parties wanted resident 701 to receive hospice service due to overall decline but gave no approval to enact DNR status. DO ' B ' said he based the death certificate findings on information provided by nursing staff via phone on [DATE], understanding her comorbidities and overall medical condition and his compiled knowledge of working with the resident since 2008. During an interview with licensed practical nurse supervisor (LPN) ' C ' on [DATE] at 12:00 PM, LPN ' C ' said, on [DATE] in the evening , LPN ' A ' reported that resident 701 showed no signs of life. LPN ' C ' said no code was called because LPN ' A ' provided information indicating resident 701 was a hospice patient and DNR status. LPN ' C ' said it was later found out that resident 701 was a full code and the incident was reported to management. During an interview with hospice nurse (RN) ' D ' on [DATE] at 12:55 PM, RN ' D ' said, on [DATE] at approximately 8:20 PM, the hospice supervisor informed her go to the facility for (resident 701) . RN ' D ' said she arrived at the facility approximately 30 minutes later around 8:45 PM and observed resident 701 clearly dead , unresponsive with no vital signs and not breathing. RN ' D ' said she did not know why staff failed to initiate cardiopulmonary resuscitation (CPR) because it was well known that resident 701 was a full code as the family didn't ' t want DNR status. RN 'D' said she reviewed the chart again and saw resident 701 was clearly a full code. RN ' D ' said she pronounced resident 701 dead on [DATE] at 8:50 PM. Observations on [DATE] at 10:10 am, with the director of nursing (DON) revealed four crash carts available to facilitate emergent care needs including the initiation of CPR. All four crash carts had backboards, oxygen and suction and various medical supplies available. Two of the carts had defibrillators available. On [DATE] at 11:00 AM the clinical records for resident # 701 revealed Probate court letters of guardianship with extension date of [DATE] that provided the names of two individuals appointed full guardianship of resident 701. Hospice election of benefits form signed by resident 701 ' s legal guardian on [DATE] that indicated, Do Not Resuscitate status is not required for admission to hospice but Cardiac [MEDICAL CONDITION] Resuscitation is not consistent with the hospice philosophy of care. Resident Code Status form (undated) that indicated resident 701 was a full code, required full resuscitation and to perform CPR. Face sheet (undated) that indicated resident 701 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum data set assessment dated [DATE] that indicated resident 701 had BIMS score (brief interview for mental status score) of 2 (severely impaired cognition). Physician determination of decision making capability form last signed [DATE] that indicated resident 701 was not capable to understand the Bill of Rights and participate in medical treatment decisions. Progress notes dated [DATE] at 3:53 PM indicated resident 701 had a good appetite and had been quiet all day . Progress notes dated [DATE] at 9:43 PM, written by RN ' D ' , indicated notified (701) had expired. Arrived at facility and pronounced pt (dead) at 2050 (8:50 PM). (Family member) present who states rest of family on their way . Review of the facility policy/procedure for cardiopulmonary resuscitation updated [DATE] indicated, Cardiopulmonary Resuscitation (CPR) seeks to restore and maintain the resident ' s respiration and circulation after heartbeat and breathing have stopped. 1. Attempt to wake the resident. If the resident is not breathing and is a full code, call 911 immediately and go to step 2 . , and Step 2. Begin chest compressions . , and Step 3. Begin rescue breathing . Review of the facility policy for advance directives (undated) indicated, To ensure that this facility ' s residents receive information to increase awareness of their rights to make decisions to receive, continue, discontinue, or refuse medical treatment, and to respect and honor this facility ' s residents ' medical treatment decisions. Full Code in the event of respiratory and/or [MEDICAL CONDITION] 911 will be called and the resident will receive all resuscitative measures including but not limited to CPR until EMS arrives. In the absence of a DNR order a resident will be considered a full code. Review of the facility's plan of correction dated [DATE] revealed the following: 1. The facility suspended LPN ' A ' pending results of the internal investigation and provided further disciplinary action upon the completion of the internal investigation. 2. Nursing staff have been re-educated in regard to the facility Advance Directive policy and code status, including provision of in-service education and written testing. 3. Social work director and/or designees have conducted and continue to conduct staff interviews to audit staff ' s verbal knowledge on the facility Advance Directive policy and code status identification for all residents including hospice residents. 4. Findings and related matters have been added to the monthly Quality Assurance agenda and are scheduled for a minimum 3 month period and as needed thereafter. 5. The facility provides CPR training for all licensed nurses with the majority having current CPR certification. Nurses needing CPR certification renewal had efforts in place to obtain such. 6. The facility completed audits of all resident charts to ensure the presence of advance directives and continue to initiate contact with residents and families to obtain most recent advance directive information. ( )

THIS CITATION PERTAINS TO INTAKE MI 964. BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT THE ELOPEMENT AND ENSURE THE SAFETY OF ONE RESIDENT (RESIDENT #101) OF 8 SAMPLED RESIDENTS REVIEWED FOR ELOPEMENT RISK, OUT OF A TOTAL SAMPLE OF 9 RESIDENTS, RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #101, WHEN HE ELOPED FROM THE BRADFORD MEDICAL RESORT UNIT, ON 5/10/13 BEFORE 9:30 P.M., UNBEKNOWNST TO FACILITY STAFF. RESIDENT #101, WHO PREVIOUSLY HAD EXHIBITED EXIT-SEEKING BEHAVIORS, WAS FOUND OUTSIDE OF THE FACILITY ON THE GROUND BY A FACILITY STAFF PERSON AT APPROXIMATELY 9:30 P.M. ON 5/10/13. RESIDENT #101 SUSTAINED A LEFT FEMORAL FRACTURE ASSOCIATED WITH A FALL DURING THE ELOPEMENT. THIS DEFICIENT PRACTICE PLACED 5 OTHER RESIDENTS, WHO WERE IDENTIFIED BY THE FACILITY AS BEING AT RISK FOR ELOPEMENT, AT RISK FOR SERIOUS HARM, INJURY AND/OR DEATH. FINDINGS INCLUDE: DURING AN INTERVIEW ON 6/6/13, AT 3:00 P.M., RESIDENT #101'S DAUGHTER (FAMILY MEMBER #4) REPORTED THAT SHE WAS CONTACTED BY PHONE ON 5/10/13, AT APPROXIMATELY 10:30 P.M., BY FACILITY STAFF AND INFORMED THAT HER FATHER (RESIDENT #101) WAS FOUND OUTSIDE THE UNIT ON THE GROUND IN THE PARKING LOT. SHE FURTHER REPORTED THAT AT APPROXIMATELY 2:30 A.M., ON 5/11/13, SHE WAS CONTACTED BY PHONE AND INFORMED HER FATHER WAS BEING SENT TO THE HOSPITAL FOR FURTHER TREATMENT AND EVALUATION. FAMILY MEMBER #4 STATED THAT HER FATHER WAS admitted TO THE HOSPITAL, AND ON 5/13/13, HAD surgery for [REDACTED].