Every finding on record at Regency, A Villa Center

Based on observation, interview, and record review, the facility failed to: 1. Ensure trash cans were clean and properly lined; 2. Ensure pans were properly cleaned and allowed to air dry before stacking; 3. Properly date-label food stored in the walk-in cooler; 4. Ensure staff food and personal items were not commingled with residents' food; 5 Ensure proper cooling of cooked, potentially hazardous (time-temperature for safety) food; and 6. Ensure food service equipment was maintained in a safe and sanitary operating condition. These deficient practices had the potential to affect all the residents who consumed food from the kitchen, resulting in the potential for foodborne illness. Findings include:On 1/13/26 at 8:50 AM, a kitchen tour was conducted with Dietary Director (DD) F. The following items were noted: Two trash cans, full of trash, were observed without liners. The inside of both trash cans were stained with moldy-looking black, slimy patches. The following was observed stored in the clean pot/pan area:One full-size pan and one full-size draining pan were stained with food debrisTwo quarter-size pans nestled together, and two half-size pans nestled together were wet.Two full-size pans were nestled together and were wet and soiled with food debris.A stack of eight full-size sheet pans were stored right side up. The drain lines from the three-compartment sink and the dish machine were not properly air-gapped. The following was observed in the walk-in cooler:A case of peas was not fully closed, subjecting the contents to contamination. A multi-shelf metal cart contained the following: a disposable food storage container of cooked seasoned steak fries; a staff member's personal pot; a 20-ounce size disposable cup, essentially empty but contained the remnants of an orange-colored liquid; and 1/4 size pan containing folded towels. The following items, also stored on this metal cart, were not labeled or dated: 1/4-size pan of yellow pureed food, 1/4-size container of orange and yellow pureed food, 1/4-size pan of ground meat which also contained a full hot dog; and a 1/2-size pan of cooked rice. A second multi-shelf metal cart contained the following items that were not labeled or dated: 1/3 size pan of pureed yellow substance and 1/4 size pan of ground meat. On 1/15/2026 at 12:40 PM, DD F provided no evidence that the cooked food observed in the walk-in cooler had been properly cooled. DD F said food should be cooled properly to avoid bacterial food growth. DD F added that food stored in the walk-in cooler should be properly dated and labeled in order to know when it should be discarded and to properly identify it. DD F said pans should be properly cleaned and fully dry prior to being stored face down. DD F expected the garbage cans to be cleaned and lined daily, and the drain lines from the three-compartment sink be properly air gapped to prevent sewage backing up into the sink. On 1/16/2026 at 9:51 AM, the Nursing Home Administrator (NHA) said kitchen staff were expected to label and date stored food and only resident food should be stored in the kitchen coolers, and that trash cans should have liners. On 1/16/26 at 1:30 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked. A review of the 2013 FDA Food Code revealed the following:- Section 3-101.11, Safe, Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under S 3-601.12, honestly presented.- Section 3-501.14 Cooling. (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 135 F to 70 F; and (2) Within a total of 6 hours from 135 F to 41 F or less.- Section 4-901.11, Equipment and Utensils, Air-Drying Required. After cleaning and sanitizing, equipment and utensils shall be air-dried.- Section 5-402.11. Backflow prevention. Except as specified in paragraph (B), (C), and (D) of this section, 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.- 5-501.116 Cleaning receptacles. 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.

Based on interview and record review the facility failed to ensure there was a Registered Nurse (RN) for 8 consecutive hours 7 days a week. This deficient practice has the potential to affect all residents residing in the facility.Findings include:During review of the facility's staffing schedule from 10/1/2025 through 1/14/2026 it was noted there was no RN working in the facility for the entire day of 12/28/25. On 1/15/2026 at 2:06 PM the Director of Nursing (DON) reviewed the facility's staffing schedule and confirmed there was no RN on 12/28/25. The DON said, The RN scheduled to work that day called in sick. There is no documentation to indicate the facility was able to fill that staffing vacancy with another RN. The DON reported there was no facility policy specific to RN coverage because it was a regulation.

Based on observation and interview, the facility failed to ensure meals were served at palatable temperatures for multiple residents in the facility, resulting in dissatisfaction with the meal experience. Findings include: On 1/14/26 at 8:50 AM, the last tray on a fourth-floor breakfast meal cart was obtained to be used as a test tray. Certified Nurse Aide (CNA) E was present during the testing of food temperatures on the breakfast tray. The following temperatures were obtained using a metal stem thermometer: Scrambled eggs: 95 ºF (Fahrenheit) Oatmeal 115 ºF 8 oz. carton of milk 52.8 ºF The temperatures of the following items were not obtained using a thermometer, but congruent observations were made: The raisin bread was room temperature to the touch. The bacon was cool to the touch. On 1/14/2026 at 8:57 AM, R4 was observed eating breakfast and commented that the temperature of the oatmeal was hot, but the temperature of the eggs was so, so. On 1/14/2026 at 9:11 AM, R185 was observed eating breakfast and commented that his eggs were cold. R185 requested that butter be spread on his eggs. When this was done, the butter did not melt. On 1/15/2026 at 12:57 PM, Dietary Director (DD) F was queried about his expectations for food temperatures at the point of service. DD F said scrambled eggs should be at least 120 degrees. Raisin bread was okay at room temperature, but the bacon should be hot. DD F stated, We will have to revisit how we cook and serve bacon. On 1/16/26 at 10:10 AM, the Nursing Home Administrator (NHA) said that food temperatures were expected to be within the range that they are supposed to be. On 1/16/26 at 1:30 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked. Anonymous Resident Council- On 1/14/26 at 2:00 p.m. an Anonymous Resident Council meeting was held with ten cognitively intact residents that resided on the second, third, and fourth floors of the facility. Seven of ten residents verbally expressed strong dissatisfaction with food services. Two of the seven residents that expressed concern about food palatability eat their meals in their room, the other five eat their meals in the dining room. The residents (all three floors) stated, All meals are cold and sometimes don't come to the floor on time or sit in the hall for a while before being passed. The breakfast is the worse. If the food isn't cold, it's just not good. Three residents said the alternative such as a hamburger is often dry, cold, and overcooked. The hot dogs are grey and shriveled up. The group said the food concerns have been brought to the attention of the facility multiple times and the food is getting worse. They also said there is supposed to be a food committee to discuss how to make the food better but has never happened.

Based on observation, interview, and record review the facility failed to ensure the call light was within reach for one (R15) of one resident reviewed for accommodation of needs, resulting in the delay in incontinence care and potentially other unmet care needs.Findings include:Findings include:On 1/13/2026 at 11:48 a.m. while in the hall of the fifth floor, a voice can be heard saying hello, hello, hello. Upon entering the room, R15 was observed facing the wall. R15 stated, I need help. I'm all wet (while patting backside). R15 was asked to reach and turn on the call light. R15 attempted to reach for the call light and could not be due to it not being within reach. The call light was observed on the nightstand tucked behind a towel, a stuffed animal, and other personal items.On 1/13/2026 at 11:51 a.m. LPN H approached the room and asked R15 what was needed. R15 stated, I'm all wet and need to be changed. LPN H was asked can R15 use the call light. LPN H looked for the call light and said they should have put the call light within reach after putting R15 to bed.On 1/16/26 at 12:30 a.m. the Director of Nursing (DON) was interviewed and acknowledged call lights should always be in reach for residents to use when they need help.Review of the clinical record documented R15 was initially admitted into the facility on 7/18/19 with diagnoses that included autistic disorder, epilepsy, schizoaffective disorder, depressive type, atherosclerosis of native arteries of extremities, bilateral legs, and legal blindness. According to the Minimum Data Set (MDS) dated [DATE], R15 was severely cognitively impaired (BIMS-3) and required extensive one-person assistance with activities of daily living.Review of the self-care performance care plan dated 8/5/25 documented in part: The resident (R15) has an activity of daily living self-care performance deficit related to dx of epilepsy, autistic disorder, schizophrenia, bipolar disorder, & legal blindness.prefers to have staff assist to the toilet. Intervention: .Toileting: Resident requires physical assistance x 1 staff with clothing and wiping during toileting and incontinence care. Encourage the resident to use bell to call for assistance.Review of the facility's policy titled Quality of Life -Accommodation of Needs dated 11/2013 documented in part: Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being. The resident's individual needs and preferences shall be accommodated to the extent possible.Review of the facility's policy titled Answering the Call Lights dated 11/2013 documented in part: . When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on interview and record review the facility failed to complete a discharge summary that included a recapitulation of stay for two (R12, R222) of five residents reviewed for discharge planning.Findings include:Resident 12 (R12): On 1/13/2026 at 11:29 AM R12 was seated in a wheelchair in the hallway and reported they were being discharged today. The resident said, I'm going to stay with my daughter for a little while. R12 was able to self-propel in her wheelchair independently. A review of the R12's Electronic Health Record (EHR) indicated the resident admitted on [DATE] with diagnoses that included cerebral infarction (stroke) affecting the dominate side and a fractured left humerus from a fall at home.R12's Recapitulation of Stay (Discharge Summary) form dated 1/13/2026 at 5:53 PM was incomplete. The Summary of Stay sections 1a-8 were blank. This included information for continuing care and/or special instructions or precautions for continuing care. The Additional Information section was also blank. This included contact information. Resident 222 (R222):On 1/14/26 at 1:08 PM R222 said, [NAME] set up home care for me when I left. It took a week after I was home before I could get ahold of anyone. The paper they gave me didn't have any phone numbers on it. I had to call the Social Worker several times before anyone could give me the right number for home care. R222 reported they were living in their home, followed up with their physician, and was receiving home care at this time. According to R222's electronic health record (EHR) the resident admitted to the facility on [DATE] with several diagnoses that included surgical repair of a fractured left femur after a fall at home, anxiety, and left eye blindness. R222 was discharged to their home on [DATE].There was no Recapitulation of Stay (Discharge Summary) form or discharge summary.R222's My Transition Home-Discharge form dated 10/22/25 at 3:42 PM was significantly incomplete. There was no phone number for the Home Health Care Agency. There was no information regarding the resident's follow-up appointments. The sections for; Contact information, Medication information, Nursing instructions, Dietary, and Discharge instructions were blank. On 1/15/26 at approximately 10:00 AM the Director of Social Services (SW) G reviewed R222's EHR and could not provide any documentation to support R222 had Recapitulation of Stay (Discharge Summary) form completed. On 1/15/26 at approximately 11:00 AM the Director of Nursing (DON) reviewed R222's EHR and said, There is no Recapitulation of Stay (Discharge Summary) form. The DON acknowledged the resident had no Recapitulation of Stay (Discharge Summary) form, discharge care plan or discharge summary. A request for the facility's Discharge policy was requested. According to the facility's Transfer and Discharge Guideline last revised on 5/5/2025 in part reads; Discharge Planning ProcessResidents will be evaluated for their discharge goals, preferences, and care needs to meet their goals.D. Discharge SummaryA discharge summary will be completed upon discharge to include g. A recapitulation of the residents stay in the facility (diagnoses, course of illness/treatment, therapy, lab, radiology and consultation reports)h. A recapitulation of resident's status.i. A reconciliation of resident's pre-discharge meds with post discharge medications.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for a foley catheter (indwelling urinary catheter) for one (R5) of three residents reviewed for catheter care resulting in the potential for inappropriate and ineffective care of the resident's indwelling catheter.Findings include: On 1/13/26 at 12:53 PM, R5 was observed lying in bed with foley catheter tubing hanging off the bed draining a small amount of amber urine into a collection bag. The collection bag had a privacy cover and was attached to the bed frame, below the level of the resident's bladder. The resident said there were problems with the foley catheter leaking urine last night. R5 said, There was urine all in my diaper and the bed. The CNA (certified nursing assistant) had to change my brief and the whole bed. The nurse came in and changed the bag. It seems to be working fine now. Upon further observation the catheter was not connected to an anchoring device. The catheter was pulled taut from the resident's penis through the leg hole of the brief hanging down from the bed. According to R5's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] with multiple diagnoses that included Benign Prostrate Hypertrophy and Urinary Tract Infection (UTI). The Minimum Data Set, dated [DATE] indicated the resident had intact cognition. Section H documented R5 had an indwelling urinary catheter upon admission. On 10/21/25 the physician ordered foley catheter care every shift and to change the foley drainage bag every two weeks and prn (as needed). On 11/12/25 the physician ordered a urinalysis and culture and sensitivity test to be conducted. On 1/13/25 a review of R5's care plans revealed there was no care plan for a urinary catheter. On 1/14/25 at 10:40 AM during an interview with the Director of Nursing (DON)she said, There was no care plan until this morning. I noticed it when we were reviewing catheter issues last night and this morning. The MDS nurse was made aware of the oversight and corrected it. It was put in place earlier today. The DON acknowledged that the urinary care plan should have been initiated at the time of admission. A request for the facility's policy for care planning was made. According to the facility's Care plan Standard Guideline effective dated 11/18/2017 in part reads;GuidelineAll resident/client will be evaluated for individual risk factors which may increase the chance of hospitalization. Myocardial Infarction, Congestive Heart Failure, Pneumonia, Sepsis, and Urinary Tract Infection have been identified as high risk diagnoses, however, all potential conditions that could increase the chance of hospitalization should be identified for care planning needs. The resident care plan will incorporate risk factors identified in preadmission assessment, hospital records and admission evaluations, with changes in condition, reviewed and updated quarterly.Procedure1. The interdisciplinary team will collect and record data within 24 hours for the admission baseline Care Plan. Comprehensive Care planThe facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following:1. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. DPS #2: Based on observation, interview, and record review the facility failed to develop a person-centered comprehensive dialysis care plan for one (R73) of one resident reviewed for dialysis resulting in inadequate care for a dialysis patient.Findings include:On 1/14/26 at 11:59 a.m. R73 was observed on the unit, in a wheelchair at the nurse's station. R73 was observed to be anxious and restless. R73 was shouting (at no one in particular). Staff attempted to redirect R73's behavior by attending to needs however R73 became more agitated and would not communicate what was needed. Staff were observed transporting R73 away from the nurse's station. While in the bedroom, R73 continued to display agitation but would not say what the cause was.On 1/16/26 at 8:10 a.m. R73 was observed by the facility's entrance door (preparing to go to dialysis), as very angry and anxious. The Director of Nursing said R73 was upset because he didn't want to put shoes on to go to dialysis.A complaint was submitted to the State Agency reported by the dialysis center that R73 often arrives at dialysis very angry and anxious. It takes the dialysis staff a while (up to 40 minutes) to calm R73 down to administer the dialysis treatment. The dialysis staff have reported the behaviors to the facility multiple times and requested the facility to administer medications prior to R73 arriving to dialysis.Review of the clinical record documented R73 was initially admitted into the facility on 3/3/25 and readmitted on [DATE] with diagnoses that included end stage renal disease, dysphagia, dementia, psychotic disturbance, mood disturbance, and anxiety, and schizophrenia. According to the significant change Minimum Data Set assessment dated [DATE], R73 had severe impaired cognitive impairment (BIMS-6), unclear speech, and required one-two person assistance with most daily activities.Review of the Dialysis care plan dated 6/9/24 did not document person-centered goals or interventions to adequately address R73's dialysis needs. There was documentation the care plan problem and interventions were reviewed or revised since 6/9/24. Review of the facility's policy titled Care plan Standard Guideline dated 11/28/17 documented in part the following: All resident/client will be evaluated for individual risk factors which may increase the chance of hospitalization. The interdisciplinary team will continue develop a resident/client centered care plan that includes problem, need, or strength statements, measurable goal statements and resident/client specific interventions. The care plan is to be revised to reflect the current status of the resident. Interventions should be specific to reflect the specific goal. The intervention should be individualized to the resident.

Based on observation, interview, and record review the facility failed to implement pressure ulcer care as prescribed for one (R5) of five residents reviewed for pressure ulcer care resulting in the potential for R5's pressure ulcer to worsen.Findings include:On 1/13/26 at 12:53 PM, R5 was observed lying in bed watching TV. During interview the resident said there were problems with the foley catheter leaking urine last night and the CNA (certified nursing assistant) did a complete brief and bed change. Further inquiry and observation revealed the resident was incontinent of stool. The resident said, Yes, my diaper needs to be changed again. It's soiled. I was waiting until after lunch to ask them to clean me up. At this time CNA L entered the room to remove the lunch trays and the resident requested care. During observation of incontinence care, R5's sacral area pressure ulcer was without a dressing covering it and directly open to a soiled brief. The pressure ulcer was clean, pink, moist, and without foul odor or drainage. CNA L said, Oh, this should be covered. I'll tell the nurse. At 1:05 PM Licensed Practical Nurse (LPN) M entered the room, observed R5's sacral pressure ulcer and said, Oh yeah, it needs to be covered. It must have not been replaced after the brief change on night shift. I'll let the wound care team know the dressing needs to be done. According to R5's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] with multiple diagnoses that included Benign Prostrate Hypertrophy and Urinary Tract Infection (UTI). The Minimum Data Set, dated [DATE] indicated the resident had intact cognition and admitted to the facility with a stage 3 pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed.) A wound care note dated 10/3/25 measured the pressure ulcer at 3.8 centimeters (cm) length x 0.8 cm width x 0.30 depth. A care plan for 'sacral pressure ulcer' was initiated on 10/7/25 and included the following intervention: evaluate and treat per physician's orders. A physician's order dated 10/21/25 prescribed the following skin care treatments; [Activon] medi-honey to sacrum after normal saline/wound cleanser and cover with dry dressing every day shift and as needed for skin care. Triad past to periwound (around the wound). The wound care note dated 1/8/26 revealed the sacral pressure ulcer measured 3.7 cm length x 0.7 cm width x 0.3 depth. There were no progress notes for 1/13/26 during the evening or night shift. On 1/13/26 at approximately 2:00 PM wound care LPN D acknowledged that R5 did not have a dressing to the sacral area and should have been cleaned and dressed after incontinence care on the night shift. LPN D said, I'm not sure why the treatment was not done. Any nurse can and should re-do the dressing if it becomes soiled during incontinence. The orders are every day and as needed. The resident has been hospitalized for other medical issues causing a delay in healing. The wound is stable and has no signs of infection. On 1/14/25 at 10:40 AM during an interview with the Director of Nursing (DON) she said, The night shift nurse should have re-dressed the resident's pressure ulcer after incontinence care. The DON said that LPN B was assigned to R5 during the 1/13/26 night shift. No progress notes were documented on 1/13/26. The DON said there was a call to LPN B. A request for LPN B contact information and the facility's pressure ulcer care policy was requested. LPN B was unable to be interviewed during the survey. On 1/15/26 at 9:30 AM CNA A was interviewed via telephone. CNA A said, Yes, his (R5) catheter had leaked all in the brief and bed. I did a complete bed change. I think there was a dressing on his buttocks and I removed it. I did tell the nurse (LPN B) that his catheter needed to be looked at because it had leaked all in the brief and bed. I don't recall if I told her about the dressing. According to the facility's 'Skin Management Guideline' effective date 11/28/2017 reads in part. 11. When a pressure ulcer is present, daily wound monitoring should include: An evaluation of the ulcer, if no drainage is present An evaluation of the status of the dressing, if present The status of the area surrounding the ulcer (that can be observed without removing the dressing)

Based on interview and record review the facility failed to develop, implement, or document an effective discharge plan of care for one (R222) of five residents reviewed for discharge planning resulting in the delay of home care services and potential delay for follow-up appointments for R222.Findings include: The State Agency received a complaint from R222 that they were not provided with sufficient information at the time of discharge regarding home health care services or follow-up appointments. On 1/14/26 at 1:08 PM R222 said, [NAME] set up home care for me when I left. It took a week after I was home before I could get ahold of anyone. The paper they gave me didn't have any phone numbers on it. I had to call the Social Worker several times before anyone could give me the right number for home care. R222 reported they were living in their home, followed up with their physician, and was receiving home care at this time. According to R222's electronic health record (EHR) the resident admitted to the facility on [DATE] with several diagnoses that included surgical repair of a fractured left femur after a fall at home, anxiety, and left eye blindness. R222 was discharged to their home on [DATE].A review of R222's care plans revealed there was no plan of care for discharge or post-discharge. There was no discharge summary.Progress notes from 9/17/25 - 10/23/25 were reviewed and did not reveal any discharge planning.On 9/17/25 a Social Work (SW) note documented the resident's discharge plan is to return to home. The next SW note dated 10/20/25 reads; Resident received a NOMNC (Notice of Medicare Non-Coverage) with LCD (Local Coverage of Determination) of 10/22/5. He will discharge home with HHC (Home Health Care).The final SW dated 10/23/25 documented the following: The resident was discharged to their home without DME (durable medical equipment) because they already have it at their home.R222's My Transition Home-Discharge form dated 10/22/25 at 3:42 PM was significantly incomplete. There was no phone number for the Home Health Care Agency. There was no information regarding the resident's follow-up appointments. The sections for; Contact information, Medication information, Nursing instructions, Dietary, and Discharge instructions were blank. On 1/15/26 at approximately 10:00 AM the Director of Social Services (SW) G reviewed R222's EHR and could not provide any documentation to support R222 had a discharge care plan or discharge planning. SW G acknowledged R222's 'Transition Home form was incomplete and did not include the HHC agency's phone number or any information regarding the resident's follow-up appointment. SW G said, The Home Health Care agency did not show up to the resident's home until 10/29/25 because they kept missing the calls. It was a week after the resident discharged and he called here because home care hadn't shown up. We called the (HHC) agency to work it out. I was told the resident had missed their (the HHC agency) calls and did not call them back. On 1/15/26 at approximately 11:00 AM the Director of Nursing (DON) reviewed R222's EHR and said, The transition form is incomplete. The Home Care agency was called by us and suppose to call the resident to set up visits, but the resident kept missing the agency's call. The resident did get their medications faxed to the pharmacy of their choice. I don't know why that information is not documented on the form or in medical record. The DON acknowledged the resident had no discharge care plan or discharge summary. A request for the facility's Discharge policy was requested. According to the facility's Transfer and Discharge Guideline last revised on 5/5/2025 in part reads; Discharge Planning ProcessResidents will be evaluated for their discharge goals, preferences, and care needs to meet their goals. The evaluation information will be used to develop a comprehensive discharge care plan. * The resident will be re-evaluated periodically to identify changes, and the discharge care plan will be modified to reflect any changes. The care plan will be developed by the interdisciplinary team, including the resident's physician, a registered nurse, other staff or professionals in disciplines determined by the resident's needs or requested by the resident, a member of the nutrition services staff and to the extent practicable, the resident and their representative. The resident will be periodically reassessed to identify changes that require modification of the discharge plans and update the plans as needed The resident and representative will be provided with the final discharge care plan.A. Assessments and Discharge [NAME]. Upon admission to the facility and on an ongoing basis, resident will be evaluated based upon a comprehensive assessment and a person-centered discharge care plan will be initiated to address:i. Resident desires and choices1. Goals2. Treatment preferences3. Preference and feasibility for dischargei. Resident representative involvementii. Teaching with resident/resident representative and caregiver support needsiii. Medical condition/diagnoses1. Signs and symptoms2. When to notify a physician3. Laboratory/radiology testing and result explanationi. Medications and Treatments1. Reason for medications2. Common side effects3. Dose, time of day, duration, route4. Evidence of understanding/return demonstrationi. Functional and cognitive statuses and needs1. Resident specific ADLs2. Evidence of understanding/return demonstrationi. Advance Directivesii. Supplies and durable medical equipment (DME)iii. Follow-up appointments (including transportation)iv. Support Services for care following dischargev. Post discharge location (if known)vi. Risk factors for preventable re-hospitalization.C. Discharge .c. Update the resident's comprehensive care plan and discharge plan (if applicable) with any information received form referrals to local contact agencies or other appropriate entities.D. Documentationa. The resident needs and discharge plan must be documented in the medical record. If a discharge to the community is determined to not be feasible, document who made the determination and reason.b. The resident and resident representative will be informed of the final discharge plan. Proper Notice of Discharge will be provided according to the above guidance.c. An evaluation of the resident's discharge needs will be documented in the resident record on a timely basis. The results of this evaluation will be discussed with the resident or resident representative.d. Relevant resident information will be incorporated into the discharge plan to facilitate implementation and avoid unnecessary delays in resident discharge or transfer.e. The Discharge Care Plan as part of the comprehensive care plan and correlating documentation will be maintained in the medical record.D. Discharge SummaryA discharge summary will be completed upon discharge to include:a. Participation with the resident/resident representativeb. How facility will assist resident adjustment to new living environmentc. Details of where resident will resided. Post discharge follow-up detailse. Post discharge medical and non-medical servicesf. Information regarding how the location meets the resident's needs, provides needed support and resources, and meets the resident's preferencesg. A recapitulation of the residents stay in the facility (diagnoses, course of illness/treatment, therapy, lab, radiology and consultation reports)h. A recapitulation of resident's status.i. A reconciliation of resident's pre-discharge meds with post discharge meds

This citation pertains to Intake 2711513.Based on interview and record review the facility failed to ensure correspondence between the facility and the dialysis center was implemented for one (R73) of one resident reviewed for dialysis resulting in missed communication for continuity in care. Findings include:On 1/14/26 at 11:59 a.m. R73 was observed on the unit, in a wheelchair at the nurse's station. R73 was observed to be anxious and restless. R73 was shouting (at no one in particular). Staff attempted to redirect R73's behavior by attending to needs however R73 became more agitated and would not communicate what was needed. Staff were observed transporting R73 away from the nurse's station. While in the bedroom, R73 continued to display agitation but would not say what the cause was. On 1/16/26 at 8:10 a.m. R73 was observed by the facility's entrance door (preparing to go to dialysis), as very angry and anxious. The Director of Nursing said R73 was upset to put on shoes and go to dialysis. A complaint was submitted to the State Agency reported by the dialysis center that R73 often arrives at dialysis very angry and anxious. It takes the dialysis staff a while (up to 40 minutes) to calm R73 down to administer the dialysis treatment. The dialysis staff have reported the behaviors to the facility multiple times and requested the facility to administer medications prior to R73 arriving to dialysis. The complaint noted RN I as the facility staff that was contacted about the R73's behavior while at dialysis. On 1/15/26 at 3:34 p.m. RN I was interviewed and said the antianxiety medication was not at the facility on 1/7/26 for R73 to take prior to going to dialysis. The medication could not be ordered in time and arrive at the facility before R73 went to dialysis. Although there was a physician order, a script was needed to order the medication through pharmacy or retrieve from the backup box. RN I was queried about the communication between the facility and the dialysis center. RN I said the telephone communication was not documented because the medication was ordered immediately. Review of the clinical record documented R73 was initially admitted into the facility on 3/3/25 and readmitted on [DATE] with diagnoses that included end stage renal disease, dysphagia, dementia, psychotic disturbance, mood disturbance, and anxiety, and schizophrenia. According to the significant change Minimum Data Set assessment dated [DATE], R73 had severe cognitive impairment (BIMS-6), unclear speech, and required one-two person assistance with most daily activities. R73 go to dialysis on Monday, Wednesday, and Friday with a chair time at 9am and pick up from the facility at 8am. Review of the Dialysis care plan dated 6/9/24 did not document person-centered goals or interventions to adequately address R73's dialysis needs. Review of the nurse's progress notes for 1/7/26 did not document the communication between the dialysis center and the facility. Review of the dialysis communication forms for the month of December and January documented the following in part:12/21/25- Completed by dialysis unit. Complications during visit: Agitation.1/2/26- Completed by dialysis unit. Complications during visit: Agitation.The communications for 1/5 (Monday), 1/7 (Wednesday), 1/9 (Friday) were not in the electronic medical record. On 1/16/25 at 8:33 a.m. the dialysis communication for the dates of 1/5, 1/7, and 1/9 were requested by the Director of Nursing (DON). The DON said they were not readily accessible and had to be found. The DON said documentation is an area that needs to be improved. On 1/16/26 at 11:23 a.m. the dialysis communication forms requested did not include the dates for 1/5, 1/7, and 1/9. On 1/21/26 at 9:21 a.m. the Dialysis Center Administrator N and the Dialysis RN O was interviewed via telephone and said the center is always calling the facility with concerns with R73 such receiving medications prior to arriving to dialysis or behavior. RN O said on 1/7/25 a call was placed to the facility regarding R73's behaviors. R73 was very agitated and angry. R73's behavior was distressing to both the resident and other patients in the clinic. R73 had been exhibiting behaviors for the last three weeks and the facility was notified both in writing using the communication form and telephone. The dialysis center does not keep copies of the communication forms sent back to the facility. Review of the facility's policy titled Clinical Guideline: Dialysis dated 1/2007 documented in part the following: .Residents receiving hemodialysis are transported routinely out of the facility. Communication is essential for continuity of care. Communication between outpatient dialysis provider and facility should include Written communication form with review of daily weights, any changes in condition or mood. Be cognizant of medications ordered and timing of administration. Review Communication Folder for any pertinent information.

Based on observation, interview, and record review the facility failed to ensure a functioning call light for one (R15) of one resident reviewed for environment resulting in unmet safety needs.Findings include:On 1/16/26 at 11:58 a.m. upon entering R15's bedroom, an unidentified resident was observed standing at the bedside, standing behind the wheelchair. R15 was then observed attempting to scoot to the edge of the bed and get into the wheelchair. The resident was asked what was occurring and the other resident stated, She wants to get up. The wheelchair wheels were not locked as the other resident stood behind the chair. The other resident was asked to put on the call light so staff can assist. The call light was observed activated while in the room. After several minutes of no staff response to the room, LPN H was observed at the end of the hall and asked to come to the room. The call light indicator that was located above the door of the bedroom was not illuminated. LPN H came to the room and redirected the other resident out of the room. LPN H attempted to activate the call light and the hall indicator would not come on. On 1/16/26 at 12:10 p.m. CNA K arrived at R15's bedroom to assist R15 into the wheelchair. CNA K attempted to activate the call light and stated, It comes on but you have to hold it down so it can stay on. When CNA K held the button down, the hall indicator remained on, but when released the hall indicator did not stay on. LPN H said they were unaware the call light was not working properly. Both LPN H and CNA K said the call light indicator at the nurse station was not heard and possibly not working properly. On 1/16/26 at 12:20 p.m. Maintenance Assistant J was interviewed with the Nursing Home Administrator (NHA) and Director of Nursing (DON) present. Maintenance Assistant J said they were not made aware of R15's call light not working. All bedroom call lights are checked twice a week and R15's call light could have broken that day. Maintenance Assistant J was unable to account for the last time R15's call light was checked. Review of the clinical record documented R15 was initially admitted into the facility on 7/18/19 with diagnoses that included autistic disorder, epilepsy, schizoaffective disorder, depressive type, atherosclerosis of native arteries of extremities, bilateral legs, and legal blindness. According to the Minimum Data Set (MDS) dated [DATE], R15 was severely cognitively impaired (BIMS-3) and required extensive one-person assistance with activities of daily living. Review of the self-care performance care plan dated 8/5/25 documented in part: The resident (R15) has an activity of daily living self-care performance deficit related to dx of epilepsy, autistic disorder, schizophrenia, bipolar disorder, & legal blindness.prefers to have staff assist to the toilet. Intervention: . Transfers: Resident requires physical assistance of 1 staff . Bed Mobility: assist x 1 staff to guide in bed and sitting to lying position.Encourage the resident to use bell to call for assistance. Review of the facility's policy titled Answering the Call Lights dated 11/2013 documented in part: Report all defective call lights to the nurse supervisor promptly. If assistance is needed when you enter the room, summon help by using the call signal.

Based on observation, interview, and record review the facility failed to provide appropriate indwelling urinary catheter (foley) care for one (R5) of three residents reviewed for catheter care.Findings Include: On 1/13/26 at 12:53 PM, R5 was observed lying in bed with foley catheter tubing hanging off the bed draining a small amount of amber urine into a collection bag. The collection bag had a privacy cover and was attached to the bed frame, below the level of the resident's bladder. The resident said there were problems with the foley catheter leaking urine last night. R5 said, There was urine all in my diaper and the bed. The CNA (certified nursing assistant) had to change my brief and the whole bed. The nurse came in and changed the bag. It seems to be working fine now. Upon further observation the catheter was not attached to an anchoring device to secure the catheter tubing to the resident's thigh. The catheter was pulled taut from the resident's penis through the leg hole of the brief hanging down from the bed. The resident was incontinent of stool.At approximately 1:00 PM CNA L entered the room to remove the lunch trays and R5 requested care. During observation of incontinence care, the CNA noted that R5's foley catheter did not have an anchoring device to stabilize the catheter and said, There should be a device that holds the foley to the thigh without pulling on it. I'll let the nurse know his is not on. At 1:05 PM Licensed Practical Nurse (LPN) M observed R5 during incontinence care and confirmed that the resident should have an anchoring device in place to secure the foley. LPN M went on to say, The catheter was leaking last night. The night shift nurse (LPN B) told me she changed the tubing and the bag. The anchoring device was probably removed because it was wet. I'll get another one. LPN M could not say what other actions the night shift nurse (LPN B) did for the resident's leaking foley catheter. She didn't say anything else. Just that she changed the bag. According to R5's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] with multiple diagnoses that included Benign Prostrate Hypertrophy and Urinary Tract Infection (UTI). The Minimum Data Set, dated [DATE] indicated the resident had intact cognition. Section H documented R5 had an indwelling urinary catheter upon admission and was always incontinent. On 10/21/25 the physician ordered foley catheter care every shift and to change the foley drainage bag every two weeks and prn (as needed). On 1/13/26 a review of R5's care plans revealed there was no care plan for a foley (indwelling urinary) catheter. There were no progress notes on 1/13/2026 during the afternoon or night shift. There was no documentation to support R5's foley catheter had leaked, been provided with care, or the collection bag changed. On1/13/26 at approximately 11:00 AM the nurse unit manager, Registered Nurse (RN) C said she was aware that R5's foley catheter had leaked last night. She said, I talked to the night nurse about changing the resident's catheter bag because it was leaking. I talked her though the process of changing the collection bag. I don't believe the catheter was changed or irrigated. That was not discussed. At this time RN C reviewed R5's EHR and confirmed there was no documentation to support the foley catheter bag had been changed or that the resident's urinary output was assessed or monitored. There were no progress notes for R5 on 1/13/2026 during the night shift. On 1/14/2026 at 9:57 AM, R5 said he did not feel well and there was pain around his penis area. Observation of the resident's foley catheter revealed there was no urine in the collection tubing and very little urine in the collection bag. At this time LPN D was asked about R5's urinary status. LPN D entered the resident's room and confirmed there was no urine in the foley catheter tubing or collection bag, and the resident was complaining of discomfort. LPN D said, I'll notify the Nurse Practitioner. LPN D reviewed R5's EHR and confirmed there was no documentation to indicate that R5's foley catheter had leaked on 1/13/26. On 1/14/25 at 10:40 AM during an interview with the Director of Nursing (DON) she said she was aware of R5's catheter leaking after it was brought to her attention yesterday by RN C. The DON said she spoke with LPN B on the phone and confirmed the resident's foley catheter had leaked the night before (1/13/26) and the tubing and collection bag were changed. There was no irrigation of the foley nor was the entire foley catheter changed. The DON acknowledged there was no documentation to support those actions or to indicate there was any further monitoring of the catheter or urine output. The DON said, She should have documented what occurred. Yes, there should have been an anchoring device for the resident's foley catheter. No, there was no care plan for the resident's foley catheter until today. It should have been initiated at time of admission. The DON reported that the Nurse Practitioner was made aware and the resident's urinary catheter was ordered to be changed along with a urinalysis. The DON was asked to provide the contact information for LPN B and the facility's policy for foley catheter care. On 1/15/26 at 9:30 AM CNA A was interviewed via phone and said, Yes, I cared for the resident on night shift 1/13/26. His bed was soaked with urine because the catheter was leaking. I did a complete brief and bed change. I told the nurse, but I don't know what she did because it was towards the end of the shift and I left. LPN B was unable to be interviewed during the survey. The facility's Urinary Indwelling Catheter Management Guideline effective date of 11/28/2017 reads in part:Indwelling catheters may be associated with significant complications, including bacteremia, febrile episodes, bladder stones, fistula formation, and erosion of the urethra, epididymitis, chronic renal inflammation and pyelonephritis Completion of a Bladder Observation will be complete upon admission and with a change in condition. The Bladder Observation will be reviewed quarterly and annually. When indwelling catheterization is recommended a Medical Necessity for Indwelling Catheters evaluation will be completed prior to urinary catheter intervention or upon admission with observation of an indwelling urinary catheter.Changing indwelling catheters and drainage bags at routine or fixed intervals is not recommended. Rather, catheters and drainage bags should be changed based on clinical indications such as: Infection Obstruction When the closed system is compromisedEnsuring the catheter is secured to eliminate dislodgement or irritation resulting from tension or pulling on the tubing. Developing a plan of care upon admission and / or placement that includes: o A review every quarterly, annually and with a change in condition, o Causal and or contributing factors;o Associated risks including infections;o Goals including trial removals if indicated;o Individualized interventions

This citation pertains to intake 1316302.Based on interview and record review the facility failed to prevent the misappropriation of resident's property for one (R702) of seven residents reviewed for abuse resulting in R702 missing 28 doses of hydrocodone (narcotic pain medication).Findings include:The State Agency received a Facility Reported Incident (FRI) on 5/20/25 that identified the misappropriation of a resident's (R702) pain medication by Licensed Practical Nurse (LPN) I. The medication was a schedule II drug; a substance that is classified as having a high potential for abuse and severe psychological or physical dependence.On 7/28/25 at 1:00 PM R702 was interviewed and said that they had received all their pain medications and had no complaints regarding medication administration.On 7/29/25 at approximately 9:30 AM the Director of Nursing (DON) reviewed the FRI investigation report and confirmed that R702's pain medication had been taken by LPN I. The DON stated, On May 6th a nurse went to give the pain med to the resident and saw the cartridge for that medication was empty. She attempted to reorder it from the pharmacy and was alerted that it was not time for refill. We reviewed the narcotic count and realized that 28 pills of the resident's pain meds were missing and unaccounted for. It was easy to determine when the pills were taken. During my discussion with the nurse (LPN I) they refused to come in for an interview. They said they knew they had a problem. The DON said all the nurses had been given an education on the procedure for narcotic reconciliation. Further review revealed the following: the DON could not produce any documentation to indicate there was compliance after the incident was identified, and education had been given. There was no evidence that Agency nurses had received the education. The DON reported, No, there are no audits or follow-up to determine or confirm the nurses are following the narcotic reconciliation procedure. There is no education for the agency nurses.On 7/29/25 at 9:55 AM LPN I was left a voice message on the last known contact information provided by the facility. LPN I has not been available for interview by end of the survey.According to the facility's policy for Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property effective 11/28/2017 in part read, It is the policy of facility that each resident will be free from 'Abuse'.

