Every finding on record at Regency at Westland

Based on observation, interview, and record review, the facility failed to complete an annual PASARR (Pre-admission Screening and Annual Resident Review/3877) assessments for one resident (R12) of two reviewed for PASARR assessments. Findings include: On 1/27/26 at 7:05 AM, R12 was observed resting in bed awake. R12 was observed to be wearing hearing aids and repeatedly asked to have the hearing aid batteries changed several times during the visit. A review of R12's medical record reveal R12 was admitted on [DATE] and readmitted on [DATE] after a brief hospitalization with diagnoses including Bipolar Disorder, Depressive Disorder, and Vascular Dementia. A review of the Minimum Data Set (MDS) assessment revealed R12's Brief Interview for Mental Status (BIMS) score was 13/15, indicating intact cognition, and needing extensive assistance with bed mobility and transfers.Further review of the medical record revealed the last annual PASARR assessment was completed in October of 2024. A request was made for the most recent updated annual PASARR. On 01/29/2026 at 12:11 PM, during an interview with Social Worker (SW) G, they were asked about the recent requested for the most recent annual PASARR to which they indicated the form had been missed when R12 was readmitted back into the facility. On 01/29/2026 at 2:28 PM, in an interview with the Nursing Home Administrator (NHA), they confirmed the PASARRs should be completed on admission and annually.

Based on observation, interview, and record review, the facility failed to timely implement care plan interventions following falls for one resident (R107) out of three reviewed for plans of care. Findings include:On 1/27/2026 at 6:30 AM, R107 was observed lying in bed with their feet hanging off the side. R107's bed was not observed in a low position, with a blanket and sling pad underneath them. Registered Nurse (RN) H reported R107 had just returned from the hospital following a fall where they hit their head and was on a blood thinner.A review of the medical record revealed R107 was admitted into the facility on 1/13/2026 with the following medical diagnoses, Muscle Wasting and Atrophy. A review of the most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 5/15 indicating an impaired cognition. R107 also required staff assistance with bed mobility and transfers. Further review of Incident and Accidents (IA) reports noted the following: Date:1/24/2026.Nursing Description: Resident observed on [their] right side on the floor in-front of wheelchair before bedtime.Immediate action taken: Description: ROM (Range of Motion) performed without difficulty. No apparent injuries observed. Date: 1/26/2026.Nursing Description: Resident A&O X 1 (Alert and Oriented x 1), observed on the floor with head down. Abrasion observed to right side of face. Residents appear more confused than usual, old bruise to L (left) ring finger, and R (right) thigh. Unable to follow simple directions. Throwing self to the floor, and on the side of the bed several times with difficulty to redirect. Also, on Eliquis (Blood Thinner) Oral Tablet 5 MG twice a day.Immediate action taken: Description: On call provider.made aware. New order received to send resident to ER (Emergency Room) for eval and tmt (treatment) post fall.A review of R107's fall care plan did not reveal any new fall prevention interventions on 1/24/2026 or 1/26/2026 after R107's readmission back into the facility.On 1/29/2026 at 11:45 AM, an interview was conducted with RN K, they reported when a resident falls in the facility, they (facility staff) talk about the fall in their interdisciplinary team (IDT) meeting and decide what should be put in as an intervention. RN K stated the floor nurse is responsible for putting in a timely intervention after a resident fall. On 1/29/2026 at 1:53 PM, an interview was conducted with the Director of Nursing (DON), they confirmed timely interventions should be put in after someone falls. The DON reported the floor nurse does have guidelines they can follow to put in timely interventions until the IDT meeting occurs.A review of a facility policy titled, Fall Management revealed the following, .4. The licensed nurse will complete.Review and/or revise care plan and link to the resident Kardex (resident care guide).

This citation pertains to Intake 2638964Based on observation, interview, and record review, the facility failed to follow physician orders for two residents' (R122, R134) out of three reviewed for physician's orders. Findings include:On 1/27/29 a review of the After (hospitalization) Visit Summary (AVS) for R134 revealed; You will need to be seen in the office for suture staple removal in 4 weeks, Vascular Surgeon, October 16, 2025, 2:50 PM. A review of the medical record revealed R134 was admitted to the facility on [DATE] with the following pertinent diagnoses: Osteomyelitis of Ankle and Foot, Below Knee Amputation of Left Foot (LBKA), and Protein Calorie Malnutrition. R134 had a Brief Interview for Mental Status score of 6/15 indicating severe cognitive impairment. Further review of the medical record revealed on 9/29/25 (1 day after admission into the facility) Physiatry Physician Assistant-Certified (PPA) S, entered an order for the staples to be removed from left below knee stump per protocol. On 1/28/26 at 2:10 PM, an interview with Wound Care, Licensed Practical Nurse (LPN) R revealed on 9/29/25 they noted the staples on R134's left below knee amputation had a skin growth over the staples. At that time, they did not know how long the staples had been in. LPN R then contacted PPA S to assess the wound and subsequently removed the staples causing some bleeding where the staples were overgrown. On 1/29/26 at 1:15 PM, in an interview with PPA S they confirmed on 9/29/25 they assessed R134's staples on the LBKA stump and said the staples were overgrown. Both PPA S and LPN R were unsure how long ago the LBKA surgery had been, so the staples were removed (17 days before AVS documented). On 1/29/26 at 1:22 PM, an inquiry was made to PPA S, regarding a review of the AVS recommendations and PPA S did not remember reviewing them. PPA S revealed after the staples were removed, they contacted the Vascular Surgeon to advise the staples had been removed due to skin overgrowth. PPA said the Vascular Surgeon requested to see R134 earlier than the October 16, 2025, appointment to re-evaluate early staple removal. On 1/29/26 at 1:29 PM, Physician F revealed suture/staple removal is generally the domain of the medical team and in general they would like to see sutures/staples first and review the chart, however sutures had already been removed before they could see them. The suture removal protocol was requested on 1/28/26 and was not provided by survey exit. On 1/27/2026 at 12:08 PM, R122 was observed sitting up in their wheelchair. A back brace was observed on the dresser in the room. On 1/27/2026 at 12:09 PM, an interview was conducted with Family Member (FM) T. FM T reported R122 is supposed to have their back brace on whenever they are out of the bed. FM T reported they were unsure why the back brace was not applied and that R122 should have it on. A review of the medical record revealed R122 admitted into the facility with the following medical diagnoses, Unspecified Fracture of T9-T10 Vertebra and Disorders of Muscle. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 0/15 indicating an impaired cognition. R122 also required staff assistance with bed mobility and transfers. Further review of the physician orders revealed the following, Start: 1/8/2026.Status: Active.Order: TLSO (Thoracic, Lumber, Spinal, Orthopedic) Brace to be work when out of bed for back. Start: 1/8/2026.Status: Active.Order: Brace should be applied prior to patient being weight bearing. On 1/27/2026 at 12:10 PM, R122 was observed eating in the dining room in their wheelchair. No back brace was applied. On 1/28/2026 at 9:07 AM, R122 was observed sitting in a stationary chair with their breakfast tray in front of them and their head down on their bedside table. No back brace applied. On 1/28/2026 at 10:25 AM, 10:42 AM and 11:17 AM, R122 was observed up in a stationary chair. No back brace was applied. On 1/29/2026 at 9:58 AM and 11:17 AM, R122 was observed in sitting up in their wheelchair. No back brace was applied. A review of the care plan and progress notes did not note any refusals regarding the application for R122's back brace. On 1/29/2026 at 10:45 AM, an interview was conducted with Licensed Practical Nurse (LPN) U. LPN U reported R122 tends to take off their back brace when it is applied. LPN U reported they put the brace on this morning and has not gone back to check and see if they still had it on. LPN U reported that it should be documented if R122 removed the back brace or refused to wear it. A review of a facility policy titled, Physician's Order revealed the following, .It is the responsibility of the licensed nurse to follow physician orders.