#101, HAD BEEN diagnosed with [REDACTED]. FAMILY MEMBER #4 STATED THAT HER FATHER RESIDED ON THE BRADFORD MEDICAL RESORT UNIT AT THE TIME THAT THE INCIDENT OCCURRED. REVIEW OF THE CLOSED CLINICAL RECORD REVEALED THAT RESIDENT #101 WAS AN [AGE] year-OLD MALE, WHO HAD BEEN admitted to the facility on [DATE], WITH MULTIPLE [DIAGNOSES REDACTED]. THE RESIDENT HAD AN INDWELLING URINARY (FOLEY) CATHETER AND REQUIRED STAFF ASSISTANCE WITH HIS PERSONAL CARE NEEDS. THE RESIDENT REQUIRED A WHEELCHAIR FOR LONG DISTANCE MOBILITY AND UTILIZED A WALKER WITH SUPERVISION FOR AMBULATION, ACCORDING TO THERAPY NOTES COVERING THE PERIOD OF 5/1/13 THROUGH 5/7/13. ON 6/7/13, AT 10:00 A.M., DURING A TOUR OF THE BRADFORD MEDICAL RESORT UNIT, OBSERVATION REVEALED THAT THIS UNIT HAD ITS OWN EXTERNAL ENTRANCE EQUIPPED WITH AUTOMATIC DOORS. THIS ENTRANCE WAS ADJACENT TO A CIRCLE DRIVE AND THE PARKING LOT AREA FOR BRADFORD MEDICAL RESORT UNIT VISITORS. THIS UNIT WAS ACCESSIBLE TO THE REST OF THE FACILITY BY AN INTERNAL KEY- CODED DOOR. DURING AN INTERVIEW ON 6/7/13, AT 10:10 A.M., THE DIRECTOR OF NURSING, KNOWN AS EMPLOYEE "E", REVEALED THAT AT THE TIME OF RESIDENT #101'S ELOPEMENT INCIDENT, THE DOORS AT THE EXTERNAL ENTRANCE INTO THE BRADFORD MEDICAL RESORT UNIT WERE UNLOCKED AND UNALARMED AT ALL TIMES, BECAUSE THE UNIT WAS INTENDED TO SERVE INDIVIDUALS WITH INTACT COGNITION WHO REQUIRED SHORT-TERM SUB-ACUTE REHABILITATION. EMPLOYEE "E" FURTHER STATED THAT AT THE TIME OF THE ABBREVIATED SURVEY, ALL RESIDENTS RESIDING ON THE BRADFORD UNIT WERE "ALERT AND ORIENTED TIMES THREE (PERSON, PLACE, AND TIME)." ACCORDING TO EMPLOYEE "E", SUBSEQUENT TO THE INCIDENT AND BEGINNING ON 5/13/13, THE ENTRANCE DOORS TO BRADFORD MEDICAL RESORT WERE AUTOMATICALLY LOCKED AT 8:30 P.M., WHICH WAS THE SAME SCHEDULE FOR ALL OTHER ENTRANCE DOORS IN THE FACILITY. WHEN QUERIED ABOUT THE ELOPEMENT INCIDENT REGARDING RESIDENT #101, EMPLOYEE "E" STATED THAT WHEN SHE REVIEWED VIDEO SURVEILLANCE THAT HAD BEEN AVAILABLE (FOR 5/10/13), AT APPROXIMATELY 9:30 P.M., THE VIDEO FOOTAGE DOCUMENTED THAT RESIDENT #101 WAS SEEN SITTING IN HIS WHEELCHAIR AT THE AUTOMATIC DOOR ENTRANCE ON BRADFORD UNIT, LOCKING THE BRAKES TO HIS WHEELCHAIR, ELEVATING INTO A STANDING POSITION AND AMBULATING FREELY TO THE OUTSIDE. EMPLOYEE "E" STATED THAT SHE WAS INFORMED THAT RESIDENT #101"WENT OUTSIDE FOR SOME FRESH AIR." EMPLOYEE "E" FURTHER REPORTED THAT RESIDENT #101 WAS DISCOVERED ON THE GROUND AND ON HIS KNEES IN THE CIRCLE DRIVE BY A CERTIFIED NURSING ASSISTANT, KNOWN AS EMPLOYEE "A". RESIDENT #101 WAS APPROXIMATELY 100 FEET FROM THE BRADFORD MEDICAL RESORT UNIT ENTRANCE. THE FACILITY ADMINISTRATOR (EMPLOYEE "F") INFORMED THE SURVEYOR THAT AT THE TIME OF THE ABBREVIATED SURVEY, THAT THE VIDEO SURVEILLANCE WAS NO LONGER AVAILABLE FOR REVIEW. ON 6/10/13, AT APPROXIMATELY 9:45 A.M., INTERVIEW WITH EMPLOYEE "A" REVEALED THAT AT APPROXIMATELY 9:30 P.M., ON 5/10/13, HE WENT OUTSIDE FOR A SMOKE BREAK. EMPLOYEE "A" STATED THAT HE EXITED THE EXTERNAL ENTRANCE OF THE BRADFORD MEDICAL RESORT UNIT AND WALKED TOWARDS THE CIRCLE DRIVE, WHERE HE DISCOVERED RESIDENT #101 ON THE GROUND, ON HIS KNEES, TRYING TO STAND. EMPLOYEE "A" STATED THAT HE IMMEDIATELY ALERTED A LICENSED PRACTICAL NURSE, KNOWN AS EMPLOYEE "C", WHO PROVIDED ASSISTANCE. EMPLOYEE "A" STATED THAT HE WAS UNAWARE THAT RESIDENT #101 HAD LEFT THE BUILDING. EMPLOYEE "A" STATED THAT HE AND EMPLOYEE "C" IMMEDIATELY RETURNED RESIDENT #101 BACK INSIDE THE BUILDING. DURING AN INTERVIEW WITH EMPLOYEE "C" AT 2:30 P.M., ON 6/10/13, SHE REPORTED THAT AT APPROXIMATELY 9:30 P.M., ON 5/10/13, SHE WAS SUMMONED BY EMPLOYEE "A" TO ASSIST HIM WITH RESIDENT #101, WHO EMPLOYEE "A" HAD FOUND WAS ON THE GROUND, OUTSIDE, IN THE PARKING LOT. EMPLOYEE "C" STATED THAT WHEN SHE WENT OUTSIDE THE BRADFORD MEDICAL RESORT UNIT, SHE OBSERVED RESIDENT #101 IN A STANDING POSITION IN THE CIRCLE DRIVE. RESIDENT #101 TOLD EMPLOYEE "C" THAT HE HAD WANTED TO GO OUTSIDE. EMPLOYEE "C" STATED THAT SHE WAS UNAWARE THAT RESIDENT #101 HAD GONE OUTSIDE AND THAT SHE WAS NOT AWARE THAT RESIDENT #101 WAS ALLOWED TO LEAVE THE FACILITY WITHOUT SUPERVISION. EMPLOYEE "C" FURTHER STATED THAT SHE IMMEDIATELY REPORTED THE INCIDENT TO THE REGISTERED NURSE (RN), KNOWN AS EMPLOYEE "B", WHO WAS ASSIGNED AS THE RESIDENT'S PRIMARY NURSE, FOR THE 7:00 P.M. TO 7:00 A.M. SHIFT ON 5/10/13. DURING AN INTERVIEW WITH EMPLOYEE "B" AT 11:20 A.M., ON 6/7/13, SHE REPORTED THAT SHE IMMEDIATELY ASSESSED RESIDENT #101 FOR INJURIES AFTER BEING INFORMED THAT EMPLOYEE "A" HAD FOUND RESIDENT #101 OUTSIDE ON THE GROUND. EMPLOYEE "B" STATED THAT RESIDENT #101 TOLD HER THAT HE WENT OUTSIDE AND HE fell IN THE PARKING LOT. EMPLOYEE "B" STATED THAT RESIDENT #101 TOLD HER THAT HIS KNEES AND ANKLE HURT, SO SHE ASSESSED HIM FOR INJURIES AND OBSERVED MINOR SKIN TEARS TO THE LEFT ELBOW AREA AND AN ABRASION TO HIS LEFT KNEE. EMPLOYEE "B" STATED THAT RESIDENT #101 BEGAN TO VERBALIZE COMPLAINTS OF PAIN IN HIS LEFT RIB CAGE AREA AND LEFT LEG. EMPLOYEE "B" STATED THAT SHE IMMEDIATELY CONTACTED THE PHYSICIAN, WHO ORDERED X-RAYS TO RULE OUT POSSIBLE FRACTURES. EMPLOYEE "B" STATED THAT SHE ALSO NOTIFIED RESIDENT #101'S DAUGHTER ABOUT THE INCIDENT. A FURTHER INTERVIEW WITH EMPLOYEE "B" REVEALED THAT SHE WAS NOT AWARE THAT RESIDENT #101 HAD EXITED THE BUILDING ALONE. EMPLOYEE "B" STATED THAT THE RESIDENT WAS TRANSFERRED TO AN AREA HOSPITAL emergency room AT APPROXIMATELY 2:30 A.M., ON 5/11/13, WHERE AN X-RAY REPORT REVEALED HE HAD AN ACUTE LEFT FEMORAL FRACTURE. REVIEW OF RESIDENT #101'S CLINICAL RECORD REVEALED A "SOCIAL WORK" ENTRY DATED 4/24/13, INDICATING THAT BOTH RESIDENT #101 AND HIS DAUGHTER STATED THAT THEY "WOULD LIKE A PSYCHE (PSYCHIATRIC) EVAL (EVALUATION) TO REVIEW AND (TO) TAKE OFF ZYPREXA (ANTIPSYCHOTIC) MEDICATION." THE ENTRY INDICATED THAT THE PHYSICIAN WAS NOTIFIED AND THE PSYCHIATRIC EVALUATION WAS ORDERED. THE ENTRY ALSO INDICATED THAT RESIDENT #101 SCORED A 13 ON THE BIMS ASSESSMENT, INDICATING HIS COGNITION STATUS WAS OVERALL INTACT, BUT THAT HE HAD SOME IMPAIRED MEMORY. FURTHER REVIEW OF RESIDENT #101'S CLINICAL RECORD REVEALED A REPORT ENTITLED "INITIAL PSYCHIATRIC DIAGNOSTIC EVALUATION," DATED 4/26/13, DOCUMENTING THAT RESIDENT #101 EXHIBITED PERIODS OF CONFUSION, WITH A DIAGNOSTIC IMPRESSION OF ANXIETY AND SENILE DEMENTIA. THE RESIDENT WAS ALSO PRESCRIBED PSYCHOTROPIC MEDICATION AS INDICATED ON THE PSYCHIATRIC EVALUATION FORM. ADDITIONAL REVIEW OF RESIDENT #101'S CLOSED CLINICAL RECORD, NURSES' NOTES SECTION, REVEALED AN ENTRY AT 1:50 A.M., ON 4/27/13, THAT RESIDENT #101 HAD EXPERIENCED "MULTIPLE EPISODES THIS EVENING OF PARANOIA AND VERBALIZED ANXIETY. KEPT AMBULATING IN ROOM, OPENING AND CLOSING DOORS AND LAYING IN ADJOINING ROOM BEDS. OBSERVED WALKING WITH WHEELCHAIR TRYING TO GET OUT EMERGENCY DOOR NEAR ROOM. SAT RESIDENT IN WHEELCHAIR WITH WRITER AT NURSING STATION." THIS ENTRY WAS DOCUMENTED BY A LICENSED NURSE WHO WAS UNAVAILABLE FOR INTERVIEW SECONDARY TO HEALTH ISSUES, AS REPORTED TO THE SURVEYOR BY THE DIRECTOR OF NURSING. FURTHER REVIEW OF RESIDENT #101'S NURSE'S