This citation pertains to 2574104. Based on interview and record review, the facility failed to ensure adequate supervision to prevent a resident to resident altercation for one resident (R712) of seven residents reviewed for abuse, resulting in R712 being struck on the head by R711 and the potential for continued physical abuse to occur.Findings include:A review of the facility's investigation summary of a resident-to-resident incident between R711 and R712 documented in part the following: On 7/5/25, at approximately 6:30 PM, there was a verbal exchange between R712 and R711 resulting in R711 ambulating across the room and initiating physical contact with R712. Residents were immediately separated with licensed nurses performing skin, pain, and psychosocial assessments. No injuries noted. Witness statement from Certified Nurse Assistant (CNA) O, dated 7/5/25, I (CNA O) was assisting (unnamed resident) and while walking past the dining room I witnessed (R711) standing over (R712) punching him. I immediately stopped the altercation and called out for assistance. Witness statement from Licensed Practical Nurse (LPN) N, dated 7/5/25, I (LPN N) was in the med room doing paperwork for shift change and (CNA O) came and got me to tell me that (R711) and (R712) were fighting in the dining area. I did not witness the fight. On 7/29/25 at 10:50 AM, Unit Manager/LPN (UM/LPN) F said she was the Unit Manager for the memory care unit where R711 and R712 reside. UM/LPN F said staff must keep certain residents away from other residents to avoid conflict, and this included R711 and R712. When residents are in the dining room, even during non-mealtimes, there should be a staff present to watch what the residents are doing. On 7/5/25 after dinner, around 6:30 PM, there was no staff present supervising the residents in the dining room. A review of the clinical record for R711 documented an admission date of 10/25/24 with diagnoses that included anxiety disorder and vascular dementia. A Minimum Data Set (MDS) assessment dated [DATE] documented severe cognitive impairment. Review of R711's care plans documented in part the following:- Focus: The resident has Vascular dementia with psychotic disturbance, unspecified dementia, unspecified severity with agitation. Date Initiated: 10/31/2024. Inventions: Anticipate and meet needs. Monitor effectiveness of communication strategies and assistive devices. Date Initiated: 11/25/2024- Focus: (R711) has Vascular dementia with psychotic disturbance, unspecified dementia, unspecified severity with agitation. Date Initiated: 10/31/2024- Focus: (R711) has a mood problem related to dementia. Date Initiated: 11/25/2024. Interventions: -Communication: Provide a calm and safe environment to allow resident to express feelings as needed. Provide resident with area for decreased stimulation as needed. Date Initiated: 2/11/2025 A review of the clinical record for R712 documented an initial admission date of 12/14/20 and readmission date of 6/2/25. R712 diagnoses included schizoaffective disorder-bipolar type, schizoaffective disorder-depressive type, antisocial personality disorder, unspecified mood disorder, and anxiety disorder. A MDS assessment dated [DATE] documented severe cognitive impairment. Review of R712's care plans documented in part the following:Focus: (R712) does at times become physically aggressive and bangs on tables or his chair when residents are close to him during activities. (R712) does have difficulty communicating, prefers to use gestures. Dated 10/12/23.Focus: The resident is/has potential to be physically aggressive related to Dementia. Date Initiated: 04/20/2024.Focus: The resident has a psychosocial wellbeing problem (potential) related to resident-to-resident altercation. Date Initiated: 09/07/2021. On 7/29/25 at 12:00 PM, Nursing Home Administrator (NHA) and Director of Nursing (DON) were interviewed regarding the incident between R711 and R712. The NHA reported a video of the incident was reviewed by herself and the DON. The NHA stated the information included in the facility's investigation summary was gleaned from the video of the incident. The NHA indicated the video tape was no longer available for review. The DON recalled the following from reviewing the video: R711 was sitting on a bench leading to the hallway and R712 was sitting at a table. R711 was looking in the direction of R712. R712 put his hand up. The DON noted there was no audio available, but R712 has a history of being verbally aggressive. R711 then stood up and walked over to where R712 was sitting. R711 was observed standing over R712. R711 was observed using his hands and making contact with R712's head. The DON added that staff were not in the dining room when the physical altercation occurred. The DON stated staff should be present in the dining room when residents are in the dining room to provide supervision and make sure things are okay. A review of the facility policy titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, dated 11/28/17, documented in part the following.- Resident will be protected from abuse while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection.- The facility leadership will assess the needs of the residents in the facility to be able to identify concerns in order to prevent potential abuse.- The facility will ensure a comprehensive dementia management program to prevent resident abuse. A facility document titled, Dementia - Clinical Protocol, dated 2001, was reviewed and revealed in part the following: Direct care staff will support the resident in initiating and completing activities and tasks of daily living. Bathing, dressing, mealtimes, and therapeutic and recreational activities will be supervised and supported through the day as needed. A facility document titled, Dementia Treatment and Services, dated 6/29/21, was reviewed and revealed in part the following:- Care and services are person-centered and reflect the resident's goals, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety.

This citation pertains to intake 2565437.Based on interview and record review the facility failed to report a potential incident of neglect for one (R707) of seven resident reviewed for abuse/neglect. Findings include:The State Agency (SA) received an anonymous complaint that a resident had eloped from the facility unbeknownst to facility staff on 7/15/25.On 7/28/25 at 11:30 AM the Nursing Home Administrator (NHA) was asked if any resident had eloped from the facility. The NHA said, Yes, we had a resident that was new to us. The first time he went out to the patio enclosure during an activity he climbed over the fence. We notified the family and the police. At that time the resident's son told us that the resident had eloped from the hospital two times in the past. The resident was found shopping at Kohl's without any injury and is currently with living with his son. The NHA provided an investigation report that confirmed the police, and family had been notified of the missing resident but there was no incident report to the SA. The NHA was asked why the facility did not report the incident to the SA and replied, It got away from us. When the resident was found shopping at Kohl's and safe with the son. I finished the investigation and didn't report it.A review of R707's Electronic Health Record revealed the resident admitted to the facility on [DATE] with multiple diagnoses that included one sided weakness (hemiplegia) and cerebral infarction (stroke). The 5-day Minimum Data Set was incomplete due to R707 not remaining in the facility for the 5 days.A review of the facility's Investigation Report for the incident revealed the police and family had been notified, but not the SA.According to the facility's policy for Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property effective 11/28/2017 in part reads; Neglect is the failure of the facility.to provide goods and services to a resident that are necessary to avoid physical harm.G. Reporting and Response.It is the policy of this facility that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility.

This citation pertains to MI00153114. Based upon interview and record review, the facility failed to ensure transfer documentation was in place for one resident (R101) reviewed for transfer, resulting in the lack of information regarding resident's health status, safety, and transfer arrangement and destination upon transfer from the facility. Findings include: A review of the clinical record documented R101 was originally admitted to the facility on [DATE] and readmitted on [DATE]. R101's medical diagnoses included anxiety disorder, mood disorder, unspecified psychosis, and unspecified dementia with other behavioral disturbance. A Minimum Data Set assessment dated [DATE] documented moderate cognitive impairment, impairment on one side of the lower extremity, and the use of a wheelchair for mobility. Census documentation in the EHR (electronic health record) revealed a stop billing date of 5/15/25 which indicated R101 no longer resided in the facility. Beginning on 7/7/25 at 2:58 PM, the Director of Nursing (DON) was interviewed regarding R101's status. The DON provided an incident report for R101 dated 5/15/25 that documented in part the following, Resident repeatedly became agitated with staff regarding a pair of overalls he insists that were lost at the facility. Resident did not come to the facility with any belongings, staff tried to redirect resident over 5x regarding overalls and calm him down, resident was given all of his prn (as needed) medications and continued to become increasingly agitated despite being given prn meds .resident went down the hallway and staff thought resident was going back to his room, instead of going to his room, resident went down to the end of the hallway and kicked in the stair well door, staff heard the door be hit and went running down the hallway, down the stairs towards the resident, resident then dragged his wheelchair and pushed his wheelchair down the stairs, staff went down the stairs towards the resident and attempted to get him to stop going down the stairs. Resident began kicking, screaming, and spitting at staff. Resident then got down to the 3rd floor and got the door opened and began charging at the 3rd floor unit manager. Three staff members were able to get the resident calm enough to get him into the elevator and back to the 5th floor. Once back on the 5th floor the resident continued to kick staff members and spit on them and repeatedly threatened to punch and kill the staff members trying to redirect him. Writer was able to get a verbal (order) to send the resident to the hospital via 911 on a psychiatric petition. Resident was given a one time order for 5 mg/1 ml of Haloperidol .for his aggressive behavior. Staff was able to give the resident the injection. Resident was taken to (local hospital) on a psychiatric petition. The incident report revealed the information on this document was Privileged and Confidential - Not part of the Medical Record. At the time of this interview and record review, the only progress note dated for 5/15/15 was entered at 12:06 PM regarding an order note for the administration of Haloperidol. There were no progress notes, or a late entry note, regarding R101's transfer disposition and/or destination. The DON also confirmed that a hospital transfer notice had not been completed regarding the 5/15/25 incident. The DON said R101 went to a local hospital on 5/15/25 but that R101's transfer information was not in the medical record. A review of the facility document titled, Transfer and Discharge Guideline, revised 5/5/25 documented in part the following: - This guidance supports safe discharges and transfers for all residents, regardless of initiating party. - There are a few circumstances when the facility may issue a discharge notice to the resident: A transfer or discharge is necessary for the resident's welfare or well-being and the resident's needs cannot be met in the facility. Documentation for this circumstance: includes facility's attempts to meet the resident's needs. The health and/or safety of others in the facility is in jeopardy. - If the transfer/discharge was an emergency, the notice will be issued as soon as practicable when the safety of the individuals in the facility would be endangered, and an immediate transfer or discharge is required by the resident's urgent medical condition. - The resident's physician and facility staff will document the resident's record: The resident's health status at the time of notice. Reason the services provided by the facility are no longer needed, document discharge needs and discharge plan. - Documentation will include the bases for the transfer and the services to be provided by the receiving health care provider that will meet the resident's needs. On 7/7/25 at 5:00 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.

This citation pertains to MI00153114. Based on interview and record review, the facility failed to provide documentation in the EHR (electronic health record) for a psychiatric petition to the hospital for one resident (R101), resulting in missing clinical information regarding the resident's psychiatric status at the time of the transfer. Findings include: It was reported to the State Agency that a resident kicked open locked doors to the fifth and third floor and attacked staff and other residents. A review of the clinical record documented R101 was originally admitted to the facility on [DATE] and readmitted on [DATE]. R101's medical diagnoses included anxiety disorder, mood disorder, unspecified psychosis, and unspecified dementia with other behavioral disturbance. A Minimum Data Set assessment dated [DATE] documented moderate cognitive impairment. Census documentation in the EHR revealed a stop billing date of 5/15/25 which indicated R101 no longer resided in the facility. Beginning on 7/7/25 at 2:58 PM, the Director of Nursing (DON) was interviewed regarding R101's status. The DON provided an incident report for R101 dated 5/15/25 that documented in part the following, Resident repeatedly became agitated with staff regarding a pair of overalls he insists that were lost at the facility. Resident did not come to the facility with any belongings, staff tried to redirect resident over 5x regarding overalls and calm him down, resident was given all of his prn (as needed) medications and continued to become increasingly agitated despite being given prn meds .resident went down the hallway and staff thought resident was going back to his room, instead of going to his room, resident went down to the end of the hallway and kicked in the stair well door, staff heard the door be hit and went running down the hallway, down the stairs towards the resident, resident then dragged his wheelchair and pushed his wheelchair down the stairs, staff went down the stairs towards the resident and attempted to get him to stop going down the stairs. Resident began kicking, screaming, and spitting at staff. Resident then got down to the 3rd floor and got the door opened and began charging at the 3rd floor unit manager. Three staff members were able to get the resident calm enough to get him into the elevator and back to the 5th floor. Once back on the 5th floor the resident continued to kick staff members and spit on them and repeatedly threatened to punch and kill the staff members trying to redirect him. Writer was able to get a verbal (order) to send the resident to the hospital via 911 on a psychiatric petition. Resident was given a one time order for 5 mg/1 ml of Haloperidol .for his aggressive behavior. Staff was able to give the resident the injection. Resident was taken to (local hospital) on a psychiatric petition. The incident report revealed the information on this document was Privileged and Confidential - Not part of the Medical Record. The DON reviewed R101's EHR and said the clinical record did not document the 5/15/25 incident. The DON stated this incident should be part of R101's clinical record because it showed his behaviors and what was going on with him. The DON added because we had to petition R101 out for a psychiatric admission we should have documented why we weren't able to provide care for him. A review of the facility policy titled, Charting and Documentation, revised July 2017, documented in part the following: - All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. - The following information is to be documented in the resident medical record: Objective observation, medications administered, treatments or services performed, changes in the resident's condition, events, incidents or accidents involving the resident, and progress toward or changes in the care plan goals and objectives. On 7/7/25 at 5:00 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.

Based on observation, interview, and record review, the facility failed to implement physician orders for one (R603) of four residents reviewed for falls, resulting in R603 not receiving a topical pain medication or having a urinalysis (laboratory test used to detect urinary tract infections) completed. Findings include: On 3/18/25 at 10:36 AM, R603 was observed in the dining room seated in a wheelchair with a purple discoloration surrounding the left eye and upper left cheek bone area. R603 was interviewed and could not recall how they obtained the black eye. R603 denied having any pain. Certified Nursing Assistant (CNA) I was present and said the resident had a fall, about a week ago. According to R603's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] with multiple diagnoses that included Parkinson's disease and Alzheimer's disease. The Minimum Data Set (MDS) dated [DATE] indicated R603 had severely impaired cognition status with a Brief Interview for Mental Status (BIMS) score of 4/15. A progress note dated 3/1/25 at 2:30 PM indicated R603 fell out of the wheelchair and hit their head on the floor when another resident pushed R603's wheelchair out of the way in an attempt to move past the resident in the dining room. R603 was assessed and denied pain. No injuries were observed at that time and the resident was assisted back into the wheelchair. Nurse Practitioner (NP) B was notified and ordered the following; urinalysis, blood draw for CMP (complete metabolic panel) and CBC (complete blood count). The resident was sent to the hospital for CT scan of head (Computed Tomography Scan- cross sectional X-ray). A review of R603's hospital records dated 3/1/25, revealed the resident's CT scan of the head was negative. The resident had CMP and CBC results, but no urinalysis was completed. The resident was returned to the facility with new orders for Lidocaine 4 % topical pain patch every 12 hours for 5 days. Review of R603's re-admission orders or 3/1/25 did not transcribe the order for the Lidocaine 4% topical pain patch every 12 hours for 5 days. R603's Medication Administration Record (MAR) did not include the Lidocaine 4% topical pain patch as a medication to be administered. There were no progress notes on 3/1/25 to indicate the Lidocaine 4% patch was ordered. There was no documentation or results to indicate the resident had a urinalysis completed. The MAR had documented pain assessments every shift that indicated the resident had denied pain. On 3/19/25 at approximately 10:00 AM Licensed Practical Nurse (LPN) A and the Director of Nursing (DON) reviewed R603's EHR and confirmed that the resident's order for Lidocaine 4% topical pain patch had not been transcribed or administered to the resident. The DON said, I don't know how this got missed. When a resident returns from the hospital we should review the summary visit and call the physician to clarify orders. It looks like we did not do this. LPN A reviewed the EHR and said, I don't know why we did not complete the urinalysis. I thought maybe they did it at the hospital, but it was not done there either. On 3/19/25 at approximately 11:00 AM, NP B acknowledged that R603 did not receive the Lidocaine 4% topical pain patch after the fall on 3/1/25 as prescribed by the hospital physician. I don't remember getting called when they (R603) returned to the facility. I would have agreed with that order. It should have been on the MAR. I did order the resident to have urinalysis. I don't know why that did not get done.

Based on observation, interview, and record review the facility failed to change soiled linens for one resident (R131) of 27 reviewed for homelike environment resulting in R131 sleeping on soiled and damp linens and dissatisfaction with living conditions. Findings include: On 10/29/24 at 8:20 AM, R131 was observed lying on a soiled sheet that had a urine ring that was wet in the center and dried around edges and measured approximately two feet long and two feet wide. R131, reported that they (staff) should change the sheets after my shower. On 10/30/24 at 8:30 AM, R131's bed was observed to be soiled with a urine ring that was wet in the center and had dried edges. Soiled area measured approximately three feet long by two feet wide. R131 reported that staff had not changed the bed linens after shower yesterday and slept on the same linens last night. R131 further reported that sheets should be changed when they are dirty. Review of R131's electronic medical record (EMR) revealed admission into the facility on [DATE] with a diagnosis of traumatic brain injury. According to the Minimum Data Set (MDS) dated [DATE], R131 had intact cognition and requires assistance with ADLs. Review of ADL care plan revised on 6/19/23 documented, Toilet Use: The resident requires assistance x 1 for transfer to toilet, clothing management . Interview on 10/30/24 at 8:45 AM with Licensed Practical Nurse (LPN) A, After observing the soiled linens, it was reported that resident's linens should be changed when they are soiled. Interview on 10/30/24 at 2:48 PM with Director of Nursing (DON), it was reported that residents' linens should be changed on shower days and as needed. Residents should not have to lie on soiled sheets. Interview on 10/30/24 at 3:10 PM with Certified Nursing Assistant (CNA) A It was reported that residents should be checked often during each shift and soiled bed linens should be changed as needed.

Based on observation, interview and record review the facility failed to maintain dignity while assisting during mealtime for one resident (R163) of three residents reviewed for dignity, resulting in the potential for feelings of embarrassment and low self-esteem. Findings include: On 10/29/2024 during a lunch meal observation on the fifth-floor dining room, certified nurse aide K (CNA) was observed feeding R163. During the observation R163 was observed positioned in a Broda Chair (a chair like a geriatric chair but with more versatile features for comfort staff flexibility). Occasionally, R163 was observed with a forward jerking movement. CNA K was observed standing on the resident's left side and shifting to the right trying to prompt R163 to eat the food displayed in front of the resident, as CNA K stood over R163 portions of the resident's pureed food dropped onto the resident's clothing. On 10/30/24 at approximately 12:40 P.M. R163 was observed being fed by CNA K, while attempting to sit in a dining room chair which was too low for the height of the Broda chair R163 was seated in. CNA K moved to the resident's left and right side prompting R163 to eat, commenting to others this chair is different than the old [NAME] chair. On 10/30/24 at 3:00 P.M. CNA K was interviewed concerning how had staff been in serviced to assist with feeding when a resident was seated in a Broda Chair? CNA K indicated R163 had previously had a geriatric ([NAME] Chair) and staff could sit comfortably and be at eye level with the resident during feeding. CNA K stated, we (referring to two other CNA's present) were trying to figure out how to feed the resident, the chairs we have will not allow us to be at eye level. In a subsequent interview and observation with Unit Manager H concerning staff education on feeding R163 while seated in the Broda Chair, UMH indicated staff should feed residents in the safest manner and should not be standing. The UM was unaware of any specific training staff had been provided in reference to the Broda Chair. During the observation UM H indicated it was a concern and further investigation was required to assist the staff in appropriately feeding the resident while in the Broda Chair. On 11/1/24 at approximately 12:05 P.M. the Director of Nursing was interviewed and acknowledged staff should be seated at eye level with the resident during feeding. According to the Admission Record R163 was admitted to the facility 12/29/2022, with diagnoses which included: dementia with behavioral disturbance, schizoaffective disorder, repeated falls, functional quadriplegia, and adjustment disorder with anxiety. The Quarterly Minimum Data Set (MDS) dated [DATE] indicated R163 was severely impaired in cognitive skills for decision making and required extensive assistance of one person for eating. Review of the facility's policy titled Assistance with Meals, dated 3/2014 revised 10/2020, stated in part under section Titled Residents requiring Full Assistance: . 2) Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: Not standing over residents while assisting them with meals.

Based on observation, interview and record review, the facility failed to maintain and respect the personal privacy by opening packages of one resident (R142) of two residents reviewed for privacy, resulting in a breach of personal privacy and the feeling of anger and disrespect. Findings include: On 10/31/2024 at 10:30 am, R142 discussed during Resident Council that their packages were being opened by staff. On 10/31/24 at 11:55 PM, R142 was observed in bed watching television. R142 was asked about concerns related to personal privacy and mail being opened. R142 said, Sometimes when a package is delivered to me, it's already opened .that's not right to open my mail .what if they take something .that makes me mad. 10/31/24 11:38 AM, Receptionist P was interviewed and queried about when the residents receive mail/packages. Receptionist P stated, All packages are inventoried prior to delivery to the residents. On 10/31/24 at 12:16 PM, Facility Concierge Q was interviewed and queried about the process of delivering packages to residents. Facility Concierge Q said, Their (residents) boxes are inventoried then given to the residents. On 10/31/24 at 12:23 PM, the Administrator was queried about their process of receiving packages for residents. The Administrator said, We check their packages because we have to make sure there is not contraband . we will open before the resident or open in front of the resident. A review of R142 electronic medical record noted and admission on 11/22/2023 with a diagnosis of Hypertension, Low back pain, Falls, Prostate Hyperplasia, Chronic Embolism of Left Lower Extremity, and abnormal walking. A review of R142's Minimum Data Set (MDS) dated [DATE] noted A Brief Interview for Mental Status (BIMS) score of 14 out of 15 (intact cognition). The MDS also indicated that R142 was independent with bed mobility, sit to stand, upper body dressing, and eating. A review of R142's care plan noted the following: The resident has limited physical mobility r/t (related to) weakness. Date Initiated:12/08/2023 .Uses [NAME] .Uses Wheelchair. A review of the facility's policy Resident Rights dated 11/28/2017 noted the following: It is the practice of this facility to provide for an environment in which residents may exercise their rights, each day .Privacy and Confidentiality-The right to send and receive mail and packages. Facility staff should never open your mail unless a resident allows it.

Based on interview and record review the facility failed to allow one resident (R210) to discharge from the facility at her request until the Ombudsman intervened on 6/27/24 of six residents reviewed for resident rights, resulting in psychological distress, depression, and physical attempts at leaving the facility. Findings include: On 7/2/24 at 1:13 PM an interview with the Ombudsman was held by telephone. The Ombudsman said that on 6/27/24 following a telephone interview with R210 and R210's significant other the Ombudsman came to the facility. R210 had explained to the Ombudsman that attempts were made for 2 days to discharge AMA from the facility and the requests were refused. The Ombudsman obtained permission from R210 to advocate for discharge rights. The Ombudsman then met with the Director of Nursing (DON) who said they were not going to discharge resident R210 because they were awaiting a court guardianship hearing. The Ombudsman educated the DON concerning resident's rights. According to the EMR R210 was then discharged AMA on 6/27/24 at 4:29 PM after the intervening Ombudsman. On 7/2/24 at 2:44 PM an interview with R210 was held by telephone. During the interview R210 emphatically expressed the feeling of being stripped of my rights, I felt imprisoned, and was depressed R210 explained. I was told I had been deemed incompetent. They had put me in a lockdown dementia unit and when you are in a lockdown dementia unit they don't hear you. They don't listen. R210 explained that she had asked for two days to go home and many times in the past as well. During the final two-day period she had repeatedly and persistently requested to be discharged and had made physical attempts to discharge and had been refused. Review of the electronic medical record (EMR) revealed R210's admission into the facility on [DATE] with pertinent admission diagnoses of Encephalitis, unspecified, (an inflammation of the brain), Inhalant Abuse with other Inhalant-Induced Disorder, Cognitive Communication Deficit, Other Schizophrenia (a mental disorder), Bipolar Disorder Unspecified (a mental disorder characterized by mood swings), Major Depressive Disorder, Recurrent, Moderate, and Anxiety Disorder Unspecified. Further record review revealed that upon admission resident had a Brief Interview for Mental Status (BIMS) score of 11/15 indicating moderate cognitive impairment. Upon admission R210 signed a Consent for Treatment and signed the Admission Packet form which is subtitled Admission Agreement - Michigan. The form contains, among other items, resident rights information, financial agreement, and advance directive information. The form is 109 pages in length. Record review of the EMR disclosed a note entered by Psychiatric Mental Health Nurse Practitioner (NP) D on 6/3/24 which documented the following in part, that resident was alert and orientated to person, place, time, situation. Speech: coherent, rapid, pressured. and further documented the following in part, Capacity Evaluation completed for multi-disciplinary review and input. At this time PT (patient) has signs of cognitive decline, poor judgement, poor insight into medical conditions. On 6/17/24 a Social Worker (SW) note was entered by A which read It was explained to resident she was deemed incompetent after capacity (which a copy was shown and given to resident) was done by psych and she was in need of a guardian. Record review disclosed a nursing note entered on 6/21/24 by Licensed Practical Nurse C Resident deemed incapable of making own decision by both hospital and facility psych. Further review of the EMR notes disclosed the following note made by the Social Worker (SW) A on 6/26/24: Resident at this time deemed incompetent to make own decisions by psych hospital and facility psych and cannot go AMA on own at this time. Further record review disclosed a nursing note entered on 6/26/24 by Licensed Practical Nurse B, Resident was informed that she could not leave AMA because she was deem in competent to make her own decisions. The facility could not let her go. Review of the EMR disclosed the following note made by the DON on 6/27/24 documenting the meeting with the Ombudsman during which time the DON was informed R210 had the right to leave the facility . even though she has been deemed incapacitated to make decisions by physicians; due to the fact the guardianship hearing has not taken place yet. On 7/3/24 at 10:36 AM, Psychiatric Mental Health Nurse Practitioner (NP) D was interviewed and stated, I can only evaluate capacity. It takes a Judge to deem someone incompetent. There was no documented evidence R210 was deemed incompetent by a judge. On 7/3/24 at 2:36 PM during interview with the Administrator it was confirmed that upon admission R210 had signed the admission paperwork. Review of the Nursing Evaluation dated 5/2/24 by LPN E on day of R210's admission reads, Resident is alert . Resident speech is clear. Hand grasp is equal bilaterally. A Daily Skilled Nursing Note on 5/22/24 entered by LPN E read Resident orientation, person, situation. Makes self understood without concern. Review of the facility policy titled Resident Rights with an effective date of 11/28/17 states in part, Our residents have certain rights and protections under Federal law that help ensure appropriate care and services are provided. Our facility will provide residents with a written description of their legal rights. The document further states, Our facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The document further states, Residents have the right to exercise rights as a resident of the facility without fear of interference, coercion, discrimination or reprisal.

This citation pertains to intake MI00134840. Based on interview and record review the facility failed to provide adequate supervision when on January 31, 2023, at approximately 3:20 PM, Residnet #936 (R936), a cognitively impaired resident (BIMS of 3) eloped from the facility wearing a shirt, pants, and socks. The recorded temperature that day was 20 degrees Fahrenheit. R936 crossed Telegraph Road (a six lane highway) and proceeded to [NAME] Daly Road (approximately 1/4 of a mile from the facility). R936 was returned to the facility by police at approximately 4:00 PM. This deficient practice resulted in an immediate jeopardy on 1/31/23. R936 was at risk for the likelihood of serious injury, serious harm, serious impairment, or death related to being struck by a vehicle and exposure to extreme weather temperatures. Findings Include: Review of a complaint intake revealed an allegation by a concerned citizen that reported the following, . On January 31st at approximately 3:45pm while driving down Northline near [NAME] Daily, I noticed an older gentleman near the road looking confused and he had no jacket on. I pulled my car over, he was only able to tell me his name was (redacted), he looked confused when I asked where he lived, I noticed a yellow arm band on his wrist, but it only said Fall. I live in the area and am familiar with having three nursing homes in the area, I called the three nursing homes and described the resident to them. I proceeded to call the [NAME] police, I remained there with the gentleman until the police arrived, as they were arriving staff from one of the nursing homes, also came and said he was a resident of theirs . Record review revealed R936 was admitted into the facility on [DATE] with diagnoses of dementia (conditions that result in decreased memory loss and judgement) and schizophrenia (mental illness). According to the Minimum Data Set (MDS) dated [DATE], R936 had severe cognitive impairment and required limited to extensive assistance with Activities of Daily Living (ADLs). According to the Wander/Elopement Risk Evaluation dated 1/26/23, R936 was assessed to be at risk for elopement with a score of 7 (A score of 6 or greater indicated a risk for elopement). During an interview on 3/23/23 at 10:30 AM, the Director of Nursing (DON) said R936 had eloped (a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision) from the facility on 1/31/23. When asked to explain the incident, the DON said, The maintenance man was performing a load test (monthly performance test for the generator), when the test was performed the locked doors on the unit unlocked. R936 opened the door and went down the stairwell and left the building. We obtained this information on video camera. When asked to view video footage, DON said, It is not available anymore. When asked to review the incident report, it was not provided by the exit time of the survey. During an interview on 03/23/2023 at 10:33 AM with the Nursing Home Administrator (NHA), it was confirmed that R936 had eloped from the facility. The NHA explained that according to the video the resident (R936) exited the unit at approximately 3:20 PM alone. When asked how the facility was made aware of this elopement, the NHA said, When the police brought the resident back to the facility at 4:00 PM. According to the facility's Wandering and Elopement Guideline dated 3/17/17, . Door alarms- Any suspected or confirmed malfunctioning of any door alarm will have an immediate 1:1 supervision of the exit until repairs can be made or alternate alarm accommodations can be applied. The facility's policy did not address how staff would monitor exit doors during the load test. The Administrator was notified of the Immediate Jeopardy (IJ) on 3/23/23 at 2:50 PM due to the facilities failure to provide adequate supervision resulting in an elopement of R936. A written plan of removal for the immediate jeopardy was received on 3/23/23 and verified on 3/27/23. RESIDENT AT RISK Resident identified #936 remains in the facility and resides on the closed memory care unit. Resident identified #936 returned to the facility injury free on 1/31/2023. IDENTIFYING OTHER RESIDENTS AT RISK 1. A 100% audit was completed by facility nurse management team to identify any resident who demonstrates a risk for elopement based on the elopement risk assessment. 2. Residents identified have received an updated care plan to address interventions for monitoring each shift and additional monitoring during drills, door alarm checks, power outages, and generator load testing. 3. An audit of the Elopement Binder was conducted by the Reginal Director of Clinical Operations for accuracy and completion. PROCESSES IMPLEMENTED TO PREVENT FURTHER OCCURRENCE 1. The identified door was immediately checked and returned to functioning on 1/31/2023, the date of the incident. The door unlocked during a scheduled generator load test. The maintenance staff immediately identified this area of concern and implemented a procedure to require exit door assignments for any generator test or door alarm check. Staff are required to cover exit doors during scheduled maintenance for any process that may affect power to the doors. 2. Facility wide education was started on 1/31/2023 and continued to completion on 2/1/2023 to inform the staff of the potential risk issue associated with unlocked doors during scheduled maintenance. Staff was educated to monitor exit doors to prevent elopements. This training was conducted by the Clinical Management Team. Education has been scheduled on a quarterly basis and to all new hires to ensure continued compliance. This plan has been effective. Since 1/31/2023, there has been no further issues with elopement. 3. Maintenance staff will make overhead announcements prior to routine door alarm checks/ power outages (generator load testing) to alert staff to initiate additional monitoring for elopement risks. MONITORING 1. Residents who score a 6 or above on the wander and elopement evaluation, will be identified and monitored by staff during routine generator/door alarm checks to prevent exit seeking behavior. 2. Random weekly staff inquiries are in place to ensure staff have an understanding of the Wandering and Elopement Guidelines for a period of 6 week then as needed moving forward. 3. These audits will be reviewed and discussed at the facility monthly QAPI Committee. 4. The Administrator is responsible for substantial compliance of this Plan of Action The facility alleges the immediacy of these discrepancies have been removed on 2.1.2023. Although the immediate jeopardy was removed on 2/1/23, the facility remained out of compliance at a scope of isolated and severity of no actual harm, with the potential for more than minimal harm that is not immediate jeopardy due to sustained compliance had not yet been verified by the State Agency.

This citation pertains to intake MI 578. Based on observation, interview, and record review the facility failed to properly maintain two mechanical lifts (Lift #1 ,Lift #2) when two (R17 and R47) of nine residents reviewed for accidents fell to the floor because a bolt broke off the mechanical lifts during transfers of R17 and R47 resulting in injury and the potential for injury. R17 sustained a compression fracture of the T12 vertebrae. R47 did not sustain any injury. Findings include: Lift#1, R17: According to the 'Event Report' dated 11/18/21 at approximately 12:00 PM, R17 was being transferred with a mechanical lift (Lift #1). The mechanical lift broke, dropping R17 to the floor. The resident was assessed and transferred out to the emergency room for complaints of pain. The Hospital's emergency room note dated 11/18/21 at 1:10 PM indicated the resident fell straight down on butt from mechanical lift that broke during transfer at approximately 1 - 2 feet from the floor. The patient is not in acute distress. CT scan of the thoracic spine shows an Anterior wedge compression fracture of T12 (thoracic vertebrae 12, lower back area) that is of uncertain age but given the patient's reported history and acute process is not excluded. According to the physician's impression on 11/18/21 at 2:13 PM the patient (R17) had a T12 compression deformity. CT of thoracic spine shows a compression deformity of the T12 although it is 'age indeterminate' (can't tell if it is old or new) the recent fall very well could be acute (new). The closed medical record review revealed that R17 admitted to the facility with multiple diagnoses that included: [CONDITION(S)], history of stroke with left sided [CONDITION(S)], diabetes type 2, and [CONDITION(S)]. The Minimum Data Set (MDS) dated [DATE] indicated that R17 had moderately impaired cognition and required 2 persons with the use of the mechanical lift for transfers. A progress note dated 11/18/21 at 12:00 PM written by Licensed Practical Nurse (LPN) F documented that she observed R17 laying on her back on top of the mechanical lift's legs. R17 had no visible injuries and was able to move all four extremities. R17 complained of back and neck pain. 911 was called immediately to transport to the hospital. On 3/3/22 at approximately 12:00 PM during an interview with LPN F she said she was called to the room on 11/18/21 by an agency Certified Nursing Assistant (CNA) and observed the mechanical lift (Lift #1) had broken at the bottom part and R17 was laying on the legs of the mechanical lift on her back with the upper part of the lift intact and sling underneath her. The pin had broken from the bottom, underneath the cylinder part. It was confirmed that LPN F was describing the bolt underneath the electric [MEDICATION(S)] ([MEDICATION(S)] is the cylinder-shaped mechanism that is the power source to lift the load). LPN F went on to say that a similar incident had occurred in February with another resident (R47) and another lift (Lift #2). LPN F confirmed that Lift #1 had been taken out of service and this was another lift, but the same type. LPN F said Lift #2's pin broke in the same spot as R17's incident in November. LPN F confirmed that she was again referring to the bolt that is underneath the [MEDICATION(S)]. Lift#2, R47: According to the 'Event report' dated 2/15/22 at 2:30 PM R47 was being transferred from bed to wheelchair when mechanical lift (Lift #2) broke, and resident landed on her back on the legs of the lift. R47 did not sustain any injury. A progress note on 2/15/22 at 15:50 written by LPN F reported resident observed laying on her back on top of the mechanical lift's legs. Resident did not hit her head and there were no visual injuries. There was a malfunction of the mechanical lift. X-rays were taken and no fractures were noted. On 3/3/22 at 12:30 PM R47 was interviewed regarding the broken lift incident on 2/15/22. R47 said she was getting into wheelchair and before the CNA's got her over the wheelchair the lift just broke and she landed on her butt and back. R47 denied any injury. According to R47's medical record she admitted to the facility with multiple diagnoses that included [CONDITION(S)], [CONDITION(S)], and Diabetes type 2. The Minimum Data Set, dated dated dated [DATE] indicated R47 had no cognition deficits and required 2 staff persons with the assist of a mechanical lift for transfers. According to the User's Manual for Lift #1 and Lift #2; The electric [MEDICATION(S)] is the mechanism attached to the base of the mechanical lift (mast) and the boom (extending arm). The electric [MEDICATION(S)] is the power source that extends the boom, lifting the load (resident) when the 'UP' button is pressed on the controller. Page 18 of the User's manual indicates that the bottom of the electric [MEDICATION(S)] will already be assembled to the mast mounting bracket upon delivery. Page 41 Maintenance Schedule for The Hydraulic Pump/Electric [MEDICATION(S)] Assembly indicated inspection of hardware on the mast and boom and to check for wear or deterioration is to be institutionally inspected and adjusted monthly with and 'in-home' inspection every 6 months. On 3/2/22 at approximately 3:30 PM, Maintenance Director, MD L, along with Administrator AA, and Director of Nursing (DON) BB produced Lift #1 and Lift #2 for observation. MD L said both lifts had been stored in the facility's garage. MD L said Lift #1 had been out of service since the incident on 11/24/21. Lift #1 was observed to have a bolt missing from underneath the electric [MEDICATION(S)] that was previously attached to the mast. MD L could not produce any maintenance or service records on Lift #1 prior to the incident on 11/18/21, nor could he produce the broken bolt. Lift #2 was observed to be missing the bolt underneath the electric [MEDICATION(S)] that connected to the mast, in the same place as Lift #1. Lift #2's [MEDICATION(S)] had a plastic piece covering it that was broken. MD L provided a maintenance record for Lift #2 dated 12/20/21 indicating the lift was inspected and acceptable for use. MD L could not produce the broken bolt for Lift #2. It was noted that Lift #2 had a scale (attached component to weigh residents) on it and Lift #1 did not. MD L said the scales can be interchanged between lifts. MD L said an outside company had recently been contracted to perform service and provide mechanical lifts to the facility. Administrator AA confirmed that the contracted company had been in the facility last week. On 3/2/22 at approximately 4:00 PM the Contracted Service Technician (ST) I said the facility had contacted the company on 11/23/21 for a service estimate on their Mechanical Lifts. On the first visit on 12/20/21, Lift #1 was observed to have a missing bolt from underneath the [MEDICATION(S)]. ST I said he was told the bolt had broken. ST I said he had never seen or heard of that before and asked to see the broken bolt. It was not provided to him. ST I confirmed he was in the facility on 2/28/22 and observed Lift #2 with a missing bolt underneath the [MEDICATION(S)]. ST I said he was surprised that two lifts could have a broken bolt in the same spot and asked to see the broken bolt for Lift #2. ST I said the bolt was not provided. ST I said he had been contracted by the facility to provide services for mechanical lifts to the facility and placed a sticker on each lift he inspected on 2/28/22. On 3/8/22 at approximately 9:35 AM observations of the two mechanical lifts on the 2nd floor revealed they were new lifts that were not similar in design as Lift #1 and #2. Both lifts were functional and had current inspection date stickers that were less than 3 months old. Observations of the two mechanical lifts on the 3rd floor revealed one newer lift that belonged to a rental company that was not similar in design to Lift #1 and #2. The other lift was the same type as Lift #1 and #2. It had a P/M inspection date sticker of 2/28/22 from the contracted company. This lift was in the Dining Room with a dead battery. Observations of the two mechanical lifts on the 4th floor were like Lift #1 and #2. Both lifts were operational and had P/M inspection stickers of 2/28/22. There were no mechanical lifts on the 5th floor.