This citation pertains to Intakes 2719898 and 2724780. Based on interview and record review, the facility failed to ensure consistent monitoring of residents exiting from the facility for two (R17, R82) of two residents reviewed for supervision and leave of absences. Findings include: R82 A review of the facility reported incident revealed R82 had exited the facility to obtain snacks on 1/17/26 at 4:23 PM. A review of the leave of absence sign out book revealed the resident did not sign out or advise staff they were leaving the building. Review of the medical record revealed, R82 was admitted to the facility on [DATE] with the following relevant diagnoses: Alcohol Dependence, Opioid Dependence, and Frequent Falls. On 1/14/26 R82 had an initial Brief Interview for Mental Status (BIMS) of 11/15 indicating moderate cognitive impairment. Review of the admission record revealed an elopement assessment was completed in conjunction with the nursing admission assessment on 1/13/26 with a score of 6 indicating a low risk. On 1/14/26 an order was entered by Physician F as follows: May go on leave of absence with medications with supervision. On 1/28/26 at 3:10 PM, an interview with Registered Nurse (RN) N revealed they had received a phone call on 1/17/26 from Certified Nurse Assistant (CNA) P at approximately 5:30 PM indicating R82 was missing. RN N and began searching the outside area saying, the ground was slippery and it was dark and cold out (17 degrees Fahrenheit). The nurse said as they searched near a local restaurant, an employee of the restaurant came out and notified them there was a person with a walker and a bag inside. RN N identified R82 and returned them to the facility. At 3:20 PM, an interview with CNA P said on 1/17/26 they were notified by a family member that a possible resident was observed off the property, walking with a walker near a local restaurant. CNA P further revealed the family member stated the possible resident had fallen to his knees, resumed standing and continued walking away from the area. On 1/28/26 at 11:30 AM, an interview with Licensed Practical Nurse (LPN) L provided an assessment which noted an abrasion on R82's knee after the outdoor fall. Wound Care Nurse R examined and treated a skin tear (partial flap loss) .55 centimeters (cm) wide x .65 cm deep, below the right anterior knee. At 12:49 PM, R82 was interviewed regarding leaving the facility. R82 revealed they walked out the front door, spoke with someone's family outside, looked around and it did not seem far to where they wanted to go get snacks, so they headed towards the store. R82 revealed they just walked out, no one spoke to them. When asked about signing out, R82 revealed they must have forgotten. On 1/28/26 at 2:58 PM, Restorative Certified Nursing Assistant (RCNA) M revealed they relieve the staff at the front desk and was working the desk on 1/17/26. RCNA confirmed the process regarding resident's going on a leave of absence (LOA) was to ask an approaching resident if they signed out at the nursing station. RCNA M revealed they were not sure the person, later identified as R82, was a family member or resident. On 1/29/26 at 3:00 PM, an interview with the Nursing Home Administrator (NHA) revealed admission assessments are completed by the assigned nurse. The NHA revealed that the process for a Leave of Absence (LOA) was for the resident to sign in and out in the LOA log book. When a resident is given permission to leave with supervision and resident tries to sign out without supervision, he would be asked to sign out Leave of Absence, Against Medical Advice (LOA-AMA) if the resident insisted on leaving. The NHA reported in this instance R82 did not sign out. On 1/29/26 a video of R82's exit on 1/17/26 was reviewed with the NHA. At the time R82 was seen walking through the lobby toward the front door at approximately 4:23 PM wearing a coat, hat, gloves, sweatpants and gym shoes, the resident was not acknowledged by RCNA M. A review of the facility reported incident revealed R82 was returned to the building at 5:14 PM. R17 A review of a facility reported incident revealed R17 had exited the facility for a smoke break on 01/12/26. A review of the leave of absence sign out book revealed R17 had not signed out in the book which indicated R17 had not notified a nursing staff of their departure. On 01/27/2026 at 6:27 AM, it was reported the wing R17 had lived on had 68 residents. Two nurses and three Certified Nurse Assistants (CNAs) were observed to be on this unit. Staff reported they should have three nurses and four certified nursing assistants (CNAs) to provide sufficient care on the midnight shift. At 6:53 AM, CNA J reported three CNAs and two nurses on R17's unit and also reported the other wing only had two CNAs. CNA J further reported it was 50/50 for short staffing related to call offs and CNAs just not scheduled. On 01/28/2026 at 10:44 AM, Receptionist A reported R17's routine was to exit and re-enter the facility multiple times daily and for variable lengths of time from about 5 to 30 minutes. The receptionist reported the exit and re-entry of R17 were to be logged in the LOA sign out book at the nurse station. It was noted R17 was not required to sign out at the reception desk. 01/28/2026 10:49 AM, CNA B reported R17's routine included walking around the facility and since R17 was a smoker, reported R17 would go outside at least once or twice every day. 01/28/2026 10:53 AM, Licensed Practical Nurse (LPN) C, reported R17 was alert times three and basically independent. LPN C reported R17 went out to biweekly appointments. LPN C did not recall if R17 had signed out on 01/12/26, but was aware R17 made multiple entry and exits during the day. LPN C reported R17 was normally out of the facility for 15 to thirty minutes unless on an appointment. On 01/28/2026 at 11:18 AM and 4:02 PM, a review of R17's actions with the Administrator revealed staff were aware of R17's routine to exit and renter the facility. At 4:02 PM the LOA (leave of absence) sign out log for R17 was reviewed and revealed for the year 2025, R17 signed out once in September, two times in October, and once in December. In January 2026 one entry was reported without an actual dated listed. No entry for 01/12/26 was documented. A request for any additional LOA sign-out documentation revealed no additional sign outs for a LOA was completed since the resident's admission on [DATE]. On 01/28/2026 at 2:22 PM, Unit Manager Registered Nurse (RN) I, reported R17 was an independent smoker and because the facility was non-smoking, R17 would have to go outside and off property to smoke. On 01/28/2026 4:07 PM, Receptionist, E reported they had known R17 since their admission and generally went out at the same time and about the same number of times each day. On 01/29/2026 at 12:08 PM, the Director of Nursing (DON) was aware R17 would go on LOA, and the nurse should be informed of a resident's departure, even when accompanied by a CNA. On 01/29/2026 at 12:48 PM, Social Worker (SW) G was asked about R17 and reported they had known of R17 since their admission and R17 had consistent LOAs due to the resident ear appointments. R17's care conferences and mental status were reviewed, and it was noted that all Minimum Data Set (MDS) assessments since admission had documented R17 as cognitively intact with a 15/15 Brief Interview for Mental Status (BIMS) score. It was confirmed the last care conference had been held on 02/25/25 and a care plan entry for an LOA was not routinely completed unless there had been a problem. A review of the elopement risk documentation indicated R17 was at No risk. 01/29/2026 2:59 PM, Physician F reported 'leave of absence with medications' orders are only given when residents have capacity (deemed competent). A review of the record for R17 they were admitted into the facility on [DATE] and readmitted [DATE], 01/26/25 and 03/19/25. Diagnoses included Nicotine dependence, Alcohol Dependence, Falls, Stroke and Syncope (Fainting). The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition with a 15/15 BIMs score and R17 was independent for all activities of daily living which included walking without an assistive device. A review of the progress notes revealed no indication staff were aware R17 was not signing out or back in following smoke breaks or appointments. A review of the care plan revealed R17 was at risk for falls. It was confirmed by the Administrator on 01/29/26 at 2:25 PM via email that no care plan for the LOA had been completed. A review of the facility policy titled, Care Planning effective 03/03/25 revealed, .The care plan must be specific, resident centered, individualized and unique to each resident . A review of the policy titled Resident Leave of Absence Policy, dated as last approved on 3/7/2023 revealed the following: Specifically, the IDT shall evaluate whether it is clinically appropriate for the Resident to leave and/or discharge from the Facility without supervision, and/or whether there are any other concerns related to such leaves or discharges whether they be supervised or unsupervised. Such concerns may include, but are not limited to, the Resident's possible use and/or possession of drugs or alcohol, and behaviors involving the possible participation in illegal activities. Further review of the facility policy titled, Resident Leave of Absence Policy dated as last approved on 3/7/2023, .IV. LEAVE PROCEDURE: .2.If the Resident has been approved for a Leave of Absence or is Leaving the Facility Against Medical Advice, the Resident and/or Responsible Party shall make an effort to notify the Facility in advance regarding the date, time location and expected length of a planned leave of absence from the Facility. 3. Residents and/or Responsible Parties shall Sign Out before leaving the Facility for a Leave of Absence by indicating the time of the leave, any family or friends accompanying the Resident during the leave, applicable contact information and the proposed location and estimated length for the leave. Residents or Responsible Parties shall also 'Sign In upon returning to the Facility following a Leave of Absence. If the Resident refuses or fails to Sign In or Out relative to a Leave of Absence, Facility staff should document such information, if known, in the medical record.

This citation pertains to intake 2648023Based on observation, interview, and record review, the facility failed to complete colostomy (an opening on the abdomen connecting the large intestine to the outside of the body) care for one resident (R148) out of two reviewed for colostomy care. Findings include:On 1/28/2026 at 9:21 AM, R148 was observed lying in bed. R148 was noted to have a colostomy located in their left lower abdomen. R148 reported they had a colostomy and sometimes the staff forgets to empty it. R148 reported if they tell staff, then they will empty it or change it. The resident stated one time their colostomy bag was so full, staff had to take two trips to empty it and were surprised their colostomy bag did not burst.A review of the medical record revealed R148 admitted into the facility on 1/24/2026 with the following medical diagnoses, Colostomy Status and Diverticulitis of Large Intestines. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental status score of 11/15 indicating an impaired cognition. R148 also required staff assistance with bed mobility and transfers. A review of the physician's orders did not reveal any orders related to colostomy care. Further review of the Treatment Administration Record (TAR) did not reveal any documentation related to providing colostomy care to R148.On 1/29/2026 at 9:21 AM, an interview was conducted with Unit Manager (UM) V. UM V reported when a new admit comes in, the admitting nurse should put in the orders for things like a colostomy. UM V reported they complete chart audits and will clean up orders or add missing orders. On 1/29/2026 at 1:51 PM, an interview was conducted with the Director of Nursing (DON). The DON stated they were unsure why the colostomy care orders were not entered on admission. The DON reported the unit managers do chart audits and double check the orders after new admissions.A review of a facility policy titled, Colostomy did not address colostomy care.