NOTES REVEALED AN ENTRY DATED 5/1/13, AT 5:00 A.M., WRITTEN BY EMPLOYEE "B", INDICATING "RESIDENT (#101) RESTLESS ALL EVENING. STATING I (#101) GOT TO GET OUT OF HERE. AT 3:00 A.M., RESIDENT (#101) ON ONE-TO-ONE SUPERVISION AT NURSING STATION. AT 3:30 A.M., RESIDENT (#101) OBSERVED IN HALLWAY WITHOUT WHEELCHAIR AND HEADING TOWARD EXIT DOOR. PLACED (RESIDENT #101) ON FIFTEEN MINUTES CHECKS (FOR WHEREABOUTS)." DURING THE INTERVIEW ON 6/7/13, AT 11:20 A.M., EMPLOYEE "B" REPORTED THAT RESIDENT #101 HAD EXHIBITED SYMPTOMS OF "SUNDOWNER'S SYNDROME" AND EXIT-SEEKING BEHAVIOR. EMPLOYEE "B" FURTHER STATED THAT SHE DOCUMENTED HER CONCERNS ON 5/1/13 IN RESIDENT #101'S CLINICAL RECORD AND ON THE "24 HOUR NURSING REPORT FORM." REVIEW OF THE FORM ENTITLED "24 HOUR NURSING/CHANGE OF CONDITION REPORT FORM" REVEALED THAT ON 5/1/13 AN ENTRY WAS MADE REGARDING RESIDENT #101, THAT HE HAD "ELOPEMENT BEHAVIORS AT 3 AM TO 4 AM AND ON AND ON." THE ENTRY WAS SIGNED BY EMPLOYEE "B". FURTHER REVIEW OF RESIDENT #101'S CLOSED CLINICAL RECORD REVEALED AN "SBAR" (SITUATION, BACKGROUND, ASSESSMENT, REQUEST) FORM, DOCUMENTING THAT ON 5/5/13, AT 6:00 A.M., RESIDENT #101 HAD EXHIBITED A CHANGE IN MENTAL STATUS WITH SYMPTOMS OF COMBATIVE BEHAVIOR THAT ESCALATED WHEN HE WAS PREVENTED FROM LEAVING THE FACILITY. THE FORM WAS COMPLETED BY EMPLOYEE "C". THE FORM INDICATED THAT RESIDENT #101 WAS CONFUSED, COMBATIVE, AND ABUSIVE TO STAFF. THE FORM FURTHER INDICATED THAT RESIDENT #101 PULLED OUT HIS FOLEY CATHETER AND ATTEMPTED TO EXIT THE BUILDING SAYING, "EVERYBODY GET OUT OF MY WAY." RESIDENT #101 WAS TRANSFERRED TO AN AREA HOSPITAL FOR FURTHER TREATMENT AND EVALUATION AT APPROXIMATELY 6:30 A.M., ON 5/5/13, AS INDICATED ON THE FORM. ON 6/10/13, AT 2:30 P.M., INTERVIEW WITH EMPLOYEE "C" VERIFIED THE DETAILS DOCUMENTED ON THE "SBAR" FORM AND THAT RESIDENT #101 HAD EXHIBITED EXIT SEEKING BEHAVIOR ON 5/5/13. FURTHER REVIEW OF THE CLOSED CLINICAL RECORD REVEALED THAT ON 4/23/13, AN ASSESSMENT PERTAINING TO ELOPEMENT RISK WAS COMPLETED ON RESIDENT #101. REVIEW OF THE FORM ENTITLED, "RESIDENT ELOPEMENT ASSESSMENT" DATED 4/23/13, INDICATED A TOTAL SCORE OF 9 WITH A TOTAL SCORE OF 10 OR HIGHER INDICATING "AT RISK." THERE WAS NO EVIDENCE THAT STAFF HAD REASSESSED RESIDENT #101 FOR ELOPEMENT RISK, DESPITE THE ENTRIES INDICATING EXIT SEEKING BEHAVIORS ON 4/27/13, 5/1/13, AND 5/5/13 BY THREE DIFFERENT LICENSED NURSES WHO WORKED THE 7:00 P.M. TO 7:00 A.M. SHIFT ON THE BRADFORD MEDICAL RESORT UNIT. FURTHERMORE, THERE WAS NO EVIDENCE THAT A CARE PLAN HAD BEEN DEVELOPED TO ADDRESS RESIDENT #101'S EXIT SEEKING OR ELOPEMENT RISK BEHAVIOR AS EXHIBITED ON THESE DATES. REVIEW OF THE FACILITY'S POLICY ENTITLED "RESIDENT ELOPEMENT" POLICY, DATED APRIL 2011, REVEALED THAT WHEN "A RESIDENT ATTEMPTS TO LEAVE THE FACILITY WITHOUT AUTHORIZATION AND THERE IS NO WITNESS," NURSING STAFF WILL COMPLETE AN UNUSUAL OCCURRENCE REPORT FORM; IMPLEMENT STRATEGIES TO MINIMIZE RECURRENCE OF ELOPEMENT ATTEMPT; AND UPDATE THE RESIDENT'S CARE PLAN WITH PREVENTIVE MEASURES FOR ELOPEMENT. THERE WAS NO EVIDENCE THAT STAFF HAD IMPLEMENTED THESE REQUIREMENTS AS OUTLINED IN THE ELOPEMENT POLICY IN RECOGNITION THAT RESIDENT #101 HAD EXHIBITED EXIT SEEKING AND ELOPEMENT ATTEMPTS. THE ADMINISTRATOR (EMPLOYEE "F") WAS NOTIFIED ON 6/11/13 AT 3:00 P.M., OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 5/10/13, AS A RESULT OF THE FACILITY'S FAILURE TO PREVENT THE ELOPEMENT AND ENSURE THE SAFETY FOR RESIDENT #101, WHEN RESIDENT #101 LEFT THE BRADFORD MEDICAL RESORT UNIT UNBEKNOWNST TO FACILITY STAFF AND WAS FOUND OUTSIDE ON THE GROUND. RESIDENT #101 SUSTAINED A LEFT HIP FRACTURE AND OTHER INJURIES. THIS DEFICIENT PRACTICE PLACED 5 ADDITIONAL RESIDENTS WHO WERE ASSESSED BY THE FACILITY AS BEING AT ELOPEMENT RISK IN THE FACILITY AT RISK FOR SERIOUS HARM, INJURY AND/OR DEATH. ON 6/11/13 AT 3:00 P.M., THE SURVEYOR CONFIRMED THAT THE FACILITY HAD IMPLEMENTED THE FOLLOWING MEASURES TO REMOVE THE IMMEDIATE JEOPARDY: 1. INITIATED BRADFORD NURSES RE-EDUCATION ON ELOPEMENT RISK ON MAY 14, 2013. 62 OF 67 LICENSED NURSES HAVE BEEN RE-IN-SERVICED ON IMMEDIATE 1:1 OVERSIGHT FOR ANY RESIDENT ON THE BRADFORD UNIT WHO COULD BE DEEMED AT RISK FOR ELOPEMENT. 5 NURSES REMAIN AND WILL BE RE-IN-SERVICED PRIOR TO WORKING. 2. THREE LICENSED NURSES WERE DISCIPLINED. TWO OF THE DISCIPLINES OCCURRED ON MAY 21, 2013 AND ONE OCCURRED ON MAY 22, 2013. 3. THE RESIDENTS CURRENTLY RESIDING ON THE BRADFORD MEDICAL RESORT UNIT ARE ALL ALERT AND ORIENTATED TIMES THREE AND THEIR ELOPEMENT SCORES STATE THEY ARE NOT AT RISK. BEGINNING ON MAY 14, 2013 THE NURSING UNIT MANAGERS WILL REVIEW THE ELOPEMENT RISK ASSESSMENT SCORE IN THE MORNING CLINICAL MEETING. ANY RESIDENT WHO IS IDENTIFIED AS A RISK WILL BE PUT ON A ONE-TO-ONE MONITORING AND WILL BE MOVED TO THE BOULEVARD NURSING CENTER WHERE ALL DOORS ARE ALARMED. 4. THE ELOPEMENT BOOK WAS REVIEWED BY SOCIAL SERVICES ON 5/14/13, TO ENSURE THAT ALL OF THE RESIDENTS WHO ARE AT RISK FOR ELOPEMENT WERE IN THE BOOK. THE REVIEW REVEALED ALL 5 RESIDENTS WERE ALL IN THE BOOK AND ALL 5 RESIDENTS RESIDED IN THE BOULEVARD HEALTH CENTER AND NOT ON THE BRADFORD UNIT. 5. THE ELOPEMENT POLICY HAS BEEN REVIEWED ON 5/14/13, BY THE IDT TEAM AND NO REVISIONS ARE NECESSARY. THE LICENSED NURSES HAVE BEEN RE-EDUCATED ON THE POLICY WHICH STATES AN UNUSUAL OCCURRENCE FORM WILL BE COMPLETED UPON RESIDENT ATTEMPTING TO LEAVE THE FACILITY WITHOUT AUTHORIZATION. 6. BEGINNING ON MAY 14, 2013, TO ENSURE THE MONITORING COMPONENT OF THE ELOPEMENT RISK ASSESSMENT THE NURSING UNIT MANAGERS IMPLEMENTED THE REVIEW PROCESS OF 24 HOUR REPORT BOARDS, AND NEW ADMISSION IN THE CLINICAL MEETING ON A DAILY BASIS. ANY ISSUES THAT TRIGGER ELOPEMENT CONCERN THAT WERE NOT ADDRESSED APPROPRIATELY BY LICENSED NURSING STAFF WILL BE IMMEDIATELY ADDRESSED BY THE NURSE MANAGER AND DIRECTOR OF NURSING. ALL FINDINGS WILL BE REPORTED IMMEDIATELY TO THE ADMINISTRATOR AND THE QUALITY ASSURANCE PROCESS IMPROVEMENT COMMITTEE MONTHLY TIMES THREE MONTHS AND AS NEEDED THERE AFTER. THE IMMEDIATE JEOPARDY (IJ) WHICH BEGAN ON 5/10/13, WAS REMOVED ON 5/14/13. THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF "ISOLATED" AND SEVERITY OF "NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY" DUE TO NOT ALL FACILITY STAFF HAVING BEEN IN-SERVICED ON RE-EDUCATION OF ELOPEMENT RISK FACTORS AND THE FACILITY'S ELOPEMENT POLICY AND PROTOCOL, AND UNTIL SUSTAINED COMPLIANCE CAN BE VERIFIED.