This citation has two deficient practice statements and pertains to the following Intakes MI 1424, MI 1939, and MI 3578. Deficient practice #1. Based on observation, interview, and record review, the facility failed to properly use a mechanical lift on two occasions for one resident (R17) of nine residents reviewed for falls/accident by 1) failing to ensure R17 was safely transferred during a '2 person with mechanical lift' transfer resulting in a fractured 2nd toe of the right foot and 2) failing to properly use the 'emergency release' process on (Lift #1) when the mechanical lift's battery died during the transfer resulting in R17 being lowered to the floor by staff and subsequently sustaining nondisplaced (bone cracks/fractures in proper alignment) fractures of left tibia and fibula (shin bones). Findings include: According to an 'Event report' dated [DATE] at 5:00 PM, R17's right foot got caught on the mechanical lift during a transfer from wheelchair to bed. R17 sustained a skin tear that was bleeding between right toes 1, 2 and 3. (Great toe, and 2nd and 3rd right toes). An X-ray report on [DATE] at 8:00 AM revealed a fracture of the base of the right 2nd proximal phalanx (right 2nd toe). The Nurse Practitioner ordered a splint, and the Podiatrist was consulted. Pain management was prescribed. No surgical treatment was recommended. On [DATE] at 12:00 PM during an interview with Licensed Practical Nurse (LPN) F she said on [DATE] she was called to the room by a Certified Nurse Assistant (CNA) Y and saw blood on the resident's right foot. Two CNAs Y and Z had assisted the resident with transferring back to bed but somehow the resident's right big toe got stuck on the lift during transfer. The resident had a skin tear between the big toe and the second toe. The skin tear was assessed, treated, and X-rays were taken. The resident did have a fractured second toe on her right foot. LPN F said neither CNA Y or CNA Z s who assisted with the transfer currently work in the facility. According to an 'Event report' dated [DATE] at 8:45 AM, R17 was being transferred from bed to wheelchair with 2 persons and a mechanical lift, while transferring the mechanical lift's battery died . Resident was lowered to floor while waiting on functional battery pack. No injury, skin intact, no bruising. Resident safely transferred to wheelchair. According to a progress note dated [DATE] at 6:05 PM, R17 complained of left leg pain and x-rays were ordered. On [DATE]at 4:00 PM, a progress note reported the following X-ray results: Acute (sudden onset) Nondisplaced transverse proximal tibial shaft fracture. Nondisplaced proximal transverse fracture through the fibular shaft. R17 was transferred to the ER (emergency room ). R17 had been treated for leg pain. On [DATE] at 2:42 PM during an interview with LPN D she said she was present during the transfer of R17 on [DATE] because she had just completed wound care for R17. LPN D said that R17 was crying and complaining of pain during the wound care treatment prior to the transfer. During the transfer two CNAs were assisting and the lift stopped working while the resident was suspended about 2- 3 feet above the floor over the wheelchair. LPN D said the nurse unit manager went to the get a fully charged battery and upon return the new battery did not work. At this time the wheelchair was moved, the 'emergency release' red button was pushed on (Lift #1) and R17 was slowly lowered to the floor with four staff members holding the sling. LPN D confirmed that she did not know how Lift #1's emergency release was done at the time of the incident. LPN D confirmed that R17 was lowered to the ground in the sling with 4 staff persons instead of activating Lift #1's 'primary emergency release'. LPN D said, She (R17) was not abruptly dropped or jolted downward toward the floor. I immediately assessed her (R17) and there were no visible signs of injury, and she (R17) had no change in level of pain to her (R17's) legs. I cannot understand how this resulted in a fracture. According to the user manual for Lift #1 (Lift#1 is the type of mechanical lift that was used to transfer R17 on the [DATE] incident). If the Electric [MEDICATION(S)] (mechanism that lifts the load) fails to lift when 'up' button is pressed on the controller. It may be due to the following: Battery low, or the RED emergency stop button is pressed IN. Solutions included the following: Rotate RED emergency stop button CLOCKWISE until it pops out, or Replace the battery pack. Activating a Mechanical Emergency Release Primary Emergency Release To activate the primary emergency release, insert a pen into the hole labeled emergency on the control box of the lift and push down on the boom at the same time. All lift actuators are equipped with a (secondary) mechanical Emergency release. The (secondary) mechanical release will enable the [MEDICATION(S)] to retract (lower the load) without power. The [MEDICATION(S)] will only retract while under load (has weight on the lift) and the mechanical Emergency release is pulled. The release is colored reddish orange with the word Emergency spelled out in white. On [DATE] at 9:45 AM during an observation of Lift#1, a blue control box had a red knob that has arrows pointing in a clockwise direction. The red knob needs to be turned, not pushed. According to the user's manual pushing this red button causes Lift#1 to stop, not release. The word 'Emergency' in white letters is underneath this red knob, next to a small hole. The small hole has a white arrow pointing downward underneath it. According to the user's manual inserting a pen into this hole is the primary emergency release procedure. Lift #1's 'secondary' emergency release was observed to be a reddish-orange plastic 'release' on the base of the lift and has the word Emergency in white on it. The closed medical record review revealed that R17 admitted to the facility with multiple diagnoses that included: [CONDITION(S)], history of stroke with left sided [CONDITION(S)], diabetes type 2, and [CONDITION(S)]. The Minimum Data Set (MDS) indicated that R17 required 2 persons with the use of the mechanical lift for transfers. A review of R17's hospital record revealed R17 arrived at the emergency roiagnom on [DATE] with diagnoses of nondisplaced fracture of right tibia and fibula. On [DATE] R17 underwent surgical repair for these fractures and returned to the facility on [DATE]. On [DATE] at approximately 3:00 PM, Administrator AA said R17's sustained injuries during transfers on [DATE] and [DATE] that both involved mechanical lift transfers. The incident on [DATE] most likely resulted from the resident moving her foot during the transfer and getting her toe caught on the lift. It is unknown what type of lift was utilized in this incident. There were 2 CNAs present and no problems with the lift. During the [DATE] incident, the battery died during the transfer and when the battery was replaced, the second battery was also dead. During out investigation we concluded that the primary 'emergency release' procedure was not used and R17 was lowered to the floor in the sling by staff. Training was conducted with all nursing staffing in [DATE] that included proper transfer technique, primary 'emergency release' procedure for Lift #1, and battery charging. Administrator AA said there has been no other events or accidents regarding improper transfers, use of the 'emergency release' or dead battery. The facility is in the process of obtaining new lifts and currently renting other lifts from an outside company that do not have that type of emergency release or battery. On [DATE] at 2:30 PM CNA S and CNA T were observed using a mechanical lift that was the same type as Lift #1. During interview both CNAs said they were from an agency and had not received any special training from the facility how to use the mechanical lift if it stopped working. Both CNAs said they would get the facility nurse (LPN M) if this happened. There were no concerns with the use of the lift. On [DATE] at approximately 3:00 PM LPN M confirmed she had received training on use of the mechanical lift but could not recall if the pen was to be put in the hole first or the reddish-orange button pulled first. On [DATE] at 9:30 AM on the 3rd floor a mechanical lift, the same type as Lift #1 was observed in the Dining Room and not functioning. CNA V confirmed the mechanical lift was not functioning and said, the battery is dead. CNA V confirmed she had received training on the mechanical lift but did not replace the dead battery because the charger was up on the 4th floor. CNA V said she used the other mechanical lift on the floor. Another mechanical lift that was not the same type at Lift #1 was observed on the 3rd floor that was functional. On [DATE] at approximately 12:00 PM with LPN F observations of the 4th floor storage room behind the nurse's station that housed the 'mechanical lift battery chargers' for the type of mechanical lift as Lift #1 revealed two battery chargers but only one was plugged in. Neither charger had a battery 'charging' on it. Three batteries were on the shelf next to the chargers. LPN F placed each battery on the charger and found all the batteries needed to be charged. According to the facility's 'Full Body Mechanical Lift Equipment and Guideline' dated [DATE]. Purpose: This guideline outlines the actions that are required for mechanical lift application and use. Always read the manufacturer's guideline prior to using any mechanical lift or equipment for the care and service of our residents. Procedures included, Have your coworker support the Resident ' s legs, move the lift and Resident away from the bed. Position the lift so the Resident ' s back is toward the chair and align the chair so the Resident can be lowered into it. Deficient Practice Statement #2: Based on observation, interview, and record review the facility failed to 1.) consistently supervise one resident (R35) from wandering into two other resident's rooms resulting in the potential for accidents, resident - to - resident altercations, and invasion of privacy during ADL (activities of daily living) and 2.) provide adequate one-to-one supervision for one (R11) to prevent a resident-to-resident incident resulting in a potential for injury. Findings include: Complainant reported to the State Agency that the facility failed to prevent R35 from wandering into other resident's room (R7 and R43). On [DATE] at 8:20 AM Licensed Practical Nurse (LPN) LL was administering medications to R7 a female resident when R35 wandered into the room. LPN LL had to suspend medication administration to redirect R35 out of R7's room. LPN LL said, He does this all the time, he doesn't cause any problems just wanders in other resident's rooms. R7 said, I want him out!. On [DATE] at 8:30 AM, R43 and R44 are seated in their wheelchairs inside the doorways of their rooms. R43 said that R35 wanders into her room all the time. He never says anything or does anything he just comes in my room and looks out the window. Sometimes he lays down in the empty bed and takes a short nap. R44 confirmed that R35 wanders into his room and does the same thing. Both R43 and R44 are in rooms at the very end of the hall. Both have an empty bed in their room. According to the Minimum Data Set (MDS) dated [DATE] R35 has multiple diagnoses that include non-traumatic brain injury and dementia with severe cognition impairment. The MDS indicated that R35 is independent with ambulation but requires supervision by one staff person. On [DATE] at 8:30 AM R35 was observed standing outside R43's doorway, looking inside. R43 loudly said No, get out and moved her wheelchair into the doorway of her room. R35 walked away without incident. There was no facility staff observed in the hallway. R43 said, I feel like I have to stay in my room to prevent him from coming in here. I don't want to complain but isn't there something I could put across my doorway to keep him out? On [DATE] at 8:50 AM LPN MM confirmed that R35 wanders into R7 and R43's room at times because it is at the end of the hallway. LPN MM said, They (staff) usually watch him, but right after breakfast everyone is busy with other residents. Deficient Practice #2 Based on interview and record review the facility failed to supervise one resident (R11) of one resident placed on 1:1 supervision resulting in another resident being shaken and pushed out of their wheelchair and onto the floor. Findings include: On [DATE] at 3:08 p.m., the facility submitted a facility investigation and other pertinent documentation regarding a facility reported incident (FRI) that occurred on [DATE] at approximately 11 p.m. It was reported R11 was observed shaking and pushing the wheelchair of another resident, causing the other resident to slide out of the wheelchair. This incident occurred while R11 was on one-to-one supervision by staff for aggressive behavior towards other residents and staff. Review of the electronic clinical record documented R11 was initially admitted into the facility on [DATE] with diagnoses that included traumatic brain injury and history of homelessness. According to the admission MDS assessment dated [DATE], R11 was cognitively intact with a BIMS score of 14 and required extensive assistance with most ADLs. The electronic record also documented R11 was petitioned out to the hospital on [DATE] and [DATE] for aggressive behavior towards staff and another resident. R11 was discharged to the hospital on [DATE] and did not return to the facility. The Behavior Care Plan dated [DATE] documented: The resident is/has potential to be physically aggressive regarding to anger and poor impulse control. There were no previous care plans regarding the history of R11's aggressive behaviors with interventions. Further review of the facility's investigation documented a witness statement from Nurse Supervisor OO which stated, I was assigned to (resident's name) from 11:00 p.m. to 7:00 a.m. (midnight shift) for one-to-one supervision. I was sitting right outside of the door with the door slightly closed when I heard yelling. We immediately went into the room, and I observed the resident shaking the wheelchair that (another resident's name) was sitting in. As I was separating them, the resident (R11) began to get very aggressive towards me. The other resident slid out of the wheelchair. On [DATE] at 2:27 p.m., Nurse Supervisor OO was called for an interview but was not available. On [DATE] at 2:39 p.m. the DON was interviewed. The DON confirmed R11 was on a one-to-one supervision the evening the incident occurred ([DATE]). When asked about the lack of adequate supervision provided to R11, the DON stated, The nurse was doing a one-to-one outside of the room because the resident didn't want her in the room and was getting mad. He had been combative with staff. The night before, the resident threw a television across the room when the nurse tried to give medication. The resident also has the right to privacy. The resident was in the room alone and the other resident entered the room through the bathroom. The DON was asked to provide documentation reporting R11 was combative with staff and not wanting staff to enter the room. That information was no provided by the DON.

This citation pertains to intake MI 5669. Based on observation, interview and record review the facility failed to:1.) provide adequate supervision during an activity in the courtyard and 2.) provide adquate staff training to prevent elopement in 1 of 3 residents (R #26) reviewed for elopement, from a total sample of 33 residents, resulting in an immediate jeopardy for R#26 who was a high elopement risk, who eloped on 5/17/21 at 2:08 pm from the courtyard during an activity. R#26 was found approximately 49 minutes later, after crossing a 5 lane 45mph road, at a local restaurant 0.5 miles away and was escorted back to the facility by facility staff and police at 3:45pm on 5/17/21. This deficient practice placed 39 additional residents at risk for serious injury, harm, and/or death. Findings include: On 5/17/21 at approximately 2:08 PM, an overhead announcement of Code White was heard. Observation was made of staff members searching the interior and exterior of the building. One staff member was asked what Code White meant, to which they responded, Missing resident. In an interview on 5/17/21 at 2:58 PM, the facility's Administrator was asked about the missing resident alert. Administrator said (R#26) was walking with Activities Aide (Aide A) in the outdoor courtyard when he eloped. Administrator state the resident was located at a local restaurant at 2:55 PM. Review of the Face Sheet revealed that R#26 was admitted into the facility on [DATE] with diagnoses which included [CONDITION(S)], cognitive deficit, depression and [CONDITION(S)]. Review of a Minimum Data Set, dated dated dated [DATE] documented moderate cognitive impairment. Review of the Elopement Risk assessment dated [DATE] revealed R#27 scored a 28.0 (total score of equal to or greater than 6 is at risk). Review of the care plan titled, The resident is an elopement risk/wander related to verbal displays of wanting to leave dated 3/3/21 revealed interventions of frequent monitoring and staff aware of residents wander risk. In an interview on 5/17/21 at 3:15 PM, Activities Aide (AA) A said that she had been hired approximately 3 weeks ago by the facility to work as an Activities Aide on the secured Dementia Unit. AA A indicated that she told R#26 that she would take him for a walk in the outdoor courtyard after lunch. AA A reported that at around 1:55 PM she took R#26 off the secured Dementia Unit and was walking next to him along the courtyard path. AA A stated that she stopped to tie her shoe and the resident was gone. I went and looked for him, but he was gone. So I told another staff member (AA B) to help me look for him. AA A reported she was unaware that R#26 was assessed to be a high elopement risk . AA A stated, They didn't tell me nothing about him. AA A reported she had not received any training about runners (high elopement risk residents) since her hire. At 3:35 PM, AA A was asked to reenact the events from earlier that day. AA A walked around the pathway in the outdoor courtyard and reported that R#26 was right by her side. Observation in the courtyard, in four different areas, was of alarm buttons in that said Push for Help. Aide A said she was not aware of the call for help system. On 5/17/21 at 5:15 PM, with the facility's Administrator and Nurse Consultant P the video for the elopement event was reviewed. Camera 5 revealed the courtyard area and pathway. On 5/17/21 at 2:00 PM the video revealed AA A walking in the opposite direction of R#26, with her back to the resident unsupervised. At 2:03 PM, AA A was observed walking alone in the courtyard,R#26 was not visualized on the camera view. At 2:06 PM, AA A was again seen walking, but away from R#26. At 2:08 PM, R#26 was seen scaling up a playground slide and then out of site of the camera. AA A was not in camera view at this time. The Administrator was asked if based on what she saw on the video and what the residents plan of care was, did AA A provide sufficient supervision to prevent elopement. The Administrator stated, No. She should have been closer to the resident. In an interview on 5/17/21 at 4:14 PM, with AA B and the Activities Director (AD C). AA B said that she was asked to help search for R#26, but after searching for about 5 minutes without success, she and AA A reported the missing resident to the receptionist, who subsequently announced a Code White overhead. AD C reported that she told AA A that anytime she has a resident from the fifth floor (the locked dementia unit) outside to keep them right by your side. Keep your eyes on them at all times. AD C reported that resident's that were assessed to be at high risk for elopement have a photo posted at the front reception area. This survey and AD C observed the reception area and noted there was no photo of R#26 posted to notify staff that he was a high elopement risk. Review of the facility 3/16/17 policy titled, Wandering and Elopement Guideline documented, .At any time during a resident stay there may present indication of an elopement risk. Example: Making statements of wanting to leave, attempting to actively exit or wear coat making statements of have an appointment etc. It is the responsibility of our staff to remain with the resident until a licensed nurse is able to conduct an evaluation. Following the evaluation the licensed nurse together with an interdisciplinary team including a nursing assistant, and representative from Social Services, and / or designee, the physician, and resident representative will determine appropriate continued interventions and modify the plan of care as appropriate. Documentation of this process will be included within the medical record . The Administrator was notified of the Immediate Jeopardy (IJ) on 5/18/21 at 10:48 am, due to the facilities failure to provide adequate supervision and training to prevent the elopement of R#26 on 5/17/21. On 5/19/21, the surveyor verified the facility took the following steps to remove the immediacy: 1. R#26 was escorted back to facility at approximately 3:45 pm by facility staff and police after leaving the facility grounds at approximately 2:06pm. R#26 was reassessed for Elopement/Wandering Risk, care plan was reviewed/updated on 5/17/21. 2. All residents have the potential to be affected. Facility Clinical Managers completed 200 resident Elopement/Wandering Assessments, of those 200, 40 were identified with a score of 6 or higher, 40 care plans were reviewed/updated on May 17,2021 at 9:00pm. 3. Some of the Play Scape slide was removed at 6:00pm on May 17, 2021. The remainder of the Play Scape was removed on May 18, 2021 around 12:00pm. 4. Facility exit doors/courtyard alarm systems were checked to ensure alarms were in place and working on May 17,2021 by the Maintenance Director or designee. Maintenance Director replaced 2 of the 4 Courtyard alert system batteries on May 17, 2021. Facility exit doors/courtyard alarm systems were rechecked on May 18, 2021; all systems were found to be working. 4. On May 18, 2021 facility initiated facility staff education on courtyard alert system, facility staff will be educated on this before the start of their next scheduled shift. 5. An audit of the Elopement Books and front reception picture wall were conducted by the Administrator and Assistant Administrator on May 17, 2021 at 7:00pm. A total of 3 resident photos were identified not to be in the books and a total of 7 resident where added. 6. The facility Administrator and Director of Nursing reviewed guidelines on Wandering and Elopement and deemed the guidelines appropriate on May 17,2021. 7. Facility staff have been/are being educated on the guideline Wandering and Elopement by Assistant Administrator/Unit Managers, starting on May 17, 2021 continuing until all facility staff has been educated. As of 12:00pm on May 18, 2021, 151 staff members have been educated. Staff members who have not received the education will be required to prior to starting next scheduled shift. The education provided was verbal lecture and visual guideline hand out. 8. Activity Staff Member AA A was been suspended pending investigation on May 17,2021, prior to return on May 19, 2021 and will have 1:1 education on the Wandering and Elopement guideline and will receive additional Relias Training on Dementia and Elopement/Wandering Residents before returning to the floors. 9. Starting on May 18, 2021 at 9:00am facility exit doors/courtyard alarm systems tests will be conducted by the Maintenance Director or designee daily x 4 weeks, then 5x's week moving forward. Although the immediate jeopardy was removed on 5/19/21, the facility remained out of compliance at a scope of isolated and severity of no actual harm, with the potential for more than minimal harm that is not immediate jeopardy due to all facility staff had not received education and sustained compliance had not yet been verified by the State Agency.

This citation pertains to intake numbers MI 962. Based on interview and record review the facility failed to perform neurological assessment (neuro checks-including pulse, respirations,blood pressure, pupil size and reactivity, equality of hand grip strength, motor function, pain response and level of consciousness) after a fall with head injury for 1 of 5 residents (R#20) reviewed for falls, from a total sample of 33 residents, resulting in likely undetected mental status changes. R#20 was pronounced dead on [DATE]. Finding include: Review of the Face Sheet revealed that R#20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission nursing assessment dated [DATE] documented that R#20 was confused and only oriented to self and required maximum staff assistance with transfers. Review of the initial skin assessment dated [DATE] documented bilateral discoloration back of both hands, left elbow, scar mid chest, pressure ulcer left lower extremity for R#20. There was no documentation of any scabs noted to the head. Review of the Fall Risk assessment dated [DATE] revealed R#20 had a score of 21 (Fall risk score above 5 indicated a high risk for falls). Review of the Falls care plan dated [DATE] revealed, (R#20) is at risk for falls r/t Dementia. Interventions included: .Do not leave resident unattended in the bathroom and anticipate and meet the resident's need. A [DATE] nurses note documented Patient incontinent bowel and bladder (B&B). Unable to make needs known .Call light within reach. Pt is unable to demonstrate use of call light . A [DATE] 19:33 nurses note documented, Resident was up in the chair for over an hour and was cleansed and assisted to bed for Dinner . Few minutes later Resident roommate call and stated (residents name) was on the floor . This writer was notified Head to Toe assessment done, vital signs (VS) within normal . Lacerations noted to part of the head. Physician (MD) notified order for Skull X-Ray and Ointment Topically . Family notified Spoke with (name of daughter) . Reported to night nurse to monitor. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Skull Complete, minimum 4 views. Reason for exam: Post fall and head laceration. Priority: Stat (as soon as possible). Order time: 6:40 pm. A [DATE] at 00:44am (5 hours and 15 minutes later) Discharge/Transfer Summary Note: Resident found unresponsive, CPR initiated, and 911 called. (name of local city) fire dept arrived to take over. Resident's time of death 12:20 am. Resident's daughter called and made aware. Per family request (Name of funeral home) called to pick up body. Review of the facility provided documents revealed the following: -Report of resident fall (Incident/Accident) dated [DATE] (2 days after the fall on [DATE]). Resident (R#20) was up in the chair as requested per resident for an hour then was cleansed and assisted to bed for dinner. Few minutes later residents roommate call and stated (name of resident) was on the floor. Assigned nurse (Licensed Practical Nurse/LPN T) was notified and performed head to toe assessment to assure no injuries .Small open area noted to head, resident has multiple scabs noted to head prior to admission related to dry skin. The part of the head that has area of concern appears to be possible scab that came off during said fall .MD notified and new orders were received to obtain skull x-ray as well as ointment to to be applied to small area noted .Night nurse to continue with neuro checks and observe for changes. Assigned Certified Nurse Assistant (CNA K) educated to observe for changes and report any changes in condition . Review of the medical record revealed there was no evidence of neurological checks being performed for R#20 after the fall with head laceration. There was no evidence that the Skull x-ray was completed. Review of the Neurological Assessment Flow Sheet revealed neuro checks are to be completed every 15 minutes for 1 hour, every 30 minutes for the next 2 hours, then hourly for 2 more hours, then every shift for 72 hours. Neuro checks included level of consciousness (alert, drowsy, tuporous, comatose), pupil response (PERL, brisk, sluggish, nonreactive, pinpoint, dilated, fixed), hand grasps (equal, right greater than left and visa versa, unable to follow commands, and absent) and extremety motor function (moves all extremities to unable to follow commands), pain response, and vital signs In a telephone interivew on [DATE] at 2:15 pm, LPN T reported she did not complete an incident/accident report and start neuro checks after R#20 fell and hit his head on [DATE]. When queried what the facility's protocol was after a resident falls with a head injury, Nurse T became quite and asked to end the phone call. On [DATE] at 2:25 PM, the Director of Nursing (DON) was asked to provide the neurological assessment for R#20. On [DATE] at 3:50 PM, upon entering the DON's office, Unit Manger (UM I) was observed sitting across from the DON copying information from one Neurological Assessment Flow Sheet to another Neurological Assessment Flow Sheet and stated, I'm recopying them so that they are clearer to read. Upon comparing the two Neurological Assessment Flow Sheets the documentation did not mirror each other. 1. Document #1 had 10 date and timed entries; Document #2 had 11 date and timed entries. The entry times differed from each other. 2. Document #1 indicated that R#20 had a change in level of consciousness (from alert to drowsy) at 10:15 PM; Document #2 indicated the resident was alert from 7 PM up until 12 AM. 3. Document #1 indicated the residents vital signs were within normal limits at 12:15 AM. A [DATE] at 00:44 Discharge/Transfer Summary Nursing Note documented, Resident found unresponsive, CPR initiated, and 911 called. Resident's time of death 12:20 AM (5 minutes after the resident's vital sign were documented as being within normal limits). 4. Both Neurological Assessment Flow Sheets had dated entries of ,d+[DATE] (21) to ,d+[DATE] (21). Resident R#20 was admitted into the facility for the first time on [DATE] (47 days later). 6. The intialed signatures appeared identical to this surveyor. On [DATE] at 4:43 PM, during an interview with UM I she was queried regarding the Neurological Assessment Flow Sheets she was observed recopying. UM I said that the nurse who completed the original Neurocheck sheet handwriting was very terrible so she got permission from the nurses to recopy and sign the form. UM I was asked to provide a copy of the original form to which she said, I cannot find it. UM I could not explain why she was recopying the form for a third time. UM I could not explain why if all she was doing was recopying to make it clearer to read, the documents did not mirror one another. In an interview on [DATE] at 2:50 pm Director of Nursing (DON) stated, The nurse is to complete a fall incident report and start neuro checks to make sure the resident does not have a change in mental status. Review of the facility's policy titled, Fall Evaluation Safety Guideline dated [DATE] documented, Residents who are evaluated as being at risk for falls will be identified and individualized fall precautions will be developed for each resident. Preventative measures shall be taken to decrease the number of falls whenever possible. PURPOSE: 1. To consistently identify and evaluate residents who fall and to treat or refer for treatment appropriately. 2. To achieve each resident's maximum potential of physical functioning. 3. To prevent or reduce injuries related to falls. 4. To enhance resident dignity and self-worth. 5. To rehabilitate residents to their fullest potential of function. 6. Individualize interventions for each resident. The policy did not address neurological assessment after a fall with head injury.

This citation pertains to intake number MI 9604, MI 9256, MI 5431, MI 0311. Based on interview and record review the facility failed to provide timely weight monitoring for four sampled residents (R#'s 33, 1, 17, and 18) out of four residents reviewed for weight status from a total sample of 33, resulting in undetected significant weight loss and compromised nutritional status, and the potential for further decline in nutritional status and undetected weight loss to occur. Findings include: R#33 Review of the Face Sheet revealed that R#33 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set Assessment (MDS) dated [DATE] indicated the resident required extensive 1 person assistance with eating and had moderately impaired cognition. Review of the Comprehensive Nutritional assessment dated [DATE] revealed, He was unsure what his UBW (usual body weight) was but stated that he feels like he lost weight. Per hospital documentation, his current weight is 152# (pounds) .The Nutritional-Focused Physical Findings: General appearance is: thin, moderate orbital and [MEDICATION(S)] fat loss moderate temporal muscle loss. Resident is not well nourished. Body Fat and Muscle Mass completed. Resident has moderate fat loss. Resident has moderate muscle loss . Nutrition Intervention: Modify diet to Low fat/low cholesterol, NAS (no added salt), continue pureed texture, honey thick liquids per SLP (speech therapy), obtain weight, encourage PO intake . The only weight taken at the facility was on 5/7/21 (15 days after admission into the facility) documenting R#33's weight as 136.5 pounds. Review of the 4/26/21 care plan titled, At risk for malnutrition related to (r/t) dysphagia (difficulty swallowing), stroke, low Body Mass Index (BMI) for age, fat and muscle loss, difficulty chewing r/t poor dentition as evidenced by pureed diet with honey thickened liquids. Goal: Resident will consume an average of at least 75% of food/beverages at meals. Interventions: Evaluate any weight changes. Determine percentage changed and follow facility protocol for weight change, obtain and document weights per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Food Acceptance Records (FAR) for April 2021 indicated R#33 began having an food intake decline from 75-100% of meals to 26-50% of meals from 5/12/21 to 5/20/21 (date of discharge to hospital). Review of the Progress Notes and medical record revealed that R#33 was discharged to the hospital on 5/20/21 with a hospital weight of 116.6 pounds. Review of the hospital record dated 5/20/21 revealed, Physical Exam: Appearance: He is underweight. In an interview on 5/27/21 at 1:49 PM, Registered Dietician (RD) F calculated the facility weight to the hospital admission weight (136.5 to 116.6 pounds) and stated, It's a 15.7% weight loss in 13 days. Yes, that is a significant weight loss. RD F said I would do a reweigh. I personally did not ask for a re-weigh. That's good rationale for getting weight upon admission. He was determined to be at nutritional risk before the weight difference was identified and staff did not inform me that he was not eating. RD F stated, I personally would have put an order in for a supplement. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/25/2021 at 3:00 PM, Registered Dietitian (RD E) stated that it was the facility's policy to obtain resident's weight upon admission or readmission. A review of the facility's guidelines for weight monitoring did not provide a specific time frame for obtaining admission/readmission weights. RD E indicated that in her expert opinion a reasonable time frame to obtain initial weights was within 24 to 48 hours. RD E added that admission weights are needed to see where the resident's weight is at. So, we can calculate their estimated nutritional needs. We compare (the admission body weight) to usual body weight and hospital weight. We obtain weekly weights after that if there is a discrepancy. RD E added the interdisciplinary team determines the frequency of weight monitoring for new admissions. A review of the electronic health record (EHR) for the following residents was conducted with RD E and the following was revealed: Resident #1 (R1) R1 was admitted into the facility on [DATE] and discharged on [DATE]. R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Weights obtained on R1 included: 177# (6/5/2020), 167.2# (6/10/2020), 140.2# (7/3/2020), and 141.4# (7/23/2020). A weight change note on R1, dated 6/23/2020, was in reference to the weight of 167.2# obtained on 6/10/2020. This note indicated to reweigh R1. The reweigh did not occur until 7/3/2020. During the interview on 5/25/21 at 3:00 PM, RD E indicated that almost a month should not have passed before R1 was weighed again. RD E said, I think it would have been beneficial to have another weight between (6/10/2020 and 7/3/2020) because we questioned the accuracy of the weight. Resident #17 (R17) R17 was admitted to the facility on [DATE] and discharged on [DATE]. R17's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The first weight on R17 was 183.2# on 4/15/2021. R17 had a documented hospital weight of 203#. During the interview on 5/25/21 at 3:00 PM, RD E said, Ideally (R17's) weight should have been obtained within 24 to 48 hours (of her admission). Resident #18 (R18) R18 was admitted to the facility on [DATE] and discharged on [DATE]. R18's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nutrition Assessment completed on 4/21/2021 did not include an admission weight. During the interview on 5/25/21 at 3:00 PM, RD E indicated that R18 should have been weighed upon admission to the facility. RD E agreed that weight measurements are needed to do an accurate and thorough nutrition assessment. In an interview on 5/27/2021 at 2:31 PM, the Director of Nursing (DON) indicated that nurses and certified nurse aides are responsible for obtaining resident's weights upon admission. The DON added that admission weights should be obtained typically the day of admission within 24 hours. The DON said the purpose for obtaining an admission weight was to establish a baseline of where their weight is so we can monitor if they are gaining or losing, so the dietitian can determine if interventions are necessary. A review of the facility document titled, Weight Monitoring, undated, revealed the following: -To ensure the resident maintains acceptable parameters of nutritional status unless their clinical condition demonstrates that this is not possible, the resident's body weight is monitored. -The resident is weighed on admission or readmission. Admission weight may be compared to the resident's usual body weight if the usual body weight is known. New admissions may be weighed weekly for the first four weeks as deemed necessary. -Residents are weighed monthly. The monthly weight is compared to the previous weights to determine significant and insidious weight changes. Resident with a 5% weight change in one month are re-weighed. Finalized weights are entered into the computer on a predetermined date, established by the facility's administration team. -Significant weight change is defined as 5% in one month, 7.5% in three months, and 10% in six months. -Once a significant weight change has been identified, the director of nursing or person in charge notifies the physician, dietitian, diet technician, and the director of food and nutrition services.

This citation pertains to intake numbers MI 757 and MI 7994. Based on observation, interview and record review the facility failed to ensure residents were were free from abuse in 2 of 17 residents (R#13, R#8) reviewed for abuse, from a total sample of 33 residents, resulting in Resident #13 being physically abused by a staff member and the potential for continued resident to resident abuse. Findings include: R#13 Review of the Face Sheet revealed that Resident #13 (R#13) was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 2/6/21 Quarterly Minimum Data Set Assessment (MDS) indicated the residents R#13's cognition was intact and he required one person assistance with bathing and hygiene. During an observation and interview on 5/20/21 at 8:15 AM, R#13 was noted to be in his room. The bed was up against the wall with the head of the bed in the flat position. R#13 was observed sitting on the opposite side doing arm exercises. R#13 was observed to have a left AKA. R#13 reported an incident where a staff member was rough with him. R#13 stated, The Certified Nurse Assistant (CNA V) came into change me and put a clean sheet on the bed. She wanted me to roll to my left. I told her I was scared and fearful of falling. I told her to stop and go get someone to help her, but she continued to roll me and grabbed me by my wrists. R#13 demonstrated rolling himself to his left side and how he did not have a limb to stabilize himself saying, I told her, I'm going to fall, I'm going to fall. She just pushed me right over. I was trying to get her hands off me when she grabbed my wrists. I grabbed her wrists to stop her. R#13 reported that due to his left AKA, he was unstable on his left side and preferred staff provided care from the left side for stabilization. Review of the facility's investigation revealed, On 2/11/21 at approximately 5:15pm Administrator and Director of Nursing (DON) were notified by (Licensed Practical Nurse/LPN M) that she heard loud voices coming from (R#13's) room, when she entered the room, she observed (R#13) holding (CNA V) by both wrists pulled into his chest. (LPN M) immediately removed (CNA V) from the room. (R#13) reported to (LPN M) that he is a Left AKA, she (CNA V) wanted him to roll to the left, he was fearful he would fall, he told her to stop and get help, she continued to roll him and grabbed him by his right wrist, so he grabbed hers. Resident reported to (LPN M) that he felt safe, had no pain, and just likes to be changed from the left side of his bed. Upon initial skin assessment on 2/11/21 (LPN M) noted right forearm and right dorsal wrist with dark ecchymosis (bruising), zero swelling or zero redness . On 5/20/21 at 8:35 AM, LPN M was interviewed regarding the incident between R#13 and CNA V. LPN M reported she responded to R#13's room and saw the resident holding onto the CNA V's wrists saying, She tried to roll me and I thought I was going to fall, she continued to roll me and grabbed my right wrist. LPN M reported she removed the CNA from the room and immediately did a skin assessment where she noted dark bruising on R#13's right forearm and right dorsal (upper side) wrist. LPN M said she worked with R#13 the next day and observed more bruising on R#13's arms. LPN M described the right forearm and wrist area as dark ecchymosis around the wrist with peri skin red in color with scattered red tissue up the forearm. LPN M acknowledged the bruising was new for R#13, but stated she did not see the staff member grab the residents wrist. In an interview on 5/25/21 at 12:59 PM, DON indicated that CNA V disputed the event and said that she blocked the residents arm when he was swinging at her, and that is what caused the bruising of the right wrist/forearm. The DON was requested, but did not provide documentation of the CNA's statement regarding blocking the resident when he was swinging at her. Review of CNA'V's employee discipline form located in the Human Resource file revealed staff member terminated (name of staff) CENA- was terminated on 2/18/21 for failure to follow residents rights and unprofessional, discourteous conduct while provided care to resident. R8 A review of the facility's investigation summary of a resident-to-resident incident between Resident #7 (R7) and Resident #8 (R8) documented in part the following: On October 30, 2020, (R8) was wandering in and out of rooms on the Memory Care Floor. (R8) entered a room and (R7) followed behind him. (R7) made physical contact with (R8) resulting in superficial abrasions to (R8's) chest. Both residents were immediately separated for safety. A facility document titled, Interview/Statement Record, date and time of 10/30/2020 at 2:30 PM was reviewed and documented that License Practical Nurse (LPN W) reported the following: (R8) was wandering on the unit. (R7) thought (R8) was trying to take (his) stuff. (R7) scratched (R8's) chest. Review of the Progress Note dated 10/30/20 at 7:30 PM revealed, (R7) hit and scratched another resident. When asked the resident why, (R7) pointed to his radio. (R8) was wandering in and out of various residents rooms Review of the Face Sheet revealed R7 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] documented severe cognitive impairment and the use of a wheelchair for mobility about the unit. Review of the Face Sheet revealed R8 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented severe cognitive impairment and supervision as he walked about the unit. R8's care plans were reviewed and revealed the following: Focus: (R8) has a behavior problem of taking food items from old trays and kitchenette, as well as taking clothing and personal items from other residents and common areas, resident wanders into other residents rooms and lays in their bed. Date initiated 2/14/2018. Interventions included the following: -Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him as passing by. Date initiated 2/14/2018. -Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Date initiated 2/14/2018. Focus: The resident is an elopement risk/wanderer related to dementia. Observed wandering daily on unit, in dining room and other hall. Date initiated 3/23/2019. Interventions included the following: -Staff aware of resident's wander risk. Date initiated 3/23/2019. On 5/24/2021 at 12:15 PM, the Director of Nursing (DON) was interviewed about the 10/30/2020 resident-to-resident incident between R7 and R8. The DON stated she conducted the interview with LPN W who was the Unit Manager at the time. According to the DON, LPN W observed (R8) wandering wandering in and out of resident rooms. The DON stated, (LPN W) should have attempted to redirect him. The DON confirmed there was no documentation to indicate that staff attempted to address R8's wandering in and out of residents' rooms. Review of the facility's policy titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property dated 9/11/20 documented, .An Owner, licensee, Administrator, Licensed Nurse employee or volunteer of a nursing home shall not physically, mentally or emotionally abuse, mistreat or neglect a resident. Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the Nursing Home Administrator . Abuse prevention strategies included: .The facility leadership will assess the needs of the residents in the facility to be able to identify concerns in order to prevent potential abuse.