Based on observation, interview, and record review, the facility failed to ensure medication were properly stored for one (R27) of one reviewed for medications storage. Findings include: On 1/27/2026 at 6:34 AM, R27 was observed in bed with the over bed table next to them. Observed on the over bed table was a small plastic cup with five unidentified pills and a cup of water. R27 was asked if the medication in the cup was their morning medication. R27 indicated it was but they are not taking them anymore because it made them sick. A review of R27's medical record noted, R27 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Vascular Dementia without Behavioral Disturbance and Alzheimer Dementia. A review of R27's Minimum Data Set (MDS) quarterly assessment dated [DATE], revealed R27 with an impaired cognition and required assistance for activities of daily living. R27's medical record did not reveal a self-administration of medication assessment. A review of R27's care plan noted, Focus: Cognition/communication: [R27] is at risk for decline in cognition and has impaired cognitive function or impaired thought processes r/t (related to) diagnoses of Vascular Dementia without Behavioral Disturbance and Alzheimer Dementia. Interventions Administer meds as ordered. Observed/tx (treatment) for adverse side effects prn (as needed). Date Initiated: 3/13/2018.On 1/29/2026 at 1:45 PM, the Director of Nursing (DON) was asked about medication left at the bedside of R27's bed. The DON explained unless a resident has an order to self-administer the Nurse needs to stand and watch the resident take their medication. A review of the facility's policy titled, Medication Administration dated 3/1/2023 noted, Resident medications are administered in an accurate, safe, timely, and sanitary manner. INFORMATION Authorized Personnel - Medications are prepared, administered, and recorded only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications. Physician's Orders - Medications are administered in accordance with written orders of the attending physician. If a dose is inconsistent with the resident's age and condition or a medication order is inconsistent with the residents current diagnosis or condition, contact the physician for clarification prior to administration of the medication. Document the interaction with the physician in the progress notes and elsewhere in the medical record, as appropriate. New Medication Starts - Begin new medication orders timely. Begin routine orders on the same day ordered, unless the next dose would be normally given the next day. Self-Administration - residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with the guideline for self-administration of medication. A self-administration evaluation will be completed prior to the resident starting the self-administering process. Self-administration of medication will be reflected in the resident care plan along with any special considerations.

This citation pertains to Intake MI00151509. Based on interview and record review, the facility failed to provide timely treatment to a pressure ulcer for one resident (R801) out of two reviewed for pressure ulcers. Findings include: A review of complaint called into the State Agency noted the following, Facility did not appropriately treat bed sore that ended up being stage 4 (full thickness skin loss) after surgical debridement at [hospital name] . A review of the medical record revealed that R801 admitted into the facility on [DATE] with the following medical diagnoses, Muscle Weakness and Moderate Protein-Calorie Malnutrition. A review of the most recent Minimum Data Set (MDS) assessment reveals a Brief Interview for Mental Status (BIMS) score of 12/15 indicating an impaired cognition. R801 also required staff assistance with transfers and bed mobility. Further review of the admission progress note revealed the following, 12/13/2024 at 9:13 PM .Skin assessment performed with small open area to inner sacrum. Further review of the physician's orders revealed that a wound care order was not entered and active until 12/16/2024, three days after R801 was admitted into the facility. On 4/8/2025 at 12:43 PM, an interview was conducted with the Director of Nursing (DON). The DON reported they did not see an order until an 12/16/24 in the physician orders. The DON indicated they did see the skin assessment stating that R801 had a wound upon admission, and the nurse should have called and asked for an treatment order. A review of a facility policy titled, Skin Management noted the following, .4. Residents admitted with any skin impairment will have: Appropriate interventions implemented to promote healing. A physician's order for treatment, and skin impairment location, measurements and characteristics documented.

This citation pertains to Intake MI00146972. Based on observation, interview, and record review, the facility failed to ensure spoiled food items were discarded, open food items dated when opened, and cooking utensils were clean when stored, potentially affecting all 115 residents at risk for food borne illnesses. Findings include: On 10/29/24 at 9:41 AM, a review of the kitchen with the dietary manager revealed: -dust build up on top of the ovens; -a prepared salad in the chef's refrigerator was dated 10/18/24 with the salad items wilted and appeared moldy; -a package of sliced american cheese was open and not dated; -three scoops/strainers with dried food debris or white and opaque dried liquid stains; -in the walk-in freezer chocolate chip cookie dough were open to air, chicken chunks were open to the air and the bags were not dated; -in the freezer turkey patties were open to the air; -in the walk-in refrigerator a package of sliced cheese had a black mold like growth on multiple slices; -a box of whole green peppers had at least five peppers with a green mold or wilted areas. The identified concerns were reviewed with the Dietary Manager who reported the staff are trained to rotate the stock in the walk-ins (refridgerators). A review of the facility policy titled, Food Purchasing and Storage dated 11/11/21 revealed, .Space will be allowed on all sides of shelving to permit ventilation .Leaking or spoiled items will be discarded .Containers with tight fitting covers or sealed plastic bags will be used for storing foods that have been removed from their original container .Opened dry items, such as pasta, rice, and crackers will be stored, labeled, and sealed .Perishable Storage Facilities: The shelving will be adequate to allow air circulation around the foods. Foods will be stored so there is no contamination from items stored above 5. Perishable Food Storage: Food stored in the refrigerator or freezer will not be overcrowded, allowing adequate air circulation . All food items in refrigerators will be properly dated, labeled, and placed in containers with lids, will be wrapped, or stored in sealed food storage bags . All frozen food will be dated, labeled and wrapped or sealed. Moisture-proof, tight-fitting materials will be used to prevent freezer burn .

Based on observation, interview, and record review, the facility failed to properly assess for self-administration for eye drops for one resident (R273) out of one reviewed for self-administration of medications. Findings include: On 10/29/2024 at 12:43 PM, R273 was observed in bed. R273 stated they had just put their eyedrops in. Four bottles of eyedrops were observed on the bedside table in a bag. R273 stated they always do their own eye drops and they do not trust anyone else to do them on time for them. A review of the medical record revealed R273 admitted into the facility on [DATE] with the following medical diagnoses, Macular Degeneration and Irritable Bowel Syndrome. A review of the Minimum Data Assessment set revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition and required assistance for bed mobility and transfer. Further review of the medical record did not reveal an order, care plan, or assessment documenting R273 was able to self administer their own eyedrops. On 10/29/2024 at 3:21 PM, the eyedrops were still observed at bedside. R273 stated they had just administered them and were about to go to sleep. On 10/31/2024 at 9:15 AM, an interview was conducted with the Director of Nursing (DON). The DON stated with short term stay residents, they don't always know what they come in with. The DON stated the midnight nurse approached them, some time after admisison and told them the eye drops were at bedside and they went and spoke with the resident she determined they were able to self administer medication. The DON stated they obtained an order from the physician, completed and assessment, and entered a care plan. The DON was asked if this should have been completed on admission to which she stated the nurses would check the medication off the medication administration record (MAR) after they watched R273 administer them. A facility policy related to self administration of medications was requested on 10/30/2024 at 12:47 PM, and not received by end of survey.