REFER TO INTAKE MI 091. BASED ON INTERVIEWS AND CLOSED RECORD REVIEW, THE FACILITY FAILED TO PROVIDE NECESSARY SERVICES TO PREVENT AND TREAT PRESSURES SORES FOR 1 (#500) OF 4 SAMPLED RESIDENTS WITH PRESSURE SORES IN A TOTAL OF 9 SAMPLED RESIDENTS RESULTING IN DETERIORATION OF FACILITY ACQUIRED PRESSURE SORES AND hospitalization FOR INFECTED PRESSURE SORES. FINDINGS INCLUDE: RESIDENT #500, [AGE] years OLD, WAS admitted to the facility on [DATE], PER THE RESIDENT ADMISSION RECORD. A PHYSICIAN IN REHABILITATION MEDICINE DOCUMENTED IN THE HISTORY & PHYSICAL (H&P) REPORT, DATED 4/6/12, THAT RESIDENT #500 HAD BEEN LIVING IN A PRIVATE HOME PRIOR TO hospitalization on [DATE] AND HAD BEEN INDEPENDENT WITH AMBULATION AND ACTIVITIES OF DAILY LIVING (ADLS). RESIDENT #500'S [DIAGNOSES REDACTED]. ACCORDING TO THE PHYSICIAN'S H&P DATED 4/6/12, RESIDENT #500 ALSO HAD A [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS) ASSESSMENT, DATED 4/12/12, INDICATED THAT RESIDENT #500 HAD COGNITIVE AND MEMORY IMPAIRMENT AND REQUIRED EXTENSIVE TO TOTAL ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING. ON ADMISSION (4/6/12) RESIDENT #500 HAD NO OPEN PRESSURE SORES, PER THE NURSING ADMISSION RECORD, DATED 4/6/12. ACCORDING TO THIS DOCUMENTATION, THE SKIN ON RESIDENT #500'S SACRO-COCCYGEAL (THE AREA OF THE BODY AT THE BASE OF THE TAILBONE) AREA WAS "PINK." THERE WAS NO OTHER DESCRIPTION OF THE "PINK" AREA ON THE ADMISSION RECORD OR IN THE ADMITTING NURSE'S NOTE. A PRESSURE SORE RISK ASSESSMENT, COMPLETED ON 4/6/12, INDICATED THAT RESIDENT #500 WAS AT "HIGH RISK" FOR PRESSURE SORE DEVELOPMENT WITH RISK FACTORS THAT INCLUDED LIMITED MOBILITY, BLADDER AND BOWEL INCONTINENCE, THE NEED FOR MULTIPLE MEDICATIONS, DIABETES MELLITUS, AND HYPERTENSION (HIGH BLOOD PRESSURE WITH IMPAIRED BLOOD FLOW). A CARE PLAN DATED 4/6/12 ADDRESSED "IMPAIRED SKIN INTEGRITY" FOR RESIDENT #500. THE CARE PLAN LACKED A PROBLEM STATEMENT AND GOALS. INTERVENTIONS WERE PREPRINTED AND WERE NOT INDIVIDUALIZED FOR RESIDENT #500'S RISK FACTORS. A SECOND CARE PLAN FOR "SKIN BREAKDOWN," DATED 4/20/12, NOTED THAT RESIDENT #500 HAD BEEN admitted TO THE FACILITY WITH A "REDDENED COCCYX"; THAT AN OPEN WOUND ON RESIDENT #500'S COCCYX WAS IDENTIFIED ON 4/21/12; AND, THAT RESIDENT #500 HAD DEVELOPED "MUSHY HEELS DISCOLORED" ON 4/25/12. THE GOAL OF THIS SECOND CARE PLAN HAD BEEN STATED AS " . . . SKIN BREAKDOWN WILL BE MINIMIZED WITH INTERVENTIONS THROUGH NEXT REVIEW." INTERVENTIONS IMPLEMENTED FOR RESIDENT #500 ON THIS CARE PLAN INCLUDED TOILETING, ". . . TURNING & REPOSITIONING WHEN IN BED OR UP IN W/C (WHEELCHAIR)," DIET AS ORDERED, ELEVATE LOWER EXTREMITIES WHILE IN BED, SHOWER AND SHAMPOO TWICE WEEKLY, AND SKIN ASSESSMENT PER PROTOCOL. ON 4/21/12 AN ALTERNATING PRESSURE MATTRESS WAS ADDED TO THE INTERVENTIONS. ON 4/25/12 "HEEL PROTECTORS" WERE ADDED. ON 5/3/12 "ONLY UP FOR 2 HRS AT A TIME AND AIR CUSHION IN W/C" WAS ADDED. THE GOAL TARGET DATE FOR THIS PLAN OF CARE WAS 7/20/12. THIS CARE PLAN FOR RESIDENT #500 INCLUDED NO SPECIFIC INFORMATION REGARDING TURNING AND REPOSITIONING. THE CARE PLAN DID NOT SPECIFY THE TYPE OF HEEL PROTECTORS USED, AND THERE WAS NO DOCUMENTATION WHEN, OR IF, THEY WERE ACTUALLY INITIATED. A DIETARY PROGRESS NOTE, DATED 4/24/12, DOCUMENTED THAT RESIDENT #500 WAS EATING POORLY, EVEN WITH CLOSE SUPERVISION. THE RESIDENT'S FOOD ACCEPTANCE FOR APRIL AND MAY 2012 WAS MONITORED ONLY 15 MEALS OUT OF A TOTAL OF 91 MEALS. THE RESIDENT WAS ON A MECHANICAL SOFT DIET WITH PUREED VEGETABLES AND THIN LIQUIDS, PER A physician's orders [REDACTED]. ON 5/4/12 THE RESIDENT'S SERUM [MEDICATION NAME] WAS 2.2 GM/DL (NORMAL: 3.5 TO 5.0 GM/DL) AND A TOTAL SERUM PROTEIN WAS 6.3 GM/DL (NORMAL: 6.0 TO 8.0 GM/DL), DESPITE THE ADDITION OF A PROTEIN SUPPLEMENT ON 4/9/12. RESIDENT #500'S "CERTIFIED NURSING ASSISTANT (CNA) RESIDENT STATUS RECORD," UNDATED, WHICH DIRECTED CARE PROVIDED BY CNAS, INDICATED ONLY FLOAT HEELS, HEEL PROTECTORS (NO TYPE OR DIRECTIONS INDICATED) AND THE USE OF A PRESSURE RELIEVING MATTRESS. THERE WERE NO DIRECTIONS ON THE RECORD STATING THAT PRESSURE SORES WERE PRESENT. THERE WERE NO DIRECTIONS TO TURN THE RESIDENT, NO DIRECTIONS TO GET THE RESIDENT OUT OF BED, AND NO POSITIONING DIRECTIONS. IT WAS NOT POSSIBLE TO DETERMINE FROM REVIEW OF RESIDENT #500'S RECORD WHEN THE "PINK" SKIN ON THE ADMISSION ASSESSMENT DETERIORATED. TWO LICENSED PRACTICAL NURSES (LPN), #5 AND #6 WERE IDENTIFIED BY THE FACILITY AS BEING RESPONSIBLE FOR WOUND CARE. THE TWO WOUND CARE NURSES WERE INTERVIEWED ON 5/25/12, AT 3:30 P.M. ABOUT THE DETERIORATION OF RESIDENT #500'S SACRO-COCCYGEAL AREA FROM "PINK," AS DESCRIBED ON THE NURSING ADMISSION RECORD, DATED 4/6/12 TO "COCCYX HAS SUPERFICIAL 1 X 3 LENGTH OPEN AREA," AS DESCRIBED ON A "WEEKLY HEAD TO TOE CHECK" FORM, DATED 4/19/12. NEITHER LPN #5 NOR LPN #6 COULD ACCOUNT FOR THE DEVELOPMENT OF THE OPENED AREA ON RESIDENT #500'S COCCYX, AS NO NURSE'S NOTE DESCRIBED THE WOUND AS OF 4/19/12. ACCORDING TO THE TWO WOUND CARE NURSES, WOUND TREATMENT ORDERS WERE INITIALLY WRITTEN ON 4/19/12 AND THEY BEGAN TO PROVIDE CARE FOR RESIDENT #500 ON 4/21/12. LPN #6 STATED THAT SHE WAS NOT AWARE OF RESIDENT #500'S CONDITION BEFORE SHE WAS NOTIFIED OF THE BREAKDOWN ON 4/21/12. LPN #6'S NURSE'S NOTE, WRITTEN ON 4/21/12 DOCUMENTED THAT AN "OPEN WOUND NOTED TO COCCYX AREA MEASURE 3 X 1 X 0.1 WITH 35 % GRANULATING TISSUE SLOUGH NOTED." (GRANULATION TISSUE IS PINK-RED TISSUE IN A WOUND THAT IS HEALING. SLOUGH TISSUE IS NECROTIC TISSUE.) THE FACILITY ARRANGED FOR RESIDENT #500 TO BE SEEN BY THEIR WOUND CARE SPECIALIST. THE SPECIALIST FIRST SAW RESIDENT #500 ON 4/26/12. ACCORDING TO THE WOUND CARE REPORT DATED 4/26/12, THE SACRAL WOUND, A STAGE III, WAS 2.8 CM X 1.5 CM X 0.2 CM. THE WOUND HAD A PINK BASE WITH A YELLOW NECROTIC CORE. RESIDENT #500 HAD DEVELOPED BREAKDOWN BOTH OF HER HEELS. ON HER RIGHT HEEL, WAS A WOUND DESCRIBED AS 4.5 CM X 6.0 CM (ACTUALLY TWO WOUNDS WITH A SMALL BRIDGE). THE LEFT HEEL WAS 4.0 CM X 7.0 CM. BOTH WOUNDS WERE COVERED WITH ESCHAR (THICK, LEATHERY, BLACK OR BROWN DEAD TISSUE). ON 5/3/12 THE WOUND CARE SPECIALIST SAW RESIDENT #500 FOR A SECOND TIME, DOCUMENTING THAT THE SACRAL AREA (STAGE III) PRESSURE SORE WAS 4.0 CM X 3.5 CM WITH A NECROTIC BASE. AN ADDITIONAL AREA, A RIGHT BUTTOCK WOUND (STAGE II) WAS DESCRIBED AS 2.5 CM X 1.5 CM WITH A RED BASE. RESIDENT #500'S RIGHT HEEL WOUND WAS DESCRIBED AS 4 CM X 5 CM, AND HER LEFT HEEL WOUND WAS 4.0 X 6.5 CM . ESCHAR COVERED BOTH HEELS. A NURSE'S NOTE ON 5/7/12 AT 8:30 A.M. INDICATED THAT RESIDENT #500 HAD A DECREASED FLUID INTAKE, LETHARGY AND POOR WOUND HEALING. THERE WAS A physician's orders [REDACTED]. HOSPITAL RECORDS FOR RESIDENT #500 WERE REVIEWED ON 6/5/12. A WOUND/OSTOMY NURSE, ON 5/8/12 AT 10:27 A.M. DOCUMENTED THE FOLLOWING. 1) RIGHT HEEL HARD BLACK ESCHAR, 2) LEFT HEEL HARD BLACK ESCHAR, 3) LEFT LOWER EXTREMITY POSTERIOR ASPECT 2 SUSPECTED DEEP TISSUE AREAS NOTED APPROXIMATELY 1 CM IN DIAMETER, 4) SACRAL UNSTAGEABLE PRESSURE SORE LENGTH 6 CM X WIDTH 4 CM, SOFT BLACK ESCHAR/BEIGE SLOUGH, 5) LEFT BUTTOCK STAGE II, LENGTH 3 CM X WIDTH 2 CM, 100% GRANULATION TISSUE, 6) RIGHT BUTTOCK STAGE II LENGTH 4 CM X WIDTH 3 CM, 100% GRANULATION TISSUE. ON 5/9/12, ACCORDING TO A HOSPITAL MEDICAL CONSULTATION, RESIDENT #500 WAS TAKEN TO surgery for [REDACTED]. THE HOSPITAL DISCHARGE SUMMARY, DATED 6/5/12 INDICATED THAT RESIDENT #500 HAD BEEN hospitalized WITH "INFECTED DECUBITUS OF THE COCCYX AREA." A WOUND CULTURE, DATED 5/9/12 INDICATED THE PRESENCE OF MULTIPLE ORGANISMS IN THE WOUND. RESIDENT #500 RECEIVED ANTIBIOTIC THERAPY FOR THE treatment of [REDACTED].#500 WAS TRANSFERRED TO A LONG TERM ACUTE CARE hospital on [DATE] FOR CONTINUED treatment of [REDACTED].