This citation pertains to Intake number MI 092. Based on observation, interview and record review the facility failed to implement interventions to maintained the highest level of range of motion (ROM) for one sampled resident (R#2) from a total sample of three residents reviewed for ROM resulting in the actual decline in upper and lower extremity movement. Findings include: Review of a complaint called into the State Agency documented, It was alleged facility staff are failing to ensure the resident is provided with adequate and appropriate care and treatment to prevent her muscles from becoming contracted, resulting in her inability to move her arms and legs. On 12/8/20 at 10:15 AM, record review revealed that R#2 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The 10/2/2020 Quarterly Minimum Data Assessment (MDS) indicated the residents cognition was severely impaired. A comparison review of the MDS comprehensive assessments, Section G0400. Functional Limitation in Range of Motion revealed: -10/2/2019 Quarterly; Upper extremity (UE-shoulder, elbow, wrist, hand)- No impairment. Lower extremity (LE-hip, knee, ankle, foot)-No impairment. -1/2/2020 Quarterly; Upper extremity - No impairment. Lower extremity -Impairment both sides. -4/3/2020 Quarterly; Upper extremity - Impairment one side. Lower extremity -Impairment both sides. Reflecting that R#2 had acquired functional limitations to one UE and both LE's in a 6 month time frame. Clinical record reviewed revealed no documented evidence of treatment and services for mobility and/or maintaining mobility for R#2 when a decline was assessed from 10/2/19 to 4/3/20. The clinical record revealed no clinical condition demonstrating that the decline in range of motion was unavoidable. On 12/8/20 at 2:50 PM, along with the Restorative Nurse C, R#2 was asked to move her upper and lower extremities. R#2 was unable to independently move her left upper extremity (UE), and used her right hand to manually mover left hand. The resident was unable to independently move either lower extremities. Review of the care plan titled, The resident has an Activities of Daily Living (ADL) self-care performance deficit related to Impaired mobility due to history [MEDICAL CONDITION] history of left weakness dated 10/3/2018, had an intervention of Physical Therapy and/or Occupational therapy (PT/OT) evaluation and treatment as per doctors orders. On 12/9/20 at 10:30 AM, during an interview with the Administrator and the Director of Nursing DON), they provided a care plan dated 4/6/18 documenting, Range of Motion exercises several times a day. If resident is unable, teach how to correct active range of motion. The DON was asked for documented evidence that ROM was provided to R#2 several times a day per the plan of care. No additional information was provided by survey exit. Review of the facility's policy titled, Restorative Nursing Guideline dated 10/1/19 documented, Purpose: To ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and a resident with limited range of motion receives appropriate treatment and services to include range of motion and/or to prevent further decrease in range of motion.

This citation pertains to Intake number MI 193 and MI 304. Based on interview and record review the facility failed to provide nutritional services consistent with assessed needs of the resident for one sampled resident (R#4) from a total of three residents reviewed for nutrition/hydration status, resulting in interventions not put into place for weight loss. Finding include: On 12/8/20 at 12:29 PM, during an interview with R#4's Power of Attorney (POA, who was also the residents husband) he indicated that the resident was sent out to the hospital on [DATE] due to the resident not being able to Lift her head. Her mouth, lips and tongue were so dry it looked like jerky. Record review revealed that R#4 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 11/20/20 Nursing Admission Assessment indicated the residents cognition was oriented only to self. The Occupational Therapy (OT) initial evaluation and treatment plan dated 11/21/20 (day after admission into the facility) documented, Self feeding=Total Dependence (requiring staff total assistance) without attempts to initiate (feed self). Review of the care plan titled, Inadequate oral intake related to decrease appetite as evidenced by PO intake (less than) <50% for most meals per shift Certified Nurse Assistant (CNA) report dated 11/23/2020, had an intervention of Provide feeding/dining assistance as needed. Review of the 11/23/2020 Initial Comprehensive Nutrition Assessment document, .Appears thin. Resident is not well nourished .Resident is not able to understand and be understood .Weight 115.6 lbs - 11/21/2020 .Ideal Body Weight (BW) is 140 lbs .Low Body Mass Index (BMI) Facility wt: 115.6, height (ht) pending. Hospital ht: 68, wt: 136# on 11/19/20 (one day prior to admission into facility). Which would indicate a 20.4 lb (15% weight loss) x 4 days. Unclear if facility weight is accurate. Will request reweigh .Shift Certified Nurse Assistant (CNA) reported poor by mouth intake (less than 30-40%) and resident able to eat independently .Appeared thin, but robust .Client may benefit from progression to a liberalized diet regular diet. Should weight loss become an issue during course of stay approach may be to add daily supplements . Inadequate oral intake related to decrease appetite as evidenced by mouth intake less than 50% for most meals per shift CNA report .Encourage by mouth intake. Consider liberalizing diet to regular diet. Consider adding daily supplements should weight loss become an issue. Request weekly weight x 4 weeks . Weights for R#4 documented on the November 2020 Medication Administration Records (MARS) dated 11/21/20, 11/22/20 and 11/23/20 were all exactly the same at 115.6 pounds (Lbs.). There was no documented evidence of a re-weight that was requested by the dietician due to unclear if facility weight is accurate. On 12/9/20 at 12:10 PM, the Senior Dietician was interviewed regarding the lack of dietary interventions implemented for R#4 who had a 20.4 lb weight loss x 4 days. The Senior Dietician indicated that she was not aware of the three exact weights documented on the MARs because it was not the standard of practice to look on the nursing (MARS) for resident weights. At 3:42 PM, During an interview with the facility's Director of Nursing (DON) she was asked for clarification of R#4's level of feeding assistance. The DON said she was aware the OT therapist evaluated the resident to required total staff assistance, the care plan interventions reflected the resident to required assistance as needed and the CNA's documented that the resident was eating independently saying, I was told the resident ate independently. The DON did not elaborate if independent eating was the best intervention for a resident who eating poorly (less than 30-40%), was identified as underweight and had a 20.4 lb weight loss x 4 days. Review of the hospital records dated 11/29/20 documented, .Per nursing home and husband noted with worsening confusion and poor oral intake over the last 2-3 days. Pt unable to provide history due to clinical status and history of dementia .workup noted with significant Acute Kidney Failure (AKI), [MEDICAL CONDITION] (Increased potassium level), [MEDICAL CONDITION] (increased sodium level), elevated troponin and elevated [MEDICATION NAME] phosphokinase (CPK- enzymes in body) .suspect secondary to hypovolemia (abnormally low extracellualr fluid in body) with poor oral intake .PHYSICAL EXAMINATION: Blood pressure 108/65 (normal range 120/80), pulse 99 (normal range 60-100) , temperature 99.1 °F (normal 98.7), respiration rate 23 (12-16 breaths per minute), height 1.575 m (5' 2), weight 110 lb 3.7 oz (5.3 lbs less than last weight obtained at nursing home), .Mood is not stable-- confused and in restraints . Review of the facility's undated policy titled, Weight Monitoring documented, .Collaboration with the speech pathologist, pharmacist, psychiatrist, or other key individuals may be needed to determine the cause of the weight loss and determine interventions. Clinically qualified professionals can initiate interventions prior to assessment of the resident's nutritional status by the dietitian. Review of the facility's undated policy titled, Weight Monitoring Guidelines dated 7/1/19 documented, Residents will be weighed; documentation will be recorded in PCC: Upon admission and re-admission. Hospital weights should be verified and compared to facility admission and / or re-admission weight. Daily for three days. Weekly for four weeks post admission and / or until the weight is determined to be stable. Monthly by the 7th of each month. Anytime as needed with a change in condition or specified by NAR committee. As specified by the physician or mid-level practitioner. The Licensed Nurse: Will verify the accuracy of the weight by comparing the weight with the most recently recorded weight. Direct a re-weight for variances < or > 5 pounds. Consult with the physician and dietian / designee with a confirmed 5 % weight variances in 30 days and 10% in 6 months and / or as ordered by the physician with weight parameters. For residents on daily weights for fluid volume overload prevention and monitoring weight notification parameters should be discussed with the physician and at minimum consultation should be completed with a 5 pound weight change in 1 week for residents with heart failure or fluid volume overload risk. Monitor weight reports produced inside PCC for significant changes and for gradual insidious changes that may indicate a risk factor for nutrition or hydration status and / or clinical condition. Dietitian: Review significant weight change reports daily for review and evaluation Review weight reports at least weekly to ensure residents with weight variances of 5% in 30 days and 10% in 6 months are reviewed and evaluations for nutritional risk and timely interventions is completed. Review weight reports for significant weight changes following the 7th of the month. Refer residents with significant weight changes to the NAR committee for review.

This citation has two deficient practices. Deficient practice #1. This citation pertains to intake numbers MI 747, MI 926, and MI 008. Based on observation, interview and record review the facility failed to ensure timely provision of weight loss interventions for three sampled resident (R#'s 702, 708, and 709) from a total sample of 17 resulting in the potential for further weight loss and compromised health condition. Findings include: R709 A complaint called into the State Agency documented, It was alleged the facility staff failed to assist the resident with feeding. On 8/25/20 at 10:20 AM, R709 was observed sitting up in his wheelchair in his room. Two half drunk bottles of pop were noted on the bedside table. On 8/26/20 at 8:15 AM, R709 was observed feeding himself a bowl of cereal saying, My mouth is sore. Record review revealed that R709 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set Assessment ((MDS) dated [DATE] documented the resident cognition was moderately impaired and required one person assistance with feeding. Review of the current weights revealed that R709 had an admission weight of 177.0 Lbs on 6/5/2020 and on 8/1/2020 weighed 142.2 Lbs (a difference of -34.8 lbs loss in 8 weeks). The current physician orders [REDACTED]. A nutritional assessment dated [DATE] documented NO RICE; double portions with breakfast for nutrition. Monitor po (by mouth) intake, weight and labs. The 6/7/20 care plan titled, The resident has nutritional problem or potential nutritional problem related to limited adherence to nutrition-related recommendations, Diet restrictions=Carb controlled had an intervention of Evaluate any weight changes. Determine percentage changed and follow facility protocol for weight change .Resident is blind, and needs assistance and cues with eating. At 10:36 AM, Dietician C was interviewed and asked about R709's weight loss and stated, That is a 75% weight loss in 2 months, that's pretty severe. I don't know why it wasn't brought to my attention in morning meeting. I review the weights monthly and didn't see that. Dietician C indicated no additional nutritional assessment or supplements were implemented because I was not aware of the weight loss, no one brought it to my attention. On 8/26/20 at 3:15 PM, during an interview with the facility's Director of Nursing (DON) she said that she was aware of the concern regarding the resident's weight loss and nutritional supplements were ordered. Review of the facility provided Clinical Nutrition Guidelines documented, .Refer residents with significant weight loss, skin breakdown, or those on tube feeding or [MEDICAL TREATMENT] to the dietitian for further nutritional assessment .The resident is weighed on admission or readmission Admission weight may be compared to the resident's usual body weight if the usual body weight is known. New admissions may be weighted weekly for the first four weeks .Significant weight change is defined as 5% in one month, 7.5% in three months, and 10% in six months .Once a significant weight change has been identified, the director of nursing or person in charge notifies the physician, dietitian, diet technician, and the director of food and nutrition services .Interventions are provided to address a decline in a resident's appetite and food intake, a significant weight loss or an insidious weight loss trend. Resident #702- A review of the clinical record for Resident #702 (R702) revealed an admission into the facility on [DATE] and discharge from the facility on 8/7/2020. R702's [DIAGNOSES REDACTED]. A MDS dated [DATE] documented R702 required extensive one-person physical assistance for eating. On 8/26/2020 at 8:46 AM, when Dietary Director, Staff B was queried about the facility's weight monitoring policy, she said, Residents are weighed upon admission and then weekly for four weeks; and, if stable, they go monthly. Staff B added, this schedule is maintained to make sure the residents are meeting their nutritional needs, maintaining their weights, and to establish a baseline. On 8/26/2020 at 9:09 AM, when Registered Dietitian, (RD) C was queried about the facility's weight monitoring policy, she said, There is an initial weight (obtained) on new admissions and then redone weekly for four weeks. RD C added, For example if the weight was done on a Monday, it should be redone the next Monday. It's a set day. It's better for us to stay on a set day because then it's put in the computer to specify. It's a trigger for the nurses to ensure that it's done. A review of R702's clinical record was completed with RD C. During this review, it was confirmed that R702 was a resident in the facility from 7/7/2020 to 8/7/2020. During her stay, the facility obtained only one weight on R702 dated 8/1/2020. When RD C was queried about the lack of weights obtained on R702, she said, It's horrible that her first weight was done on 8/1/2020. Resident #708- A review of the clinical record for Resident #708 (R708) revealed an admission into the facility on [DATE] and discharge from the facility on 4/22/2020. R708's [DIAGNOSES REDACTED]. A MDS dated [DATE] documented intact cognition, and R708 required only supervision for eating. A comprehensive nutrition assessment dated [DATE] documented resident has many food allergies [REDACTED]. The only weights obtained on R708 were 140# on 4/13/2020 and 139.2# on 4/14/2020. On 8/26/2020 at 12:56 PM, when the Director of Nursing was queried about her expectations for weighing residents in the facility, she said, Residents are weighed upon admission; weekly times four weeks; and reviewed after that to determine what we need to do. The facility document titled, Weight Monitoring, undated, was reviewed and revealed in part the following: -Guideline: To ensure the resident maintains acceptable parameters of nutritional status unless their clinical condition demonstrates that this is not possible, the resident's body weight is monitored. -Procedure: The resident is weighed on admission or readmission. New admissions may be weighted weekly for the first four weeks. Residents are weighed monthly. The monthly weight is compared to the previous weights to determine significant and insidious weight changes. Resident with a 5% weight change in one month are re-weighed. Finalized weights are entered into the computer on a predetermined date, the 7th of the month. Significant weight change is defined as 5% in one month, 7.5% in three months, and 10% in six months. Once a significant weight change has been identified, the director of nursing or person in charge notifies the physician, dietitian, diet technician, and the director of food and nutrition services. Deficient practice #2. This citation pertains to MI 481. Based on interview and record review, the facility failed to provide a follow-up nutritional evaluation for one resident (#710) reviewed for a tube feeding and determined to be at nutrition risk, resulting in the potential for nutrition concerns to go undetected. Findings include: It was reported to the state agency that the facility was not appropriately monitoring resident's tube feeding. A review of the clinical record for Resident #710 (R710) revealed an admission into the facility on [DATE] and discharge from the facility on 8/7/2020. R710's [DIAGNOSES REDACTED]. A Minimum (MDS) data set [DATE] documented moderate cognitive impairment. A review of physician orders [REDACTED]. On 8/26/2020 at 10:02 AM, an interview was conducted with Registered Dietitian, (RD) C. When RD C was queried if R710 was a resident considered at nutrition risk, she said, Yes because of COVID-19, [MEDICAL CONDITION], diabetes mellitus, obesity, and dysphagia. A review of a nutrition note dated 6/19/2020 was conducted with RD C and the following was documented: Nutrition at risk meeting held on 6/17/2020. Resident consumes carb controlled, mechanical soft, thin liquids diet. Weight loss 5%: 4/20 265# to 6/20 243#. Recently in past resident was diagnosed with [REDACTED]. Nurse Practitioner asked if we could decrease tube feeding in hopes of increasing by mouth intake. Food Acceptance Record 51-100%. Will continue to monitor for next decrease in tube feeding with maintenance of weight. Will follow with interdisciplinary team. A review of a nursing note dated 7/22/2020 was conducted with RD C and the following was documented: New orders received to discontinue tube feeding related to weight gain with decrease in amount. Weights to be done weekly to monitor weight. Resident to continue to receive flushes via peg (Percutaneous Endoscopic Gastrostomy tube). When RD C was queried if there was monitoring and follow up by the dietitian as stipulated in the nutrition note of 6/19/2020, she said, It's not there. There should be some follow up. When RD C was queried about the justification for the discontinuation of R710's tube feeding, she said, If there is a decrease in tube feeding, we should know about it. It should be discussed in morning meeting. This resident would be one of the first people we see. If we are decreasing tube feeding, I should go see them. We should have been notified in morning meeting and she would have been one of the first people I saw. I should have gone and put a note in (the clinical record). There has to be a failure to communicate. I should have been notified. There should be a note from me saying I saw the patient and completed a full assessment. There should have been an assessment by the RD. Because she was at risk, there should have been a note from the RD in July. On 8/26/2020 at 12:56 PM, the discontinuation of R710's tube feeding was discussed with the Director of Nursing (DON). When the DON was queried if the dietitian should have completed an evaluation on R710 regarding the discontinuation of the tube feeding, the DON said, Yes. A review of the following facility documents revealed in-part the following: -Registered Dietitian Job Description: Timely completion of the Medical Nutrition Therapy is required in accordance with company policy and current standards of practice. Assesses nutritional needs of residents and patients. -Registered Dietitian Roles & Responsibilities: Assess the nutrition needs of residents who are deemed both high risk and low risk. The effectiveness of the nutrition interventions is re-evaluated as needed to determine if they continue to be appropriate -Dietary Recommendations: Upon assessing a resident's nutritional status the dietitian and/or diet technician may make a recommendation to change the diet order. -Enteral Tube Feeding: The dietitian may recommend changing the tube feeding if necessary. The dietitian will monitor the nutritional status of the tube-fed residents on a monthly basis or more frequently if indicated. -Tube Feeding Advancement: The dietitian will monitor the tube feeding and the oral feeding to determine the best combination to meet the resident's nutritional needs.

This citation pertains to intake MI 007 Based on Observation, Interview, and Record Review, the facility failed to accurately assess, and document a resident's skin integrity, and update interventions to prevent the development and worsening of pressure ulcers for 1 resident (703) out of 3 residents reviewed for pressure ulcers. Findings include: A summary of an allegation submitted to the state of Michigan provided concerns related to the treatment of [REDACTED]. On 8/25/20 at 11:04 am the surveyor approached Nurse (O) and requested an observation of the dressing change for resident 703. Nurse (O) stated, sure, you are lucky the resident is back from [MEDICAL TREATMENT]. I figured you would be looking at the resident's abdominal wound, he no longer has a wound vac. and the wound looks a lot better than it did. Nurse (O) was asked if that was the resident's only wound, and she stated no he has some dried up scabs on his heels that are vascular and only require dry dressing changes at this point, the wound scabs were removed by the wound care team. After the completion of the upper abdominal dressing change, and the application of dry dressings to the resident's feet, the surveyor left the resident's room. Approximately 5 minutes later the surveyor returned to the room of resident 703 and observed Nurse (O) receiving assistance with turning resident 703 from his back to his side. The surveyor observed nurse (O) applying a dressing to the sacrum of resident 703. The dressing was dated 8/25/20 and included nurse O's initials. When Nurse (O) left the room, the surveyor asked her why a dressing was covering the resident's sacrum, Nurse (O) stated, that area is just a little inflamed, it is mostly cicatrix (skin scaring from old wounds). Now it has gotten worse, and I will have to let my boss know. On 8/25/20 at 3PM a review of the clinical record revealed resident 703 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident goes out of the facility for [MEDICAL TREATMENT] 3 times a week. The resident's admission MDS (minimum data set) dated 8/5/20 revealed a BIMS (brief interview of mental status) score of 3/15, indicating a severe cognitive (thought processes) impairment. Resident 703 is non-ambulatory (cannot walk) and requires the use of a mechanical lift; supported by 2 staff, when removed from the bed. Resident 703 requires extensive one-person assistance with bathing. The resident has a urinary catheter in his bladder and is consistently incontinent (cannot control) of stool. Resident 703 has no use of his arms and requires extensive assistance 1-person assistance with bed-mobility. On 8/26/20 at 9:15AM, the surveyor approached nurse (O) and asked if the dressings were already changed on resident 703. Nurse (O) stated, yes I just changed them. Nurse (O) was asked if the surveyor could just look at the resident's sacral area. Nurse (O) stated, yes I can just lift the dressing open. The surveyor looked at the sacral area and noted a moderately sized sacral pressure ulcer, with eschar, pale pink tissue, slough, and an undetermined depth. Nurse (O) stated, when the sacral area was first observed it was fragile skin however as of yesterday evening it was noted to have areas of pressure breakdown. I called the residents doctor for wound treatment orders. I also let the resident's daughter know about the pressure ulcer. The surveyor requested any available documentation specific to the sacral pressure ulcer. Nurse (O) stated you will have to obtain that information from my boss. When asked if she was referring to the Director of Wound Care, Nurse (O) stated, yes. An interview was conducted with Nurse (N) on 8/26/20 at 9:45am regarding the sacral pressure ulcer of resident (703). Nurse (N) stated, I was told you needed some documentation related to the sacral pressure ulcer for resident (703), I don't understand what it is you want because there is only one document. Nurse (N), stated I was made aware of the sacral pressure ulcer yesterday by the wound nurse, and I was present when she notified the family. Nurse (N) requested to view the surveyor's computer to locate the skin assessments for resident (703). Nurse (N) located the most recent skin assessment for resident 703 dated 8/17/20. There were no identified skin conditions noted in the sacral area of the skin assessment diagram. Nurse (N), looked at the diagram again and stated, I did not think the resident's sacral pressure ulcer occurred over night. A record review of a nursing progress note entitled; skin/wound note dated 8/25/20 at 17:55 was conducted on 8/26/20. The progress note indicated nurse (O) spoke with a family member of resident (703) to inform them of a new facility acquired wound to bilateral buttock/coccyx. Nurse (O) reviewed the planned treatments with the family member of Resident (703). According to the progress note the family member stated she was aware this might happen because the resident is not able to move freely. An interview was conducted with the DON on 8/26/20, the DON stated she was aware of the pressure ulcer situation and would provide the surveyor with the facility policy and procedure that addresses skin management. A document entitled, Villa (skin management guideline) with an effective date of 11-28-17, identified its purpose as ensuring residents that are admitted to the facility are evaluated to determine appropriate measures to be taken by the interdisciplinary care team to determine appropriate measures and individualized interventions to prevent, reduce, and treat skin breakdown. Guidelines for the prevention of Pressure Ulcers consists of: (1) All residents admitted to the facility will be evaluated for actual and potential skin integrity issues. (2) The Admission Evaluation will be completed upon admission. (3) The skin and body check section should be completed within the first 2 hours. (3) The Pressure Injury Notice will be completed and provided for the resident and/or Resident Representative providing notice of predicting factors and baseline care plan interventions to support prevention treatment and healing. Under the section of the document entitled, Monitoring of Skin Integrity the skin should be: (1) Observed daily during care by the nursing assistants. If any skin concerns are noted they are to be reported to the licensed nurses. (2) Weekly skin observations on the bath/shower day will be performed by a Licensed Nurse. (3) If a skin concern is noted, refer to the skin and wound care formulary (4) The Care Plan for Skin Integrity is to be evaluated and revised based on response, outcomes, and needs of the resident. (5) The Physician will be consulted with changes suggesting impairment in skin integrity

Based on Interview and Record Review the facility failed to ensure equipment compatibility of a mechanical lift with a shower gurney bed for one sampled resident ( #706) out of four resident reviewed for falls; resulting in a slide to the floor; sustaining a traumatic subarachnoid hemorrhage (brain bleed). Findings included: According to a record review conducted on 3/11/2020 resident 706 was hospitalized with a subarachnoid hemorrhage (brain bleed) following a fall from a Mechanical Lift (A piece of equipment that allows residents to be transferred between a bed and a chair or other resting place). Resident 706 has diagnoses that included: [CONDITION(S)] ( A disease in which immune system eats away at the protective covering of the nerves that disrupts communication between the brain and the body), and Contractures (shortening of muscles) at multiple sites. Additional record review revealed resident 706 scored 6/15 on the BIMS (Brief Interview for Mental Status) test, indicating a severe cognitive (thought process) impairment. The resident required total 2-person total transfer assistance from one surface to another via a mechanical lift. Per a record review (fall investigation) conducted on 3/11/20, resident (706) sustained a fall on 1/28/20, the fall was witnessed, during a Mechanical Lift Transfer. During this fall, bleeding was noted on the right side of the resident's head. The MD was notified and submitted orders for a Stat skull X-ray. The nursing staff were instructed via the MD to wait for results from the Stat X-ray. Following the Stat X-ray results the resident was sent to the emergency roiagnom on [DATE] due to a Traumatic Subarachnoid Hemorrhage (Brain Bleed). On 3/11/20 at 2:30 PM, CNA (A) was interviewed regarding the resident's fall from the mechanical lift. CNA (A), stated, I don't remember the date, but I do remember the incident. At 11:00 AM another aide asked me to help put the resident (706) on the gurney bed for a shower. At that time, she was already lying on the mechanical lift sling while in the bed. The aide and I hooked the sling to the mechanical lift with the resident on it. We tried to put her on the gurney shower bed. I was stabilizing the resident (by holding on to the mechanical lift sling to make sure she was not spinning during the transfer as we pushed her closer to the gurney shower bed. The gurney shower bed was not even (aligning) with the mechanical lift. We had to elevate her to the level of the shower bed (by pushing her up through the sling) to get her on the gurney shower bed; she was positioned lower than the shower bed while in the mechanical lift. This process (the action of pushing her up) caused the resident to slide out the mechanical lift sling on to the floor. When the nurse flipped her over, the resident's head was bleeding. The nurse instructed us to get towels. We gave her the towels and she stopped the bleeding . CNA (A) was asked what the problem was with the Hoyer lift that prevented it from aligning evenly with the shower gurney? CNA (A) stated, the problem is that the mechanical lift is old and the old mechanical lifts never align with the shower gurneys; you always have to lift the resident up with your hands to get him or her on to the shower gurney. On 3/11/20 at 4:16 PM an interview was conducted with the DON regarding the resident's fall from the mechanical lift; specifically, why the facility was using mechanical lifts that were unable to rise to the height of the shower gurney bed? The DON stated, all the old mechanical lifts have been removed from the facility following the incident of resident (706) falling from the mechanical lift during a transfer to the shower gurney. The DON was unable to explain why the old mechanical lifts were not replaced when it brought to the attention of nursing staff there was a problem transferring residents to the shower gurney beds.

Based on observations, interviews, and record reviews the facility failed to provide prescribed skin treatments and interventions to prevent the development of new pressure ulcers, and the worsening of existing pressure sores for three of 11 residents (R90, R123, R440) reviewed for pressure ulcer care, resulting in R90 developing a 'stage 3' pressure ulcer on his coccyx area, and an 'unstageable' pressure ulcer on his left stump/[MEDICAL CONDITION] area (BKA), and R123 developing a new 'unstageable' pressure ulcer to her right lateral ankle/heel area and a stage 2 pressure ulcer to her gluteal region , along with the high likelihood for R440's existing pressure ulcer to worsen. A 'stage 2' pressure ulcer is a loss of skin that is a shallow crater or blister. A 'stage 3' pressure ulcer is total loss of skin, a crater exposing the soft fatty tissue, but not tendon, muscle, or bone. An 'unstageable' pressure ulcer is the inability to see the bottom of the sore to see how deep it is due to dead or infected tissue covering it, and therefore unable to be staged. Findings include: Resident 90: During an observation on 7/23/19 at 9:24 AM, R90 was laying on his back in bed on a perimeter mattress (has soft lipped edge around perimeter) watching TV. R90 has bilateral BKA amputations with a dressing on the left stump that was dated 7/22/19. The dressing had a moderate amount of yellowish drainage that had saturated through it. Both of R90's BKAs were resting flat on the mattress. At approximately 10:00 AM, R90 was observed during a bed bath with a hospice nursing assistant and nurse 'K'. A quarter sized opened area was observed on his sacrum area with moderate amount of serosanguinous (clear liquid mixed with blood) drainage. There was no cream or any type of skin treatment on the coccyx/sacral area. Upon interview, nurse 'K' said she was unaware if R90 had a pressure ulcer on his coccyx area. Nurse 'K' was not R90's nurse, and only assisting with the bed bath. At approximately 10:05 AM, nurse 'M', who was assigned to R90, was interviewed regarding his coccyx/sacral pressure ulcer. Nurse 'M' reviewed the electronic medical record and said, 'the wound care team documented that the wound on the sacral area was resolved on 1/30/19'. 'A skin assessment was done on 6/26/29, and only documents the left stump (BKA area) pressure ulcer, there is no documentation/assessment of the coccyx/sacral area'. 'The last skin assessment that mentioned the sacral area is 6/14/19. It reports red area on sacrum, nothing else'. Nurse 'K' did not go to R90's room to assess his skin at this time. During observations on 7/23/19 at 3:30 PM, R90 was in bed, laying on his back with his BKAs resting flat on the mattress. The dressing on his left BKA area was dated 7/22/19, and had the same amount of yellow drainage on the dressing. An observation on 7/24/19 at 7:42 AM, revealed R90 was in the same position; asleep in bed on a perimeter mattress, on his back with his BKAs resting flat on the mattress. R90's left BKA area had a clean bulky gauze dressing that was dated 7/23/19. On 7/24/19 at 7:45 AM, a medical record review was conducted for R90. There was no progress note, or documentation that a skin assessment had been conducted since 6/26/19, and that assessment does not mention the sacral area. According to the medical record, R90 admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. left stump (BKA area). On 6/24/19, the 'wound care' skin assessment indicated that R90 had developed an unstageable pressure ulcer on his left stump that measured 1.5 cm (centimeter) x 1.8 cm. There is no mention of the coccyx/sacral area. The last Minimum Data Set (MDS) initiated for 'significant change' on 5/11/19 indicated that R90 had only one 'stage 2' (loss of skin, shallow crater) pressure ulcer on his buttocks area. R90 was identifed to required extensive assistance from one person for bed mobility and was a 2 person transfer with use of mechanical lift. A physician's orders [REDACTED]. The Treatment Administration Record (TAR) for (MONTH) 2019 revealed that nurses had placed their initials on the TAR to indicate the prescribed treatments for the coccyx were administered every day, twice a day from 7/1/19 - 7/23/19. A care plan for 'potential' impairment to skin integrity was last revised on 4/12/19, and indicated that R90 had a pressure ulcer on his coccyx and right buttocks that had resolved. There was no update to include the pressure ulcer on the left BKA area. The care plan had interventions that included the following; follow facility protocol for skin treatments, and document weekly treatments to include measurement of each area of the skin breakdown's, width, length, depth, and type of tissue, exudate and any other notable changes or observations. There is no intervention regarding repositioning the resident, or applying a specialty low pressure mattress. The medical record also had a care plan for 'actual' impairment to skin integrity that was last revised on 1/14/19, and indicated that R90 had a 'stage 2' pressure ulcer on his coccyx. There was no update to include the pressure ulcer to the left BKA area. The interventions included the following, resident needs pressure relieving/reducing mattress and pillows at times to protect the skin while in bed. There is no intervention regarding repositioning the resident. There is no documentation, plan of care, or interventions for R90's left BKA area/left stump, and no revisions for the coccyx area to indicate it had re-opened. During an observation on 7/24/19 at 11:23 AM, R90 was laying in bed with the perimeter mattress, on his back with pillows under both of his BKAs. However, the pillows were not positioned to off-load any pressure to the BKA/stump area. The left BKA dressing, dated 7/23/19, has a small spot of yellow drainage saturating through the bulky dressing. During an observation and interview with nurse 'L' and CNA 'Y' on 7/24/19 at 12:36 PM, they conducted a skin assessment and confirmed that R90 had a new open area on his coccyx. At this time, the resident was cleaned for a moderate amount of serosanguinuous drainage on the open area to the coccyx/sacral area that had soaked into his brief. CNA 'Y' and nurse 'L' could not find any dermaseptin cream to apply to the resident's buttocks to complete the prescribed skin treatment order. CNA 'Y' said that there was no dermaseptin cream on the 5th floor because she had looked for some a day ago, and there was not any. CNA 'Y' said she asked the wound care team for some, because it is kept in their office, but none had been delivered yet. Nurse 'L' checked the treatment cart and the 5th floor medication room and confirmed there was no dermaseptin cream. R90 was cleaned, and no topical creams or treatments were applied. He was repositioned on his right side with pillows. The left BKA area had a bulky gauze dressing with an approximately quarter sized yellow stain that had saturated through the end of the dressing. The dressing was dated for 7/23/19. The nurse 'L' did not change the left BKA dressing. Upon inquiry nurse 'L' said that she had page the wound care team and they were on their way up to complete the dressing and assess the resident's coccyx area. On 7/24/19 at 5:15 PM, R90 was laying on his back, in bed with his stumps resting directly on a pillow. His left BKA dressing now had an approximate 2 inch circle of yellow drainage that had saturated through the bulky gauze dressing, it was dated 7/23/19. The Director of Nursing (DON) was present and conducted a skin assessment, and confirmed the coccyx area had developed a new pressure ulcer and that no prescribed cream had been applied to the area. The left BKA dressing was removed and revealed an unstageable pressure ulcer that had moderate amount of creamy yellow and serosanguinous drainage on it, saturating through the dressing. The DON could not explain why the wound care team had not completed the skin treatments for R90 as of today. The DON said she would order a low air loss mattress for R90, and update his care plan to include updated interventions for both the coccyx area and left BKA pressure ulcers. A medical record review conducted on 7/25/19 at 11:05 AM revealed a progress noted dated 7/24/19 at 7:35 PM that documented R90 had a stage 3 pressure ulcer on his coccyx that measured 2.0 cm x 4.0 cm. A low air loss mattress had also been ordered for R90. Resident #123: During an observation in the 5th floor dining room on 7/23/19 at 12:37 PM, R123 is seated in her wheelchair at a table eating lunch. Her right foot has bulky gauze dressing with a sock over it, there is a half-dollar sized serosanguinuous stain saturating through the lateral side (outer side) of the bulky dressing and through the sock. The resident was not interviewed at this time due to her eating lunch. During an observation on 7/23/19 at 2:58 PM, R123 was laying in bed, on her back with her feet elevated with pillows. R123 consented for her sock to be pulled back over her right foot to reveal an undated, bulky gauze dressing that had serosanguinuous drainage approximately 3.0 cm in diameter, saturating through the dressing and onto the sock. There is no dressing to her left foot/heel area. During an observation with nurse 'L' on 7/24/19 at 11:30 AM, R123 was seated in her wheelchair in the dining room. The right foot has a bulky gauze dressing with a sock over it. After consent from the resident, Nurse 'L' pulled back the sock to reveal the right heel dressing with a small dime-size serosanguinuous drainage seeping through the dressing, but not on the sock. The dressing has the date of 7/23/19 and the initials 'WCT' on it. Nurse 'L' said that 'WCT' stands for 'wound care team'. There is a soft foam dressing to the resident's right anterior shin area approximately 2 inches x 5 inches with no date or initials on it. There is no dry dressing to the left foot/heel area. Nurse 'L' was unaware of R123 having any injury to her right anterior shin and was asked to page the wound care team for an interview. According to R123's medical record, she admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The MDS initiated for significant change on 5/30/19 indicated that R123 now had one 'unstageable' pressure ulcer to the right heel. Section V of the MDS indicated that necrotic tissue on R123's right heel was identified on 5/27/19, was unable to determine depth or stage, and a wound care specialist was consulted. R123 was identifed to require one person assist with transfers and bed mobility. There was no documentation to indicate there were additional pressure ulcers. However, an order dated 7/4/19, prescribed the following; cleanse the left gluteal fold daily and as needed with wound cleanser, pat dry and cover with a comfort foam dressing. There are no progress notes or skin assessments documenting the left gluteal fold area at this time. A physician's orders [REDACTED]. An order dated 7/15/19, prescribed the following skin treatment; dry dressing to left ankle for fragile skin on heel every 36 hours. There are no progress notes on the right lateral heel, the right thigh, the right skin, or the left ankle area. On 7/16/19, a skin assessment indicated the following; left gluteal fold, open area, treatment (tx) in progress, right lower left heel tx in progress, right heel tx in progress. The last wound care assessment dated [DATE] identified the right heel to have an 'unstageable' pressure ulcer that measured 3.5 cm x 2.0 cm with scant exudate. There is no mention of a left gluteal fold pressure ulcer, or the right skin or thigh area. During an observation on 7/24/19 at 4:44 PM with nurse 'L', R123 was in her bed, on her back with a pillow under her heels. The right foot/heel dressing is clearly stained with serosanguinuous drainage over the right lateral side of the ankle. There is no dressing to the left ankle or the right thigh. There is a soft foam dressing to the right shin. Nurse 'L' confirmed there is no wound on the resident's right thigh area. Nurse 'L' said, 'the order from 7/11/19 must mean the right shin area'. The wound care team had not responded to the page from earlier today at approximately 11:30 AM, and therefore had not been interviewed regarding these orders. R123's buttocks areas was observed after obtaining consent from the resident. The left gluteal fold area was bright pink with scant drainage, appears as a shallow crater that was approximately the size of a half dollar, there was no dressing or skin treatment to this area, it is open to air inside the resident's brief. At approximately 5:30 PM, the DON was asked to observe the dressing to the right ankle/foot area, the right skin area, and lack of dressing to the left gluteal fold and left ankle foot area. The DON confirmed that the right ankle dressing was seeping throught her dressing and sock and could not explain why the wound care team had not completed the dressing change as of today. The DON confirmed there was no wound to the resident's right thigh, and could not explain if there was an error with the order for the right thigh skin treatment area. The DON said that R#123 did have an order for [REDACTED]. During an observation on 7/25/19 at approximately 11:30 AM, R123 was observed in the shower room with CNA 'N'. R123's left gluteal fold pressure ulcer did not have any dressing on it, and remained untreated, open to air. The left ankle did not have any dressing on it, the right ankle had dressing that was clean and dry, dated 7/24/19. According to the facility's 'Skin Management Guideline' policy, revised 11/28/17, Purpose: .It is the practice of the facility to properly identify and evaluate residents whole clinical condition increase the risk for impaired skin integrity, and pressure ulcers; to implement preventable measures; and provide appropriate treatment modalities for wounds according to industry standards of care. Procedure, 1. prevention of pressure ulers, inspection of skin daily with care and treatments by a licensed nurse. Examples of care planning for pressure ulcer prevention with treatment intervetnion guidleines or skin risk evaluation interventions. A. Turning and repositioning observations; .For those residents that are immobile or need assistance with mobility - evaluate turning and repositioing needs; .with a change of condition. Resident #440: On 7/23/19 at 12:01 p.m., R#440 was observed sitting in a Geri chair (recliner chair) alert and oriented to name with a family member pushing the Resident back to his room. On 7/23/19 at 12:45 p.m., R#440 was observed lying in bed with family members (Daughter) at bedside. R#440 was observed lying on a Regular Standard Mattress. Observe R#440 with a left lateral arm skin tear and a wound on the buttocks with no dressing applied. The Resident's Daughter said, the wounds should be covered. On 7/23/19 at 12:50 p.m., the Daughter of R#440 said, I had been asking for a Low-Air-Loss mattress for a while, and have not received one yet. R#440's Daughter stated,I have told several people, but I can't remember their names. On 7/24/19 at 11:10 a.m., a review of the clinical record revealed R#440 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) was unavailable. On 7/24/19 at 1:20 p.m., review of the resident's 'Skin' care plan, initiated on 7/12/19, documented the following; Evaluate and treat per physicians' orders, educate resident/family/caregivers of causative factors and measures to prevent skin injury, encourage good nutrition and hydration in order to promote healthier skin, and evaluate resident for sign and symptoms of possible infections. According to R#440's wound progress notes titled Michigan Wound Care, dated 7/18/18, treatment recommendations were as follows; Duoderm every two days and as needed to the coccyx, pressure reduction mattress, frequently reposition. A review of the Physician order [REDACTED]. On 7/24/19 at 1:42 P.M., during an interview with wound Nurse H, she was asked, what are the interventions for R#440's wounds. Wound Nurse H stated, low loss air mattress, and every two hours repositioning, Wound Nurse H was asked to pull up the skin care plan in the Electronic Health Record (EHR) and review the interventions. Wound Nurse H stated, I don't see the air loss mattress, turn and reposition and the float heel interventions. Its only four things on the skin care plan. Wound Nurse H stated, I am new here and trying to cover everything. Wound Nurse H was asked, how do the Nurses' Aides know to turn and reposition R#440 every two hours. Nurse H stated, it should be on their Kardex (The Nurse's Aide care plan Guide for the Residents). Wound Nurse H pulled up the Kardex and stated, It should have been there, but it's not. On 7/24/19 at 1:55 p.m., requested a copy of R#440's Skin care plan to Wound Nurse H. On 7/24/19 at 2:18 p.m., the DON was interviewed. The DON was asked who are responsible for ordering and making sure a low loss air mattress is delivered. The DON stated, The Wound Care Nurses are suppose to order the specialty mattress. On 7/24/19 at 3:05 p.m. Nurse H presented a copy of the R#440's Skin care plan with the revision date of 7/24/19; New Interventions: Float heels while in bed as tolerated, evaluate the Resident for changes in pain level and if appropriate request a scheduled pain medication from the physician. Apply barrier cream per Facility's Protocol to help protect the skin from excess moisture, low air loss mattress to protect the skin while in bed, turn and reposition frequently or more often as needed, and use a draw sheet or lifting device to move the Resident. On 7/25/19 at 2:29 p.m., R#440 was observed with a low air loss mattress on his bed, and his bilateral heel elevated, with wound dressing applied to the right lateral arm and to the coccyx.