Based on interview and record review, the facility failed to ensure the Preadmission Screening (PAS)/ Annual Resident Review (ARR) form for Mental Illness (MI)/ Intellectual Disability (ID)/ Related Conditions Identification (DCH-3877) document was completed and sent to the local state agency for an evaluation for a Level II determination for two residents (R11 and R74) of four residents reviewed for PASARRs. Findings include: R74 On 10/29/24 at 9:42 AM, R74 was interviewed in their room regarding their stay in the facility, and indicated they are a Veteran, and was a prisoner of war for 55 months, and as a result, suffers from nightmares every night. A review of R74's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Traumatic Subdural Hemorrhage, Diabetes, Hypertension, and Muscle Weakness. Further review of R74's medical record revealed they had a moderately impaired cognition, and required partial to moderate assistance for transfers and mobility. Further review of R74's medical record did not reveal a PASARR Level I screening completed by the facility. On 10/30/24 at 2:43 PM, Social Worker A was about R74's Level I screening, and she indicated she would investigate it and get back to surveyor. On 10/30/24 at 3:18 PM, Social Worker A returned and explained there wasn't a Level I screening completed by the facility for R74, and there should have been one completed. 49102 R11 On 10/29/24 at 9:35 AM, R11 was observed lying in bed watching television in their room On 10/29/24 at 12:51 PM, R11 was observed lying in bed with a sad facial expression and holding their head. R11 stated , my head hurts. On 10/30/24 at 1:00 PM, R11 was observed lying in bed. A half eaten lunch tray was visible on tray table. R11 stated there were no concerns today and was watching television. A review of R11's medical record revealed they were admitted into the facility on [DATE]. R11 has diagnose of Dementia, Psychotic disturbance, Mood disturbance, Psychotic disorder with delusions and Schizoaffective disorder. A review of the most recent Minimum Data Set assessment dated [DATE] was completed with a Brief Interview for Mental Status (BIMS) score of 3 indicating severely impaired cognition. Further review of R11's medical record did not reveal an Annual PASARR Level I screening had been completed by the facility. On 10/31/24 at 1:45 PM, Social Worker A was interviewed about R11's updated PASARR screening. Social worker A they would investigate it and get back to surveyor. On 10/31/24 at 2:20 PM, Social Worker A returned and explained there was not an updated 3877 for R11, and there should have been one completed. A review of the policy titled, Pre-Admission Screening and Guest/Resident Review - PASRR Michigan dated 12/01/2017 and last revised 11/12/2021 revealed The PASRR process was established in 1987, as part of the OBRA ruling, to screen all individuals admitted for nursing care to ensure that needs are met to assist the individual in reaching their highest potential. All persons seeking admission to a nursing facility, who are seriously mentally ill and/or have an intellectual/developmental disability, are required to be evaluated to determine if a nursing facility is the appropriate place to receive services. Additionally, a Level 1/3877 is completed annually for all guests/residents and maintained in the electronic medical record. For those who screen positively for a mental illness/intellectual/developmental disability the facility submits the annual Level 1/3877 screen to the local community mental health program for comprehensive screening (Level 2).

This citation has two Deficient Practice Statements. Deficient Practice Statement #1 Based on interview and record review the facility failed to follow a physician's order for a urology consult for one resident (R74), of one reviewed for physician orders. Findings include: On 10/29/24 at 9:42 AM, R74 was interviewed in their room about the care they are receiving in the facility. R74 explained they have been having pain during urination which causes burning sensations. R74 explained they have been feeling like this for weeks and nothing has been done. A review of R74's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Traumatic Subdural Hemorrhage, Diabetes, Hypertension, and Muscle Weakness. Further review of R74's medical record revealed they had a moderately impaired cognition, and required partial to moderate assistance for transfers and mobility. Further review of R74's medical record revealed a physician's order dated for 8/7/24 for the following, Urology (for issues related to urtinary tract, kidneys or prostat) consult for continued symptoms of BPH (benign prostatic hyperplasia, a noncancerous increase in size of the prostate gland) on dual therapy. Further review of the order revealed that it was, completed. On 10/30/24 at 9:18 AM, R74 was observed in their room, and asked about their symptoms, and they explained they are still having concerns with burning during urination. On 10/30/24 at 9:56 AM, R74's urology consult was requested from the facility, and they responded with the following, .[R74] doesn't have any orders for urology consults. [R74] has neurology (for issues related to nerves), but not urology. A review of R74's progress notes revealed the following: 8/5/2024 00:00 Progress Notes Date of Service: 8/5/2024, Visit Type: Acute: Pt (patient) reports difficulty urinating and dysuria (painful urination) . states he has not seen urology. Previous UA's (urinalysis) were insufficient/rejected. UA with reflex C&S (culture and sensitivity) ordered. There is not a bladder scanner available per nursing. Will order urology consult for continued symptoms on dual therapy . On 10/31/24 at 10:00 AM, an interview was completed with the Director of Nursing (DON) regarding R74's urology consult. She explained she would look into it however, there was no additional information received prior to survey exit. A review of the facility's Physician's Orders policy did not address physician orders not being followed. 44750 Deficient Practice Statement #2 Based on observation interview, and record review, the facility failed to ensure transportation to outside appointments for one resident (R270) out of three reviewed for outside appointments. Findings include: On 10/29/2024 at 10:30 AM, an interview was conducted with Family Member (FM) F. FM F stated they were unhappy with the care being provided for R270. FM F stated R270 has missed 3 out of four follow up appointments set up by the hospital while in facility due to transportation errors by the facility. FM F stated they were told R270 must go by stretcher because they are on Total Parenteral Nutrition (TPN - receiving all nutrition through a tube). FM F stated they missed an Endocrinologist appointment on 10/23/2024 due to them needing a stretcher instead of wheelchair, a cardiologist appointment on 10/28/2024 due to transportation having an emergency, and 10/29/2024 because they never showed up. FM F stated the last two appointments were for the Cardiologist. FM F stated they don't understand why they don't use a different transportation company. A review of the medical record revealed R270 admitted into the facility on [DATE] with the following diagnoses, Muscle Weakness and Disease of Pancreas. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score revealed a Brief Interview for Mental Status score of 9/15 indicating an impaired cognition. R270 also required staff assistance for bed mobility and transfers. On 10/30/2024 at 12:04 PM, an interview was conducted with [NAME] Clerk (WC) H. WC H stated they believe that FM F gave them the follow up appointments from the hospital and they made the transportation. FM F stated FM F originally stated R270 could go in a wheelchair, however they were unable to because of the TPN so they had to order transport that could accomodate a stretcher. WC H confirmed they were unaware if the appointment had been rescheduled or not. WC H stated R270 missed their other two appointments due to transportation running late and then not showing up. On 10/31/2024 at 9:20 AM, an interview was conducted with the Director of Nursing (DON). The DON stated they have six companies they use for transportation and were in the process of looking for alternative companies to take R270 to their appointment. A review of a facility policy titled, Social Service Referrals to Outside Providers did not address transportation.