THIS CITATION PERTAINS TO MI 543 AND MI 722 BASED ON OBSERVATION, INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND ENSURE THAT THE EXIT DOOR ALARM SOUNDED WHEN OPENED, TO PREVENT THE ELOPEMENT OF 1 OF 4 SAMPLED RESIDENTS (#601) IDENTIFIED AS ELOPEMENT RISKS, FROM A TOTAL SAMPLE OF 8, RESULTING IN IMMEDIATE JEOPARDY WHEN RESIDENT #601 OPENED THE AUBURN UNIT EXIT DOOR AND WALKED OUT OF THE FACILITY UNSUPERVISED, PLACING RESIDENT #601 AND 12 ADDITIONAL RESIDENTS, IDENTIFIED AS ELOPEMENT RISKS, AT RISK FOR SERIOUS HARM OR INJURY. FINDINGS INCLUDE: ON 11/03/2011 AT 1:00 P.M., A SURVEILLANCE VIDEO TAPE FROM 10/25/11 WAS REVIEWED WITH THE DIRECTOR OF NURSING (DON). THE VIDEO DOCUMENTED THE FOLLOWING SERIES OF EVENTS: AT 0647 A.M., RESIDENT #601 COULD BE SEEN, WALKING ALONE ALONG THE AUBURN UNIT HALLWAY, WEARING SHOES, A JACKET AND CARRYING A PURSE. AT 0648 A.M., THE RESIDENT REACHED THE EXIT DOOR AND WALKED OUT OF THE FACILITY. THE SURVEILLANCE VIDEO TAPE DID NOT PROVIDE ANY EVIDENCE OF STAFF MONITORING OF THE RESIDENT'S WHEREABOUTS. THE DON IDENTIFIED THE AUBURN UNIT MIDNIGHT SHIFT NURSE ON THE VIDEO (RN #19), WHO WAS SEEN GOING IN AND OUT OF RESIDENT ROOMS ON A DIFFERENT HALL ON THE AUBURN UNIT. THE DON IDENTIFIED TWO CERTIFIED NURSE AIDES (CNA) #4 & #13 ON THE VIDEO AS THE MIDNIGHT CARE GIVERS FOR THE AUBURN UNIT. THE SURVEILLANCE VIDEO TAPE DOCUMENTED THAT THE CNAS "LEFT THEIR ASSIGNED POST EARLY." THE DON STATED THAT "THEY WERE LEAVING THE UNIT WITH THEIR COATS ON. ACCORDING TO THE TIME CLOCK, THEY PUNCHED OUT AT 6:50 A.M. ACCORDING TO THE DON, THE EXIT DOOR USED BY RESIDENT #601 WAS EQUIPPED WITH AN ALARM THAT SOUNDED WHEN OPENED. THE SURVEILLANCE VIDEO TAPE DID NOT PROVIDE ANY EVIDENCE OF STAFF RESPONSE WHEN THE RESIDENT OPENED THE "ALARMING DOOR" AND WALKED OUT OF THE FACILITY. THE DON REPORTED THAT A PREVENTATIVE MAINTENANCE CHECK WAS DONE ON THE AUBURN UNIT DOOR AT 0700 A.M. (ON 10/25/11, AFTER THE ELOPEMENT) ON THE DAY OF THE INCIDENT, AND THE ALARM WORKED THEN. THE SURVEILLANCE VIDEO TAPE FOOTAGE FURTHER DOCUMENTED CNA #7 RETURNING RESIDENT #601 BACK INTO THE FACILITY AT 0654 A.M., AS CNA #7 REPORTED TO WORK ON THE DAY SHIFT. THE DON WAS UNABLE TO ANSWER WHEN ASKED HOW THE RESIDENT MANAGED TO LEAVE THE BUILDING WITHOUT ANYONE'S KNOWLEDGE. AT 1:30 P.M., ON 11/03/2011, OBSERVATION OF ALL 15 EXIT DOORS WERE MADE IN THE PRESENCE OF THE DON AND ALL ALARMS WERE IN FUNCTIONING ORDER. THE DON STATED, "WE RECENTLY CHANGED THE ALARM SYSTEM SINCE THE INCIDENT ON 10/25/11. OUR PRIOR ALARM SYSTEM RANG FOR 3 TO 4 MINUTES, THEN SHUT OFF AUTOMATICALLY, BUT THE NEW SYSTEM REQUIRES A KEY TO DEACTIVATE AND REACTIVATE THE ALARM." PER THE DON, THE FACILITY RELIED ON A SYSTEM OF MONITORING EVERY 15 MINUTES AND DOOR ALARMS FOR TO PREVENT RESIDENT ELOPEMENTS. DURING AN INTERVIEW ON 11/03/11 AT 3:00 P.M, THE INTERIM ADMINISTRATOR #2 EXPLAINED THAT ALL OF THE ALARMS IN THE FACILITY WERE CHANGED IMMEDIATELY AFTER 10/25/11, BECAUSE THERE WERE DIFFERENT TYPES OF ALARMS USED. ACCORDING TO INTERIM ADMINISTRATOR #2, "SOME DOORS ALARMS HAD SWITCHES TO ACTIVATE OR DEACTIVATE THE ALARM, OTHER ALARMS REQUIRED KEYS TO ACTIVATE OR DEACTIVATE AND THE KEYS WERE ALL DIFFERENT. SO WE WANTED ALL OF THE ALARMS TO OPERATE WITH ONE KEY." ACCORDING TO THE CLINICAL RECORD, RESIDENT #601, AN [AGE] year OLD FEMALE, WAS admitted INto the facility on [DATE]. THE MINIMUM DATA SET ASSESSMENT (MDS), dated [DATE], DOCUMENTED THAT THE RESIDENT COULD INDEPENDENTLY AMBULATE, AND TRANSFER HERSELF. HER COGNITIVE SKILLS WERE SEVERELY IMPAIRED AND SHE DISPLAYED DISORGANIZED THINKING. THE RESIDENT WAS IDENTIFIED AS A HIGH RISK FOR ELOPEMENT AS THE INITIAL PSYCHIATRIC EVALUATION DESCRIBED THE RESIDENT AS CONFUSED AND "A POTENTIAL ELOPEMENT." ACCORDING TO NURSE'S NOTES, DATED 10/04/11, THE RESIDENT "MAKES ATTEMPTS TO EXIT THE BUILDING." THE CHANGE OF CONDITION FORM, DATED 10/08/2011, DOCUMENTED THAT THE RESIDENT WAS OBSERVED DIRECTLY OUTSIDE OF THE FACILITY ON THE SIDEWALK. NURSE #8 WAS INTERVIEWED AND CONFIRMED THAT SHE COMPLETED THE CHANGE OF CONDITION FORM, DATED 10/08/11. NURSE #8 EXPLAINED THAT RESIDENT #601 "LOOKS LIKE A VISITOR BECAUSE SHE CARRIES A PURSE, AND ON THAT DAY SHE WALKED OUT OF THE BUILDING BEHIND OTHER VISITORS." THE NURSE REPORTED THAT SHE SAW THE RESIDENT LEAVE THE BUILDING AND REDIRECTED HER BACK TO THE UNIT. ACCORDING TO THE CHANGE OF CONDITION FORM, DATED 10/24/11, THE RESIDENT WAS OBSERVED GOING THROUGH AN EXIT DOOR TO THE OUTSIDE BY A NURSE WHO FOLLOWED THE RESIDENT AND RETURNED HER TO THE FACILITY. AN INTERVIEW WAS CONDUCTED WITH NURSE #5 ON 11/03/11 AT 5:15 P.M. NURSE #5 EXPLAINED THAT RESIDENT #601 HAD ALZHEIMER'S, WITH A VERY RAPID DECLINE. THE NURSE REPORTED THAT THE RESIDENT EXHIBITED WANDERING BEHAVIORS DAILY. ACCORDING TO NURSE #5, ON 10/24/11 AT AROUND 5 P.M., THE ALARM ON AN EXIT DOOR ON THE AUBURN UNIT SOUNDED AND THE NURSE SAW THE RESIDENT (#601) WALK THROUGH THE DOOR, BUT SHE (THE NURSE) WAS RIGHT BEHIND HER. THE NURSE EXPLAINED THAT THE RESIDENT "APPEARS AS A VISITOR" AND THAT THE ALL STAFF IN THE FACILITY "KNOW THAT SHE IS A WANDERER AND AN ELOPEMENT RISK." THE NURSE FURTHER STATED, "(ON 10/24/11) THE DOOR ALARM RANG FOR ABOUT THREE MINUTES, THEN IT SHUT OFF. I DIDN'T HAVE THE KEY TO REACTIVATE THE ALARM. I HAD TO FIND ANOTHER NURSE TO REKEY THE ALARM." DURING AN INTERVIEW ON 11/03/11 AT 5:15 P.M, CNA #6 . EXPLAINED THAT SHE WAS ASSIGNED TO WORK ON THE AUBURN UNIT ON 10/24/11. WHEN THE RESIDENT MADE AN ATTEMPT TO LEAVE THE BUILDING, CNA #6 STATED THAT SHE HEARD THE NURSE SAY, "SHE GOT OUT. I CAN'T BELIEVE THIS." ACCORDING TO CNA #6, THE RESIDENT (#601) "WANDERS ALL THE TIME . . . IT IS DIFFICULT TO KEEP AN EYE ON HER ALL THE TIME BECAUSE STAFFING IS TERRIBLE." WHEN CNA #6 WAS ASKED ABOUT THE DOOR ALARMS, SHE STATED, "HONESTLY, SOMETIMES THEY WORK AND SOMETIMES THEY DON'T." THE UNUSUAL OCCURRENCE REPORT, DATED 10/25/11 AT 0700 A.M., DOCUMENTED, "OBSERVED RESIDENT WALKING OUTSIDE IN THE SIDEWALK BY CNA." THE DON REPORTED THAT THE RESIDENT WAS STANDING AT THE NURSES' STATION JUST PRIOR TO EXITING THE BUILDING AND STAFF MEMBERS WERE PRESENT. ON 11/03/11 AT 4:15 P.M., AN INTERVIEW WAS CONDUCTED WITH CNA #4, WHO REPORTED THAT SHE WORKED THE MIDNIGHT SHIFT ON THE DAY (10/25/11) THE RESIDENT ELOPED. ACCORDING TO CNA #4, THERE WERE ONLY 2 CNAS AND ONE NURSE SCHEDULED TO TAKE CARE OF 43 RESIDENTS, INCLUDING TWO WHO WERE KNOWN TO BE WANDERERS AND ELOPEMENT RISKS. CNA #4 REPORTED THAT SHE WAS AT THE NURSES' STATION AT THE TIME THE RESIDENT LEFT THE FACILITY AND THE DOOR ALARM WAS NOT WORKING, BECAUSE "IT DIDN'T MAKE A SOUND." THE CNA WAS NOT ABLE TO EXPLAIN WHY THE RESIDENT WAS NOT CLOSELY MONITORED PRIOR TO HER ELOPEMENT. ON 11/07/2011 AT 4:00 P.M., AN INTERVIEW WAS CONDUCTED WITH CNA #13, WHO REPORTED THAT SHE AND CNA #4 REALIZED THAT STAFFING WAS "SHORT" WHEN THEY ARRIVED TO WORK THAT NIGHT. CNA #13 STATED THAT THEY (#4 AND #13) ASKED THE HOUSE SUPERVISOR TO PULL A CNA FROM ANOTHER UNIT TO ASSIST ON AUBURN, BUT THE SUPERVISOR REFUSED THEIR REQUEST. CNA #13 EXPLAINED THAT SHE WAS ASSIGNED TO RESIDENT #601 THAT NIGHT AND SHE STAYED WITH THE RESIDENT THE MAJORITY OF THE SHIFT BECAUSE OF HER WANDERING BEHAVIOR. THE CNA DID NOT EXPLAIN WHY RESIDENT #601 WAS NOT CLOSELY MONITORED UNTIL THE END OF THE SHIFT (AT 7 A.M.) OR WHERE SHE (#13) WAS WHEN RESIDENT #601 LEFT THE BUILDING UNNOTICED. THE CNA REPORTED THAT "THE DOOR ALARM DID NOT GO OFF." AN INTERVIEW WAS CONDUCTED WITH NURSE #19 ON 11/08/2011 AT 11:15 A.M., NURSE #19 VERIFIED THAT SHE WAS THE NURSE ON DUTY ON THE MIDNIGHT SHIFT THE DAY (10/25/11) THAT THE INCIDENT TOOK PLACE. NURSE #19 REPORTED THAT SHE HAD BEEN ASSIGNED TO WORK ON THE AUBURN UNIT FOR 4 TO 5 MONTHS PRIOR TO 10/25/11, AND SHE WAS