This citation pertains to Intake #MI 19. Based on interview and record review the facility failed to assess for and implement adequate safety devices for one sampled resident (R#501) out of a sample of three residents reviewed for falls resulting in a fall with fracture. Findings include: Record review revealed that R#501 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Nursing assessment dated [DATE] indicated the resident cognition was intact and required partial/moderate assistance while transferring. A Physical Therapy note dated 1/9/19 documented, The resident requires supervision for safety. Review of a facility provided document titled, Medical Record Event Review from Event 1/10/19 documented the following occurrence: Resident noted to have a documented safety occurrence (fall) on 1/9/19 (day after admission) .Interdisciplinary Team (IDT) follow up and intervention of a perimeter mattress (defined edge mattress) as well as re-education regarding call light use .Facility further finds two safety occurrences (falls) occurred on 1/10/19, however assigned nurse did not complete an Incident/Accident (I/A) report . On 4/10/19 at 4:00 PM, during an interview with Nurse G she was asked about the falls for R#501. Nurse G said that she was working the midnight shift on the night of 1/10/19 into the early morning of 1/11/19. Nurse G said that she was not assigned to R#501 that night, Nurse H was. Nurse G said that on 1/10/19 around 9:30 p.m. she walked past the room where R#501 resided and noticed that he was on the floor. He was next to his bed on his hands and knees facing the wall. The nurse indicated that she assessed for injuries (the patient denied pain and no injuries were identified) and with another staff member assisted the resident back into bed and Nurse G said that she reported the fall to R#501's assigned nurse, Nurse H. The nurse went on to say that on 1/11/19 around 1 a.m. (3.5 hours later), she was walking back towards the nursing station and R#501 was observed on the floor again. This time the patient was lying flat on his stomach with his top half of his body facing the foot of his bed and the other half in the bathroom. The nurse indicated that she assessed for injuries (the patient denied pain at this time and was able to move all extremities) and she along with Nurse Bassisted the resident into his wheelchair. Nurse B's statement documented, I stuck my head in the room (where Nurse H was located) and said, I hate to be the bearer of bad news but your resident (R#501) fell , but seems to be ok. But ask (Nurse G) because she checked him out. Review of the medical record progress notes dated 1/8/19 through 1/11/19 failed to document the fall event from 1/10/19 at 9:30 PM or the fall from 1/11/19 at 1:00 am. There was no evaluation or analysis of hazards and risks identified after the second or third fall. Review of the Resident is at risk for falls care plan dated 1/9/19 had safety interventions initiated on 1/9/19. There were no new individualized safety approaches implemented after the second and third falls to reduce the resident's risk for further fall events. A nurses noted dated 1/11/19 15:08 (3:08 PM-14 hours after last fall) documented, .spoke with family member stating she would like resident transferred to hospital related to (r/t) right side pain. She also states the resident's roommate told her that the resident had fall over night. Director of Nursing (DON) notified .STAT (right away) x-ray to right ribs ordered while awaiting for transport r/t right side pain . A nurses note dated 1/11/19 18:03 (6:03 PM) documented, Resident reassessed for falls r/t roommate reported to residents sister that resident fell during the night. No injury noted although resident complains of increased pain to right side (rib area). X-rays ordered-no fracture, dislocation, lytic (injury to bone tissue) process is demonstrated .Sister insists resident goes to hospital anyway . At 19:27 (7:27 PM-18.5 hours after last fall) .resident was transferred to (Name of Hospital). Review of a the hospital records dated 1/15/19 (day 4 of hospital stay) documented, Patient present from (Name of Nursing Home) after sustaining a fall x 2 the previous day. He was found to have fractured ribs and right pneumothorax (abnormal collection of air in between the lung and chest wall. The air pushes on the outside of the lung and makes it collapse). A chest tube to suction was placed in the emergency department (ED) .During his time in the ED he became unresponsive and was intubated (insert a tube into the trachea for ventilation). He was recently [DIAGNOSES REDACTED]. On 4/12/19 at 9:50 AM during an interview with the facility's DON she stated she was not the DON at the facility at the time of the event. She was asked about the facility's procedure regarding completion of a Report of Resident Fall (I/A). The DON said that as a rule of thumb, the nurse that's assigned the resident completes the Fall Report. The DON went on to say that a Report of Resident Fall will guide the nurse to take immediate action after the event. Any changes to the plan of care and interventions should be documented in the medical record and care plan for the resident. Review of the facility's Fall Evaluation Safety Guideline policy dated 11.28.17 documented, Fall prevention is achieved through an IDT approach of managing predicting factors and implementing appropriate interventions to reduce risk for falls .Preventative measures shall be taken to decrease the number of falls whenever possible .Procedure: #3. Initiate, review and revise the fall care plan as appropriate, with new or discontinued interventions. Review of the facility's Care plan Standard Guidelines policy dated 11.28.17 documented, The resident care plan will incorporate risk factors identified in preadmission assessment, hospital records and admission evaluations, with changes in condition,reviewed and updated quarterly .the care plan is to be revised to reflect the current status of the resident.

This citation pertains to Intake #MI 910. Based on interview and record review the facility failed to provide adequate supervision to prevent a fall for one sampled resident (#501) out of four residents reviewed for accidents resulting in a fall with hospitalization and subsequent diagnoses/precautions for closed head injury. Findings include: On 9/26/18 at 8:35 a.m., review of a facility provided incident and accident report dated 9/9/18 documented the following; Was called into the residents (#501's) room by a Certified Nurse Assistant (CNA-A). Ran into the room and saw resident laying on his left side on the soft floor mat next to his bed. Resident is unable to verbalize needs. No signs or symptoms of pain were noted. Range of motion performed within his normal limits. Residents big toe was bleeding. No other bruising or physical injuries noted. Resident was assisted back into bed .His wife stated that she wanted him to be sent to the hospital for evaluation because he is on a blood thinner . Record review revealed that R#501 was originally admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set Assessment ((MDS) dated [DATE] indicated the residents cognition was severely impaired. Section G-Functional status documented that R#501 was totally dependent and required two staff persons for bed mobility and personal hygiene. Review of the facility provided statement from CNA A (whom was rendering care the R#501 at the time of the fall) documented the following; About 12:36 a.m. resident (#501) voided and had a bowel movement (BM). Wedge was taken from left side and inserted snug against residents right hip. Sheet and blanket was pushed up under residents entire right side (from top to bottom). Resident was slightly rolled (log rolled) toward the right. Resident extended back (like an arch but backwards) then immediately coughed very hard swiftly reversing arch into a fetal position. Resident kept going forward followed by another immediate cough causing his body to raise up and over the wedge that was inserted under his right side. I screamed for a nurse twice stat (immediately), while quickly grabbing sheet and blanket with one hand and resident midsection with other (hand) pulling back to break impact of fall. Residents right shoulder touched down on the mat first followed by lower body which did not hit hard (by observation). Resident did not hit head . At 10:06 a.m., a called was placed to CNA A to interview regarding fall. The mailbox on the phone number was full and was unable to leave a message. There was no call back from CNA A. Chart review revealed a Fall Risk assessment dated [DATE] with a risk score -37 (High Risk of Fall). A second Fall Risk assessment dated [DATE] had a risk score -42 (High Risk of Fall). A nurses progress note dated 8/31/18 documented, resident has a cough and yellow sputum [MEDICAL CONDITION] . A physician's orders [REDACTED].#501 was ordered Eliquis Tablet 2.5 milligram (mg) give one tablet two times a day for Anticoagulant (blood thinner). Review of the care plan dated 2/6/18 titled Activities of daily Living (ADL) self care performance deficit related to immobility, impaired cognition, weakness status [REDACTED]. He is not responsive to verbal or tactile stimuli, he does not open his eyes or move his limbs upon stimulus. He is dependent on staff for all care . With interventions of; The resident is totally dependent on (2) staff to provide bath/shower. The resident is totally dependent on (2) staff for repositioning and turning in bed. The resident is totally dependent on (2) staff with personal hygiene and oral care . The resident was on the Yellow Star Program (residents with a history of 2 or more fall will be added to the Falling/Yellow Star program by the interdisciplinary team-IDT). The CNA kardex (a guide for the CNA's to use to individualize resident care) documented that R#501 required (2) staff to provide bath/shower, (2) staff for repositioning and turning in bed, and (2) staff with personal hygiene and oral care . Review of the hospital discharge summary dated 9/9/18 (after the fall) documented Diagnoses: [REDACTED].You have a head injury. It does not appear serious at this time. But symptoms of a more serious problem, such as a mild [MEDICAL CONDITION] (concussion) or bruising or bleeding in the brain, may appear later . On 9/26/18 at 10:48 a.m., the facility's Assistant Director of Nursing (ADON) was queried regarding the fall for R#501. The ADON said that during the facility's investigation into the fall they discovered that only one staff member was rendering care to R#510 at the time of the fall. The ADON provided a 1:1 inservice with CNA A documenting, While performing care for residents, the plan of care/kardex shall be utilized to ensure each residents needs are anticipated/met. If unsure how to provide care for a resident, immediately discuss the needs/tasks for the resident with the nurse. The ADON went on to say that CNA A was new to the facility and did not have computer access. when asked what that meant, the ADON stated, (R#501's) plans of care and CNA kardex was not available for CNA A to use. She should have had a discussion with the nurse before she rendered care to the resident. On 9/26/18 at 11:32 a.m., Nurse Practitioner (NP B) was interviewed regarding the hospital [DIAGNOSES REDACTED].#501. NP B sated that the resident had sutures in his head from previous head injury. They (the hospital physician's) have to give a diagnosis/reason to perform the Computed tomography CT) scan of the resident head. NP A was asked why the hospital physician's couldn't have used one of the multiple other [DIAGNOSES REDACTED]. This resident has had many head CT scans. Review of the facility's Falling/Yellow Star Program (provided by the facility when falls policy was requested) dated 8/28/18 documented, Each resident with tow or more documented fall will be added to the Falling/Yellow Star Program to indicate high risk for repeated falls .Subsequent to a fall, a post fall assessment will be completed and/or reviewed by the IDT team and make recommendations for appropriate interventions.

This citation pertains to Intake MI 036. Based on interview and record review the facility failed to identify, assess, provide care and transfer out a resident experiencing a change in condition in a timely manner for one sampled resident (#502) out of three residents reviewed for care needs resulting in a hospitalization requiring critical care to prevent imminent or life-threatening deterioration. Findings include: Record review revealed a face sheet documenting that R#502 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The face sheet indicated the resident was her own responsible party and her husband was listed as an emergency contact. The admission Nursing Evaluation dated 9/6/18 indicated the residents cognition was intact. Hospital discharge records revealed that on 9/6/18, prior to admission into the facility, at 11:44 and again at 06:45 the residents blood glucose levels were 26 and 35 respectively ([DIAGNOSES REDACTED]-low blood glucose levels). The mean normal blood glucose level in human is about 70-130 milligrams per deciliter (mg/dL) per www.thediabetescouncil.com. Review of the 9/6/18 admission physician's orders [REDACTED]. The care plan titled, Nutritional Problem dated 9/11/18 documented an intervention of Obtain and monitor lab/diagnostic work as ordered. report results to MD (physician) and follow up as indicated. On 9/26/18 at 10:36 a.m., review of the clinical progress notes revealed the following; -Nurses Note-9/9/18 (3 days after admission into the facility). Resident request for blood sugar (BS) check at night, reading 54, resident is asymptomatic. Alert and awake, resident states she bottoms down (blood glucose level drop) sometimes. Protein shake given along with residents sugar pills. BS recheck after one hour, reading 44, resident still asympotmatic. Resident took more sugar pills. Will recheck in an hour. Physician (MD) notified and stated to recheck BS. New lab order in place (name of lab test). Review of the physician's orders [REDACTED]. -Physician Note-Effective date (date entered into electronic medical record): 9/11/18. Narrative late note (date resident was seen by physician) for 9/10/18. Patient seen for increasing lethargic and [DIAGNOSES REDACTED]. Assessment: [DIAGNOSES REDACTED]: given Intramuscular (IM) Glycogen (therapeutically administered glycogen-glucose to effectively increase blood glucose levels) improving, suspected infection, if no improvement transfer to emergency room (ER). Review of the (MONTH) (YEAR) Physicians orders and Medication Administration records revealed no documented evidence that IM Glycogen was ever ordered or administered to R#502. -Nurses Note-9/11/18 @ 11:14 am. .family member present in room and requesting resident be sent to hospital because she is not herself .Eyes open, responding to verbal commands .BS-41. Resident awake and able to drink fluids with assistance, sips of apple juice taken, BS-71 upon reassessment after 5 minutes. Family member at bed side .continuing to demand resident be sent to hospital .Resident is her own responsible party and husband in only additional listed emergency contact .Assistant Director of Nursing (ADON) contacted husband to notify of residents current condition and states he would like resident to be transferred to hospital. Husband spoke with resident and resident states she would like to be transferred to hospital. Floor nurse paged (Attending Physician) to follow up with orders. -Nurses Note-9/11/18 @11:19 am. Writer called to room related to residents family member was requesting resident to be transferred to the hospital .Nurse completed vital signs and provided apple juice for resident .(name of husband) was contacted and requested resident to be transferred (to hospital) .Writer did inform (name of husband) that the Doctor has been paged and we would request to get new orders for some testing. (name of husband) declined requesting resident to be transferred. -Nurses Note-9/11/18 @11:29 am. Resident in room with family member. Family states that resident does not seem right and she wants her (R#502) to go to the hospital .Family member called residents husband and were told to transport resident to ER per husband's request .BS-40, orange juice was given to resident to drink, BS increased to 70 several minutes after .(Name of Physician) notified about transfer (request to hospital) and MD suggested we attempt to keep resident in facility and draw labs if family approves, otherwise ok to send to ER. -Interact Transfer Form-9/11/18 @ 11:30 am. Resident #502 transferred/discharged to (name of local hospital). On 9/26/18 at 3:36 p.m., along with the facility's Director of Nursing (DON), R#502's Attending Physician (MD D) was called. The MD stated that is was facility protocol for any diabetic resident to have blood sugars monitored upon admission stating, Blood sugars should be checks 3 to 4 times a day. MD D said that it was his protocol that if a residents BS should go lower than 80 the resident should be given Glycogen. MD D could not recall if he ordered Glycogen for R#502. When asked about the progress note dated 9/10/18 entered into the electronic medical record on 9/11/18, MD D indicated that he has 24 hours to enter a patient visit into the clinical record. The physician was then asked why on 9/10/18 he documented suspected infection, if no improvement transfer to emergency room (ER) and on 9/11/18 he did not order for the resident to be sent directly to the ER to which he responded, I didn't tell them not to send her out. Review of the ER notes for R#502 from 9/11/18 documented Critical care was necessary to treat or prevent imminent or life threatening deterioration of the following conditions: Circulatory failure, metabolic crisis (a serious condition caused by low blood sugar and the build up on toxic substances in the blood), hepatic (liver) failure, renal (kidney) failure [MEDICAL CONDITION] (complication of an infection). Review of the facility's policy titled Acute Change in Condition revised 4/2016 documented, Recognize condition change early, assess symptoms and physical function, document descriptions of observations and symptoms, report residents status to physician and responsible party as appropriate, ensure effective communication of necessary information to other members of the interdisciplinary team including relevant clinicians, Certified Nurse Aides, patient/resident, healthcare surrogates, therapists and others responsible for care.

Based on interview and record review the facility failed to implement safety devices (non-skid footwear) for one sampled resident (#603) from a total sample of six residents, resulting in fall with left [MEDICAL CONDITION]. Findings include: On 6/12/18 at 9:00 a.m., review of a facility provided Incident and Accident (I/A) report dated 1/24/18 documented that R#603 was observed lying on floor beside bed in (room number not assigned to resident). Resident left elbow skin tear noted .Resident complained of severe pain to left hip and low back. Range of motion (ROM) completed, unable to move left lower extremity (LLE) .stated, I tripped and fell . The I/A documented, Were safety interventions in place prior to incident? Yes. Record review revealed that R#603 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set Assessment ((MDS) dated [DATE] indicated the resident cognition was severely impaired and required supervision with set up for transfers and locomotion in the room. Further review of I/A's revealed that R#603 had incidents of falls/throwing self on floor on 1/13/18 and 1/15/18 prior to the fall on 1/24/18, no documented evidence that non-skid foot wear in use. Review of the document titled, Fall Risk Evaluation dated 1/16/18 documented a fall risk score of 18 (a total risk score of 10 or above represents High Risk. Review of the Fall/Safety/Prevention plan of care dated 12/13/17 had safety interventions which included, Ambulates Ad lib (as much or as often as desired) .Ensure bed is in lowest position .Yellow Star Program (resident with a history of 2 or more falls .yellow star symbols to identify High Risk residents with a repeat fall history to alert staff at a glance and raise safety awareness .Non-skid footwear-as tolerated (safety intervention added to care plan on 12/15/17). Review of a Nurses note dated 1/24/18 at 6:15 a.m., Writer heard noise while in the hallway and started walking toward sound. Certified Nurse Assistant (CENA) came out of room (adjoining room to resident #603's room) and stated, 'She (R#603) fell ' .Observed resident laying on back on floor beside bed. Resident yelling and swearing .asked what happened, R#603 stated, 'I tripped and fell ' .resident complained of pain to left hip, groin and low back received assistance from staff nurse and CENA. Staff assisted resident to wheelchair. During transfer resident yelled at staff and attempted to punch (nurse). Staff assisted resident to resident room (resident #603's assigned room number) and transferred to (assigned) bed. Resident continued to yell and scream and pound on the wall next to her bed while yelling 'It hurts, it hurts. Get me out of here'. ROM completed but resident able to move all extremities except for LLE .Received orders to transport to hospital (name of hospital) .Resident left facility at 7:00 a.m. (Nurse) assessed location of fall and noted not wetness on the floor, and resident non-slip/gripper socks were not on. A hospital x-ray dated 1/24/18 documented, Hip; Left. Clinical History: Fall 2 view study of the left hip and pelvis were obtained. The current examination demonstrates a varus angulated comminuted intertrochanteric (left hip bone) fracture. There is avulsion (the action of pulling or tearing away) of the lesser trochanter (part of hip bone). Review of the Behavior Monitoring Flow Record dated 12/22/17 through 1/17/18 documented behaviors of crawling into others bed, wandering into other rooms, yelling and raising hand, inappropriate language, and physical aggression (there was no target behavior that indicated that R#603 would remove the non-slip/gripper socks). The targeted behavior interventions were as follows: re-direct to quiet area, maintain calm environment, avoid over stimulation, attempt to toilet, accompany while walking. On 6/12/18 at 3:10 p.m., the facility's Director of Nursing (DON) was queried regarding the incident with R#603 trying to get into another bed (at standard height) and subsequently falling. The DON said that one of the assessed safety devices for R#603 was non-skid footwear or grippy socks, as tolerated. The DON was asked to explain how staff would know what as tolerated meant for R#603, to which she stated, If the resident refused to wear the grippy socks or non-skid footwear would be an example of as tolerated. The DON went on to say that if the resident refused to wear the non-skid foot wear, The staff should document the residents refusal. Additionally, if the resident 'refused' (to wear the grippy socks) that should be care planned and re-evaluated if that is an effective safety intervention. Review of the facility's policy titled, Fall Management reviewed 4/1/18 documented, If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls.

This citation pertains to MI 526. Based on observation, interview, and record review, the facility failed to identify a hazard and implement measures to prevent a fall for one (#701) of three sampled residents reviewed for fall from a total sample of six, resulting in a fall from a bed which caused a laceration requiring sutures and facial swelling. Findings include: On 3/19/18 at 10:10 AM, the concerned family member (CFM) of Resident #701 (R701) was interviewed and stated R701 returned to the facility from the hospital on [DATE] with a black eye and a gash on the top of his head which required stitches. The CFM stated these injuries occurred when R701 fell from his bed on 12/13/18. The CFM added that R701 was in a coma and couldn't move so how could he roll out of the bed onto the floor. On 3/19/18 at the following times, R701 was observed lying in his bed with a [MEDICAL CONDITION] and feeding tube in place: 10:55 AM, 11:15 AM, and 1:05 PM. R701 did not respond when addressed. On 3/19/18 at 11:50 AM, a review of the clinical record for R701 was begun. R701 was originally admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A Minimum (MDS) data set [DATE] documented moderately impaired cognition and the resident was totally dependent upon staff for bed mobility. On 3/19/18 a facility log used to document the time and date when a resident arrived from a hospital was reviewed and revealed R701 arrived at the facility on 12/13/17 at 6:39 PM. A facility document titled, Nursing Home to Hospital Transfer Form documented that R701 was transferred to the hospital on [DATE] at 10:30 PM for a lrg (large) laceration to forehead; Usual Mental Status: Not alert; Usual Functional Status: Not ambulatory; Risk Alerts: Anticoagulation; Additional Relevant Information: Laceration to left eyebrow, swelling to left cheek face. A nursing note of 12/13/17 at 10:50 PM documented: (R701) arrived at 7 PM from hospital. EMS (Emergency Medical Service) placed pt. in bed. All equipment in room and set up. Pt. covered up .Writer left room to start rounds and med pass. Checked on pt. again at 8:30 PM. Approx pt. was in bed. Then at 9-9:15 PM, writer went to room and observed pt. on the floor on his left side with sheets under him and waffle mattress on the ground next to him. Laceration noted to left eye. (Large) amount of blood. Swelling to left cheek noted. MD notified. EMS called to send pt. for stitches and assessment. Steri strips and first aid applied to face and eyebrow. EMS arrived at 10:50 PM. A facility document titled, Incident & Accident, dated 12/13/17, revealed the following: Description of incident: resident observed on the floor next to his bed on his left side laceration noted to eyebrow. Waffle mattress next to him as well. Comments: upon investigation it was determined that EMS brought resident to facility and placed resident in bed. Resident's facility mattress was a low air loss; EMS placed resident on waffle mattress on top of low air loss, causing resident to slide off bed. Hospital discharge papers dated 12/20/17 were reviewed with the Director of Nursing (DON) and documented: --Additional instructions: stitches with large band aide on left brow. --Procedures and test performed during (R701's) visit: Laceration repair. The facility document titled, Nursing Comprehensive Evaluation dated 12/20 included a skin assessment which revealed left side forehead wounds, staples. The Detailed Skin Assessment: Comprehensive Review, dated 12/21/17, documented sutures on the forehead and black eye lid above the left eye. On 3/19/18 at 1:45 PM, an email to the facility dated 12/20/17 was reviewed. The email was received from an EMS transportation company and documented a message sent to all of their employees. The message was as follows: EMS Team, when transferring a patient into their bed at (facility of concern) please DO NOT leave the patient on an air mattress (APM mattress) at any time. All patients must be placed on the facilites bed mattress. If you utilize an air mattress (APM mattress) from the sending hospital on your stretcher, please ask someone at (facility of concern) to dispose of it after patient transfer. NEVER leave a patient on the air mattress (APM mattress) as this is a fall risk precaution. On 3/19/18 at 12:49 AM, when Unit Manager, Staff A was queried about nursing procedures for admitting a resident from the hospital, she said, We would get the (hospital) paper work and report from EMS. Check the vitals of the resident to make sure they are stable. The CNA would make sure the resident is clean and dry. The nurse would begin the Nursing Comprehensive Evaluation. R701's clinical record was reviewed with Staff A. Staff A said, We don't have a 'Nursing Comprehensive Eval' from 12/13/17 and there should be one. Vitals should have been done right away. The clinical record did not document vitals had been taken upon R701's return to the facility on [DATE]. On 3/19/18 at 1:12 PM, when Licensed Practical Nurse (LPN), Staff B was queried if he was familiar with the daily care R701 required, he said, (R701) is unable to do anything for himself. He requires total assistance. (R701) is not able to move in the bed. He cannot even move a finger. When queried if he was familiar with the installation of a waffle mattress, Staff B said, The (waffle) mattress has some ties to secure it. Our maintenance guys will secure the mattress. I have secured the mattress when maintenance is not available like on the weekends. On 3/19/18 at 1:15 PM, Certified Nurse Aide (CNA), Staff C said, We have had residents on waffle mattresses in the past. It has its own straps that have to be secured. On 3/19/18 at 1:20 PM when the DON was queried about nursing procedures for residents admitted from the hospital, she said, Nurses go to the patient to make sure they are transferred comfortably to the bed. The nurse and CNA will be there to make sure this happens. Because the resident may be disoriented, staff are to make sure no accidents will happen. Sometimes the paramedics will just put the resident in bed, so the nursing staff are to position the patient and make sure everything is in the right place. On 3/19/18 at 2:25 PM, the person who was the Acting DON on 12/13/18, Staff D was interviewed. Staff D stated, when EMS brought R701 into his room from the hospital, he was on a waffle mattress. EMS laid the waffle mattress on top of his bed which had a APM mattress on it. (An Alternating Pressure Mattress is designed to be used by a bed ridden patient who has lost the ability to move in bed, change their resting position or with lowered mental awareness level. APM consist of individual air tubes that automatically inflate and deflate on a set schedule.) The APM mattress was turned in on. The waffle mattress (which was placed on top) should have been removed if it wasn't secured. On 3/19/18 at 2:40 PM the DON and Administrator agreed that the APM mattress moves and it would be a problem (fall risk) for R701 to be on an unsecured waffle mattress placed on top on the APM mattress. On 3/19/18 at 3:07 PM, LPN, Staff E was queried over the phone. Staff E said, I was on duty when EMS dropped (R701) off. I saw the resident in the bed but had not started his physical assessment yet. I made sure his air loss mattress was turn on. The waffle mattress looked like a pool float, but it did not have any straps (to secure it). When I found him on the floor, the waffle mattress was half on the bed and half on the floor. On 3/19/18 at 3:50 PM, the facility document titled, Maintenance of Low Air Loss Mattresses, revised 6/1/13, was reviewed and documented the following: All low air loss mattresses shall be checked by nurse QS (every shift) for proper function . On 3/19/18, the facility document titled, Fall Management, undated, was reviewed with the DON and document the following: The facility identify hazards and resident risk factors and implement interventions to minimize falls.

Citation pertains to MI 524 and MI 329 Based on interview and record review the facility failed to supervise two Residents (R#1 and R#2) two of four residents sampled during an abbreviated survey, resulting in fall for R#1 and R#2 and fractures of R#1's left arm. R#1 On 12/6/17 at 9:21 a.m., Interview with R#1, when asked how he/she received the black eye and broken arm, R#1 stated, Well, it was on Thanksgiving Day (11/23/17), I was feeling nauseous after lunch and had asked my nurse to give me an emesis pan, in case I would start throwing up. I later asked the Certified Nursing Assistant (CNA) to help me to the bathroom. When I got on to the toilet I asked the CNA to stay with me because I was week, but she left. In a while another CNA came and checked on me and gave me another emesis pan. I was on the toilet an hour and had put my call light on and was screaming for someone to come and get me off the toilet and so was the lady that was in the next room. I was just physically exhausted. I couldn't stay on the toilet any longer and had to get off. When I went to stand up, I stumbled and hit my face on the sink and then fell backwards and went through the door and falling on my arm. When asked what happened next, R#1stated, They put me in the wheel chair and called 911 and went to the hospital. That's when I found out that my arm was broke in two places and they had to glue the cut on my head. On 12/6/17, record review of R#1 revealed admission into the facility on [DATE] with [DIAGNOSES REDACTED].#1 had impaired cognition and extensive assist with Activities of Daily Living (ADLs) and transfers. MDS was prepared after fall. Further investigation reveals Falls Risk Evaluation- Score 12- Total score of 10 or above represents High Risk. OT (Occupational Therapy) Evaluation and Plan of Treatment- Toileting = SBA (Stand by Assist- Help provided to a person that cannot complete an activity of daily living), Toilet/Commode Transfers = SBA. 12/6/17 at 3:33 p.m., Interview with CNA A, when asked if on 11/23/17 was R#1 assisted with a SBA to the toilet. CNA A, stated, Yes. While R#1 was on the toilet did you leave the floor without notifying other staff members, CNA A stated, Yes. Review of 1:1 Education. Date: 11/24/17, Topic: Coverage When Leaving Patient Care Units. On 11/23, there was an incident where a patient was assisted to the toilet and ultimately sustained a fall . It is the expectation that anytime you leave a patient care unit, you leave your assigned patients under another co-workers supervision. Signed and dated by CNAA and Assistant Director of Nursing. On 12/6/17 at 3:30 p.m., Interview with Nurse B, when asked if she was the nurse assigned to R#1 on 11/23/17, Nurse B states, Yes. When asked if a resident with an order for [REDACTED]. On 12/6/17 at 4:00 p.m., Interview with Director of Nursing (DON), when asked if R#1 was alert and oriented to person, place and time and able to make needs known, DON states, Yes, he/she is alert and oriented and can make needs known with no problem . R#2 On 12/6/17, record review of R#2's medical records revealed an admission into the facility on [DATE] and readmit on 11/17/17 with [DIAGNOSES REDACTED]. According to Minimum Data Set ((MDS) dated [DATE] documents impaired cognition and extensive assistance with Activities of Daily Living (ADLS) and transfers. Further review of investigation of fall on 11/7/17 provided by facility. 11/7/17 resident making attempts to get out of bed after breakfast, staff nurse had staff get resident out of bed and into w/c (wheel chair), placed her in day room for socialization, and so staff could keep resident within eyes reach of staff for safety. 11/7/17 approximately 4pm report received on BMP (Blood Test) sodium level normal. Called MD to obtain order for fluids related to increased confusion and completion of ABT (Antibiotics). 11/7/17 4:00 pm CNA was called into room and laid resident back down in bed. 11/7/17 4:15 pm residents nurse was called into resident's room by CNA, upon entering room resident was observed lying on the floor next to her bed on the left side. Resident later complained of pain in left hip and was sent to hospital after x-rays revealed a possible fracture. On 12/6/17 at 2:13 pm, interview with Unit Manager C (UMC), when asked why resident was put in the wheelchair in the morning, UMC stated. She was put in chair to prevent falling. When asked when R#2 was put back into bed was there any interventions put in place, UMC stated, we have the Yellow Star program Asked what that means, UMC stated, We monitor them closely. Was this a different intervention than before the fall? UMC stated No. After the fall were interventions put in place? UMC stated, Yes, we put a landing strip mat down and applied a perimeter mattress to keep her from falling out of bed. Asked if the MD was called obtain and order for fluids related to confusion right before laying patient down, UMC stated Yes. On 12/6/17 at 3:20 pm, Interview with Nurse D, when asked why R#1 was put in wheel chair in morning of 11/7/17, Nurse D stated, I had received in prior reports that resident was trying to get out of bed, so we put the resident in the chair to be on the safe side. Asked why resident had to be kept on the safe side, Nurse D stated, The resident would be in public view and safe from injury. 12/6/17 at 4:00 p.m., Interview with DON, when asked if new interventions should have been put in place for R#2, DON stated, We thought she was fine she had not had a fall before this one.