Based on observation, interview, and record review, the facility failed to ensure restorative care and splint application was documented and services provided for three residents (R38, R47, and R76) of four reviewed for restorative services. Findings include: R38 On 10/29/24 at 11:09 AM, R38 was observed to be seated in a wheelchair next to their bed. R38 appeared to have the fingers of their right hand in a fixed position. A hand or wrist splint was not in place or visible in the room. On 10/30/24 at 1:04 PM, the therapy course for R38 was reviewed with Physical Therapy Assistant B. It was reported that R38 had not been on service since March of 2023 and was on the physical therapy caseload only at that time. A therapy screen conducted 10/12/24 indicated no change in status. On 10/30/24 at 2:36 PM, the restorative history of the identified resident was reviewed with Restorative Licensed Practical Nurse (LPN) C who reported R38 was discharged and not on the current caseload and reported restorative and assigned staff are able to apply a splint. A review of the record for R38 revealed: R38 was admitted into the facility on [DATE]. Diagnoses included, Muscle Weakness, Difficulty Walking, Dementia and Alzheimer's. The active Kardex (care guide) documented R38 was dependent on one staff to roll right and left in bed, and lying to sit on the side of bed and to go from sitting to lying. A review of the active tasks in the electronic medical record (EMR) documented, .to wear right wrist hand finger orthosis 3-4 hours a day as tolerated .(R38) may remove for (their) own comfort. A review of the task documentation for the task Was the resident's splint applied per the maintenance splint program revealed just one entry which was dated for 10/09/24 and which indicated not applicable. A review of the physical therapy discharge note dated 04/01/24 revealed: .RNP/FMP (Restorative Nursing Program/Functional Maintenance program) to facilitate patient maintaining current level of performance and in order to prevent decline, development of and instruction in the following RNPs has been completed with the IDT (interdisciplinary team): ROM active (range of motion), Omni cycle . R47 On 10/29/24 at 11:21 AM, R47 appeared to be resting in bed with the head of bed up. A walker and a wheelchair were observed to be in the resident's area. A review of the record for R47 revealed, R47 was admitted into the facility on [DATE]. Diagnoses included Difficulty Walking and Need for Assistance with Personal Care. The active care plan initiated 06/27/24 documented impaired visual function, bowel and bladder incontinence related to impaired mobility, at risk for falls and R47 required partial/moderate assistance for bathing, dressing, personal hygiene and toilet transfer. A review of the physical therapy discharge note dated 09/05/24 and revised 09/11/24, revealed, .RNP/FMP to facilitate patient maintaining current level of performance and in order to prevent decline, development of and instruction in the following RNPs has been completed with the IDT: ROM active and ambulation . An occupational therapy discharge note dated 09/06/24 and revised 09/11/24 documented, .referred to restorative . On 10/30/24 at 2:36 PM, the restorative history of the identified resident was reviewed with LPN C who reported R47 was on the current caseload. A progress note dated 10/30/24 at 2:59 PM and at 5:25 PM by LPN C noted R47 had refused and reported R47 said they have an 'accident' when they exercise and did not want to have an accident. No further refusals were noted or documentation provided. R76 On 10/29/24 at 12:56 PM, R47 was observed to be seated in dining room in a high back wheelchair, assisted/encouraged to eat by staff. R76 was observed to feed themselves. A splint was not observed. On 10/29/24 at 1:36 PM, R76 was on the common area of their unit seated in a high back wheelchair their legs elevated. A splint was not observed. On 10/30/24 at 11:20 AM, R76 was observed up in a wheelchair in the activity area. The footrest was elevated around 90 degrees and the legs of R76 extended straight out. R76 appeared to have a foot drop type of contracture and appeared to be asleep. A splint was not observed. On 10/30/24 at 1:10 PM, PTAB reported R76 was evaluated by therapy for their left elbow in August of 2024 and had been the therapy caseload May 2024 to July 2024 for the left upper extremity. On 10/30/24 at 1:55 PM, R76 continued to be seated in a high back wheelchair with their feet more flat on foot rest which was angled down. A splint for the elbow and hand were not observed. On 10/31/24 at 8:16 AM and 9:16 AM, R76 was observed to be in bed, asleep. A splint was not observed to be visible in the resident area nor applied to the resident. A review of the record for R76 revealed R76 was admitted into the facility 09/23/22. Diagnoses included Paralysis of the left side, Abnormalities of Gait and Mobility and Age related Physical Debility. A review of the active care plan documented, impaired cognition, bowel and bladder incontinence. A revision of the care plan dated 02/09/24 documented substantial/maximal assistance was required for bathing, dressing, bed mobility and personal hygiene. A review of the occupational therapy evaluation dated 08/08/24 revealed, .referred to OT for left elbow contracture .(left) elbow contracture brace obtained and donned on pt (patient) good fit and comfort noted by writer and (patient) . The note also documented R76 was dependent for toileting hygiene, dressing and bathing. A review of the order for restorative nursing with date imitated of 10/08/24 revealed, Nursing Rehab: Left elbow contracture splint and WHFO (wrist hand finger orthosis) to be worn at night or as tolerated to prevent contracture and optimize ADL (activities of daily living) functioning. A review of the active tasks revealed no entries had been documented for the task amount of time spent providing nursing rehab service nor that care was provided for the Left elbow contracture splint and WHFO to be worn at night or as tolerated to prevent contracture and optimize ADL functioning. On 10/31/24 at 9:08 AM, restorative concerns related to missing documentation were reviewed with the Director of Nursing (DON). The DON acknowledged the missing documentation. The DON reported they were not aware of any time in the last thirty days where the restorative staff had to work the regular floor. On 10/31/24 at 9:23 AM, LPN D confirmed R47 participated in therapy and does more when family is present. LPN D also reported they had seen R76 wear a splint a while back but had not worn it in a minute and was not always cooperative. On 10/31/24 at 9:36 AM, Certified Nursing Assistant (CNA) E reported they had not seen R47 with restorative not R38 with a splint in the last thirty days. CNA E reported R38 will tell you what they want. The most recent restorative documentation for R38, R47, and R76 was requested on 10/30/24 at 3:02 PM. Additional documentation was not received prior to survey exit. A review of the facility policy titled, Restorative Nursing revised 04/26/24 revealed, .Components of the restorative nursing program include, but are not limited to the following: .Referral from skilled therapy services via the Therapy to Restorative Program Plan .During weekly Interdisciplinary Team Meeting .Morning clinical meeting. Completion of the Restorative Initial Evaluation if placed on a Restorative Program. Development of measurable goals and individualized interventions for a specific restorative program Evaluation of progress towards goals and effectiveness of interventions. Interdisciplinary process to identify when a resident is appropriate to discharge from restorative nursing . 6. Document any refusal in the resident's medical record . 11. Document the resident's daily participation and actual number of minutes participating in in the resident's {electronic health record} EHR . 12. The licensed nurse will meet with the restorative aide(s) or nurse aide(s) to evaluate and document the effectiveness of interventions periodically but, at least quarterly .

This citation pertains to Intake MI00142904. Based on interview and record review, the facility failed to ensure physician visits, obtain blood tests, weights, and wound care treatments were provided in a timely manor, for one resident (R902) of three resident's whose care was reviewed, resulting in a delay in treatment, hospitalization and a change in condition. Findings include: A review of a complaint Intake for R902 revealed, On 12/26/23 the resident was transported to the hospital where it was determined that the resident was septic from an infection in their open wound. The resident had a low blood pressure, was very dehydrated, had high potassium and their mouth was pasty and dry. The kidneys have shut down and the resident is now on dialysis. A review of the record for R902 revealed R902 was admitted into the facility on [DATE]. Diagnoses included Acute Kidney Failure, Renal (kidney) Calculus (sediments) Obstruction and Stroke. A review of the medical provider notes indicated R902 had not been seen by a physician during their stay (12/8/23 to 12/26/23). Review of the December 2023 Medication Administration Record and Treatment Administration Record revealed no documentation of R902's weekly weights. The reports further documented systolic blood pressures in the 120's and 130's and diastolic blood pressures in the 70's. A review of the physician orders documented CBC (complete blood count) and BMP (basic metabolic panel) lab orders dated and respectiviely signed on 12/12/23, 12/15/23 and 12/19/23. Review of the December 2023 Treatment Administration Record (TAR) revealed no documentation of treatment for the coccyx on 12/16 and 12/25 on the day shift and on 12/11, 12/14, 12/18, 12/19, and 12/25 on the night shift. Colostomy care was not documented on 12/11, 12/13, 12/14, 12/16, 12/19, 12/20, 12/21 and 12/15 on the day shift and on 12/11, 12/14 12/18 and 12/19 on the night shift. The TAR further documented the wound vac was not in place on 12/24 and 12/25 as a wet to fry dressing was documented as done for the abdominal surgical wound. A nurse progress note dated 12/12/23 at 1:40 PM, documented, Writer confirmed order for CBC with dif (deferential) and BMP. Requisition completed. Responsible party notified. A medical provider note dated 12/13/23 at 10:30 AM documented, .tested positive for covid .non productive cough .CBC and BMP ordered, awaiting BMP results for paxlovid dosing .chronic kidney disease stage 3 trend BMP . Review of the lab results collected 12/13/23 and reported 12/14/23 documented a creatinine level of 2.75 with a normal range value of 0.60 - 1.30. It was flagged as high. The report documented a Glomerular Filtration Rate (GFR) value of 22 which corresponded to severely decreased kidney function and a stage four level of kidney failure. The scanned in document was not initialed or dated as acknowledged by the medical provider. A medical provider note dated 12/15/23 at 11:00 AM documented, .Chief complaint: covid .chronic kidney disease stage 3 trend BMP .paxlovid, pending kidney function awaiting lab results . A medical provider note dated 12/18/23 at 3:30 PM documented, .tested positive for covid last week, labs ordered for paxlovid dosing, TSH (thyroid stimulating hormone) ordered .chronic kidney disease stage 3 trend BMP . A progress note dated 12/19/23 at 8:00 PM, documented, .colostomy bag leaking into wound . A Nurse Practitioner medical provider note dated 12/20/23 at 9:00 AM documented, .lab results still pending .chronic kidney disease stage 3 trend BMP . A review of the lab results collected 12/20/23 and reported 12/20/23 revealed a creatinine of 5.04 with a normal range value of 0.60 - 1.30. It was flagged as high. The Glomerular Filtration Rate (GFR) indicated a value of 11 which corresponded to kidney failure. The report documented this as a stage 5 indicator of kidney function. The document was not initialed or dated as acknowledged by the medical provider. A nurse progress note dated 12/26/23 at 10:19 AM, documented a blood pressure of 88/51 taken by the facility at 9:55 AM and .general weakness .Recommendations: Administer fluids, blood work and monitor. Send to ER per family request . On 03/05/24 at 2:50 PM, Licensed Practical Nurse (LPN) B recalled R902 and reported R902 may not have been checked on as often as other as the door was closed for COVID isolation the whole time the resident was at the facility. LPN B further noted times when the ostomy leaked stool due to a build up of gas. On 03/05/24 at 4:31 PM, Nurse Practitioner (NP) C reported they had ordered the blood work and had trouble getting lab results. The lab would come to the facility but not draw the labs. NP C reported they sign the labs to acknowledged they have been reviewed. NP C commented that R902 developed low blood pressure and was sent out to the hospital where R902 was diagnosed with acute kidney injury. NP C reported they did not see any lab results until R902 was an inpatient at the hospital. NP C noted R902's creatinine was 2.49 on December 4th while at the hospital. On 03/05/24 at 4:35 PM, LPN A confirmed there was known trouble getting labs drawn and getting results during the time of R902's stay. On 03/05/24 at 4:39 PM, the Administrator reported a physician should see the residents within 48 hours for new admits to complete a history and physical. On 03/03/24 at 4:47 PM, the Director of Nursing (DON) acknowledged trouble with the laboratory and that a family member had contacted them with concerns about the care of R902. The DON also reported the lab report should be noted and initialed or signed by the provider and part of the medical record. On 03/05/24 at 4:47 PM, a policy related to lab results and review was requested and at 5:16 PM the Administrator reported they did not have a policy on obtaining labs. A review of the Physician Services policy revised 02/22/22 revealed, .All persons admitted or accepted for care by the facility must be under the care of a physician selected by the guest/resident or the guest's/resident's authorized representative .A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required .The physician must make the initial visit .