FAMILIAR WITH THE RESIDENTS WHO LIVED THERE. NURSE #19 STATED, "I HAVE A LOT OF FALL RISKS ON THAT UNIT AND TWO ELOPEMENT RISKS THERE, SO I GO UP AND DOWN THE HALLS CHECKING ON THE RESIDENTS DURING THE NIGHT." THE NURSE REPORTED THAT ON THE DAY OF THE INCIDENT, "AT ABOUT A QUARTER TO SEVEN, I SAW THE RESIDENT (#601) WITH TWO CNAS AT THE NURSING STATION. SHE WAS TALKING WITH THEM. AT THAT TIME, I HEARD A BED ALARM SO I WENT TO CHECK ON THE RESIDENT WHOSE ALARM SOUNDED. WHEN I FINISHED I NOTICED THAT THE MORNING CNAS HAD STARTED COMING IN. I DON'T REMEMBER SEEING THE RESIDENT (#601) AT THAT TIME. THE MIDNIGHT CNAS LEFT AND AT ONE POINT I WAS ALONE. THEN I THOUGHT TO MYSELF, OH NO, MISS (RESIDENT #601). I REMEMBERED THAT THE LAST TIME I SAW HER SHE HAD HER DAY CLOTHES ON. I WENT TO HER ROOM AND SHE WASN'T THERE. I REMEMBERED THAT SHE WAS BROUGHT BACK FROM THE DEVON UNIT EARLIER, SO I WAS GOING TO GO LOOK FOR HER THERE, BUT I SAW A MORNING SHIFT CNA BRINGING HER IN FROM OUTSIDE THROUGH THE EMPLOYEE ENTRANCE. I tested THE EXIT DOOR ALARM LATER, AND IT WORKED, BUT I COULDN'T GET IT TO STOP. I WAS JUST ON THE OPPOSITE SIDE OF THE HALLWAY, SO IF THE ALARM HAD SOUNDED, I WOULD HAVE HEARD IT." RESIDENT #601 WAS OBSERVED AMBULATING THROUGH THE HALLWAYS OF THE FACILITY DURING THE AFTERNOON OF 11/3/11 AND THROUGHOUT 11/4/11. THE RESIDENT WAS ALERT BUT CONFUSED. WHEN ASKED, THE RESIDENT DID NOT REMEMBER LEAVING THE BUILDING, BUT STATED THAT SHE WANTED TO "GO OUTSIDE." REVIEW OF THE RESIDENT ELOPEMENT ASSESSMENT REVEALED A SCORE OF 21 ON ADMISSION AND A SCORE OF 31 ON 10/24/11 AND 10/25/11. A TOTAL SCORE OF 10 OR HIGHER INDICATED THAT A RESIDENT WAS "AT RISK." REVIEW OF THE RESIDENT'S PLAN OF CARE THAT ADDRESSED WANDERING BEHAVIORS, DATED 10/06/11, REVEALED THE GOAL OF THE PLAN AS "RESIDENT WILL BE GIVEN A SAFE AND SUPERVISED ENVIRONMENT IN WHICH TO WANDER," AND AN INTERVENTION TO "PROVIDE 1:1 SOCIALIZATION AS NEEDED." THE FACILITY POLICY ENTITLED, "RESIDENT ELOPEMENT", DATED OCTOBER 2009, STATED, "IT IS THE POLICY FOR THIS FACILITY TO PROVIDE RESIDENTS WITH A SAFE AND SECURE ENVIRONMENT...PUT ADDITIONAL MEASURES INTO PLACE TO PREVENT RECURRENCE. UPDATE THE RESIDENT'S CARE PLAN WITH INTERVENTIONS FOR ELOPEMENT." THE IMMEDIATE JEOPARDY BEGAN ON 10/25/11 WHEN RESIDENT #601, WHO HAD BEEN IDENTIFIED AS AN ELOPEMENT RISK, EXITED THE FACILITY AT 06:48 A.M. UNBEKNOWNST TO STAFF AND WAS FOUND IN THE FACILITY PARKING LOT. THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 11/04/11 AT 2:45 P.M. THE DEFICIENT PRACTICE PLACED RESIDENT #601 AND 13 OTHER RESIDENTS, IDENTIFIED AS ELOPEMENT RISKS, AT HIGH RISK OF SERIOUS HARM, INJURY AND/OR DEATH. THE SURVEYOR VERIFIED ON 11/07/2011 AT 09:30 A.M. THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: ON 10/25/11, THE ATTENDING PHYSICIAN AND MEDIAL DIRECTOR WERE NOTIFIED OF THE ELOPEMENT. ON 10/25/11, RESIDENT #601 RECEIVED A HEAD TO TOE ASSESSMENT WITH NO INJURIES NOTED. ON 10/25/11, RESIDENT #601 WAS PLACED 1:1 (ONE TO ONE) SUPERVISION. ON 10/25/11, RESIDENT #601 HAD A MEDICAL EVALUATION CONDUCTED BY MENTAL HEALTH WORKER, WHICH RESULTED IN A MEDICATION CHANGE. FAMILY CONSENTED FOR SCHEDULED RISPERDAL. ON 10/25/11 AND 10/26/11, THE FACILITY INITIATED EMPLOYEE RE-EDUCATION ON FACILITY ELOPEMENT POLICY AND PROCEDURE AND REPORTING TO A SUPERVISOR WHEN LEAVING ASSIGNED WORK AREA. EMPLOYEES SCHEDULED TO WORK AFTER 10/26/11 RECEIVED EDUCATION PRIOR TO REPORTING TO UNITS. THE TWO CERTIFIED NURSE AIDES WERE SUSPENDED AND BOTH WERE SUBSEQUENTLY TERMINATED AS A RESULT OF FACILITY ' S PROGRESSIVE DISCIPLINE POLICY. OFFICIAL TERMINATION PAPERWORK WAS COMPLETED ON NOVEMBER 4, 2011. ON 10/25/11 AND 10/26/11, THE FACILITY REVIEWED AND UPDATED, AS NECESSARY, 162 OF 162 RESIDENT ELOPEMENT ASSESSMENTS AND CARE PLANS. ALL FOUND CURRENT AND ACCURATE. ON 10/25/11, THE FIFTEEN (15) ALARMED EXIT DOORS WERE tested AND EVALUATED FOR FUNCTIONALITY AND FOUND TO BE IN WORKING ORDER. THE DIRECTOR OF MAINTENANCE VERIFIED THAT ALARMED DOORS THROUGHOUT THE FACILITY WERE BEING CHECKED DAILY. MAINTENANCE RECORDS REFLECTED THAT DAILY CHECKS WERE BEING COMPLETED BY THE MAINTENANCE DEPARTMENT. TO ENSURE IMMEDIATE RESPONSE TO ALARMED EXIT DOORS, THE FACILITY ORDERED THE SAME ALARM FOR ALL DOORS. ALL EXIT DOORS NOW SIGNAL THE SAME AND ARE RESET UTILIZING THE SAME KEY. INSTALLATION OF THE (NEW) ALARMS WAS COMPLETED ON 10/28/11. ON 10/25/11, THE ELOPEMENT BOOK WAS REVIEWED BY SOCIAL SERVICES TO ENSURE THAT ALL 13 AT RISK RESIDENTS WERE IN THE BOOK. ON 10/25/11, THE FACILITY CONFIRMED THAT THE ELOPEMENT POLICY AND PROCEDURE WAS PART OF NEW EMPLOYEE ORIENTATION. ON 10/26/11 AND 10/27/11, ELOPEMENT DRILLS WERE CONDUCTED. ON 10/26/11, AN AD HOC QUALITY ASSURANCE (QA) MEETING WAS HELD TO REVIEW THE ELOPEMENT POLICY AND PROCEDURE. THE ELOPEMENT POLICY AND PROCEDURE WILL CONTINUE TO BE REVIEWED AT QA MONTHLY TIMES THREE MONTHS AND AS NEEDED THERE AFTER. THE IMMEDIATE JEOPARDY THAT BEGAN ON 10/25/11 WAS REMOVED ON 10/26/11, BUT THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF "PATTERN" AND SEVERITY OF "NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY" UNTIL SUSTAINED COMPLIANCE CAN BE VERIFIED BY THE STATE AGENCY. ( )

THIS CITATION PERTAINS TO INTAKE MI 722. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO CONSISTENTLY USE PREVENTATIVE MEASURES TO MAINTAIN SKIN INTEGRITY IN ONE (#602) OF THREE SAMPLED RESIDENTS REVIEWED WITH PRESSURE SORES FROM A TOTAL SAMPLE OF 8 RESIDENTS , RESULTING IN THE DEVELOPMENT OF MULTIPLE ACQUIRED PRESSURE ULCERS AND THE POTENTIAL FOR FURTHER SKIN BREAK DOWN. FINDINGS INCLUDE: ON 11/07/11 AT 9:30 A.M., RESIDENT #602 WAS OBSERVED LYING IN BED ON HIS BACK. THE RESIDENT HAD A PRESSURE RELIEVING MATTRESS AND WAS WEARING SOFT FOAM BOOTS ON BILATERAL FEET. THE RESIDENT APPEARED TO BE ASLEEP. AT 10:30 A.M., ON 11/07/11 A WOUND OBSERVATION WAS MADE WITH THE TREATMENT NURSE. THE RESIDENT HAD MULTIPLE PRESSURE AREAS ON HIS BILATERAL FEET, RIGHT AND LEFT GLUTEAL AND ON HIS COCCYX. THERE WAS NO PILLOW BETWEEN THE RESIDENTS KNEES, HOWEVER A POSITIONING WEDGE WS NOTED. OBSERVATION OF THE COCCYX WOUND REVEALED A DARK WOUND BED CONTAINING DEAD TISSUE APPROXIMATELY 3 INCHES X 1.5 INCHES (IN) IN DIAMETER THE SURROUNDING TISSUE WAS DARK RED IN COLOR. THE WOUND TREATMENT NURSE REPORTED THAT THE WOUND WAS UNSTAGEABLE BECAUSE THEY WERE UNCERTAIN OF THE DEPTH OF THE WOUND. THERE WAS A MODERATE AMOUNT OF SEROSANGUINEOUS DRAINAGE NOTED. THE WOUND NURSE CLEANED THE WOUND WITH WOUND CLEANSER AND APPLIED SANTYL TO THE WOUND. THE RIGHT AND LEFT GLUTEAL WOUNDS APPEARED TO BE APPROXIMATELY 1 IN. X 1 IN. IN DIAMETER. BOTH WOUND BEDS WERE DARK RED AND THE DEPTHS OF THE WOUNDS WERE UNKNOWN. SMALL AMOUNTS OF DRAINAGE WERE NOTED. THE GLUTEAL WOUNDS WERE CLEANED WITH WOUND CLEANER, TREATED WITH SANTYL AND COVERED WITH A DRY GAUZE DRESSING. THE RIGHT HEEL WOUND WAS OBSERVED TO BE APPROXIMATELY 1.5 IN. X 2 IN. IN DIAMETER. THE WOUND BED WAS BLACK WITH DEAD TISSUE WITH MODERATE DRAINAGE. THE LEFT HEEL WOUND HAD A DARK RED WOUND BED. IT ALSO HAD A MODERATE AMOUNT OF SEROSANGUINEOUS DRAINAGE. NO ODOR WAS NOTED FOR ANY OF THE WOUNDS. BOTH HEEL WOUNDS WERE CLEANED WITH WOUND CLEANSER AND TREATED WITH HYDROGEL AND COVERED WITH A DRY GAUGE DRESSING. THE RESIDENT WAS ASKED IF THE STAFF CAME IN TO CHANGE HIS POSITION AT LEAST EVERY TWO HOURS. THE RESIDENT'S REPLY WAS "NOT OFTEN." OBSERVATION OF THE RESIDENT'S POSITION AT 1:30 P.M. ON 11/7/11, REVEALED THAT THE RESIDENT WAS LYING ON HIS BACK IN BED. THE RESIDENT WAS OBSERVED IN THE SAME POSITION (ON HIS BACK) FROM 2:30 P.M. TO 4:30 P.M. ON 11/07/11, REVIEW OF CLINICAL RECORD REFLECTED THAT RESIDENT #602 WAS admitted INto the facility on [DATE] AND REadmitted on [DATE], WITH [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SET ASSESSMENT (MDS), THE RESIDENT'S COGNITIVE STATUS WAS SEVERELY IMPAIRED AND HE REQUIRED EXTENSIVE ASSISTANCE WITH ACTIVITIES OF DAILY LIVING INCLUDING BED MOBILITY, TRANSFERS, AMBULATION, DRESSING AND HYGIENE. THE MDS ASSESSMENT INDICATED THAT THE RESIDENT HAD NO PRESSURE SORES AT THE TIME OF ADMISSION. REVIEW OF THE NORTON PLUS PRESSURE ULCER SCALE DATED 8/24/11 AND 10/12/11 REVEALED A TOTAL NORTON SCORE OF 11 AND 12 RESPECTIVELY. A SCORE OF 10 OR LESS INDICATED A HIGH RISK FOR PRESSURE ULCERS. ACCORDING TO THE INITIAL NURSING assessment dated [DATE] THERE WAS NO PRESENCE OF PRESSURE ULCERS ON RESIDENT #602, BUT THE ASSESSMENT DID INDICATE RIGHT HEEL SOFTNESS. INITIAL DOCUMENTATION BY THE WOUND TREATMENT NURSE ON 08/24/11 STATED, "BILATERAL LOWER EXTREMITIES SKIN IS INTACT," BUT SOFT HEELS WERE NOTED. THE TREATMENT NURSE DOCUMENTED, "WILL PLACE IN SOFT BOOT TO PREVENT BLISTER." REVIEW OF CARE PLAN DATED 8/31/11 REVEALED THAT THE RESIDENT WAS AT RISK OF SKIN BREAKDOWN WITH THE FOLLOWING INTERVENTIONS NOTED: REPORT ANY SIGNS OF SKIN BREAKDOWN, SHOWER 2 X PER WEEK/SKIN ASSESSMENT PER PROTOCOL AND TURN AND REPOSITION OFTEN. THE CHANGE OF CONDITION FORM DATED 10/8/11 DOCUMENTED, "RUPTURED BLISTER NOTED TO POSTERIOR RIGHT HEEL AND SMALL BLISTER TO LEFT ANTERIOR HEEL." ACCORDING TO THE ADMISSION NURSING assessment dated [DATE] (FOLLOWING THE RESIDENTS RE-ADMISSION INTO THE FACILITY), THE RESIDENT HAD A "RUPTURED BLISTER" ON THE RIGHT HEEL AND "REDNESS" ON THE LEFT HEEL. ACCORDING TO A WOUND CONSULTATION, DATED 10/13/11, THE RESIDENT HAD HAD A WOUND ON HIS "LEFT LATERAL HEEL, 1.2 BY 0.5 CM (CENTIMETERS)" AND "RIGHT HEEL, 9.7 BY 4.2 CM." THE CONSULTATION NOTED, "SACRAL AREA NOT ASSESSED PATIENT UP IN CHAIR." ACCORDING TO THE FACILITY WOUND/SKIN HEALING RECORD, ON 10/17/11, A WOUND WAS NOTED ON THE RESIDENT'S COCCYX, "5.5 BY 3.0 CM" AND THE WOUND BED WAS "NECROTIC." ACCORDING TO A WOUND CONSULTATION, DATED 10/20/11, THE RESIDENT HAD AN "UNSTAGEABLE PRESSURE ULCER SACROCOCCYX, LEFT AND RIGHT GLUTEAL, LEFT POST(ERIOR) THIGH WITH [MEDICAL CONDITION]." ON 10/29/11, ACCORDING TO THE FACILITY WOUND/SKIN HEALING RECORD, THE PRESSURE SORE ON THE RESIDENT'S COCCYX MEASURED "4.0 BY 3.0 CM" WITH "SEROSANGUINEOUS" DRAINAGE, "SLIGHT" ODOR AND "ESCHAR" WOUND BED. ON 11/4/11, THE WOUND WAS MEASURED AT "10.0 BY 2.5 CM." THE WOUND CONSULTATION DATED 10/27/11, DOCUMENTED "UNSTAGEABLE PRESSURE ULCER SACROCOCCYX, [MEDICAL CONDITION] LEFT EARLOBE, BLISTER LEFT HEEL, PRESSURE ULCER STAGE 3 BILAT(ERAL) GLUTEALS." ACCORDING TO THE CARE PLAN WITH THE PROBLEM START DATE OF 11/04/11, THE RESIDENT HAD ALTERATIONS OF SKIN PRESENT WITH AN UNSTAGEABLE PRESSURE ULCER ON HIS SACROCOCCYGEAL, STAGE 3 ON BILATERAL GLUTEALS AND POST BLISTER ON RIGHT HEEL. IT WAS UNCLEAR WHY THE CARE PLAN PROBLEM START DATE WAS SEVERAL WEEKS AFTER THE WOUNDS WERE IDENTIFIED. AN INTERVIEW WAS CONDUCTED WITH THE DIRECTOR OF NURSING (DON) ON 11/08/11 REGARDING THE DEVELOPMENT OF RESIDENT #602'S MULTIPLE PRESSURE WOUNDS. THE DON STATED THAT THE WOUNDS WERE UNAVOIDABLE. AN INTERVIEW WAS CONDUCTED WITH THE WOUND TREATMENT NURSE ON 11/08/11 AT APPROXIMATELY 11:00 A.M. THE WOUND TREATMENT NURSE REPORTED THAT THE RESIDENT'S WOUNDS WERE PREVENTABLE AND AVOIDABLE AND THAT TURNING AND REPOSITIONING "IS IMPORTANT IN THE PREVENTION AND HEALING OF THE RESIDENTS WOUNDS." ON 11/09/11 AT 9:30 A.M. DOCUMENTATION ON TURNING AND REPOSITIONING (T&R) WAS REQUESTED FROM THE DON, BUT THE DON REPORTED THAT T&R WAS "A STANDARD OF PRACTICE IN THE FACILITY SO THE STAFF DID NOT DOCUMENT WHEN THEY T&R RESIDENTS." SHOWER SHEETS WERE REQUESTED FOR REVIEW FROM THE DON ON 11/09/11 AT 9:30 A.M. THE ONLY SHOWER SHEETS THAT WERE PROVIDED WERE DATED: 08/26/11 WHICH INDICATED BRUISES, AN OLD INCISION, FOLEY AND LONG TOE NAILS AND BLANCHABLE HEELS; 09/02/11 WHICH INDICATED CLEAR; 09/09/11 AND 09/16/11 WITH NO DOCUMENTATION NOTED; AND, 11/04/11 WHICH INDICATED OPEN AREA ON COCCYX AND OPEN AREAS TO BILATERAL HEELS. THE DON WAS UNABLE TO EXPLAIN WHY THE RESIDENT'S SKIN CONDITION WAS NOT ASSESSED DURING HIS SHOWER BETWEEN 09/16/11 THROUGH 11/04/11. ON 11/09/11 AT 12:00 P.M., REVIEW OF THE FACILITY POLICY ON FACILITY ACQUIRED PRESSURE ULCERS WITH A REVISION DATE OF JANUARY 2011 REVEALED, "RESIDENTS admitted WITHOUT PRESSURE ULCERS WILL HAVE MEASURES IMPLEMENTED TO REDUCE THE PREVALENCE OF ACQUIRED PRESSURE ULCERS. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROPERLY ASSESS PAIN AND PROVIDE INTERVENTIONS TO ALLEVIATE PAIN FOR TWO ( #'S 404 AND 405) RESIDENTS OF 21 RESIDENTS REVIEWED FOR PAIN MANAGEMENT, OUT OF A TOTAL OF 24 SAMPLED RESIDENTS, RESULTING IN UNMANAGED PAIN. FINDINGS INCLUDE: ON 8/30/11, AT 10:30 AM, RESIDENT #405 WAS OBSERVED IN BED MOANING. THE RESIDENT'S EYES WERE CLOSED WITH A FACIAL GRIMACE. THE UNIT MANAGER WAS INTERVIEWED REGARDING RESIDENT # 405 MOANING AND STATED, THE RESIDENT " MOANED WHEN IN PAIN AND PAIN MEDICATION WAS ADMINISTERED." ON 8/31/11, AT 2:55 PM, RESIDENT #405 WAS OBSERVED IN BED MOANING LOUDLY WITH FACIAL EXPRESSION. REVIEW OF RESIDENT # 405 MEDICATION ADMINISTRATION RECORD (MAR) REVEALED THAT THE RESIDENT HAD RECEIVED [MEDICATION NAME] ON 8/31/11 AT 10:55 AM. 6 HOURS SINCE THE LAST DOSE. ACCORDING TO THE FACE SHEET, RESIDENT #405 WAS readmitted INto the facility on ON 1/10/11 WITH [DIAGNOSES REDACTED]. THE QUARTERLY RESIDENT ASSESSMENT INSTRUMENT DATED 6/7/11 DOCUMENTED THAT RESIDENT #405 HAD SEVERE COGNITIVE IMPAIRMENT, NON ENGLISH SPEAKING, NONVERBAL AND UNABLE TO MAKE HER NEEDS KNOWN. RESIDENT #405 WAS BEDFAST AND TOTALLY DEPENDANT ON STAFF FOR REPOSITIONING AND ALL ACTIVITIES OF DAILY LIVING. THE PAIN ASSESSMENT SECTION OF THE RESIDENT ASSESSMENT INSTRUMENT WAS LEFT TOTALLY INCOMPLETE. REVIEW OF A PHYSICIAN ORDER, DATED 08/2011, INCLUDED [MEDICATION NAME], 325 MILLIGRAMS ( MG) EVERY 4 HOURS AS NEEDED AND [MEDICATION NAME] PM EXTRA STRENGTH AT BEDTIME AS NEEDED. REVIEW OF RESIDENT # 405 CURRENT CLINICAL RECORD REVEALED NO DOCUMENTED EVIDENCE THAT A PAIN ASSESSMENT AND PAIN MANAGEMENT CARE PLAN WAS COMPLETED. REVIEW OF NURSES NOTES FROM 1/10/11 THROUGH 8/30/11, REVEALED THAT RESIDENT #405 WAS OBSERVED FREQUENTLY "MOANING AND GROANING." THERE WAS NO DOCUMENTED EVIDENCE OF PROPER ASSESSMENT AND MONITORING OF ANY NON-VERBAL SIGNS OF PAIN, NOR INTERVENTIONS TO EFFECTIVELY MANAGE PAIN. ON 8/31/11 AT 3:00 PM, THE UNIT MANAGER STATED THE FACILITY HAD NEITHER ASSESSED RESIDENT 405'S PAIN NOR HAD ANY INTERVENTIONS BEEN IDENTIFIED TO EFFECTIVELY MANAGE RESIDENT #405'S PAIN ON 8/30/11 AT 10:00 AM, RESIDENT #404 WAS OBSERVED SEATED IN A WHEELCHAIR AT BEDSIDE WITH A PAINED FACIAL EXPRESSION (GRIMACE). THE RESIDENT STATED, "...MY BOTTOM HURTS...MY HANDS ACHE...I HURT ALL OVER..." RESIDENT #404 DID NOT HAVE SEAT CUSHION IN THE WHEEL CHAIR. LATER, AT LUNCHTIME IN THE DINING ROOM, RESIDENT #404 WAS OBSERVED SEATED IN A WHEEL CHAIR WITHOUT A CUSHION. RESIDENT #404, WITH A FURROWED BROW AND FROWNED FACIAL EXPRESSION, STATED, "...MY BOTTOM HURTS..." ON 8/31/11 AT 12:00 PM, DURING LUNCHTIME IN THE DINING ROOM, RESIDENT #404 WAS SEATED IN A WHEEL CHAIR IN THE DINING ROOM WITH CARROT SPLINTS IN BOTH HANDS. THE RESTORATIVE AIDE REMOVED RESIDENT #404'S CARROT SPLINT FROM THE LEFT HAND, RESIDENT #404 STATED, "...NO, NO, IT HURTS..." WHEN THE RESTORATIVE AIDE ATTEMPTED TO REMOVE THE CARROT SPLINT FROM RESIDENT #404'S RIGHT HAND, RESIDENT #404 CRIED AND STATED,"...NO, DON'T REMOVE IT, IT HURTS..." ACCORDING TO THE FACE SHEET, RESIDENT #404 WAS admitted INTO THE FACILITY ON 1/14/10 WITH [DIAGNOSES REDACTED]. THE QUARTERLY RESIDENT ASSESSMENT INSTRUMENT DATED 6/8/11, DOCUMENTED RESIDENT #404 HAD SEVERE TO MODERATE COGNITIVE SKILLS FOR DECISION MAKING AND WAS