Based on observation, interview, and record review, the facility failed to ensure proper supervision and failed to perform safe, injury-free surface to surface transfers for four (#'s 805, 811, 813, and 815) of eight sampled residents reviewed for accidents from a total of 32, resulting in pain, bleeding, bruising, skin tears, lacerations, multiple hematomas, multiple fractures and emergency hospital treatment. Findings include: Resident #811 On 7/25/16 at 12:22 p.m. and 7/26/16 at 8:45 a.m., Resident #811 was observed ambulating throughout the fifth floor, which included the dining room/activity areas, walking closely around other Residents seated at tables, and throughout the hallways in a hurried pace without any assistive device while staff followed the Resident. At each of these observations, a bright pink cast was observed to the Resident's right arm. On 7/25/16 at 8:30 a.m., Nurse D reported that the Nurse Manager for the fifth floor was not available (on vacation) and when asked about Resident #811, Nurse D reported the Resident currently had a sitter 1:1 for behaviors of wandering and agitation and had a history of [REDACTED]. Review of the clinical record revealed Resident #811 was initially admitted into the facility on [DATE] and readmitted on [DATE], and signed onto hospice services on 5/25/16. [DIAGNOSES REDACTED]. (There was no identification of osteoporosis in the clinical records or noted within the radiology reports.) Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] documented Resident #811 had highly impaired vision, severe cognitive impairment, felt tired or had little energy (for 7-11 days over the last two weeks during this assessment reference period), exhibited no behavioral symptoms such as wandering, rejection of care or psychosis, had improved behaviors, required supervision with walking in room and limited assistance with walking in corridor, was not steady, only able to stabilize with staff assistance for walking, did not use any mobility devices, had falls with and without injury, and received hospice services. Comparative review of the quarterly MDS assessment dated [DATE] documented Resident #811 had no vision impairment, severe cognitive impairment, no mood concerns, exhibited wandering behavior that occurred daily, required supervision with walking in room and corridor, was steady at all times with walking, did not use any mobility devices, and had two or more falls with injury. According to the Resident's fall care plan initiated 10/29/15 and updated 5/28/16, there were documented falls on 4/8/16, 4/11/16, 4/16/16, and 5/28/16. Interventions included: Environment clean and free of clutter Fall assessment per protocol Safety interventions: Red star, Yellow Star, Gripper Socks, 1:1 supervision 7a-11p (added 5/28/16) Elopement precautions Enc res to participate with activities when amb/wandering (added 4/12/16) Staff to monitor when ambul (added 4/13/16) Review of the radiology reports available in the clinical record included: 4/21/16 at 4:26 a.m. XR Hand Right .Findings consistent with distal radial fracture with dorsal displacement of the distal fragment and possible intra-articular extension Review of a consultation record dated 7/19/16 documented, Right olecranon dx (diagnosis)/healed distal radius fx (fracture) .Results of Examination: Healing displaced olecranon fx. Review of a vision consultation on 1/26/16 documented, Per RN, SW request noticing pt bumping into walls scares often .Assessment .Pseudophakia (artificial lens implantation after cataract surgery), Macular Degeneration (due to damage to macula that results in loss of central vision - objects seem blurred, distorted, or are not seen) .Our impression pt does see and will track objects in short bursts .I also feel there is a cognitive disconnect vs vision sys defect . Review of the available Fall Risk Assessments (score of 10 or greater = high risk) for Resident #811 included (none available prior to 3/9/16): 3/9/16 = 20; 4/12/16 = 19; 4/13/16 = 21; 4/18/16 = 21; 6/1/16 = 20 Review of the Incident and Accident (I/A) Records provided by the facility as requested since last survey (8/14/15) included: 1. 10/7/15 at 5:45 p.m., Resident hit foot on chair while walking has bruise on left great toe - order noted for grippee socks . 2. 1/21/16 at 2:30 p.m., Another resident unmaliciously bitten resident - injury skin tear redness around finger tips, bleeding on right ring finger .res is self ambul., staff enc (encouraged) to monitor resident when with (name of another Resident) . 3. 2/23/16 at 1:54 p.m., Res. obs. Walking into a wall causing a hematoma .staff educated to monitor res when she is up ambulating 4. 4/8/16 at 7:05 p.m., Res fell and hit her head on the floor .hematoma on forehead hairline slightly blue .order noted for res to participate with activities when wandering . 5. 4/11/16 at 3:00 p.m., Res observed on dining room floor (tripped over wheelchair) - no injury - Staff educated to monitor res. when up ambulating 6. 4/16/16 at (no time), Res tripped over antiroll backs of w/c, swelling of left arm .x-ray negative fx .enc. To stay seated in DR and staff re-educated to monitor res. when up in DR . 7. 5/28/16 at 7:40 a.m., Resident hit the floor while she was walking around the floor, tripped over a w/c (wheelchair) and hit face on floor. Injury - hematoma, skin tear, face swelling, nose discoloration, face/nose bloody, pain nose .client being transferred to (name of local hospital) .Res up amb. tripped over w/c, bleeding noted from nose sm (small) ST (skin tear) to left eyebrow, res. c/o pain to face, neuro checks initiated .Sent to ER for eval/sutures, returned to facility dx fx nose; fx right elbow, cast noted to right arm new order for 1:1 from 7 am to 11 pm noted . Additionally, review of the interdisciplinary progress notes revealed nine additional documented incidents without any further documented investigation (I/A reports) of the incidents, investigation into the circumstances and evaluation for appropriate interventions for the following entries: 4/10/16 at (no time) Res observed in day room sitting (on floor) next to w/c of (another resident) . 4/16/16 at 1:30 p.m., Resident was observed on floor and noted a skin tear on lt (left) outer forearm, .ordered stat x-ray of Lt arm (negative) . 4/18/16 at 12:45 p.m., Resident observed on the floor . 4/21/16 at 2:00 a.m., Resident was observed during med pass holding her right hand. Right hand was swollen with bruising on top of hand .Stat x-ray ordered . 4/21/16 at 6:00 a.m., X-ray came back positive distal radial fracture. Resident sent to (name of local hospital) . 4/23/16 at 12:00 a.m., at approx. 8 pm 4/22/16 CNA (certified nursing assistant) observed res trip over another res w/c and come to a sitting position on the floor in east hallway . 4/27/16 at (no time), Resident observed on floor in dining room . 5/1/16 at (no time), Resident observed on floor on East Hall . 5/2/16 at (no time), Resident observed on floor . 5/10/16 at 7:50 p.m., Resident in hallway, was observed by the aid and nurse, resident hit head .Resident unable to state where she was trying to do .Dr .notified stated didn't want an xray of the skull . 5/26/16 (no time Hospice nurse), Patient alert with confusion/fall 5/26 hematoma to right forehead .size of tennis ball . According to the facility's One to One Responsibilities policy dated 10/25/12, Stay with Resident at all times .Charge Nurse is to document Q shift summary on all one to one residents, why on one to one, any behaviors during shift . Review of the available one to one documentation revealed multiple incomplete and missing documentation since this intervention was added on 5/28/16. On 7/26/16 at 12:00 p.m., an interview was conducted with Social Service Designee (SSD) I. When asked about Resident #811's behaviors, SSD I reported, She has a history of wandering but declined overall and is now on hospice. When asked about the multiple incidents with falls that occurred while the Resident wandering throughout the fifth floor that resulted in injuries of walking into walls, encountering other Residents, tripping over objects and what interventions had been attempted to reduce the elevated risk for Resident #811 to enter into unsafe situations given the wandering behavior, SSD I stated, I'm not aware of wandering, those behaviors decreased. On 7/26/16 at 2:20 p.m., an interview and record review was conducted with Risk Nurse Manager A who reported she was responsible for managing the facility's I/A's. Risk Nurse Manager A reported she was unable to locate any further one to one documentation, had a call out to the Nurse Manager (there was no further documentation provided by the end of the survey) and would likely be changing the policy for one to one. At that time, a review of the Resident #811's I/A reports provided and the progress notes which included multiple other uninvestigated incidents was completed with Risk Nurse Manager A who was unable to offer any explanation as to the lack of documentation and reporting of these incidents and injuries. When asked what the facility's process was for reporting and documenting incidents and injuries, Risk Nurse Manager A stated, If a fall occurs, anything - falls, bruises, abrasions, skin tears, peg, foley, trach, any unusual occurrence an investigation right then and there should be initiated. Risk Nurse Manager A was asked about the incident regarding the fracture of the right arm on 4/21/16 and reported there was no investigation and was unable to offer any further explanation or clarification. When asked about what interventions had been attempted given the Resident's wandering behaviors, dementia, severe vision impairment and elevated risk of entering unsafe situations, Risk Nurse Manager A reported She always was wandering and has history of combative behaviors which could be redirected. We started noticing a pattern (falls) in January. Interventions were to monitor when ambulating Risk Nurse Manager A was asked how staff were able to offer adequate supervision for Resident #811 while ambulating as identified in the documented interventions and why the facility's decision to implement one to one supervision had not been implemented prior to 5/28/16 (following the fall with multiple fractures) and not earlier given the Resident's identified severe vision impairment in January and increased falls from tripping over items, or walking into walls, Risk Nurse Manager A reported, Maybe it should have been implemented sooner. At that time upon review of the Resident's fall care plan with incomplete and inaccurate information, Risk Nurse Manager A was unable to explain why the fall care plan had not been updated with each documented fall and why alternate interventions had not been attempted. On 7/26/16 at 11:30 a.m., during an interview with the Administrator (Abuse Coordinator, who has been at the facility for approximately two weeks) when asked about the concern regarding the lack of documentation, reporting, and investigation of incidents including those with injuries, the Administrator acknowledged she had identified concerns as well and reported, Those (I/As) are not currently being reviewed at our morning meetings, but will be changing so that way they (I/As) can be reviewed immediately. According to the facility's Fall Risk Reduction and Management policy dated 3/2013: .The Risk Nurse Manager and the Interdisciplinary Team will monitor and document resident response to interventions and modify and document goals and interventions as indicated .Notify the Risk Nurse Manager and Interdisciplinary Team if a resident experiences a fall . Resident #805 On 7/25/16 at 1:30 p.m., review of the clinical record revealed Resident #805 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]., and history of fractured femur (8/15/15). According to the most recent Minimum Data Set (MDS) assessment dated [DATE], Resident #805 had severe cognitive impairment, and required total assistance of two persons for transfers. According to the Resident's Alteration in safety R/T weakness, decreased mobility, poor safety awareness care plan reviewed 4/28/16 included an intervention added 4/5/16 which read, Hoyer lift with all transfers. Review of the Resident's CENA care guide located in a binder at the nurse's station documented Resident #805 as a Hoyer lift transfer. On 7/26/16 at 8:25 a.m., Certified Nursing Assistant (CNA F) was observed exiting Resident #805's room and stated, I need help. Where's the other CNA? A housekeeper directed CNA F down the end of the hallway. At that time, Resident #805 was observed laying in bed with no mechanical lift machine in the room. On 7/26/16 at 8:37 a.m., CNA F was observed as she exited Resident #805's room. There was no mechanical lift machine in the room. At that time, the Resident was observed seated in a wheelchair next to the bed. When asked about Resident #805's transfer status, CNA F stated, It's only my third or fourth day on the floor by myself, I'm not sure. When asked how Resident #805 had been transferred from the bed to the wheelchair in the past ten minutes, CNA F stated, After I pulled up his pants to get dressed, we (CNA F and another CNA) lifted and grabbed him by the brief and transferred him into the wheelchair. CNA F was unable to recall the name of the other CNA who assisted with the transfer. When asked how CNA's are made aware of the specific individual needs for providing care, CNA F reported, Normally we get report (at start of shift) but I didn't get today. CNA F was unaware of the specific Resident care guides located in a binder at the nursing station. According to the facility's Total Mechanical Lift policy dated 4/1/2014 included: It is the policy .to utilize a total mechanical lift to transfer a patient/resident who otherwise would not be considered safe when transferred by a minimum of two staff members and/or as determined by the Interdisciplinary Team .CENA Care Guide is the plan of care for a patient/resident for the nursing assistant to utilize for guidance with Activities of Daily Living (ADLs). Always review CENA care guide to identify how a patient/resident transfers . ( ) Resident #813- On 7/25/16 at 8:30 AM, resident #813 was observed, along with nurse manager 'M', lying in bed with a splint to the left lower leg. The resident was alert, but confused. When asked if the resident had experienced any recent accidents and/or injuries, nurse 'M' said that during a transfer from wheelchair to bed conducted by nurse aides (aides 'Q' and 'R'), a popping sound was heard which was later determined to be a fracture of the resident's left leg. On 7/27/16 at 9:45 AM, aide 'R' was asked how the resident's fracture occurred. Aide 'R' said, I was assisting (aide 'Q'). She was (the resident's) aide. We were using a gait belt to transfer (the resident) from her wheelchair to the bed. We heard a pop and looked down and her foot was twisted inward. When asked, aide 'R' said that the resident was not able to stand and pivot, move her legs or plant her feet and had to be lifted with the gait belt from the wheelchair when the transfer was initiated. She said, She was a two-person transfer with the gait belt. She was not a (mechanical total body lift) transfer. On 7/27/16 at 10 AM, aide 'Q' was interviewed by phone about the resident's fracture. She said, Me and (aide 'R') were getting her (the resident) up with a gait belt from the wheelchair to bed and heard a cracking sound. Her foot was caught on a bar under the bed. When asked how the fracture could have been avoided, aide 'Q' said, I don't know. Maybe we should have had her wheelchair closer to the bed. I don't know how it could have been prevented. The aide did not mention safety measures related to awareness of limb positioning during transfers. On 7/27/16 at 10:15 AM, the resident's clinical record was reviewed with nurse 'A', who was the facility's safety officer. The resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] noted that the resident had severe cognitive impairment, was non-ambulatory and required total two-person assistance for transfers. Fall risk assessments dated 4/26/16 and 6/15/16 noted that the resident was at high risk for falls and had fallen at the facility three or more times. A portable X-ray report dated 7/22/16 for the resident noted: Acute fracture of the left distal fibula and subluxation (dislocation) of the tibia. Per nursing notes dated 7/22/16, after the X-ray report was received showing the fracture, the resident's assigned nurse contacted a Podiatrist (foot doctor) for treatment recommendations. The Podiatrist recommended that the resident stay in the facility with leg splinted, elevated on pillow and iced as needed and to make an appointment on Monday (3 days later) to see him (Podiatrist) on Tuesday or Thursday next week. Family (of the resident) declined and wanted her sent to hospital. There was no explanation why a Podiatrist was notified or why the family had to request hospital treatment. The resident was transferred to the hospital per a hospital transfer form dated 7/22/16. Nurses notes and an Incident/Accident (I/A) report dated 7/22/16 documented that the resident was observed with swelling to the left ankle. There was no mention that an injury had occurred while being transferred by staff. When asked how the fracture occurred, nurse 'A' did not mention that it occurred during a transfer and was unable to locate in the resident's record a documented safety care plan upon request. When asked why, nurse 'A' did not explain. There was no documented intervention on the resident's nurse aide care plans to use a mechanical total body lift until after the fracture occurred. There was no explanation why a gait belt was used for this resident, who required total assistance for transfers before the fracture. Nurse 'A' did not explain why. On 7/27/16 at 2 PM, the Director of Nursing (DON) was asked about the resident's foot being caught underneath the bed, the leg fracture and how the injury could have been avoided during the transfer. The DON said that before transfers occur, Everything (body parts) should be aligned and make sure it's safe. There was no further information provided regarding resident #813's fracture before the survey exit. On 7/28/16 at 8 AM, per review of the facility's Gait Belt Transfer dated 5/15/14: Make sure the resident has both feet firmly on the floor Ask the resident to stand as you lift with gait belt to bring to a standing position. Maintain appropriate body position and mechanics throughout the motion. Provide weight bearing support and guidance throughout movement to the transfer location. Facilitate the resident to participate as much as possible. ( ) Resident #815: On 7/25/16 at 12:40 p.m., resident #815 was observed to be laying in bed, curled up on his left side. Two certified nursing assistants (CNA), came in and assisted the resident to his high-backed wheelchair. CNA 'CC' said that the resident was difficult to transfer because he could not provide much support on his legs anymore. Resident #815 was noted to be leaning forward and to the left, although his wheelchair was slightly tilted back. His feet had slipped between the foot pedals of the wheelchair, dangling down and not providing any support. CNA 'CC' pushed the resident into the dining room for lunch with the resident in that forward leaning position. Upon inquiry, CNA 'CC' said, 'that is the way the resident always sits'. The resident said that he was 'ok', but that he had fallen out of his chair recently and had to get stitches over his eye. A medical record review was conducted on 7/25/16 at 4:45 p.m. According to the Minimum Data Set ((MDS) dated [DATE], R#815 had multiple [DIAGNOSES REDACTED]. R#815 was coded to have a moderately impaired cognition level and require one persons assist for mobility and transfers. The MDS identified the resident to have had more than two falls without injury and one fall with injury. A care plan to prevent falls was initiated on 11/5/15, and had the following interventions; alarms on the wheelchair and bed, floor matts at bed, and a high-backed wheelchair with anti-tippers. A review of R#815's Incident and Accident reports (I&A), and nursing notes from 1/1/2016 through 7/27/16 revealed the following falls: 1) 1/14/16 at 10:20 a.m., resident was found on floor in the dining room, slid out of wheelchair. No injury 2) 1/31/16 at 9:50 p.m., resident observed on floor in his room, next to his bed. No injury 3) 2/15/16 at 6:30 p.m., resident leaned to the left and fell out of wheelchair in dining room. No injury 4) 3/27/16 at 9:30 a.m., resident was found on the floor in the dining room, fell out of wheelchair. No injury 5) 5/14/16 at 10:00 a.m., resident found on the floor in the dining room, fell out of wheelchair. Skin tear to right knee. 6) 5/19/16 at 6:45 p.m., resident fell out of wheelchair during transfer, resident's foot fell off the foot pedal, got caught under the wheel, and the resident fell forward onto his head. resident sustained [REDACTED]. 7) 6/20/16 no time provided, resident fell out of wheelchair while in dining room. No injury 8) 7/26/16 at 10:00 p.m., resident fell out of bed. No injury. On 7/27/16 at 11:40 a.m., resident #815 was observed seated in the dining room, in his high backed wheelchair, leaning forward and slightly to the left, his feet were dangling off the foot pedals and not providing an support. The resident's arms were at his side and not resting on any surface, his neck was contracted forward. During an interview on 7/27/16 at 11:45 a.m., with LPN 'AA' she said that resident #815 had been falling more frequently and she had recommended a foot buddy (attaches to foot rest of wheelchair to provide solid foot support) to prevent the resident's feet from slipping off to foot rest, but had not heard anything back from the therapy department. A review of the resident #815's medical record was conducted with LPN 'AA' at this time. There were no interdisciplinary (IDT) meeting notes after any of the resident's eight falls. There were no therapy screens, or post-fall evaluations after any of the resident's eight falls, or revisions to the resident's 'fall/safety' care plan . During an interview on 7/27/16 at 12:15 p.m., Occupation Therapist (staff 'T') said that she was unaware that resident #815 had fallen on 5/19/16, and obtained stitches to his right eyebrow because he had been discharged from therapy services on 5/19/16. Upon inquiry, Staff 'T' said that R#815 should have been re-screened and evaluated for additional therapy services after every fall. Staff 'T' said that there is no specific form of communication for nursing staff to reports falls to the therapy staff. Staff 'T' said if a 'fall' is not reported in morning meeting, we (therapy department) doesn't know about it. During an interview on 7/27/16 at 1:20 p.m. the Risk Management/Safety Nurse ( staff 'A') she was asked about IDT meetings, post fall evaluation and updated interventions to prevent falls for resident #815. Staff 'A' said that there was meetings regarding R#815's fall, but no documentation was located at this time. Staff 'A' said that fall assessments and therapy screens should be conducted after every fall to assist with additional safety interventions, but could not produce any documentation to support this occurred. According to the facility's 'Fall risk reduction management', revised on 8/12, and their 'Fall management clinical guidelines 102.00', the following practice guidelines will occur;; .4 when a fall occurs the nurse will complete the following; I&A report, review/revise care plan, document on the 24 hour report, initiate a Post-Fall evaluation, and document in the nursing notes for 72 hours post - fall' The Risk nurse and the IDT team will identify and implement appropriate interventions to reduce risk of falls. ( )

This pertains to intake MI 508. Based on interview and record review, the facility failed to provide proper assessment, evaluation and monitoring for bowel elimination and failed to care plan and implement an appropriate, effective bowel protocol for one (#830) of nine sampled residents reviewed for bowel elimination patterns from a total of 32, resulting in nausea, vomiting, abdominal distention and tenderness, multiple bowel obstructions and emergency hospital treatment. Findings include: On [DATE] at 5 PM, the daughter of resident #830, who was the resident's responsible party/representative (Rep) reported the following by phone: The Rep came in to visit on [DATE] at 1:30 PM and found the resident's abdomen so distended, she looked nine months pregnant. The resident had thrown up with emesis on her face and gown. The resident appeared lethargic and looked ill. The Rep immediately went to staff and asked when the resident last had a bowel movement and was told that they did not know. A nurse was asked to check the resident's bowel sounds and after doing so, told the Rep that the bowel sounds were faint. The Rep requested that the resident be sent to the hospital, but was told by the nurse supervisor (nurse 'E') that an abdominal X-ray would be obtained instead. The Rep demanded an immediate hospital transfer. The facility called EMS (emergency medical services) and said that the resident was dead upon arrival to the hospital. The Rep said that the facility failed to properly monitor the frequency of the resident's bowel movements and was unsure if medications had been given to facilitate regular bowel movements. The Rep said that the resident was previously sent to the hospital on [DATE] for an obstruction and was told by the emergency room physician that the obstruction was high up, but they would try measures, other than surgery, first to resolve it. The Rep said that hospital staff were eventually able to remove the blockage without surgery and sent the resident back to the facility on [DATE]. On [DATE] at 3 PM, the clinical record and hospital record for resident #830 were reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's undated admission Nursing Comprehensive Evaluation noted regarding the resident's usual bowel elimination pattern: At least one movement every three days. The resident was prescribed a regular diet. The resident's minimum (MDS) data set [DATE] noted: severe cognitive impairment, difficulty communicating and understanding conversation when spoken to, non-ambulatory, extensive assistance required for bed mobility and toileting, frequent incontinence of bowel/bladder, was not on a toileting program and had no problems with constipation. The resident was prescribed [MEDICATION NAME] (iron) tablets 325 milligrams (mg) once a day for [MEDICAL CONDITION]. There was no documented order for scheduled or PRN (as needed) stool softeners/laxatives. (Constipation is common side-effect from use of iron tablets.) On [DATE] at 5:42 AM, resident #830 had an X-ray of the sacrum/coccyx due to pain. The report revealed: [MEDICATION NAME] dilated loops of large bowel that is concerning for closed loop (bowel) obstruction versus volvulus (twisting of the intestines). A STAT (immediate) abdominal X-ray was not ordered until [DATE] at 10:30 AM, which was not performed until 3:14 PM. The report revealed: There is a large dilated loop of small bowel in the central abdomen, possibly of sigmoid volvulus is not excluded. Nursing notes and a hand written note at the bottom of the X-ray report, documented that the resident's Primary Care Physician (PCP) was notified of the X-ray results on [DATE] at 3:50 PM and that there were no new orders from the PCP. The X-ray report was noted to be reviewed and signed by the Nurse Practitioner (NP) on [DATE]. There was no documented work-up regarding the possible cause of the obstruction. For the month of February 2016, there were no documented bowel movements (BMs) on the resident's Patient Care Flow Sheet located on the back of the CNA (Certified Nurse Assistant) Daily Care Plan, which was used by nurse aides to document a daily record of the size and frequency of the resident's BMs. On [DATE], the resident's iron tablets were increased from once a day to twice a day. In [DATE] progress notes, the NP requested a stool sample for occult blood. On [DATE], the NP noted that the resident's stool was positive for occult blood. There was no documented work-up for the source of blood in the resident's stool. Throughout ,[DATE] progress notes, the NP documented Constipation: no, but there was no mention that the frequency of stools was known or had been obtained from staff. On [DATE], the NP noted that she saw the resident due to nausea. Intravenous (IV) fluids were initiated at 75 cubic centimeters (cc) per hour for dehydration and emesis and the NP recommended [MEDICATION NAME] 4 mg every 8 hours PRN for nausea and an abdominal X-ray. On [DATE] at 12:30 PM, an abdominal X-ray was ordered, but was not ordered STAT. That evening at 8:56 PM, the X-ray was obtained. The report noted: large bowel ileus (intestinal blockage) at the mid abdomen. Per an undated, unsigned hand written note at the bottom of the report: Date of last bowel movement? Per nursing notes, the next day, on [DATE] at 7 AM: X-ray results were positive for bowel obstruction. Doctor (PCP) notified about results. New order to be sent to (the hospital) Per a change of condition (SBAR) communication form dated [DATE], nursing staff noted vomiting, not feeling good Patient has been feeling sick, nausea, vomiting, constipation, decreased/absent bowel sounds, the condition started on [DATE], last bowel movement [DATE]. However, per the resident's CNA Daily Care Plan/Patient Care Flow Sheet, the last documented BM was on [DATE]. Resident #830 was transported to the hospital on [DATE] and returned back to the facility on [DATE]. The admission Nursing Comprehensive Evaluation was left blank regarding the resident's bowel elimination pattern. On [DATE], an order was written to add colon distention as a diagnosis. On [DATE], there was an order to increase the resident's iron tablets from twice a day to three times a day. After [DATE], there were no further BMs noted in [DATE] on the resident's CNA Daily Care Plan/Patient Care Flow Sheet. The NP documented in further progress notes for ,[DATE] Constipation: no. Per nursing notes: On [DATE], the resident had an episode of emesis. (The NP documented in progress notes throughout ,[DATE] Constipation: no.) On [DATE] at 9:30 AM: Patient complaining of upset stomach and nausea. [MEDICATION NAME] given No abdominal distention noted. There were no further nursing notes about the resident's stomach until 1:45 PM. At 1:45 PM, nurse supervisor 'E' noted that he was called to the resident's room due to complaints by the resident's REP regarding the resident's abdominal distention and the Rep wanted the resident transferred to the hospital. There was no mention in nurse 'E's notes regarding the appearance of the resident's abdomen or whether bowel sounds were present. EMS was called and arrived in ,[DATE] minutes. On [DATE] at 3:20 PM, nurse 'E' noted that he was called back to the resident's room and he observed EMS staff doing CPR (cardiopulmonary resuscitation) on the resident in the hallway and that CPR was continued as the resident was being transported out to the hospital. The NP noted on [DATE] that the resident had two episodes of emesis and abdominal distention, the PCP was notified and the resident was sent to the hospital. Throughout ,[DATE] progress notes, the NP noted Constipation: no. Per review of the hospital emergency room (ER) records: Resident #830 arrived in full [MEDICAL CONDITION], but remained with no pulse. The resident was pronounced dead at 3:57 PM. Upon physical exam, the ER physician noted: Abdominal: Distended, copious gastrointestinal contents in oral pharynx (throat), smells of stool. BMs were noted on resident #830's CNA Daily Care Plan/Patient Care Flow Sheet for [DATE], [DATE], [DATE], [DATE] and [DATE]. There were no further BMs noted for [DATE] prior to the hospital transfer on [DATE]. On [DATE] at 2 PM, the DON was asked if there were any bowel medications prescribed for resident #830. She reviewed the resident's chart and found no documented scheduled or PRN medications in the orders or noted on the resident's medication records during the resident's stay. The DON said, I don't know why they didn't put her on anything. When asked why the resident's stool was positive for occult blood, why there was no documented work-up and if it was caused by the resident possibly straining to have BMs, the DON said she did not know. She was asked to provide documentation of the resident's bowel movements. She reviewed the resident's CNA Daily Care Plan/Patient Care Flow Sheets for ,[DATE] thru ,[DATE] and said that the size and frequency of the BMs should have been documented. The DON then called medical records staff to inquire about further CNA Daily Care Plan/Patient Care Flow Sheets for the resident, but the staff said there were none. When asked how the resident's BMs were to be monitored, the DON said, They are supposed to monitor bowels daily. If no BM in three days, then usually we call the physician. We have a bowel protocol, but we call the physician. When asked about a care plan related bowel management for resident #830, the DON reviewed a care plan dated [DATE] for Bowel and/or Bladder incontinence related to impaired mobility, impaired cognitive awareness of needs to defecate/void, age The goals were related to prevention of skin breakdown and urinary tract infections and did not include prevention of bowel obstructions. Interventions did not include monitoring and documenting the resident's BMs. The DON said that this care plan was mostly about skin (integrity) and that there should have been a separate care plan specific to the resident's bowel management. She looked in the chart and found none. On [DATE] at 2:45 PM, resident #830's PCP was interviewed by phone and asked about interventions to help prevent development of the resident's bowel obstructions. When asked about measures, such as stool softeners, the PCP said, I don't prescribe anything for bowels unless they are constipated. She (the resident) couldn't tell us. The PCP was asked about prevention of constipation for this resident, who could not express herself and considering the [DATE] X-ray showing bowel obstruction, hospital treatment for [REDACTED]. The PCP said, I don't put them on anything to prevent! Unless there is a State rule I am not aware of, I don't do that! When told that there was no consistent documentation that BMs were being monitored and that the frequency of the resident's BMs were not addressed in progress notes, the PCP said, I don't know anything about that. The PCP further said, Stool softeners wouldn't prevent bowel obstruction anyway. What is causing the obstructions? There is usually a reason, adhesions, a hernia, cancer. What was causing it? When it was mentioned that there was no documented work-up for a possible cause, the PCP did not respond. There was no additional information provided before the survey exit regarding bowel management for resident #830. On [DATE] at 8 AM, per review of the facility's Bowel Protocol dated [DATE]: Purpose: To ensure residents bowel movements are monitored for frequency and size Notify Physician if no bowel movement in 3 days. The AM nurse will check the bowel record every day. (Information is located on the nurse aide (CNA) care plan). If no bowel movement in 3 days give 30 cc of milk of Magnesia by mouth. If no results in 24 hours give one [MEDICATION NAME] Suppository rectally, if no results in 24 hours, call the Physician. Per review of the Website: Drugs.Com: For Healthcare Professionals: Applies to [MEDICATION NAME] Gastrointestinal side effects have included nausea, constipation vomiting .Constipation may be relieved by administering [MEDICATION NAME] sodium (stool softener) 100 mg to 200 mg per day in addition to increasing the intake of oral fluids, such as water. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 803 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE RESIDENTS WERE FREE FROM ABUSE IN 1 OF 7 SAMPLED RESIDENTS (#501), FROM A TOTAL OF SEVEN SAMPLED RESIDENTS, RESULTING IN FEELINGS OF MENTAL ANGUISH, LOSS OF CONTROL AND #501 BEING DISCOVERED WITH SWOLLEN EYES AND NOSE, BLOOD FROM HER NARES (NOSTRILS) AND FACIAL BRUISING. FINDINGS INCLUDE: ON 2/12/13 AT 11:13 A.M., RESIDENT #501 WAS OBSERVED SEATED IN HER WHEELCHAIR AROUND THE NURSE'S STATION. #501 WAS OBSERVED WITH DISCOLORATION TO BOTH EYES, CHEEKS AND THE BRIDGE OF HER NOSE. BRUISING WAS NOTED TO BILATERAL FOREARMS AND A CUT WAS OBSERVED TO HER LEFT FOREARM. WHEN GREETED AND ASKED HOW SHE WAS DOING, #501 REPLIED, "WELL, I'M LIVING". ACCORDING TO THE FACILITY'S "ADMISSION AND DISCHARGE SUMMARY" RESIDENT #501 WAS A [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] REVEALED THAT RESIDENT #501 HAD MODERATELY IMPAIRED COGNITIVE SKILLS FOR DAILY DECISION MAKING AND REQUIRED EXTENSIVE TO TOTAL ASSISTANCE OF STAFF FOR ALL ACTIVITIES OF DAILY LIVING (ADLS) INCLUDING BED MOBILITY, TRANSFERS, DRESSING, EATING, TOILETING, PERSONAL HYGIENE AND BATHING. THE MDS FURTHER REVEALED THAT #501 REQUIRED TWO + PERSONS PHYSICAL ASSIST WITH TRANSFERS, TOILETING AND BATHING. A REVIEW OF THE FACILITY'S "INCIDENT REPORT" DATED 2/4/13 REVEALED, "...DAY SHIFT NURSE REPORTS RESIDENT OBSERVED WITH BLOODY NOSE, FACIAL BRUISING AND RIGHT ARM BRUISED. RESIDENT STATED "AID (CERTIFIED NURSING ASSISTANT) BEAT ME UP". SWELLING AROUND BOTH EYES RIGHT TO LEFT ACROSS BRIDGE OF NOSE. DISCOLORATION AROUND BOTH EYES RIGHT TO LEFT ACROSS BRIDGE OF NOSE AND RIGHT ARM. NOSE BLEEDING BOTH NARES (NOSTRILS). PAIN, YES, PATIENT KEEPS TOUCHING FACE AND RIGHT EYE. TYPE OF INJURY: HEMATOMA, BRUISING, BLOODY NOSE..." A REVIEW OF THE FACILITY'S "FACILITY INVESTIGATION REPORT - 5 WORKING DAYS" DATED 2/7/13 REVEALED, "...RESIDENT (#501) FOUND WITH SWOLLEN BLOOD NOSE BLOOD ON FINGERS/PILLOW, BRUISING TO RIGHT EYE, ECCHYMOSIS TO BILATERAL ARMS, LAYING IN BED, STATED "SHE BEAT ME UP" DENIES FALL..." A REVIEW OF THE FACILITY'S "CONDITION OF SKIN" DOCUMENT DATED 2/4/13 REVEALED THAT RESIDENT #501 WAS DISCOVERED WITH THE FOLLOWING INJURIES ON THE MORNING OF 2/4/13: "...ECCHYMOSIS (PURPLISH BRUISE) WITH SWELLING (NEW), ECCHYMOSIS TO LEFT UPPER ARM (NEW), SLIGHT SWELLING LEFT WRIST (NEW), ECCHYMOSIS TO RIGHT HAND (NEW)..." AN "INTERDISCIPLINARY PROGRESS NOTE" (IDPN) DATED 1/25/13 REVEALED "...RESIDENT INCONTINENT OF BOWEL AND BLADDER. DEPENDENT ON STAFF FOR ALL CARE..." A REVIEW OF RESIDENT #501'S "DAILY CARE PLAN" FOR THE MONTH OF JANUARY 2013 INDICATED THAT REQUIRED ASSISTANCE. UNDER THE RESTORATIVE SECTION; "ASSIST 2". AN IDPN DATED 2/4/13 AT 7:15 A.M., REVEALED "...ON INITIAL ROUNDS STAFF OBSERVED RESIDENT (#502) WITH DISCOLORATION ON BILATERAL EYES AND RIGHT ARM, NOSE BRIDGE SWOLLEN WITH BLEEDING FROM NARES. DIRECTOR OF NURSING (DON), SOCIAL SERVICES NOTIFIED, INVESTIGATION ONGOING, MD (DOCTOR) NOTIFIED, STAT (IMMEDIATE) X-RAY FACE DONE. NO FRACTURE NOTED. PLAN OF CARE (POC) IS TWO PERSON CARE WITH ALL TRANSFERS AND ADLS..." A REVIEW OF THE CLINICAL RECORD DID NOT INDICATE A HISTORY OF FALLS SINCE admitted TO THE FACILITY. ON 2/12/13 AT 9:45 A.M., DURING AN INTERVIEW, DON #1 WAS QUERIED ABOUT THE ALLEGATION OF ABUSE TOWARDS #501 AND REPORTED, "...WE WERE UNABLE TO PROVE ANYTHING BUT I DO BELIEVE SOMETHING HAPPENED. CNA #1 WAS IN A RUSH TO LEAVE AND SAID SHE HAD TO GO TO SCHOOL. I TERMINATED HER FOR OTHER ISSUES RELATED TO HER WORK PERFORMANCE...". WHEN ASKED WHEN CNA #1 RECEIVED ABUSE TRAINING, DON #1 REPORTED, "...HER (CNA #1) LAST ABUSE TRAINING WAS 9/18/12. WE HAVE MONTHLY ABUSE TRAINING AND SHE HAS MISSED THE LAST FOUR MONTHS OF ABUSE TRAINING..." ON 2/12/13 AT 10:31 A.M., DURING AN INTERVIEW THE FACILITY'S WARD CLERK (WC #1) REPORTED, "...(LPN #1) ASKED ME TO COME INTO (#501'S) ROOM WITH HER. (#501) WAS LAYING ON HER SIDE FACING THE DOOR AND SHE HAD BRUISES TO BOTH SIDES OF HER FACE. I HAVE NEVER SEE (#501) STRIKE OUT AND SHE IS EASILY REDIRECTED...". WC #1 FURTHER REPORTED, "...I SAT IN ON THE INVESTIGATION INTERVIEW WITH CNA #1 (ALLEGED PERPETRATOR) BECAUSE I AM HER UNION STEWARD. WHENEVER CNA #1 WAS ASKED A QUESTION, SHE WOULD JUST SAY "OK". SHE (CNA #1) WOULD NOT ANSWER THE QUESTIONS ASKED OF HER..." ON 2/12/13 AT 11:36 A.M., DURING AN INTERVIEW, LPN #1 REPORTED, "...I CAME IN THAT MORNING AND STARTED DOING MY ROUNDS. I WENT INTO #501'S ROOM. IT WAS DARK SO I TURNED ON THE LIGHT AND SAW BLOOD FROM HER NOSE. I THEN ASKED (WC #1) TO COME WITH ME TO WITNESS WHAT I SAW. I ASKED THE MIDNIGHT NURSE (LPN #4) WHAT HAPPENED AND SHE DIDN'T KNOW AND THAT #501 WASN'T LIKE THAT DURING MORNING MEDICATION (MED) PASS. (#501) HAD BLOOD ON HER FACE AND HER PILLOW, BRUISING, AND HER FACE WAS SWOLLEN. LPN #4 CLEANED THE FLOOD FROM (#501'S) FACE. I ASKED WHAT HAPPENED AND SHE DIDN'T RESPOND. I (LPN #1) ASKED THE ASSIGNED CNA (CNA #1) AND SHE SAID SHE DIDN'T KNOW..." WHEN ASKED IF #501 WAS A FALLS RISK, LPN #1 REPORTED, "...I DON'T THINK SHE WAS AT THE TIME AND IF SHE HAD FALLEN, SHE WOULD NOT HAVE HAD THE STRENGTH TO GET BACK UP INTO THE BED BY HERSELF. (#501) TRANSFERRED TO THIS FLOOR ON 1/30/13 AND WE WERE TOLD THAT (#501) COULD BE COMBATIVE WITH CARE BUT I'VE NEVER SEEN HER COMBATIVE..." ON 2/12/12 AT 2:14 P.M., DURING AN INTERVIEW WITH THE UNIT MANAGER (LPN #2) REPORTED, "...LPN #1 TOLD ME WHAT HAPPENED. I OBSERVED BRUISING TO HER EYES, SWOLLEN NOSE, BLOOD TO HER PILLOW AND BLOOD TO HER FACE. (#501) WAS JUST SITTING THERE. I ASKED (#501) WHAT HAPPENED AND SHE SAID, "SHE (CNA #1) BEAT ME UP...". WHEN ASKED IF #501 had a history of [REDACTED]. LPN #2 FURTHER REPORTED, "...I TRIED TO CALL CNA #1 BUT SHE DIDN'T RETURN TO THE FLOOR AS INSTRUCTED. IF SOMEONE ISN'T ACCEPTING YOUR CARE, THAT'S WHAT OTHER STAFF IS FOR. SHE (CNA #1) DIDN'T LOG THAT #501 WAS COMBATIVE AND CNA #1 DIDN'T INFORM THE NURSE OF AN COMBATIVE BEHAVIOR. LPN #4 LAST SAW #501 DURING THE 6:00 A.M. MED PASS WHEN SHE ADMINISTERED EYE DROPS AND SHE WAS FINE AT THAT TIME..." ON 2/13/13 AT 4:00 P.M., DURING AN INTERVIEW, THE IN-SERVICE DIRECTOR (LPN #3) REPORTED, "...CNA #1 MISSED HER REQUIRED ABUSE IN-SERVICE TRAINING FOR THE LAST FOUR MONTHS (OCTOBER 2012 THROUGH JANUARY 2013). THAT'S ONE OF THE PROBLEMS. CNA #1 HASN'T MADE ANY OF THE IN-SERVICES UP TO DATE. I GAVE HER A "SUGGESTION FOR IMPROVEMENT" FORM..." A REVIEW OF THE FACILITY'S "SUGGESTION FOR IMPROVEMENT FORM REVEALED THAT CNA #1 HAD "... MISSED MANDATORY IN-SERVICES ON 1/7, 1/9, 1/17 AND 1/22. LAST ATTENDED ABUSE IN-SERVICE 9/2012..." A COMMENT WRITTEN BY CNA #1 REVEALED, "...I HAVE SCHOOL CLASSES TO ATTEND IN A DIFFERENT COUNTY, I CAN NOT MISS CLASS FOR A IN-SERVICE QUIZ..." ON 2/14/13 AT 9:25 A.M., DURING A FOLLOW UP INTERVIEW, DON 1 REPORTED, "...CNA #1 WAS INSTRUCTED TO STAY AND GIVE A STATEMENT, BUT SHE LEFT THE FACILITY PRIOR TO DOING SO AND WITHOUT INFORMING THE NURSE THAT SHE WAS LEAVING. CNA #1 CAME BACK LATER THAT DAY (2/4/13) AND DROPPED OFF A TYPED STATEMENT SO I CALLED HER AND TOLD HER SHE HAD TO COME IN FOR AN INTERVIEW BUT SHE DIDN'T COME BACK. I CALLED HER AGAIN AND SAID THAT I NEEDED TO SEE HER IN PERSON IMMEDIATELY SO SHE SAID "OK". SHE CAME IN LATER THAT DAY. ON THE 24 HOUR REPORT, CNA #1 WROTE THAT SHE HAD BEEN SCRATCHED AND PUNCHED BY #501. I ASKED HER TO SHOW ME THE ALLEGED SCRATCHES, THEN SHE (CNA #1) SUDDENLY DENIED BEING SCRATCHED OR PUNCHED...". WHEN QUERIED ABOUT REQUIRED ABUSE TRAINING, DON #1 REPORTED, "...STAFF ARE EXPECTED TO ATTEND THE IN-SERVICES. WE IDENTIFIED CNA #1 HAD NOT ATTENDED THE REQUIRED MANDATORY IN-SERVICES AND STARTED DISCIPLINARY ACTION FOR IMMEDIATE IMPROVEMENT..." ON 2/14/13 AT 11:22 A.M., DURING AN INTERVIEW, LPN #4 REPORTED, "...I WAS FINISHING MY MORNING MEDS WHEN LPN #1 ASKED ME WHAT HAPPENED TO #501. LPN #1 INFORMED ME THAT #501 HAD A BLACK EYE AND BLOOD ON HER PILLOW. #503 (#501'S ROOMMATE) SAID THAT CNA #1 WAS IN THE ROOM WITH #501. I HAD LAST SAW #501 ABOUT 5:00 A.M. DURING MED PASS. SHE LET ME ADMINISTER HER EYE DROPS AND SHE (#501) WAS NOT COMBATIVE WITH ME...". LPN #4 FURTHER REPORTED, "...WHEN LPN #1 CALLED ME INTO THE ROOM, #501 KEPT TOUCHING HER FACE LIKE SHE WAS IN PAIN. THERE WAS BRUISING TO HER EYES AND SWELLING AND BLOOD ON HER FINGERS. WHEN I TRIED TO CLEAN HER UP SHE BEGAN TO RESIST. SHE HAD NEVER BEEN LIKE THAT BEFORE I ASKED HER WHAT HAPPENED AND SHE SAID, "...SOMEBODY BEAT ME UP". SHE HAD A BLACK EYE AND SAID HER FACE HURT...". WHEN ASKED IF SHE INTERVIEWED CNA #1, LPN #4 REPORTED, "...NO. I HAD TROUBLE WITH CNA #1 THAT NIGHT AND WROTE HER UP FOR UNPROFESSIONAL CONDUCT. CNA #1 DIDN'T LIKE HER ASSIGNMENT AND WALKED OFF EVERY TIME I TRIED TO TALK TO HER. SHE (CNA #1) HAD A HATEFUL AURA THAT NIGHT AND HER ATTITUDE WAS UNACCEPTABLE. SHE JUST LEFT THE BUILDING AND DIDN'T REPORT OFF...". WHEN ASKED IF CNA #1 HAD INFORMED HER THAT #501 WAS REPORTEDLY COMBATIVE DURING CARE, LPN #4 REPORTED, "...NO SHE DID NOT. SHE (CNA #1) WOULDN'T TALK TO ME AT ALL. SHE JUST KEPT WALKING OFF..." ON 2/14/13 AT 12:15 P.M., DURING AN INTERVIEW, #503 WAS QUERIED ABOUT HER OBSERVATIONS ON THE MORNING OF 2/4/13 AND REPORTED THE FOLLOWING, "...CNA #1 CAME IN THE ROOM THAT MORNING TO CHANGE #501'S BRIEF. SHE (CNA #1) THEN PULLED THE CURTAIN CLOSED SO SHE COULD HAVE PRIVACY I GUESS. #501 PROtested AND KEPT SAYING "STOP!, STOP HITTING ME!, DON'T DO THAT!" BUT CNA #1 KEPT ON. AFTER SHE (CNA #1) WAS FINISHED, SHE LEFT. CNA #1 WASN'T TAKING NO FOR AN ANSWER. SHE (CNA #1) JUST KEPT TELLING #501, "JUST TURN OVER!". #501 USED TO BE QUIET AND CALM WHEN THEY (STAFF) FIRST BROUGHT HER UP TO THIS FLOOR BUT AFTER THAT INCIDENT, SHE FIGHTS ALL THE STAFF..." A REVIEW OF THE CLINICAL RECORD REVEALED THAT A "BEHAVIORAL LOG" HAD BEEN INITIATED ON THE MORNING OF THE INCIDENT (2/4/13). THERE WAS NO DOCUMENTED EVIDENCE OF ANY COMBATIVE BEHAVIORS TOWARD STAFF PRIOR TO 2/4/13 IN #501'S CLINICAL RECORD. ON 2/19/13 AT 3:33 P.M., DURING A TELEPHONE INTERVIEW, CNA #1 WAS QUERIED ABOUT THE EVENTS THAT TRANSPIRED ON THE MORNING OF 2/4/13 AND REPORTED THE FOLLOWING: "...I SIGN IN WHEN I GET THERE AND CHECK TO SEE WHAT ASSIGNMENT I GOT. I MAKE WATERS TO PASS OUT AND I MAKE ROUNDS DEPENDING ON WHO I'M PASSING WATER TO...". WHEN ASKED ABOUT THE CARE SHE PROVIDED TO #501, CNA #1 STATED, "I ALREADY TOLD THEM WHAT HAPPENED!" CNA #1 WAS ADVISED THAT THE INFORMATION WAS REQUESTED BY THE STATE AUTHORITY AND REPORTED, "...I GAVE HER PERSONAL CARE..." WHEN ASKED TO ELABORATE, CNA #1 REPORTED, I WASHED HER UP AND CHANGED HER BRIEF. SHE (#501) WAS COMBATIVE. SHE SCRATCHED ME ON BOTH MY FOREARMS AND TRIED TO PUNCH ME...". WHEN ASKED IF SHE LEFT #501 ALONE IN ORDER TO ALLOW HER TO CALM DOWN AND RETURN LATER TO COMPLETE CARE, CNA #1 SAID, "NO". WHEN ASKED IF SHE ASKED ANOTHER CNA FOR ASSISTANCE OR REPORT #501'S BEHAVIOR TO THE NURSE (LPN #4), CNA #1 SAID, "...I DIDN'T GO GET ANOTHER CNA AND I DIDN'T GET THE NURSE. FOR ONE THING, THE NURSE WAS NO WHERE TO BE FOUND SO AFTER I WAS DONE, I WROTE ON THE 24-HOUR REPORT...". WHEN ASKED WHY SHE LEFT THE FACILITY PRIOR TO GIVING HER STATEMENT, CNA #1 REPORTED, "...NOBODY ASKED ME TO STAY! I WAS INFORMED BY THE DON WHEN SHE CALLED ME AS I WAS ON MY WAY TO SCHOOL. I DROPPED IT (STATEMENT) OFF THEN I HAD TO TURN AROUND AND COME BACK BECAUSE I WAS TOLD I HAD TO GIVE AN INTERVIEW IN PERSON...". WHEN ASKED IF SHE SHOWED THE DON HER INJURIES TO BILATERAL FOREARMS OR IF SHE SOUGHT MEDICAL CARE, CNA #1 SAID, "...NO. I DIDN'T SHOW HER (DON) ANY SCRATCHES OR SEEK TREATMENT. THERE WAS NOTHING VISIBLE ON ME DURING THE INTERVIEW WITH THE DON...". WHEN ASKED IF #501 ASKED HER TO STOP ONCE CARE WAS INITIATED, CNA #1 SAID, "YES SHE KEPT SAYING STOP. #501 DIDN'T WANT ANYTHING ON HER. SHE KEPT RESISTING WHEN I TRIED TO PUT HER BLOUSE ON SO I GOT ANOTHER BLOUSE AND SHE STILL DIDN'T WANT IT ON. SHE DIDN'T WANT ME TO CLEAN HER OR PUT HER CLOSE ON HER...". WHEN ASKED WHY SHE (CNA #1) DIDN'T JUST STOP ONCE #501 SAID TO STOP, CNA #1 REPORTED, "...BECAUSE I KNEW IT WOULD ONLY TAKE A MINUTE TO CHANGE HER SO THAT'S WHAT I DID. NOW THAT YOU'RE SAYING I SHOULD'VE GOT THE NURSE OR ANOTHER CNA, IT MAKES SENSE BUT IT'S TOO LATE NOW I'LL NEVER WORK IN HEALTHCARE AGAIN ANYWAY. I SHOULD'VE WENT TO GET THE NURSE...". WHEN ASKED IF SHE PHYSICALLY HIT OR INJURED #501 IN ANY WAY, CNA #1 REPLIED, "NOPE". A REVIEW OF THE FACILITY'S "24 HOUR CONDITION REPORT" UNDATED REVEALED, "...PUNCH STAFF, SCRATCHED, HIT IN FACE, SAID GET OUT OF MY ROOM..." ON 2/19/13 AT 4:00 P.M., DON #1 FURTHER REPORTED, "...THE THING IS, CNA #1 SAID SHE COULDN'T FIND THE NURSE (LPN #4) TO REPORT #501'S ALLEGED COMBATIVE BEHAVIOR, BUT WHEN WE LOOKED AT THE VIDEO, WE SAW CNA #1 STANDING AT THE NURSE'S STATION WRITING AND THE NURSE (LPN#4) WAS SITTING RIGHT THERE IN FRONT OF HER BUT CNA #1 WAS MAD AT LPN #4 FOR DISCIPLINING HER EARLIER IN THE SHIFT SO CNA #1 WASN'T SPEAKING TO LPN #4...". WHEN ASKED IF #501 REQUIRED THE ASSISTANCE OF ONE OR TWO STAFF PERSONS DURING CARE, DON #1 SAID, "...SHE (#501) WAS A TWO PERSON ASSIST...". WHEN ASKED WHAT IS THE PROTOCOL IF A RESIDENT IS REPORTEDLY COMBATIVE, DON #1 REPORTED, "...YOU ARE TO MAKE SURE THE RESIDENT IS SAFE, COME BACK LATER WHEN THE RESIDENT IS CALM TO COMPLETE CARE, ASK ANOTHER STAFF PERSON TO ASSIST AND REPORT IT TO THE NURSE...". DON #1 COULD NOT EXPLAIN WHY CNA #1 PROVIDED CARE WITHOUT ASSISTANCE OF ANOTHER STAFF IN ACCORDANCE WITH #501'S MDS AND PLAN OF CARE. FURTHER, DON #1 WAS UNABLE TO EXPLAIN WHY CNA #1 PERSISTED IN PROVIDING CARE FOR #501 WHO REPEATEDLY RESISTED CARE AND SAID "NO" AND "STOP". A REVIEW OF THE FACILITY'S ABUSE POLICY REVISED 3/26/12 REVEALED: "...MENTAL ABUSE: INCLUDES, BUT IS NOT LIMITED TO HUMILIATION, HARASSMENT, AND THREATS OF PUNISHMENT OR DEPRIVATION..." "...PHYSICAL ABUSE: INCLUDES, BUT IS NOT LIMITED TO HITTING, SLAPPING, PINCHING, AND KICKING. IT ALSO INCLUDES CONTROLLING BEHAVIOR..." FOR IMMEDIATE RESPONSE TO COMBATIVE/AGITATED RESIDENT: "...ALLOW SUFFICIENT PERSONAL SPACE, ABOUT 2 TO 3 FEET..." "...BE PATIENT..." "...DO NOT TOUCH THE RESIDENT, UNLESS ABSOLUTELY NECESSARY FOR HIS/HER SAFETY OF THE SAFETY OF OTHERS..." "...LEAVE AND RETURN IN 5 OR 10 MINUTES..."