This citation pertains to Intake: MI00139056. Based on interview and record review, the facility failed to ensure the safety and prevent elopement for one sampled resident (R106) who had impaired decision making and with a known elopement risk. Resulting in an Immediate Jeopardy on Friday 06/23/23 at approximately 10:30 PM when, R106 exited the facility from an alarmed door. The staff at the facility did not respond to the door alarm, which resulted in R106 unable to be be located. R106 returned to the facility by knocking on one of the facility's doors on 6/24/23 at approximately 12:24 AM. This deficient practice had the likelihood of causing serious harm, injury, and/or death. Findings include: A review of R106's medical record revealed, 6/23/2023 14:18 (2:18 PM) Social Services Note Late Entry: Note Text: Admission-Resident is a [AGE] year old single male. He presents with severe cognition impairment. He has a Dx (diagnosis) of Dementia. BIMS (Brief Interview for Mental Status) 0/0 (severely cognitively impaired). AD (advance directive)-Full code by default and D/C (discharge) to return home with son. Per, [Son] resident is a Veteran and [R106] utilizes a walker in the community. Per . resident daughter states that resident, doesn't have a hx (history) of mental illness, both children couldn't give any information regarding [R106's] VA history. [R106] is at risk for elopement and elopement protocol was put into place. [R106's children] both made aware, care plan update to reflect. Progress note: 6/23/2023 22:30 (10:30 PM) Nurses Notes: At approx: 10:30pm writer heard alarm on East wing exit door, searched resident room and resident was not present, staff then went to exit doors to search outer parameter resident was not in visual site. Staff then initiated an alert for all staff to do ahead count and search surrounding areas while a second group of staff searched outside facility. At approx: 10:25pm resident was last seen by staff in high traffic area sitting in chair across from nursing station. Family was notified. On call, DON (Director of Nursing), Police and Administer was notified of elopement. On 9/11/23 at 3:24PM, Licensed Practical Nurse (LPN A) was interviewed via phone and was asked about the day R106 left the facility. LPN A stated, The entire shift [R106] was wandering, so I kept an eye on [R106]. LPN A explained that she kept a close eye on R106 and that R106 stayed with her during the shift. LPN A continued and explained, Around 10:00 PM, I saw [R106] walking down the hall and I stopped [R106], [R106] was walking towards the door. I redirected [R106] and placed [R106] in the common area. LPN A explained that [R106] had to use the restroom around shift change and left R106 with other staff at the nurse's station. LPN A said, when [R106] exited the bathroom, she heard the door alarm and thought R106 got out. LPN A explained that she went to the area where she left R106 and didn't see R106. LPN A continued and stated that she asked the staff that was sitting at the nurse's station where R106 was left, and they said that they saw R106 walk down the hall. LPN A stated, I asked, ya'll wasn't watching [R106]? LPN A was asked if the staff was responding to the door alarm or looking for R106 and stated, No. They said they thought it was a call light. I went to R106's room, then to the outside door and did not see [R106]. LPN A was asked how did R106 return to the facility and stated, [R106] returned on [R106] own, not sure how long maybe an hour. Came to another exit door, [R106] was wet, and cover in mud. [R106] had on shoes that were on the wrong feet and socks and some belongings in [R106's] pocket. A review of R106's medical record revealed, R106 was admitted to the facility on [DATE] for respite care, with diagnosis of Dementia, Psychotic Disturbance, and Anxiety. According to the facility's Social Service assessment noted R106 with a severely impaired cognition. A review of R106's admission noted revealed, 6/20/23 Skilled Care Note. Resident is alert. Vital signs recorded and WNL. Left ankle wander guard. No s/s of respiratory distress. No pain voiced. Medications were given and tolerated well. Call light within reach. Will continue to monitor. A review of R106's assessments noted, Risk for Elopement assessment. 6/19/23. Category: At Risk. Score 13.0. Mobility. What is the resident's mobility status? (checked) Mobile with device or Ambulatory. Resident Statement 2. Is the resident verbalizing the desire to leave? Yes. Wandering. 1. Has the resident wandered? 1. Behavior of this type occurred 1 to 3 days. 2. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (e.g., stairs, outside of the facility)? 1. Yes. 3. Does the wandering significantly intrude on the privacy or activities of others? 0. No. A review of R106's care plan noted, Focus: [R106] is at risk for elopement and/or wandering R/T (related to): disoriented to place, history of attempts to leave facility unattended, Dx (Diagnosis): Dementia. Date Initiated: 06/21/2023. Orders: Confirm placement of wanderguard on resident every shift. Order Date 6/19/23. Start date 6/20/23 - End Date: Indefinite. Medication Administration Record (MAR): Confirm that wanderguard on resident is functioning appropriately. Every night shift -Start Date 6/19/2023 - 2300 -D/C Date 6/26/2023. June 2023 checked as completed 19th -25th. On 09/12/23 at 10:09 AM, the Nursing Home Administrator (NHA) was asked about R106's elopement and the reaction to the door alarm by the staff. The NHA stated, Yes, it looks like the staff did not react, until the nurse came out. We did a Past Non-compliance with a correction date of 6/27/23. The NHA continued and explained that they added a louder alarm to the doors, an additional alert on the screens that are at the nurses station. A review of the facility's policy titled, Elopement Policy dated, 9/1/2010, revealed, Policy: It is the policy of this facility to prevent to the extent reasonably possible, the elopement of guests/residents from the facility . Alarm Activation 1. If an employee hears a door alarm, he or she should: a. Immediately go the site of the alarm . During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included .(interventions/actions to correct the past noncompliance). Facility PNC noted the following, Measures of systemic changes made to ensure that deficient practice will not occur and affect others. The staff were re-educated on the elopement policy and timely response of an exit door alarm with emphasis to go to the alarming door first and to step out to see if a resident is in the vicinity and call Code Search if resident is not seen outside. The employee was educated 1:1 on the Elopement Policy but not limited to ensure they are responding to the door alarms in accordance with the policy The exit doors and wander guard system were checked by maintenance for safety appropriateness to ensure the system was functioning properly. The Elopement Drills will be increased to be completed on every shift monthly for the next 3 months to ensue staff are responding accordingly any concerns will be addresses and the drills will be reviewed at QAPI. How facility monitors its corrective actions to ensure same deficient practice is corrected and will not recur. The NHA or designee will validate the daily door alarm and wander guard checks are completed monthly for 3 months to ensure they are completed daily for safety appropriateness and functionality. Any concerns will be addressed and the audits will be reviewed at QAPI. The NHA will review the Elopement drills monthly for 3 months to ensure they are being held on every shift monthly for 3 months and staff are responding accordingly. Any concerns will be addressed and the audits will be reviewed at the QAPI. Date of completion of Plan of Correction: June 27, 2023. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview, and record review the facility failed to facilitate resident choice related to requests for alternative menu items for two resident (R41 and R48) and two confidential group residents of six residents reviewed for self-determination, resulting in feelings of frustration and dissatisfaction during meals. Findings include: On 9/11/23 at 2:20 PM, resident council meeting notes were reviewed for the months of April-August 2023 and revealed the following, Guest/Resident Council 8/28/23, Dietary: [kitchen staff] doesn't answer the telephone. On 9/12/23 at 10:05 AM, a confidential group meeting was conducted with four confidential group residents and they were asked about their level of satisfaction with the food/dietary services at the facility. Two confidential group members (R41 and R48) indicated that when requesting menu items off of the alternative menu, they were supposed to call the kitchen to make their request, when they attempted to call the kitchen, the kitchen did not answer the phone. Both group members indicated that this occurred frequently and they were frustrated about it. ON 9/13/23 at 9:13 AM, R48 was observed sitting with another resident and was asked about the breakfast at the facility and stated, The food is sometimes good and sometimes not so good. R48 was asked if they were able to get an alternative when they wanted to and stated, That's a joke. The kitchen doesn't answer the phone. On 9/13/23 at 11:24 AM, Dietary Manager (DM) E was interviewed regarding the process for residents requesting alternative menu items. DM E indicated that residents typically call the kitchen to request an alternative menu item. DM E stated, I prefer they (residents) give two hours notice, but sometimes I get last minute requests. On 9/13/23 at 11:48 AM, R41 was interviewed about food choices at the facility and indicated that the kitchen doesn't answer the phone. R41 expressed frustration related to not being able to get in contact with the kitchen when needed. R41 stated, It's [swear word]. On 9/13/23 at 12:15 PM, the kitchen was attempted to be contacted by phone from R41's room. The phone rang twenty times and no one answered the phone. On 9/13/23 at 12:30 PM, the Administrator (NHA) was interviewed regarding their expectations for residents being able to make choices regarding food and the process for requesting food off of the alternative menu. The NHA indicated that the staff who bring the resident their tray should go get the resident an alternative menu item per the resident's request. It's quicker that way. The NHA also indicated that residents can call down to the kitchen to request an alternative menu item. A review of R41's electronic medical record (EMR) revealed that R48's most recent minimum data set assessment (MDS) revealed that R48 had an intact cognition and was independent with eating. A review of R41's electronic medical record (EMR) revealed that R41's most recent quarterly minimum data set assessment (MDS) dated [DATE] revealed that R41 had an intact cognition and was totally dependant/or required extensive one to two person assistance for all activities of daily living (ADLs) other than eating. On 9/13/23 at 12:54 PM, a facility policy titled Meal Alternates Last Revised 11/11/2021 was reviewed and stated the following, Policy: It is the policy of this facility to provide an alternate .when a guest/resident does not eat the majority of a meal. Procedure: 3. Nursing staff will notify Dietary department of the alternative needed verbally and return the item to guest/resident.