DEPENDANT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING. RESIDENT #404'S RANGE OF MOTION WAS LIMITED DUE TO SIGNIFICANT CONTRACTURES OF BOTH HANDS. A PHYSICIAN ORDER, DATED 08/11 INCLUDED [MEDICATION NAME] 325 MG EVERY 4 HOURS AS NEEDED FOR PAIN. THE COMPREHENSIVE CARE PLAN UPDATED 4/9/11 DOCUMENTED TO INCLUDED A CUSHION ON WHEEL CHAIR SEAT. THE RESTORATIVE REHABILITATION PROGRAM NOTE DATED AUGUST 2011, REFLECTED RESIDENT (#404) COMPLAINED OF PAIN IN BOTH HANDS BEFORE RESTORATIVE TREATMENTS. THE PAIN MANAGEMENT CARE PLAN FOR RESIDENT #404, DATED 3/11, REVEALED NO DOCUMENTED EVIDENCE OF PAIN MANAGEMENT INTERVENTIONS TO ALLEVIATE PAIN FOR RESIDENT #404. ON 8/31/11 AT 3:00 PM, THE UNIT MANAGER CONFIRMED THAT THE FACILITY HAD NEITHER PROPERLY ACCESSED RESIDENT 404'S PAIN, NOR HAD ANY INTERVENTIONS BEEN IDENTIFIED TO EFFECTIVELY MANAGE THE RESIDENT PAIN. REVIEW OF THE FACILITY POLICY, ENTITLED, "PAIN MANAGEMENT" DATED JANUARY 2011 INDICATED, THE FACILITY WILL ASSESS AND IDENTIFY RESIDENTS EXPERIENCING PAIN, DETERMINE THE TYPE AND SEVERITY OF PAIN... THE STAFF MONITORS AND DOCUMENTS THE RESIDENT'S RESPONSE TO PAIN MANAGEMENT INTERVENTIONS. A PAIN EVALUATION MUST BE COMPLETED UPON ADMISSION, QUARTERLY, WITH A SIGNIFICANT CHANGE, WITH NEW COMPLAINTS OF PAIN. OBSERVE RESIDENT FOR INDICATORS OF PAIN INDICATORS INCLUDE: MOANING, CRYING, AND OTHER VOCALIZATIONS; WINCING OR FROWNING AND OTHER FACIAL EXPRESSIONS; AND BODY POSTURE SUCH AS GUARDING OR PROTECTING AN AREA OF THE BODY..." ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT STAFF WAS PROPERLY TRAINED IN THE USE OF WHEELCHAIR EQUIPMENT RESULTING IN ONE (#414) OF 24 SAMPLED RESIDENTS RECEIVING A LACERATION TO THE LEG THAT REQUIRED SUTURES. FINDINGS INCLUDE: ON 8/31/11 AT 8:45 AM, A REVIEW OF THE FACE SHEET REVEALED THAT RESIDENT #414 HAD ORIGINALLY BEEN admitted INto the facility on [DATE]. THE PHYSICIAN ORDER [REDACTED].#414 HAD [DIAGNOSES REDACTED]. THE RESIDENT ASSESSMENT INSTRUMENT (RAI), DATED 6/3/11, INDICATED THAT RESIDENT #414 HAD MODERATELY IMPAIRED DAILY DECISION-MAKING SKILLS, REQUIRED ASSISTANCE WITH LOCOMOTION, AND HAD SOME LIMITATION IN RANGE OF MOTION IN THE LOWER EXTREMITIES. ON 8/31/11 AT 11:30 AM, A TREATMENT OBSERVATION, WITH THE TREATMENT NURSE, REVEALED THAT RESIDENT #414 HAD A 5.2 CENTIMETER (CM) LONG BY 1.2 WIDE CM WOUND ON THE SHIN OF THE RIGHT LEG THAT HAD A PINK BASE WITH SCATTERED SLOUGH. RESIDENT #414'S LEGS WERE EXTREMELY EDEMATOUS (SWOLLEN). RESIDENT #414 WAS ASKED HOW SHE GOT THE WOUND ON THE LEG. RESIDENT #414 STATED, "THE HAIRDRESSER WAS TRYING TO PUT THE LEG REST ON MY WHEELCHAIR AND INSTEAD OF PUTTING THEM ON FROM THE SIDE OF THE WHEELCHAIR, SHE TRIED TO PUT THEM ON FROM THE FRONT AND THE METAL CUT MY LEG OPEN. IT WAS DOWN TO THE BONE." AT 2:00 PM, A REVIEW OF THE "UNUSUAL OCCURRENCE REPORT", DATED 5/4/11, REVEALED THE INITIAL LACERATION HAD BEEN 10.0 CM LONG BY 5.0 CM WIDE. ON 9/2/11 AT 9:00 AM, THE DIRECTOR OF NURSING (DON) WAS ASKED HOW RESIDENT #414 GOT THE LACERATION TO THE RIGHT LEG. THE DON REVEALED THAT THE HAIRDRESSER WAS TRYING TO PUT THE FOOT REST ON THE RESIDENT'S WHEELCHAIR AND RESIDENT #414 SWUNG HER LEG OUT AND WAS CUT. THE DON WAS INFORMED HOW RESIDENT #414'S ACCOUNT DIFFERED, BUT COULD NOT OFFER AN EXPLANATION FOR THE DIFFERENCE. THE DON WAS ASKED IF THE HAIRDRESSER WAS SUPPOSED TO APPLY THE LEG REST TO THE WHEELCHAIR. THE DON STATED, "THIS RESIDENT IS NOT CONFUSED. THIS RESIDENT COULD DIRECT HER ON HOW TO PUT THE FOOT REST ON. NORMALLY THEY DON'T (PUT THE FOOT REST ON) BECAUSE IT'S A TRAINING ISSUE, BUT IT'S (PUTTING FOOT RESTS ON WHEELCHAIRS) NOT OUR PRACTICE BECAUSE IT'S NOT IN HER SCOPE." THE DON WAS ASKED IF THE HAIRDRESSER HAD BEEN TRAINED TO APPLY FOOT REST TO WHEELCHAIRS. SHE REVEALED THAT THE HAIRDRESSER HAD BEEN IN-SERVICED BY THE THERAPY DEPARTMENT. DOCUMENTATION THAT THE HAIRDRESSER WAS INSERVICED WAS REQUESTED, BUT WAS NOT PROVIDED BY THE END OF THE SURVEY. A REVIEW OF THE UNUSUAL OCCURRENCES POLICY STATED, "THE FACILITY WILL TAKE THE MEASURES NECESSARY TO PROVIDE RESIDENTS...WITH A SAFE AND INCIDENT FREE ENVIRONMENT. IF AN INCIDENT...TAKES PLACE, THE FACILITY WILL PROVIDE THE INTERVENTION AND DOCUMENTATION NECESSARY TO ADDRESS THE INCIDENT AND PREVENT FUTURE RECURRENCE. ( )

This citation pertains to intake number MI 983. Based on observation, interview, and record review the facility failed to ensure that the physician order [REDACTED].#102) from a wheelchair to the bed resulting in a Resident #102 receiving a laceration to the left leg requiring 33 stitches. Findings include: Resident #102 was a resident at the facility at the time of the investigation. Resident #102 was admitted to the facility on [DATE] and according to the facility face sheet with a medical history of [REDACTED]. Review of the MDS (Minimum Data Set) dated 3/14/2011 Resident #102 required extensive two person physical assistance to transfer between surfaces i.e. from wheelchair to bed. Resident #102 was alert and oriented to person, place and time, was totally dependent on staff for all activities of daily living, and was incontinent of both bowel and bladder. In an interview with Resident #102 on 4/4/2011 at 9:45 AM she stated that she was up in the wheelchair and when transferred from the wheelchair to the bed she suddenly felt a "burning" and the CNA (certified nursing assistant) did not use the lift and moved her from the wheelchair to bed by herself, "that's when it burned and she noticed blood on my clothes". Resident #102 was observed on 4/4/2011 at 9:45 AM with a dry intact dressing on the left calf with "stove pipe" legs (both legs swollen from thighs to toes with the toes barely showing skin is extremely tight) wearing only socks on her feet due to swelling in her feet. During an interview/record review with the Director of PT/OT (physical and occupational therapy) on 4/4/11 at 11:25 AM she stated that when 2 therapists are doing 75% of the effort and the resident is only doing 25% that is maximum assistance X 2 and the hoyer lift is recommended and ordered. She also added "by looking at this record she (Resident #102) would have needed transfer by the Hoyer lift". Review of Physician orders [REDACTED]. In an interview with the DON on 4/4/11 at 11:45 AM she stated "yes she (CNA) did not follow the care plan and use a hoyer according to the order, she is not any longer employed here for not following the plan and transferred using a gait belt only with one person she needed 2 person hoyer transfer". Review of the Nursing Care Plans dated 2/28/2011 stating "I am weak, obese and required assistance with transfers and I am at risk for a fall and injury related to decreased mobility, debility, weakness". Approach: 2 person hoyer lift for transfers. Review of the Nursing Notes dated from 2/14/11 to 3/17/11 revealed the hoyer lift was used for transfers from bed to wheelchair and from wheelchair to bed. Facility Nurses Notes dated 3/17/11 at 7:45 PM revealed "the nurse was called to the patient's room by the CNA, CNA stated that she was transferring patient to bed from her wheelchair, she pivoted patient and sat her on the bed, patient complained afterwards that her left leg is burning, CNA checked patients leg & noted a deep lacerated wound she called the nurse, noted 2 cm x 5 cm x 1.5 cm laceration. Resident was transferred to the hospital for evaluation and treatment." Resident #102 returned to the facility with 33 stitches in lower left extremity. The facility written statement dated 3/17/2011 by the CNA involved stated "I put my gait belt on to put her to bed I took her from the wheelchair to the bed when she said my leg burns, I said let me see. I then went to get help I did not look at her status sheet I just used my gait belt I'm so sorry". ( )