THIS CITATION PERTAINS TO INTAKE NUMBER MI 914 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ASSESS AND PROVIDE EFFECTIVE AND ADEQUATE PAIN RELIEF FOR ONE RESIDENT (#505) OF SIX RESIDENTS REVIEWED FOR PAIN MANAGEMENT, FROM A TOTAL SAMPLE OF SIX RESIDENTS, RESULTING IN UNRELIEVED PAIN, EMOTIONAL DISTRESS AND THE POTENTIAL FOR UNMET CARE NEEDS. FINDINGS INCLUDE: ON 10/4/11 AT 2:46 P.M., DURING A TOUR OF THE FACILITY, RESIDENT #505 WAS OBSERVED IN HER ROOM LYING IN BED. RESIDENT #505 WAS OBSERVED GRIMACING, MOANING AND RUBBING HER LOWER EXTREMITIES. WHEN GREETED, RESIDENT #505 SAID "...I NEED SOMEONE TO HELP ME. I KEEP TELLING THEM THE PAIN MEDICATION DOESN'T HELP. CAN YOU ASK THEM TO HELP ME PLEASE?..." PRIOR TO LEAVING THE UNIT, THE SURVEYOR REQUESTED TO SPEAK WITH THE NURSE ASSIGNED TO CARE FOR RESIDENT #505. LPN #1 WAS QUERIED ABOUT RESIDENT #505'S PAIN MEDICATION AND REPORTED, "...I'LL CHECK ON IT NOW..." ACCORDING TO THE FACILITY'S ADMISSION SHEET, RESIDENT #505 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. A REVIEW OF RESIDENT #505'S "ADMISSION PHYSICAL" DATED 8/31/11, REVEALED THAT #505 HAD A [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] INDICATED THAT RESIDENT #505 REQUIRED EXTENSIVE TO TOTAL ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING (ADLS) INCLUDING BED MOBILITY, TRANSFERS, DRESSING TOILETING PERSONAL HYGIENE AND BATHING. A physician's orders [REDACTED]." A PHYSICIAN'S PROGRESS NOTE DATED 9/9/11 REVEALED "...PT (PATIENT) WAS YELLING........WITH PAIN..." A PHYSICIAN'S PROGRESS NOTE DATED 9/15/11 REVEALED "...PT IS C/O (COMPLAINTS OF) PAIN IN LOWER ABDOMEN AND LEGS..." A REVIEW OF RESIDENT #505'S "ALTERATION IN COMFORT" CARE PLAN (UNDATED) REVEALED THE FOLLOWING APPROACHES: "...OBSERVE FOR SIGNS AND SYMPTOMS OF PAIN, VERBAL C/O, MOANING FACIAL GRIMACING, AGITATION, INCREASED PULSE AND RESPIRATION..." "...OBSERVE FOR EFFECTIVENESS OF PAIN MEDICATION..." "...FREQUENT REPOSITIONING FOR COMFORT..." UPON FURTHER REVIEW OF THE CLINICAL RECORD IT WAS REVEALED THAT THE CONTROLLED DRUG RECEIPT RECORDS (ACCOUNT FOR NARCOTIC USE) AND THE "PRN [MEDICATION NAME] RECORD/PAIN FLOW SHEET" HAD INCONSISTENCIES. MEDICATIONS DOCUMENTED AS RETRIEVED FROM THE CONTROLLED MEDICATION CABINET HAD NOT BEEN DOCUMENTED AS GIVEN ON RESIDENT #505'S PAIN SHEETS. ON 10/4/11 AT 3:45 P.M., DURING AN INTERVIEW, LPN #1 WAS QUERIED ABOUT RESIDENT #505'S COMPLAINTS OF PAIN. WHEN ASKED WHEN RESIDENT #505 RECEIVED HER LAST DOSE OF PAIN MEDICATION, LPN #1 SAID "...I GAVE HER SOMETHING FOR PAIN THIS MORNING..." WHEN ASK IF SHE (LPN #1) HAD ASSESSED RESIDENT #505 AFTER ADMINISTERING PAIN MEDICATIONS IN ORDER TO DETERMINE THE EFFECTIVENESS OF THE MEDICATION, LPN #1 SAID "...I ASSESS ALL MY RESIDENTS..." WHEN ASKED IF SHE WAS AWARE THAT RESIDENT #505 REPORTED THAT ALTHOUGH SHE HAD RECEIVED PAIN MEDICATIONS ON A PRN (AS NEEDED) BASIS, IT (THE PRESENT PAIN MEDICATION) WAS INEFFECTIVE, LPN #1 OFFERED NO RESPONSE. WHEN ASKED HOW IT WAS DETERMINED WHEN PAIN MEDICATION WOULD BE GIVEN, LPN #1 SAID "...IF THEY (THE RESIDENTS) ASK ME FOR IT (PAIN MEDICATION), I GIVE IT TO THEM..." LPN #1 REFERENCED THE TYPE OF HEALTH BENEFITS THE RESIDENTS ON HER ASSIGNED UNIT HAD AND STATED, "...SO EVERYBODY UP THERE IS IN PAIN..." DURING A FOLLOW UP INTERVIEW ON 10/5/11 AT 1:45 P.M., LPN #1 REPORTED, "...AFTER I SPOKE WITH YOU YESTERDAY, I GAVE HER (#505) SOMETHING FOR PAIN AND I TOLD THE OTHER NURSE ABOUT HER (#505) UNRELIEVED PAIN, SO SHE (THE OTHER NURSE) CALLED THE DOCTOR AND GOT AN ORDER TO INCREASE THE DOSE OF PAIN MEDICATION..." WHEN QUERIED ABOUT THE REASON ANOTHER STAFF NURSE CALLED THE PHYSICIAN REGARDING RESIDENT #505'S UNRELIEVED PAIN, LPN #1 SAID "...BECAUSE IT WAS TIME FOR ME TO GO HOME..." ON 10/5/11 AT 10:39 A.M., DURING AN INTERVIEW, THE DIRECTOR OF NURSING REPORTED, "...AFTER YOU LEFT, THE DOCTOR WAS NOTIFIED AND WROTE an order for [REDACTED]. THE DON FURTHER REPORTED, "...IF SHE (#505) WAS HAVING BREAKTHROUGH PAIN, SHE SHOULD HAVE BEEN OFFERED PAIN MEDICATION INSTEAD OF HAVING TO ASK FOR IT. HER PAIN ASSESSMENT WAS ALSO UPDATED TODAY (10/5/11)..." THE DIRECTOR OF NURSING COULD NOT EXPLAIN WHY THE NURSE FAILED TO ASSESS AND ADDRESS RESIDENT #505'S UNRELIEVED PAIN AND NOTIFY THE DOCTOR ACCORDINGLY FOR ADDITIONAL ORDERS. A REVIEW OF THE FACILITY'S "PAIN EVALUATION" POLICY, REVISED 11/10/08, REVEALED THE FOLLOWING: "...DURING THE EVALUATION, THE RESIDENT WILL BE EVALUATED FOR: RESIDENTS THAT ARE OBSERVED WITH GRIMACING, CLENCHED JAW, FROWNING, TEARING, MOANING, CRYING, SCREAMING, CURSING, BITING RUBBING BODY PARTS, KNEES PULLED UP..." "...THE PHYSICIAN WILL BE NOTIFIED REGARDING CONCERNS RELATED TO THE RESIDENT'S CURRENT PAIN MANAGEMENT PROGRAM..."

THIS CITATION PERTAINS TO INTAKE NUMBER MI 433 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT ONE RESIDENT (#501), OF THREE RESIDENTS REVIEWED FOR FALLS, FROM A TOTAL SAMPLE OF SIX, RECEIVED SUPERVISION AND THE APPROPRIATE ASSISTIVE DEVICES (FUNCTIONING ALARM) TO ADDRESS ATTEMPTS TO UNSAFELY SELF-TRANSFER, RESULTING IN A FALL WITH FRACTURE. FINDINGS INCLUDE: ON 10/3/11 AT 10:45 A.M., DURING AN INITIAL TOUR OF THE FACILITY, RESIDENT #501 WAS OBSERVED IN HIS ROOM ASLEEP IN BED. ACCORDING TO THE "ADMISSION AND DISCHARGE SUMMARY," RESIDENT #501 WAS admitted to the facility on [DATE] AND REadmitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] INDICATED THAT RESIDENT "...APPEARS WITH SHORT AND LONG TERM MEMORY DEFICITS AND IMPAIRED DECISION MAKING SKILLS, SPEAKS ANOTHER LANGUAGE-ARABIC..." RESIDENT #501 REQUIRED EXTENSIVE ASSISTANCE WITH TRANSFERS ("...HOW RESIDENT MOVES BETWEEN SURFACES INCLUDING TO OR FROM BED, CHAIR, WHEELCHAIR, STANDING POSITION..."), DRESSING AND TOILETING. THE MDS FURTHER INDICATED THAT RESIDENT #501 WAS NOT STEADY WITH WALKING AND TURNING AROUND AND WAS FREQUENTLY INCONTINENT. ADDITIONALLY, THE MDS INDICATED THAT RESIDENT #501 TRIGGERED FOR FALLS AND "...HAS IMPAIRED STANDING AND SITTING BALANCE AND HAS HAD MULTIPLE FALLS AT HOME. HE REQUIRES MINIMAL ASSIST WITH TRANSFERS AND HAS ATTEMPTED SELF TRANSFER ON OCCASION. HE DOES NOT USE CALL LIGHT. HE SCORES 17 (HIGH) ON FALL RISK ASSESSMENT..." RESIDENT #501'S "FALL RISK ASSESSMENT" DATED 7/26/11, REVEALED A FALL RISK SCORE OF 18. A REVIEW OF THE FACILITY'S "INCIDENT REPORT" DATED 9/8/11 REVEALED THAT ON 9/8/11 AT 6:05 P.M., RESIDENT #501 WAS OBSERVED "...LAYING ON FLOOR AT THE FOOT OF HIS BED WITH IS WHEELCHAIR BEHIND HIM, RESIDENT C/O (COMPLAINTS OF) RIGHT HIP PAIN AND STATED, "I WANT TO GO TO BED." CORRECTIVE MEASURES TAKEN: DYCEM TO WHEELCHAIR/OFFER TO GO BACK TO BED AFTER MEALS..." THE FACILITY'S "SUMMARY OF INVESTIGATION" DOCUMENTED THAT ON 9/9/11, THERE WERE NO SIGNS OR SYMPTOMS OF ANY ACUTE DISTRESS NOTED. THE SUMMARY OF INVESTIGATION FURTHER DOCUMENTED THAT ON 9/10/11, RESIDENT #501 "...COMPLAINED OF PAIN AT THE RIGHT HIP. HIS PAIN LEVEL WAS 4/10 (4 ON A SCALE OF ZERO (0) TO 10) AT APPROXIMATELY 9:00 A.M., THE X-RAY RESULTS WERE DISCUSSED WITH THE DOCTOR AND A VERBAL ORDER WAS RECEIVED TO TRANSFER (RESIDENT #501) TO A NEARBY HOSPITAL. (RESIDENT #501) WAS diagnosed with [REDACTED]. RESIDENT #501 RETURNED to the facility on [DATE]..." A REVIEW OF THE HOSPITAL RADIOLOGY REPORT, DATED 9/10/11, REVEALED: "...THERE IS EVIDENCE OF A COMMINUTED FRACTURE OF THE RIGHT FEMORAL NECK. THERE IS SLIGHT SUPERIOR SUBLUXATION OF THE DISTAL FRACTURE FRAGMENT. THE FEMORAL HEAD ARTICULATES NORMALLY WITH THE ACETABULUM..." ON 10/3/11 AT 9:40 A.M., DURING AN INTERVIEW, THE DIRECTOR OF NURSING (DON) REPORTED "...HE (#501) HAD INCREASED PAIN SO WE SENT HIM OUT TO THE HOSPITAL AND THAT'S WHEN THEY DISCOVERED HE HAD A FRACTURED HIP..." WHEN ASKED IF RESIDENT #501 WAS ABLE TO WALK, THE DON SAID "NO. HE USED A WHEELCHAIR..." WHEN ASKED IF RESIDENT #501 WAS IDENTIFIED AS A FALLS RISK ON ADMISSION, THE DON SAID, "YES." WHEN ASKED WHAT INTERVENTIONS WERE IN PLACE PRIOR TO THE FALL, THE DON SAID, "...HE WAS IN THE STAR PROGRAM AS OF 4/26/11 AND HAD AN ALARM AND LOW BED..." WHEN ASKED IF THE ALARM SOUNDED WHEN RESIDENT #501 fell , THE DON SAID "...I'M NOT SURE..." ON 10/3/11 AT 11:31 A.M., DURING AN INTERVIEW, CNA #1 (CERTIFIED NURSING ASSISTANT) REPORTED, "...AFTER DINNER, (RESIDENT #501) LEFT THE DINING ROOM. I WAS GOING DOWN THE HALL AND ANOTHER RESIDENT TOLD ME HE (#501) WAS ON THE FLOOR. I WENT IN AND HE WAS ON THE FLOOR HOLDING HIS RIGHT HIP. HIS CNA AND THE NURSE CAME IN AFTER. WE GOT HIM OFF THE FLOOR AND TRANSFERRED HIM TO THE BED. HE WAS HOLDING HIS HIP AND KEPT SAYING "HOSPITAL." HE LIKES TO TRY TO GET UP ON HIS OWN. HE KEEPS TRYING TO GET UP TO GO TO THE BATHROOM. THAT'S WHY HE HAS ALARMS..." WHEN ASKED IF THE ALARM SOUNDED WHEN RESIDENT #501 fell , CNA #1 SAID, "...THE SWITCH WAS IN THE ON POSITION BUT THE ALARM DIDN'T SOUND. I THINK HE fell FROM HIS WHEELCHAIR..." ON 10/3/11 AT 11:44 A.M., THE DON REPORTED "...HE HAS A HISTORY OF ATTEMPTING TO SELF TRANSFER..." ON 10/3/11 AT 12:15 P.M., DURING AN INTERVIEW, CNA #2 REPORTED, "...I'M THE ONE WHO GOT HIM AND HIS ROOMMATE UP AND PUT THEM BOTH IN THEIR WHEELCHAIRS. I THINK HIS CHAIR ALARM WAS ON BECAUSE WHEN HE SAT ON IT, IT SAID "BEEP BEEP." WHEN ASKED IF SHE tested THE CHAIR ALARM TO ENSURE IT WAS FUNCTIONING, CNA #2 SAID, "...I tested THE ONE ON THE BED BUT NOT THE ONE ON THE CHAIR BECAUSE IT MADE THAT SOUND..." CNA #2 FURTHER REPORTED, "...HE'S (#501) ALWAYS TRYING TO GET IN AND OUT OF BED BY HIMSELF. ONE OF THE OTHER CNAS SAID ONE DAY HE WAS GOING TO FALL. I TRY TO TELL HIM TO STAY IN BED BUT HE GETS IMPATIENT AND DOESN'T WANT TO WAIT..." WHEN ASKED WHERE SHE WAS WHEN RESIDENT #501 fell , CNA #2 SAID, "...I WAS IN THE DINING ROOM..." WHEN QUERIED ABOUT THE LOCATION OF RESIDENT #501'S CALL LIGHT AND WHEN HE WAS LAST TOILETED, CNA #2 REPORTED, "...I DON'T REMEMBERER WHEN I TOILETED HIM. I THINK I DID BUT I'M NOT SURE. I DIDN'T TOILET HIM AFTER HE fell RIGHT AWAY EITHER. LATER WHEN I TOILETED HIM, HE WAS WET. I GUESS HE URINATED ON HIMSELF. HIS CALL LIGHT WAS HANGING ON HIS BED..." WHEN ASKED IF RESIDENT #501'S ALARM SOUNDED AFTER HE fell CNA #2 SAID, "...I DON'T KNOW..." ON 10/3/11 AT 1:49 P.M., DURING A SUBSEQUENT INTERVIEW, THE DIRECTOR OF NURSING (DON) REPORTED, "...THE NURSES AND CNAS ARE RESPONSIBLE FOR CHECKING THE ALARMS. THERE COULD HAVE BEEN A MALFUNCTIONING IN THE DEVICE..." THE DON FURTHER REPORTED, "...WE HAD TO GIVE HIM MEDICATIONS TO CALM HIM DOWN EVEN BEFORE THE FALL. HE (#501) REQUIRED SUPERVISION AND NEEDS TO BE IN COMMON AREAS BECAUSE HE FREQUENTLY ATTEMPTS TO GET UP. HE MAINLY REQUIRES SUPERVISION WHEN HE'S UP..." WHEN ASKED IF RESIDENT #501 WAS IN A COMMON AREA WHERE STAFF COULD OBSERVE HIM IN THE EVENT OF AN ATTEMPT TO SELF TRANSFER, THE DON SAID, "...NO, BECAUSE HE WANTED TO GO BACK TO BED. WE WERE GOING TO UPDATE HIS CARE PLAN TO REFLECT THAT HE NEEDED TO BE IN THE COMMON AREAS..." ON 10/3/11 AT 2:46 P.M., DURING AN INTERVIEW, RN #1 REPORTED, "...WHEN I GOT TO HIS ROOM, THE ALARM WAS NOT GOING OFF. I CHECKED IT AT THE BEGINNING OF MY SHIFT AND IT WAS. I THINK IT MALFUNCTIONED. I SAW HIM WHEELING HIMSELF BACK TO HIS ROOM AND I DIDN'T FOLLOW HIM BECAUSE THERE WERE TWO CNAS IN THE AREA. IT WOULD HAVE BEEN HER (CNA #2) RESPONSIBILITY TO CHECK THE ALARM AFTER PLACING HIM IN THE CHAIR..." WHEN QUERIED ABOUT RESIDENT #501'S NEED TO BE PLACED IN A COMMON AREA WHEN AWAKE, RN #1 SAID, "...WE TRIED TO KEEP HIM WITH US AS MUCH AS POSSIBLE..." WHEN QUERIED ABOUT THE LAST TIME RESIDENT #501 WAS TOILETED, RN #1 SAID, "...I WASN'T AWARE THAT HE HAD NOT BEEN TOILETED BEFORE THE FALL. HE WASN'T TAKEN TO THE REST ROOM AFTER THE FALL..." THE FACILITY STAFF WAS UNABLE TO EXPLAIN WHY THEY FAILED TO PROVIDE ADEQUATE CARE AND SUPERVISION TO PREVENT RESIDENT #501'S FALL WITH RESULTANT RIGHT HIP FRACTURE. RESIDENT #501'S "PHYSICAL THERAPY EVALUATION AND INITIAL PLAN OF CARE" DATED 4/25/11 INDICATED THAT RESIDENT #501 REQUIRED STAND BY ASSIST FOR SIT TO STAND, STAND TO SIT AND BED TO CHAIR FOR ALL TRANSFERS AND REQUIRED STAND BY ASSIST FOR AMBULATION AND THE USE OF A FRONT WHEEL WALKER. RESIDENT #501'S "ALTERATION IN SAFETY" CARE PLAN DATED 4/25/11 REVEALED THE FOLLOWING APPROACHES: "...PERSONAL ITEMS AND CALL LIGHT IN REACH..." "...ONE ASSIST WITH TRANSFERS..." "...OFFER RESIDENT TO GO BACK TO BED AFTER MEALS..." A REVIEW OF THE FACILITY'S "FALL PREVENTION PROGRAM" POLICY DATED 11/10, REVEALED: "...ALL RESIDENTS WITH A FALL RISK ASSESSMENT SCORE AT OR ABOVE 16 WILL BE DEEMED AT HIGH RISK FOR FALLS..." "...THE RISK MANAGEMENT NURSE OR DESIGNEE WILL MAKE RECOMMENDATIONS OF PROTECTIVE AND ASSISTIVE DEVICES AND OR INTERVENTIONS AS NEEDED..."