This citation pertains to Intake: MI00135927. Based on observation, interview and record review, the facility failed to notify the resident's responsible party of a fall in a timely manner for one of one sampled resident (R23) reviewed for decision making resulting in, the potential for the missed opportunity for family to participate in healthcare decision making. Findings include: On 9/11/23 at 11:30 AM, R23 was observed lying in bed. Attempts to interview the resident were to no avail as they were pleasantly confused. A review of R23's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included, Alzheimer's Disease, Hypertension, and Heart Failure. A review of the Quarterly Minimum Data Set assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status score of 6/15 indicating a severely impaired cognition, and required extensive assistance for transfers, bed mobility, and dressing. Further review of R23's medical record revealed the following progress notes: 4/20/2023 14:25 (2:25pm) .Situation: The Change In Condition/s reported on this CIC (change in condition) Evaluation are/were: Other change in condition .Nursing observations, evaluation, and recommendations are: Observed resident on floor by his bed sitting upright. No injury noted. Denied pain. Notified PA (physician assistant). Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Will see patient 4/21/2023 10:54 (10:54pm) Nurses Notes: Writer observed resident sitting on the floor by his bed 4/20/23 approx 2:25. Writer heard resident say, I got to go to the bathroom and I'm getting up. On arrival resident was sitting upright slightly leaning to left side. Writer and CNA (certified nursing assistant) put resident back on his bed . 4/21/2023 12:35 (12:35pm) Nurses Note: Writer in to assess resident right leg resident screams out pain it hurts leg warm to touch slight swelling noted PRN (as needed) pain medication Norco was given before shift change NP in facility to assess New order STAT x-ray . resident family made aware and requested resident to be transferred to hospital NP (nurse practitioner) in facility and gave orders to transfer to hospital per family request . A review of the Incident and Accident report dated for 4/20/23 at 14:25 (2:25pm) revealed that the resident's nurse practitoner was the only person contacted following R23's fall. On 9/13/23 at 11:49 AM, the Director of Nursing (DON) was asked about R23's responsible party not being contacted following their fall on 4/20/23. The DON reviewed R23's medical record and admitted that there was no documentation that the responsible party was contacted, and that they should have been. A review of the facility's Fall Management policy revealed the following, .6. The licensed nurse will notify the attending physician and the responsible party of the fall, and document the notification in the medical record . During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included the following: How facility monitors its corrective actions to ensure same deficient practice is corrected and will not recur. The IDT (interdisciplinary team) discusses all falls in daily stand-up meetings. Appropriate interventions are put in place and care plans are revised as needed. The Administrative Nurses will interview the staff nurses on the steps they take when a resident falls weekly x 4 weeks and monthly for 2 months, any concerns will be addressed. Findings of the audits will be reviewed by the QAPI (Quality Assurance and Performance Improvement) committee. The Administrative Nurses will review 10% of the resident falls weekly x 4 weeks and monthly for 2 months, to ensure the policy was followed, any concerns will be addressed. Findings of the audits will be reviewed by the QAPI committee. Date of completion of Plan of Correction. August 25, 2023. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview, and record review, the facility failed to ensure/provide effective communicate to one resident (R30) of three reviewed for language/communication, resulting in the potential for unmet care needs or a decline in communication ability. Findings include: A review of R30's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was initially admitted into the facility on [DATE] and most recently readmitted on [DATE] with medical diagnoses of Major Depressive Disorder, Macular Degeneration, and Muscle Weakness. Further review of R30's record revealed that the resident is moderately cognitively impaired and requires extensive assistance from staff for activities of daily living, bed mobility, and transfers. R30's record indicated that the resident had a language barrier with Arabic listed as their primary language. On 9/11/23 at 12:21 PM, Confidential Witness C was interviewed and expressed concern that R30's thumb was swollen. Witness C stated that R30 would be unable to give information about the thumb since R30, Doesn't speak English and has Alzheimer's. On 9/11/23 at 12:26 PM, Registered Nurse (RN) F was interviewed and queried regarding any issues with R30's thumb(s). RN F responded that she was not aware of any issues. A review of R30's record revealed: -9/11/2023 14:12 (2:12 PM) .Nurses Note (Written by RN F) .Resident speaks Arabic .right thump (sic) is a little swollen and tender to touch, Doctor .notified with order for an X-ray . On 9/11/23 at 3:30 PM, R30 was observed in bed and appeared to be asleep. R30's hands were covered with their blanket and unable to be viewed at this time. On 9/12/23 at 10:08 AM, R30 was observed in bed. R30's bottom thumb joint area on the right hand appeared diffusely reddened and slightly more swollen compared to the left. R30 was unable to express why their thumb appeared red/swollen at this time. Continued review of R30's record revealed: -9/12/2023 08:51 (AM) .met with resident at bedside to attempt to interview resident utilizing Global Interpreting Services. Resident looked at the phone but did not provide a verbal response when the interpreter spoke with [them] . -9/12/2023 08:57 (AM) .[Attempt to] interview [R30] utilizing Global Interpreting Services. [Resident] would not respond at all to the interpreter .[R30] could hear the interpreter because [they] looked at the phone while the interpreter spoke in [their] language but [R30] would not respond . -9/12/2023 09:08 (AM) .called and spoke with [family], to inform [that R30] would not respond to the interpreter and asked if [they] would come in to assist when we call the interpreter back later . -9/12/2023 11:57 (AM) .[Multiple staff] attempted to meet with resident at bedside with Global Interpreting Services via phone. The interpreter reported that resident's responses were unintelligible during the interview . On 9/12/23 at 12:11 PM, Confidential Witness C was interviewed and asked how staff at the facility communicate with R30. Witness C stated, They don't and explained that they are often asked to translate for R30 when they are there to visit. On 9/12/23 at 12:22 PM, Certified Nursing Assistant (CNA) D was interviewed, as she had worked often with R30 and on 9/10/23 and marked in the record that R30 had been exhibiting physically aggressive behaviors (grabbing, pinching/scratching). CNA D was asked how she communicates with R30. CNA D stated, I just talk to [R30] normally, you know English is not [their] first language, I just talk to [R30] like I would anyone else. I don't speak Arabic, so I just explain what it is I'm going to do, I try to keep my tone of voice pleasant, usually there's no issue .It's not like [R30] can talk back to me I don't speak or understand Arabic . CNA D was asked how she would interpret something to or from R30 if needed, and responded that unless R30's family was there, there is no other way. CNA D was then queried regarding interpreter services offered by the facility and recalled that there is a telephone number in R30's record for an interpreter service. CNA D indicated that she has never called the number to translate for R30. On 9/13/23 at 10:11 AM, the Director of Nursing (DON) was interviewed and queried regarding how staff is expected to communicate with R30 during daily/routine care. The DON stated that there is almost always someone visiting R30 who is able to translate, but if family is unavailable, staff are expected to look for non-verbal communication signs from the resident. The DON stated that nursing has been told to use the telephone interpreter service but added that it seems as though R30 does not like utilizing the interpreter phone and communicates best when family is present. A review of the facility's policy/procedure titled, Communicating with Limited English Proficient Persons, revised 5/15/2023, revealed guidance for the utilization of bilingual staff members and Global Interpreting Services for Limited English Proficient (LEP) persons, however, it did not address using family/alternate persons for translation services.