THIS CITATION PERTAINS TO INTAKE NUMBERS: MI 516, MI 556, MI 545 AND MI 605. BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION, APPROPRIATE AND SAFE EQUIPMENT FOR TRANSFERS TO PREVENT FALL FOR 3 OF 5 SAMPLED RESIDENTS (#501, #504 AND #505) RESULTING IN A RIGHT HIP FRACTURE FOR RESIDENT #501, AND LACERATION REQUIRING SUTURES FOR RESIDENT #504 AND RESIDENT #505. FINDINGS INCLUDE: RESIDENT #501: RESIDENT #501 WAS [AGE] years OLD admitted TO THE FACILITY 12/8/10. UPON ADMISSION SHE WORE A BACK BRACE DUE TO HISTORY OF VERTEBRAL FRACTURE. RESIDENT #501'S CARE PLAN DATED 12/9/10 REQUIRED ONE PERSON ASSISTANCE WITH ADL'S (ACTIVITIES OF DAILY LIVING), TO ANTICIPATE NEEDS AND ASSIST WITH ADL'S, TRANSFERS AND TOILETING. RESIDENT #501 AMBULATED WITH A WALKER WITH STAND BY ASSISTANCE. RESIDENT #501 WAS ASSESSED AS A FALL RISK ON 12/8/10, DUE TO INCREASED WEAKNESS AND DECREASED MOBILITY. THE MINIMUM DATA SET (MDS) WAS NOT AVAILABLE WHEN REQUESTED. THE REHABILITATION SCREENING DATED 12/9/10, REVEALED THAT RESIDENT #501'S SAFETY AWARENESS, AMBULATION, TRANSFERS, AND BED MOBILITY WAS IMPAIRED. AN INTERVIEW WITH REHABILITATION ASSISTANT DIRECTOR/OCCUPATIONAL THERAPIST #6 ON 1/7/10 AT 12:15 PM,WAS CONDUCTED. SHE REPORTS THAT RESIDENT #501 WAS NOT INDEPENDENT WITH AMBULATION. SHE WAS discharged FROM PT (PHYSICAL THERAPY) ON 12/24/10 AND SHE REQUIRED ONE PERSON MINIMUM ASSISTANCE WITH AMBULATING BECAUSE OF BALANCE ISSUES. SHE AMBULATES WITH A WALKER WITH A STAND-BY ASSIST. DUE TO BALANCE ISSUES AND COGNITIVE IMPAIRMENT IT WAS NOT RECOMMENDED FOR RESIDENT #501 TO SELF AMBULATE, SELF TRANSFER, AND SELF TOILET. REVIEW OF THE FACILITY INCIDENT REPORT DATED 12/30/10 REVEALED RESIDENT #501 ON 12/25/10 AT 10:15 AM, fell AND WAS PUT BACK TO BED AFTER AN ASSESSMENT. AT THE FAMILY'S REQUEST, RESIDENT #501 WAS SENT TO THE HOSPITAL AND AN X-RAY REVEALED RESIDENT #501 HAD SUSTAINED RIGHT HIP FRACTURE. IN AN INTERVIEW ON 1/24/11 AT 3:00 PM NURSE #9 BY TELEPHONE STATED THAT SHE ADMINISTERED RESIDENT #501'S MEDICATION AT AROUND 9:45 TO 10:00 AM ON 12/25/10, RESIDENT #501 WAS LYING IN BED. AT AROUND 10:15 AM SHE WAS SUMMONED TO THE ROOM AND FOUND RESIDENT #501 ON THE FLOOR. THE SAFETY ALARM DID NOT SOUND OFF. RESIDENT #501 WAS ASSESSED AND PUT BACK IN BED. THE BED ALARM WAS TURNED ON BUT DID NOT SOUND. "THERE MUST BE A SHORTAGE IN THE WIRES OR BATTERY MALFUNCTION BUT THE ALARM DID NOT SOUND AT ALL". THERE WERE 2 NURSE AIDES ASSIGNED: ONE BEFORE BREAKFAST (NURSE AIDE #11) AND ANOTHER AFTER BREAKFAST (NURSE AIDE #10). NURSE #9 WAS NOT SURE WHO WAS RESPONSIBLE FOR THE RESIDENT BEFORE THE FALL. SHE DID NOT KNOW WHO TRANSFERRED HER TO BED AFTER BREAKFAST OR IF SHE SELF TRANSFERRED. IN AN INTERVIEW BY TELEPHONE ON 1/24/11 AT 3:13 PM NURSE AIDE # 10 STATED THAT SHE WAS ASSIGNED TO RESIDENT #501 AFTER BREAKFAST BUT DID NOT GET TO HER UNTIL AFTER SHE fell . SHE DID NOT GO IN HER ROOM, TOILET HER, OR PROVIDED CARE TO RESIDENT #501 UNTIL AFTER SHE fell . SHE WAS IN THE EAST HALL PROVIDING CARE TO 3 RESIDENTS AT THE TIME OF RESIDENT #501'S FALL. RESIDENT #501 WAS IN WEST HALL AND SHE DID NOT GET TO HER YET. IN AN INTERVIEW BY TELEPHONE ON 1/24/11 AT 2:40 PM NURSE AIDE #11 DENIED TAKING CARE OF RESIDENT #501 AFTER 7:30 AM ON 12/25/10. SHE STATED THAT SHE GOT RESIDENT #501 UP IN THE WHEELCHAIR BEFORE BREAKFAST AND HOOKED HER TO A CHAIR ALARM AND LEFT. THERE WAS ANOTHER NURSE (NURSE AIDE #10) BUT SHE RECALLED LEAVING RESIDENT #501 IN HER WHEELCHAIR IN HER ROOM. SHE PROCEEDED TO HER NEW ASSIGNMENT. LATER SHE HEARD THAT RESIDENT #501 fell AND BROKE HER HIP. HOSPITAL RECORDS DATED 12/25/10, REVEALED, AN [AGE] year OLD FEMALE WHO WAS RECOVERING AT NURSING HOME FROM RECENT THORACIC COMPRESSION FRACTURE WHEN SHE fell RESULTING IN PAIN AND INABILITY TO AMBULATE. THE X-RAY TAKEN SHOWED INTERTROCHANTERIC (UPPER, OUTER) RIGHT HIP FRACTURE. RESIDENT #501 WAS TRANSFERRED TO THE MAIN HOSPITAL FOR PLANNED SURGICAL INTERVENTION FOR RIGHT HIP FRACTURE AND FOR FURTHER EVALUATION OF POSSIBLE SUBACUTE T6 (SPINAL THORACIC VERTEBRAE #6) COMPRESSION FRACTURE. RESIDENT #505: RESIDENT #505 WAS [AGE] years OLD admitted IN THE DEMENTIA UNIT ON 11/11/10. RESIDENT #505'S MDS (MINIMUM DATA SET) assessment dated [DATE], DID NOT HAVE AN ENTRY FOR SECTION C (STAFF ASSESSMENT FOR MENTAL STATUS AS WELL AS COGNITIVE SKILLS ASSESSMENT). HOWEVER, IT REVEALED THAT HE REQUIRED EXTENSIVE ASSISTANCE WITH ADL'S REQUIRING 2 PERSON TRANSFER. RESIDENT HAD HISTORY OF UNWITNESSED FALLS ON 12/6/10 AND 12/13/10, STAFF OBSERVED RESIDENT ON THE FLOOR AND MULTIPLE EPISODES ON 12/15/10. A CARE PLAN FOR A LOW BED, FLOOR MAT, BED BOLSTERS (FOAM ROLLS PLACED ON THE EDGE OF A MATTRESS TO PREVENT FALLING OUT OF BED), AND BED ALARM WAS INITIATED ON 12/6/10. ACCORDING TO A FALL RISK assessment dated [DATE], NOTED RESIDENT #505 WAS A HIGH FALL RISK (SCORE = 24) DUE TO CONFUSION AT ALL TIMES, DEMENTIA, AND OTHER PSYCHOTROPIC MEDICATIONS AND NARCOTICS RESIDENT #505 RECEIVED DAILY. REVIEW OF AN INCIDENT REPORT DATED 12/19/10 AT 1:30 PM, A NURSE DESCRIBED SHE ENTERED THE DINING ROOM AND OBSERVED RESIDENT #505 LAYING ON THE LEFT SIDE ON THE FLOOR. RESIDENT #505 REPORTED SOME PAIN ON THE HEAD AND APPLIED PRESSURE TO A LACERATION. RESIDENT #505 AT THE TIME OF THE INCIDENT DID NOT HAVE SAFETY DEVICES SUCH AS WHEELCHAIR ALARM OR DYCEM (GRIPPER CUSHION TO PREVENT SLIDING OUT OF A WHEELCHAIR) TO PREVENT RESIDENT FROM SLIPPING OFF THE CHAIR. THE SURVEYOR VIEWED A VIDEO OF THE INCIDENT THAT OCCURRED ON 12/19/10 AT THE DINING ROOM WITH THE ADMINISTRATOR AND DON (DIRECTOR OF NURSING) ON 1/7/11 AT 2:45 PM. RESIDENT#505 WAS SITTING IN THE DINING ROOM AREA AND SUDDENLY fell OUT OF HIS CHAIR. THERE WAS NO STAFF WATCHING THE RESIDENTS AT THAT TIME. A WORKER (NOT KNOWN IF SHE WAS A KITCHEN STAFF OR A NURSE AIDE) WAS SEEN PICKING UP FOOD TRAYS AT THE OTHER SECTION OF THE DINING AREA. HER BACK WAS TURNED TOWARDS RESIDENT #505 AND HER TASK AT THAT TIME, WAS TO PICK UP LUNCH TRAYS. IN AN INTERVIEW ON 1/6/10 AT 12:22 PM NURSE AIDE #5 STATED SHE WAS PUTTING ANOTHER RESIDENT DOWN FOR HER AFTERNOON NAP WHEN RESIDENT #505 fell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fell . HOSPITAL RECORD DATED 12/19/10, REVEALED THAT RESIDENT #505 WAS treated for [REDACTED]. RESIDENT #504 RESIDENT #504 WAS [AGE] years OLD admitted to the facility on [DATE]. ACCORDING TO ADMISSION history and physical examination [REDACTED]. SHE HAD HISTORY OF CEREBROVASCULAR ACCIDENT (STROKE) AND WAS INCONTINENT IN ADDITION TO OTHER DIAGNOSIS. MDS (MINIMUM DATA SET) DATED 7/12/10, SHOWED A MODERATELY IMPAIRED COGNITIVE SKILLS. AN MDS dated [DATE], HOWEVER, DID NOT HAVE AN ENTRY FOR SECTION C (STAFF ASSESSMENT FOR MENTAL STATUS AS WELL AS COGNITIVE SKILLS ASSESSMENT). RESIDENT #504'S BED MOBILITY AND TRANSFER ABILITY WAS EXTENSIVE ASSISTANCE WITH 2 OR MORE PERSON ASSISTANCE. RESIDENT #504'S CARE PLAN DATED 11/10/10, IDENTIFIED THAT SHE IS A FALL RISK ASSIST WITH 2 PERSON TRANSFER BUT WAS NOT CARE PLANNED FOR 2 PERSON ASSIST WITH BED MOBILITY. THE DAILY CARE PLAN (NURSE AIDE CARE GUIDE) DATED 2010, WAS NOT REVISED ACCORDING TO THE RECENT 10/6/10 MDS REQUIRING 2 PERSON ASSISTANCE WITH BED MOBILITY. REVIEW OF THE FACILITY INCIDENT REPORT DATED 12/27/10 REVEALED RESIDENT #504 WAS OBSERVED ON THE FLOOR AT HER BEDSIDE. THE NURSE AIDE #7 WAS ALONE PROVIDING INCONTINENCE CARE ON 12/27/10 AT 2:45 AM. NURSE AIDE #7 LEFT THE RESIDENT ON HER SIDE TO WET WASHCLOTHS IN THE BATHROOM AND HEARD A NOISE. RESIDENT #504 WAS FOUND LYING ON THE FLOOR AND SUSTAINED LACERATION ON THE BRIDGE OF HER NOSE AND DISCOLORATION OF THE RIGHT EAR. RESIDENT #504 WAS SENT TO THE HOSPITAL FOR EVALUATION AND TREATMENT. IN AN INTERVIEW ON 1/6/11 AT 2:37 PM. NURSE AIDE #7 REPORTED "IT HAPPENED SO QUICKLY". NURSE AIDE #7 EXPLAINED THAT SHE WAS NOT ASSIGNED TO RESIDENT #504. SHE WAS COVERING FOR ANOTHER NURSE AIDE WHO WAS ON BREAK AND WENT INTO RESIDENT #504'S ROOM TO CHECK IF SHE WAS WET. SHE TOOK OFF RESIDENT #504'S BRIEF AND LEFT THE RESIDENT ON HER SIDE HOLDING ON TO THE GRAB BAR. SHE PROCEEDED TO THE BATHROOM AND WET THE WASHCLOTH IN THE BATHROOM. NURSE AIDE #7 HEARD A LOUD NOISE WHILE SHE WAS IN THE BATHROOM AND FOUND RESIDENT #504 ON THE FLOOR. NURSE AIDE #7 admitted THAT SHE LEFT RESIDENT #504 ALONE WITH NO BRIEFS DURING INCONTINENCE CARE. SHE DESCRIBED TURNING RESIDENT #504 FROM SIDE TO SIDE BUT DENIED ANY HELP FROM OTHER AIDE AT THAT TIME. NO ONE WITNESSED RESIDENT #504'S FALL. ACCORDING TO NURSE #8 WRITTEN STATEMENT DATED 12/27/10, RESIDENT #504 WAS OBSERVED LYING ON THE FLOOR NEXT TO THE BED IN FETAL POSITION ON 12/27/10 AT 2:45 AM. RESIDENT #504 SUSTAINED A LACERATION ABOVE NOSE THAT WAS BLEEDING AND HER RIGHT EAR WAS BRUISED AND DISCOLORED. RESIDENT #504'S RIGHT UPPER ARM HAD AN ABRASION. SHE FURTHER WROTE: "AIDE STATED SHE WAS CHANGING RESIDENT #504 AND WENT TO GET LINEN AND RESIDENT #504 ROLLED OUT OF BED." IN AN INTERVIEW ON 1/7/11 AT 11:40 AM THE REHABILITATION ASSISTANT DIRECTOR/OCCUPATIONAL THERAPIST #6 STATED THAT RESIDENT #504 WAS COGNITIVELY IMPAIRED AND HER SAFETY AWARENESS WAS IMPAIRED. SHE REQUIRED MAXIMUM ASSISTANCE WITH TRANSFERS BUT WAS ABLE TO MOVE IN BED. SHE HAS ENOUGH UPPER BODY STRENGTH TO HELP HERSELF TO MOVE SIDE TO SIDE USING THE GRAB BAR. HOSPITAL RECORDS DATED 12/27/10 REVEALED THAT RESIDENT #504 WAS TREATED AT THE HOSPITAL FOR LACERATION ON THE FACE REQUIRING SUTURES. ACCORDING TO emergency room TRIAGE NOTES, DATED 12/27/10 AT 4:26 AM (RESIDENT #504) "fell FROM THE BED AND HIT HER HEAD ON THE NIGHT STAND PER NURSING HOME". RESIDENT RECEIVED CARE AT THE emergency room AND HAD 3 SUTURES TO THE BRIDGE OF HER NOSE.( )

THIS CITATION PERTAINS TO INTAKE NUMBER (S) MI 227, MI 373, MI 290 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT 3 OF 12 SAMPLED RESIDENTS (#508, #509, AND #510) WERE FREE FROM INCIDENTS OF ABUSE AND NEGLECT, RESULTING IN RESIDENT #508 NOT RECEIVING NURSING CARE FOR AN INJURY OF UNKNOWN ORIGIN; RESIDENT #509 NOT RECEIVING NURSING CARE FOR COMPLAINTS OF NOT FEELING WELL WHICH LATER RESULTED IN INJURY OF UNKNOWN ORIGIN WITH RESULTANT FRACTURE, AND RESIDENT #510 BEING PUSHED AGAINST THE WALL DURING CARE, RESULTING IN COMPLAINTS OF PAIN TO HER RIGHT SHOULDER AND LEG. FINDINGS INCLUDE: RESIDENT #508 ACCORDING TO RESIDENT #508'S ADMISSION AND DISCHARGE SUMMARY, RESIDENT #508 WAS ORIGINALLY admitted to the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA ((MDS) dated [DATE] INDICATED THAT RESIDENT #508 HAD SEVERELY IMPAIRED COGNITION, SHORT AND LONG TERM MEMORY PROBLEMS AND REQUIRED EXTENSIVE TO TOTAL ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING (ADLS) INCLUDING BED MOBILITY, TRANSFERS, DRESSING, EATING, TOILETING, PERSONAL HYGIENE AND BATHING. A REVIEW OF THE FACILITY'S INCIDENT REPORT DATED 10/20/10 DOCUMENTED THAT RESIDENT #508 WAS OBSERVED IN THE DINING ROOM WITH AN AREA OF BRUISING TO THE CORNER OF HER RIGHT EYE LID. THE REPORT FURTHER INDICATED THAT RESIDENT #508 WAS UNABLE TO VERBALIZE WHAT HAPPENED. ADDITIONALLY, THE INCIDENT REPORT DOCUMENTED THAT, AS A CORRECTIVE MEASURE, RESIDENT #508 WAS IMMEDIATELY TAKEN AWAY FROM THE DINING ROOM TABLE AND WAS CARE PLANNED NOT TO BE AT THE TABLE UNLESS AT MEALTIME WITH SUPERVISION. THE FACILITY'S SUMMARY OF INVESTIGATION DATED 10/27/10 DOCUMENTED THE FOLLOWING: "...ON OCTOBER 19, 2010, RESIDENT #508 WAS OBSERVED WITH DISCOLORATION OVER THE CORNER OF THE RIGHT EYELID...". "...ON MORNING ROUNDS RESIDENT #508'S DAY SHIFT NURSE, (LPN #1), OBSERVED RESIDENT #508 LAYING IN HER LOW TO GROUND BED, WITH FLOOR MATS IN PLACE, WITH REDNESS BY HER RIGHT EYE. LICENSED PRACTICAL NURSE (LPN) #1 MOVED THE CALL LIGHT TO ANOTHER SPOT WITHIN RESIDENT #508'S REACH, AWAY FROM HER FACE. ON 11/1/10 AT 12:09 P.M., DURING AN INTERVIEW, LPN #1 REPORTED THE FOLLOWING: "...I WORKED THE 7-3 SHIFT AND I NOTICED IT EARLY THAT MORNING. THE CNA'S (CERTIFIED NURSING ASSISTANT) TOLD ME IT GOT DARKER BUT SHE TURNS FROM SIDE TO SIDE...". "...SHE (#508) WAS IN THE BED WHEN IT WAS DISCOVERED AND SHE (#508) WAS FINE..." WHEN ASKED IF THE INCIDENT REGARDING RESIDENT #508'S RIGHT EYE BRUISING WAS DOCUMENTED, LPN #1 SAID "I DON'T RECALL". WHEN ASKED IF THE DOCTOR WAS NOTIFIED, LPN #1 SAID "I DON'T RECALL". LPN #1 WAS ALLOWED TO REVIEW RESIDENT #508'S CLINICAL RECORD DURING THE INTERVIEW AND REPORTED "...I HADN'T DOCUMENTED BECAUSE THE DAY GOT HECTIC AND I GOT REALLY BUSY...". "...CNA #2 CALLED ME TO THE SHOWER BECAUSE THE AREA OVER HER (#508) RIGHT EYE HAD GOTTEN REDDER...". "...I INSTRUCTED HER (CNA #2) TO TAKE HER TO THE DINING ROOM AND KEPT HER AWAY FROM THINGS SHE COULD BUMP...". WHEN ASKED IF THE DOCTOR WAS NOTIFIED REGARDING RESIDENT #508'S WORSENING REDNESS TO HER RIGHT EYE, AND IF THESE FINDINGS HAD BEEN DOCUMENTED IN RESIDENT #508'S CLINICAL RECORD, LPN #1 SAID "...IT WAS A LOT GOING ON THAT DAY...". "...ANOTHER CNA TOLD THE UNIT MANAGER AND THE UNIT MANAGER CAME TO ME AND ASKED IF I WAS AWARE AND FOR ME TO CHECK IT OUT...". "...THE AFTERNOON NURSE ACTUALLY DOCUMENTED THE REDNESS AND NOTIFIED THE FAMILY...". LPN #1 COULD NOT EXPLAIN WHY SHE FAILED TO NOTIFY THE DOCTOR ABOUT THE BRUISING AND REDNESS TO RESIDENT #508'S RIGHT EYE, FAILED TO NOTIFY RESIDENT #508'S FAMILY, AND FAILED TO DOCUMENT THESE SIGNIFICANT FINDINGS IN RESIDENT #508'S CLINICAL RECORD. ON 11/1/10 AT 12:40 P.M., DURING AN INTERVIEW, THE DIRECTOR OF NURSING (DON), REPORTED "...THERE IS NO EXCUSE; IT SHOULD'VE BEEN REPORTED AS SUSPECTED ABUSE..." ON 11/1/10 AT 1:28 P.M., AN INTERVIEW WAS CONDUCTED WITH REGISTERED NURSE (RN) #1 WHO REPORTED THAT A CNA CAME TO HER AROUND LUNCH TIME AND SAID THAT RESIDENT #508 HAD REDNESS OVER HER RIGHT EYE. I TOOK A LOOK AT IT AND ASKED THE PHYSICIAN'S ASSISTANT (PA) TO EVALUATE HER...". "...I TOLD (LPN #1) THAT THE RESIDENT HAD DISCOLORATION OVER HER RIGHT EYE AND THAT THE PA HAD EXAMINED HER...". "...I MADE THE INCIDENT REPORT OUT AND I TALKED TO RESIDENT #508'S DAUGHTER LATER THAT DAY..." ON 11/1/10 AT 2:47 P.M., CNA #2 WAS INTERVIEWED AND REPORTED THE FOLLOWING: "...I GAVE HER (#508) A SHOWER AND HER RIGHT EYE WAS RED AND SHE (#508) KEPT RUBBING HER EYE. I CALLED FOR THE NURSE TO COME AND LOOK AT HER (#508) EYE. SHE (LPN #1) CAME IN AND LOOKED, BUT SHE DIDN'T SAY ANYTHING. SHE (LPN #1) JUST WALKED BACK OUT...". THERE WAS NO EXPLANATION GIVEN BY FACILITY STAFF AS TO WHY RESIDENT #508'S BRUISING AND REDNESS TO HER RIGHT EYE WAS NOT INITIALLY ADDRESSED AND WHY LPN #1 FAILED TO NOTIFY RESIDENT #508'S PHYSICIAN IN ORDER TO EXPEDITE CARE AND TREATMENT. FURTHER, THERE WAS NO EXPLANATION OF WHY LPN #1 FAILED TO DOCUMENT RESIDENT #508'S REDNESS AND BRUISING AND REPORT THE SAME AS SUSPECTED ABUSE. RESIDENT #509 ACCORDING TO RESIDENT #509'S ADMISSION AND DISCHARGE SUMMARY, RESIDENT #509 WAS ORIGINALLY admitted to the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] INDICATED THAT RESIDENT #509 HAD MODERATELY IMPAIRED COGNITION, SHORT AND LONG TERM MEMORY PROBLEMS AND REQUIRED LIMITED ASSISTANCE WITH ACTIVITIES OF DAILY LIVING (ADLS) INCLUDING BED MOBILITY, TRANSFERS, DRESSING, PERSONAL HYGIENE, AND TOILETING. A REVIEW OF THE FACILITY'S INCIDENT REPORT DATED 10/15/10 DOCUMENTED THAT ON 10/15/10 AT 5:30 P.M., RESIDENT #509 WAS IN HER ROOM AND COMPLAINED OF PAIN IN HER RIGHT LEG. THE RESULT OF THE INJURY WAS LISTED AS "FRACTURED RIGHT HIP". A REVIEW OF THE FACILITY'S SUMMARY OF INVESTIGATION REPORT DATED 10/22/10 DOCUMENTED THE FOLLOWING: "...ON OCTOBER 14, 2010 RESIDENT #509, AN [AGE] year OLD RESIDENT, COMPLAINED OF LEG PAIN TO THE AFTERNOON NURSE ...". "...SHE WAS LYING IN THE BED AT THIS TIME AND IT WAS APPROXIMATELY 3:45 P.M...". ON 11/1/10 AT 3:01 P.M., DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON), SHE REPORTED THAT "...RESIDENT #509 COMPLAINED OF PAIN ON 10/14/10 SO THE MIDNIGHT SHIFT SENT HER OUT..." "...SHE HAD A [MEDICAL CONDITION]" "...I DON'T KNOW HOW SHE FRACTURED HER HIP...". THE DON COULD OFFER NO FURTHER EXPLANATION OF HOW RESIDENT #509 SUSTAINED A [MEDICAL CONDITION] ON 11/3/10 AT 12:57 P.M., DURING AN INTERVIEW, CNA #1 REPORTED THAT RESIDENT #509 "...ALWAYS COMPLAINED OF PAIN ALL OVER...". "...I DIDN'T SEE HER FALL OR ANYTHING THOUGH..." "..SHE WAS ABLE TO MOVE HER LEGS AND EVERYTHING...". ON 11/3/10 AT 1:35 P.M., DURING AN INTERVIEW WITH CNA #4, SHE REPORTED "...SHE (#509) WAS IN BED WHEN I ARRIVED AT THE START OF MY SHIFT...". "...SHE (#509) SAID SHE WASN'T FEELING WELL...". WHEN ASKED IF SHE (CNA #4) REPORTED RESIDENT #509'S COMPLAINTS OF NOT FEELING WELL TO THE NURSE, CNA #4 SAID "NO". CNA #4 FURTHER STATED "...I DIDN'T REPORT IT TO THE NURSE BECAUSE SHE (#509) HAD BEEN SICK THE LAST FEW DAYS SO I ALREADY KNOW SHE WASN'T FEELING WELL...". WHEN ASKED IF RESIDENT #509 COMPLAINED OF PAIN AT THAT TIME, CNA #4 SAID "NO". CNA #4 FURTHER STATED "...I WENT TO START CARE ON MY OTHER RESIDENTS AND SHE (#509) CAME DOWN TO THE DINING ROOM. SHE TRIED TO GET UP FROM HER WHEEL CHAIR IN ORDER TO SIT ON THE SOFA, BUT THAT'S WHEN SHE SAID HER LEG WAS HURTING...". "...I TOLD HER TO STAY IN THE WHEEL CHAIR THEN I WENT TO TELL THE NURSE AND THE NURSE TOLD ME TO TAKE HER (#509) BACK TO HER ROOM AND PUT HER (#509) BACK IN THE BED...". "...WHEN I TOOK HER (#509) BACK TO BED, SHE (#509) COMPLAINED OF MORE PAIN AND SHE SAID IT HURT TO MOVE HER LEGS ON AND OFF THE BED...". WHEN ASKED IF RESIDENT #509 HAD fell , CNA #4 SAID "...I DIDN'T SEE HER FALL...". WHEN ASKED WHY SHE (CNA #4) NEGLECTED TO REPORT RESIDENT #509'S COMPLAINTS OF NOT FEELING WELL AT THE START OF THE SHIFT, CNA #4 OFFERED NO EXPLANATION. CNA #4 COULD NOT EXPLAIN WHY SHE NEGLECTED TO REPORT RESIDENT #509'S COMPLAINTS OF NOT FEELING WELL AT THE START OF THE SHIFT TO THE NURSE, WHICH RESULTED IN RESIDENT #509 NOT RECEIVING THE NECESSARY CARE TO ADDRESS HER (#509) HEALTH CONCERNS. FURTHER, WITH COMPLAINTS OF NOT FEELING WELL, RESIDENT #509 WAS ALLOWED TO TRANSFER HERSELF INTO A WHEEL CHAIR AND PROPEL HERSELF TO THE DINING ROOM WITHOUT HAVING RECEIVED MEDICAL ATTENTION FOR HER HEALTH CONCERNS. RESIDENT #510 ACCORDING TO RESIDENT #510'S ADMISSION AND DISCHARGE SUMMARY, RESIDENT #510 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO RESIDENT #510'S NURSING ADMISSION assessment dated [DATE], RESIDENT #510 WAS admitted to the facility on [DATE] AT 4:45 P.M. A REVIEW OF THE FACILITY'S INCIDENT REPORT DATED 10/13/10 DOCUMENTED THE FOLLOWING: "...RESIDENT #510 STATED THAT BETWEEN 1-2 PM, A THERAPIST SLAMMED HER INTO THE WALL WHILE ASSISTING HER IN PULLING UP HER SLACKS. RESIDENT #510 ALLEGES THAT HER RIGHT SHOULDER IS BROKE AND THAT HER RIGHT LEG IS SORE. SHE (#510) STATES HER RIGHT SHOULDER AND RIGHT LEG CONTACTED THE WALL. HER (#510) DESCRIPTION OF THE THERAPIST MATCHES THAT OF THE CNA (CERTIFIED NURSING ASSISTANT) (CNA #1) THAT MAY HAVE ASSISTED HER. RESIDENT #510'S STORY CHANGES FREQUENTLY...". A REVIEW OF THE FACILITY'S SUMMARY OF INVESTIGATION DATED 10/15/10 DOCUMENTED: "...ON 10/12/10 AT 3:00 P.M., I (ADMINISTRATOR) WAS NOTIFIED BY CUSTOMER RELATIONS THAT RESIDENT #510 HAD ALLEGED THAT SHE WAS BEING BEATEN UP BY STAFF...". THE INVESTIGATION REPORT DOCUMENTED THAT RESIDENT #510 ALLEGED THAT THE THERAPIST THREW HER AGAINST THE WALL WHILE ASSISTING IN PULLING UP HER SLACKS. "...THE THERAPIST DESCRIPTION MATCHES CNA #1 THAT WAS ASSIGNED TO RESIDENT #510...". "...CNA #1 WAS INTERVIEWED AND CONFIRMED ASSISTING RESIDENT #510 IN PULLING UP HER SLACKS DURING THE ALLEGED INCIDENT TIME FRAME BUT DENIES ANYTHING UNUSUAL REGARDING THE ASSISTANCE..." A REVIEW OF A SOCIAL WORKER SOCIAL PROGRESS NOTE DATED 10/13/10 DOCUMENTED THE FOLLOWING: "...RESIDENT MADE ACCUSATION OF ABUSE AS WRITER WAS INTERVIEWING AND ASSESSING HER (#510)...". "...SHE (#510) STATES THAT A CNA HELPED HER OFF HER BED PAN YESTERDAY AND SHOVED HER SHOULDER...". "...RESIDENT #510 STATES THAT WHEN SHE (CNA #1) SHOVED HER, SHE (#510) BUMPED HER ARM AND LEG ON THE WALL..." THE SOCIAL WORKER WAS NOT AVAILABLE FOR INTERVIEW AND WAS NO LONGER EMPLOYED BY THE FACILITY. ON 11/4/10 AT 2:21 P.M., DURING AN INTERVIEW, THE DIRECTOR OF NURSING (DON) REPORTED "...I INTERVIEWED CNA #1 AND SHE TOLD ME THAT SHE (CNA #1) WAS ROLLING HER (#510) OVER TO PUT HER ON THE BED PAN AND THE RESIDENT (#510) TOLD HER TO STOP. LATER SHE (#510) COMPLAINED THAT HER (#510) RIGHT SHOULDER HIT THE WALL...". "...SHE COULDN'T REMEMBER THE NAME OF THE CNA AND THERE WAS NO REDNESS OR BRUISING...". WHEN ASKED IF RESIDENT #510 WAS SEEN BY THE PHYSICIAN TO EVALUATE HER (#510) RIGHT SHOULDER AND RIGHT LEG, THE DON SAID "NO". WHEN ASKED IF THE PHYSICIAN HAD BEEN NOTIFIED, THE DON SAID "NO". WHEN ASKED IF RESIDENT #510 WAS SENT TO THE HOSPITAL FOR EVALUATION OF HER RIGHT SHOULDER AND RIGHT LEG, THE DON SAID, "NO". WHEN ASKED IF X-RAYS WERE TAKEN OF RESIDENT #510'S RIGHT SHOULDER AND RIGHT LEG TO RULE OUT A POSSIBLE FRACTURE, THE DON SAID, "NO". WHEN ASKED WHY RESIDENT #510'S PHYSICIAN HAD NOT BEEN NOTIFIED AND WHY NO X-RAYS HAD BEEN PERFORMED ON RESIDENT #510'S RIGHT SHOULDER AND RIGHT LEG, THE DON SAID "...BECAUSE SHE DIDN'T SEEM TO BE HURT AND SHE DIDN'T SEEM TO BE IN ANY DISTRESS...". THE DON COULD NOT EXPLAIN WHY RESIDENT #510 WAS NOT TRANSFERRED TO THE HOSPITAL FOR EVALUATION IN ORDER TO RULE OUT A FRACTURE. ON 11/5/10 AT 12:21 P.M., DURING AN INTERVIEW, CNA #1 REPORTED THAT SHE WAS ASSIGNED TO CARE FOR RESIDENT #510 ON 10/12/10. CNA #1 REPORTED THE FOLLOWING: "...SHE (#510) WAS TRYING TO PUT HERSELF ON THE BED PAN AND FECES WAS EVERYWHERE...". "...I WENT TO CLEAN HER UP AND I ASKED HER TO ROLL OVER. I PUSHED HER WITH MY LEFT HAND IN ORDER TO POSITION HER SO I COULD CLEAN HER UP WITH MY RIGHT HAND...". WHEN ASKED ABOUT THE POSITION OF RESIDENT #510'S BED IN RELATION TO THE WALL, CNA #1 SAID "...HER (#510) BED WAS AGAINST THE WALL AND THE RIGHT SIDE OF HER BODY WAS NEAR THE WALL...". WHEN ASKED IF THERE WERE ANY SIDE RAILS ON RESIDENT #510'S BED, CNA #1 SAID "...THE BED ONLY HAD SIDE RAILS ON THE LEFT SIDE...". "...THERE WAS NO SIDE RAIL ON THE SIDE OF THE BED NEAR THE WALL...". "...I TOLD HER (#510) TO START ASKING FOR HELP WHEN SHE NEEDED TO USE THE BED PAN...". WHEN ASKED IF ANY PART OF RESIDENT #510'S BODY MADE CONTACT WITH THE WALL, CNA #1 SAID "...IT'S POSSIBLE THAT I COULD HAVE PUSHED HER AGAINST THE WALL BECAUSE THERE WAS NO BARRIER THERE...". THERE WAS NO DOCUMENTED EVIDENCE THAT RESIDENT #510 HAD BEEN EVALUATED BY A PHYSICIAN OR HAD X-RAYS TO RULE OUT A POSSIBLE FRACTURE OF HER RIGHT SHOULDER AND RIGHT LEG. A REVIEW OF THE FACILITY'S ABUSE POLICY DATED 12/10/09 INDICATED THE FOLLOWING: "...PURPOSE: TO ENSURE THAT RESIDENTS ARE NOT SUBJECT TO ABUSE BY ANYONE, INCLUDING, BUT NOT LIMITED TO FACILITY STAFF, OTHER RESIDENTS, CONSULTANTS OR VOLUNTEERS, OR OTHER AGENCIES SERVING THE RESIDENT, FAMILY MEMBERS OR LEGAL GUARDIANS, FRIENDS OR OTHER INDIVIDUALS...". "...ANY PERSON WHO GAINS KNOWLEDGE OF SUSPECTED OR ACTUAL ABUSE, NEGLECT, MISTREATMENT, INJURY OF UNKNOWN SOURCE OR MISAPPROPRIATION OF PROPERTY HAS THE RESPONSIBILITY TO REPORT THIS INFORMATION TO THE NURSE SUPERVISOR, DIRECTOR OF NURSING AND OR THE ADMINISTRATOR..."

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE APPROPRIATE SUPERVISION TO PREVENT A FALL WITH INJURY FOR ONE (#605) OF FOUR SAMPLED RESIDENTS, RESULTING IN A LEFT FEMUR FRACTURE. FINDINGS INCLUDE: ACCORDING TO THE NURSE'S NOTES DATED 8/17/10 AT 11:00 P.M., RESIDENT #605 WAS OBSERVED ON THE FLOOR. RESIDENT #605'S BLUE SAFETY MAT WAS OBSERVED UP AGAINST HER BEDSIDE TABLE AND HER ALARM WAS TURNED OFF. ON 8/18/10 AT 1:15 A.M., X-RAY RESULTS REVEALED RESIDENT #605 HAD A FRACTURE OF THE LEFT FEMUR. RESIDENT #605 WAS TRANSFERRED TO A LOCAL AREA HOSPITAL FOR TREATMENT. ACCORDING TO THE HOSPITAL emergency room REPORT DATED 8/18/10, RESIDENT #605 WAS BROUGHT IN BY EMS (EMERGENCY MEDICAL SERVICES) AFTER PATIENT HAD AN UNWITNESSED FALL AT THE NURSING HOME. X-RAYS WERE TAKEN AND LEFT FEMURE WAS FOUND TO BE FRACTURED. REVIEW OF RESIDENT #605'S CARE PLAN ENTITLED "ALTERATION IN SAFETY," TO PREVENT FALLS DATED 8/13/10, REVEALED RESIDENT #605 WAS TO HAVE A PRESSURE ALARM ON HER BED AND WHEELCHAIR. ON 9/9/10 AT 10:25 A.M., DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON), IT WAS REVEALED THE DON COULD NOT EXPLAIN WHY RESIDENT #605'S ALARM DID NOT SOUND TO ALERT STAFF. ON 9/9/10 AT 10:25 A.M., REVIEW OF THE FACILITY'S INCIDENT REPORT DATED 8/17/10 AT 11:00 P.M., REVEALED RESIDENT #605 WAS OBSERVED ON THE FLOOR NEXT TO HER BED ON HER LEFT SIDE WHEN STAFF WERE CALLED TO THE RESIDENT'S ROOM. THE SUMMARY OF THE FACILITY'S INVESTIGATION OF THE INCIDENT THAT WAS SIGNED AND DATED BY THE ASSISTANT DIRECTOR OF NURSING (ADON) ON 8/25/10, REVEALED ON 8/17/10 AT 11:00 P.M., ON THE SECOND FLOOR, THE CERTIFIED NURSING ASSISTANT (CENA #I) WAS RESPONDING TO A RESIDENT'S VOICE ASKING FOR HELP, SHE (CENA #I) WENT DOWN TO RESIDENT #605'S ROOM AND CALLED THE LICENSED PRACTICAL NURSE (LPN #H) TO COME TO HER (#605) ROOM. LPN #H OBSERVED RESIDENT #605 LYING ON THE FLOOR ON HER LEFT SIDE. RANGE OF MOTION WAS PERFORMED ON RESIDENT #605'S LEFT LOWER LEG AND RESIDENT #605 RESPONDED WITH GRIMACES. ACCORDING TO LPN #H STATEMENT OF EVENTS DATED 8/19/10, WHEN LPN #H ENTERED RESIDENT #605'S ROOM, LPN #H OBSERVED RESIDENT #605 LYING ON THE FLOOR ON HER LEFT SIDE, HER BLUE SAFETY MAT WAS LEANING IN THE UPRIGHT POSITION AGAINST HER BEDSIDE TABLE AND THE BED ALARM WAS IN THE "OFF" POSITION. ON 9/8/10 AT 9:10 A.M., DURING A TOUR OF THE FACILITY, OBSERVATION REVEALED THE RIGHT SIDE OF THE UNITS (RESIDENTS ROOMS AND HALL) WAS NOT VISIBLE FROM THE NURSES STATION, HOWEVER, THE LEFT SIDE OF THE UNITS (RESIDENTS ROOMS AND HALL) WERE VISIBLE WITH THE USE OF A LARGE MIRROR MOUNTED ON THE WALL. ON 9/8/10 AT 2:30 P.M., INTERVIEW WITH LPN #Q, REVEALED THE HALL AND RESIDENT ROOMS ON THE RIGHT SIDE OF THE UNITS WERE NOT VISIBLE. SHE STATED, THERE HAS TO ALWAYS BE AT LEAST TWO CENA'S OR NURSES DOWN THE HALL FOR RESIDENT ASSISTANCE. ON 9/9/10 AT 12:15 P.M., AN OBSERVATION ON THE SECOND FLOOR DURING LUNCH REVEALED THE NURSES AND CENA'S WERE IN THE DINING ROOM. RESIDENTS WERE OBSERVED IN THE HALL AND IN THEIR ROOMS. THERE WERE NO NURSES AND/OR CENA'S VISIBLE ON THE RIGHT SIDE OF THE UNIT OR HALL FOR APPROXIMATELY 10 MINUTES. ON 9/13/10 AT 1:48 P.M., AN INTERVIEW WITH CNA #I REVEALED SHE COULD NOT REMEMBER IF RESIDENT #605'S BED WAS IN THE LOW POSITION, THE RESIDENT #605 DID NOT FALL ONTO HER SAFETY MAT BECAUSE THE SAFETY MAT WAS LYING ON THE FLOOR NEXT TO HER (#605) AND HER ALARM WAS NOT CHECKED. A CLOSED RECORD REVIEW WAS COMPLETED ON 9/9/10, SINCE RESIDENT #605 NO LONGER RESIDED IN THE FACILITY. THE FACILITY FACE SHEET REVEALED RESIDENT #605 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO THE PHYSICIAN'S PROGRESS NOTES DATED 8/17/10 (NO TIME) RESIDENT #605 WAS ALERT BUT CONFUSED. THE DAILY CARE PLAN DATED "2010" REVEALED RESIDENT #605 WAS CONFUSED AND REQUIRED ASSISTANCE WITH FEEDING, BATHING, DRESSING AND TOILETING. RESIDENT #605 REQUIRED PHYSICAL AND OCCUPATIONAL THERAPY TO ASSIST WITH MOBILITY. THE PHYSICIAN ORDER [REDACTED]. THE ORDER INCLUDED CHECKING THE ALARM EVERY SHIFT. ACCORDING TO THE FALL RISK assessment dated [DATE]. RESIDENT #605 HAD A SCORE OF 15. (LEVEL 11 (TWO) WAS A SCORE OF 11-15). THE FALL RISK ASSESSMENT DID NOT INCLUDE SCORES FOR PSYCHOTROPIC MEDICATIONS (ANTIPSYCHOTIC: SEROQUEL 50 MILLIGRAMS ORALLY THREE TIMES PER DAY, SIDE EFFECTS INCLUDE DIZZINESS, DROWSINESS, MUSCLE STIFFNESS AND WEAKNESS. AstraZeneca, 12/2009) AND ORTHOPEDIC PROBLEMS (OSTEOARTHRITIS). ACCORDING TO THE FALL PREVENTION PROGRAM, REVISED 8/10, A SCORE OF 16 OR GREATER IS CONSIDERED HIGH RISK FOR FALLS. RESIDENT'S WHO ARE IDENTIFIED AT HIGH RISK WILL HAVE A RED STAR ATTACHED TO THE MEDICATION ADMINISTRATION RECORD, CENA'S ACTIVITY OF DAILY LIVING SHEET, AND ON THE RESIDENT'S NAME PLATE OUTSIDE THEIR DOOR AND WHEELCHAIR TO IDENTIFY HIGH RISK RESIDENTS TO THE STAFF. THE FALL PREVENTION PROGRAM ALSO INCLUDED THE FOLLOWING INTERVENTIONS: 1. USE OF A LOW BED. THERE WAS NO DOCUMENTED EVIDENCE RESIDENT #605 WAS PLACED IN A LOW BED. 2. WHEELCHAIR ALARM, BED ALARM OR MOTION SENSOR. THERE WAS NO DOCUMENTED EVIDENCE RESIDENT #605 ALARM WAS CHECKED. THE DOCUMENTATION REVEALED RESIDENT #605'S ALARM WAS IN THE OFF POSITION. 3. PLACE IN ROOM NEAR NURSES STATION FOR HIGHER VISIBLY. THERE WAS NO DOCUMENTED EVIDENCE RESIDENT #605 WAS PLACED NEAR THE NURSE'S STATION FOR HIGHER VISIBLY.