This citation pertains to Intakes MI00132279, MI00132352, MI00132401, and MI00132482. Based on observation, interview, and record review, the facility failed to transcribe and carry out an order from an outside podiatrist (foot doctor) for one resident (R15) of three residents reviewed for quality of care concerns, resulting in unmet foot skin care needs and the potential for worsening chronic foot skin conditions. Findings include: On 9/12/23 at 1:31 PM, R15 was observed sitting on the edge of their bed in a hospital-type gown. The bottom of R15's right heel and mid-foot were observed to be very thick with a significant amount of built-up scaly skin. R15 indicated that the facility doesn't help take care of their feet like they are supposed to. R15 was noted to have an odor, with a stronger odor coming from their feet area. R15 was asked when they had last received a shower to which they replied, It's been a while. R15's record at this time was noted to indicate that they had received a shower/bath today, 9/12/23, as documented by Certified Nursing Assistant (CNA) J. R15 was asked about what time they had received a shower/bath today to which they replied, When? I've been in this bed all day, they lying again! When queried regarding documented refusals of showers/baths in their record, R15 stated, They lying on me! I never refused a shower! R15 was noted to be oriented to person, place, time, and situation during the interview. On 9/12/23 at 1:38 PM, the facility's Wound Care Nurse, Registered Nurse (RN) G was noted to be on the unit at this time and interviewed regarding R15's feet. RN G explained that R15 sees an outside podiatrist who will provide orders for the facility to carry out related to the resident's skin/feet. At this time, documentation from R15's last outside podiatry visit dated 7/13/23 was reviewed with RN G. The documentation included, Consultation Recommendation: Con't (Continue) use of Urea (cream) daily - soak feet 2 x (times) a week and gently use pumice stone to loosen build up/exfoliate and then apply cream. A review of R15's record along with RN G revealed that the recommendation to soak and exfoliate R15's feet was never transcribed to be carried out by the facility. RN G was unable to provide any rationale as to why the order was not entered and was unable to provide documentation indicating that the recommendation was carried out. RN G explained that soaking R15's feet would help significantly with the skin build-up. On 9/12/23 at 1:40 PM, CNA J was interviewed and asked when R15 received a shower/bed bath today. CNA J replied that the resident did not get a Shower but got Washed up, and shaved. Less than five minutes later, CNA J approached and stated that R15 was now, Apparently motivated, to go take a shower. CNA J was asked if it's typically documented that a resident receives a shower/bath when it did not actually occur. CNA J stated that staff documents that a shower/bath was given when water touches the residents. On 9/12/23 at 1:58 PM, CNA J was observed taking R15 down to the shower room. RN G was noted to accompany the resident and CNA J to the shower room and obtained a photo of the condition of R15's right foot. On 9/13/23 at 10:13 AM, the Director of Nursing (DON) was interviewed and queried regarding care concerns involving R15. The DON stated that R15's family had care concerns in the past but not recently. The DON stated that R15 sees an outside podiatrist who, Scrapes [R15's] feet. The DON stated that the resident was set to go to their next podiatry appointment on 9/14/23. A review of R15's care plan did not reveal information related to the presence or care of the chronic skin condition on their feet. Further review of R15's record revealed that the resident was admitted into the facility on [DATE] and most recently readmitted on [DATE] with medical diagnoses of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Anxiety Disorder, End Stage Renal Disease, and Muscle Weakness. R15's Brief Interview for Mental Status (BIMS) assessment dated [DATE] indicated an intact cognition. R15's Minimum Data Set (MDS) assessment dated [DATE] indicated that R15 requires extensive assistance from staff for bathing and personal hygiene.

This citation pertains to intake #MI 411. Based on interview and record review, the facility failed to appropriately assess and follow up timely following a fall for one Resident (Resident #320) of seven residents reviewed for falls, resulting in a fracture, the delay in hospitalization and unnecessary pain. Findings include: A review of the intake information provided by the complainant revealed the following information: Complainant states the resident told [their] brother .that (Resident #320) fell again on 05/08/2022 and is experiencing pain on .left hip and left leg. The complainant states the facility did not document the fall that occurred on 05/08/2022 .Residents hip is in fact broken from resident falling sometime on Sunday, 5/8 (2022), nothing was done until yesterday afternoon. The Doctor did not have any knowledge of the residents injury. Resident is now being taken to [Local Hospital] today. On 07/14/2022 at 8:52 AM, the complainant was attempted to be contacted via phone to no avail. An email was also sent, but with no response from the complainant. A review of the Progress Notes for Resident #320 revealed the following: 5/9/2022 17:30 Nurses Notes Late Entry: Note Text: At approximately 5:30 pm telephone call received from (Resident #320's) son .with a request to speak to the assigned nurse. Residents son .was informed to hold on as I would get the nurse. Resident's son proceeded to inform writer that (Resident #320) stated .had a fall Sunday night (May 8th) .stated the staff picked (Resident #320) up and put .in the bed. (Resident #320's) son .went on to say that (Resident #320) was complaining of left knee pain and that no one had called him to inform him about .alleged fall. He stated someone had called and was wondering if it was about the results of .x-rays. The assigned day shift nurse came to the phone and was queried about any reports that (Resident #320) had a fall. The assigned nurse stated she did not receive a report from the night nurse that (Resident #320) fell . The assigned nurse stated she was present in (Resident #320's) room when .complained of left knee pain to the physician assistant. The assigned nurse stated the physician assistant asked (Resident #320) did you fall and .stated no. The assigned dayshift CNA (certified nursing assistant) who cared for (Resident #320) on May 8 from 6 am-6:30 pm was queried and stated (Resident #320) did not have a fall during her tour of duty on May 8 from 6 am to 6:30 pm. Review of electronic medical records, nurse notes, provider documentation, e-interact, POC documentation did not reveal documentation to support an alleged fall on Sunday May 8th. Will continue to follow. Nursing. 05/08/2022 17:49 (05:49 PM) Late entry .On Sunday May 8, 2022, writer was informed by visitor of another resident that he had seen [res] on the floor, as I was administering medication. Writer entered the room and observed the resident on the floor with .buttocks to the floor, upper torso leaning on the right side of the bed. Writer went to obtain assistance from the assigned nursing assistant where (resident) was completely on the floor laying on (their) back as we entered the room. Writer and CNA (Certified Nurse Assistant) was able to place resident back in bed. Resident stated that (Resident #320) had to use the restroom. Resident denied pain at the time. Writer did not observe any injuries. Nursing assistant went to provide a brief change to resident. Resident initially refused brief change and made multiple attempts to hit the CNA. Resident finally allowed the CNA to remove .skirt and complete the brief change. 05/11/2022 18:02 (6:02 PM) Resident transferred out to hospital .for .x-ray to left hip, accompanied by son. A review of the Physician's Progress Note revealed the following information: 05/10/2022 .Family in room states they visited (Resident #320) on May 8 .and did well until evening. On May 9 .complained of left hip pain and stated .fell last night. Telemedicine note reviewed and no history of fall. Nursing confirmed there is no history of fall. On examination patient has left hip pain . 05/11/2022 .Patient was seen 5/10 (2022) by rounding MD (medical doctor) for complaint of left hip pain. No falls are reported by staff .(Resident #320)'s son said (Resident #320) told him they fell on [DATE]th in the evening. Left hip pain was noted on exam and MD ordered X-ray. Report was available this morning showing an acute left femoral intratrochanteric fracture with mild displacement .MS (muscle/skeletal system) .pain in left hip with lateral movement of left lower extremely, left hip tenderness . A review of the incident reports for Resident #320 revealed no report filled out for the date of 05/08/2022. A review of the X-ray for Resident #320 revealed the following: 05/11/2022 there is an acute left femoral intertrochanteric (hip) fracture with mild displacement. The joint shows no dislocation. The pubic rami (pelvis) are noted for old healed right pubic rami fractures. The bony structures appear osteopenic. A review of the Treatment Administration Record for May 2022 revealed Resident #320 had received Tylenol medicine for pain on 05/09/2022, and [MEDICATION(S)] (a narcotic pain reliever) on 05/09/2022, 05/10/2022 and 05/11/2022. On 07/14/2022 at 2:33 PM, Registered Nurse/RN D was interviewed in regard to Resident #320's fall on 05/08/2022. RN D explained that she did not know of the fall on 05/08/2022 until 05/10/2022. RN D explained that Resident #320 was confused and would often yell out repeatedly. RN D also explained that the Resident was combative at times and she would have to call the family to help calm the Resident. RN D also stated, I had to transfer (Resident #320) to the hospital because they had hip pain and a fracture, the family was with (Resident #320). On 07/14/2022 at 3:22 PM, the Director of Nursing (DON) was interviewed in regard to Resident #320's fall on 05/08/2022. According to the DON, she had received notification from Resident #320's son (Complainant) on 05/10/2022 that the Resident had called and told him that they fell , so she (the DON) did an investigation. The DON asked the staff within the building and they denied any knowledge of a fall on 05/08/2022. The DON called the agency nurse that was on the night of 05/08/2022, and was told that the Resident did in fact have a fall but had not reported to anyone (the oncoming shift) or fill out an incident report. The DON was asked if the agency nurse is still working at the facility and stated, No, she is no longer allowed in the building. The DON further explained that Resident #320's family was in and the doctor came in and the Resident had complained of hip pain, so she ordered the X-ray. The X-ray had been taken at 12:33 AM on 05/11/2022, the results were posted after 1:13 AM, and that she had not seen the results until later that morning and notified the doctor of the results, who in turn, sent the Resident to the hospital. A review of the MDS dated [DATE] revealed that Resident #320 was most recently admitted to the facility on [DATE] with a Brief Interview for Mental Status (BIMS) score of 09, indicating an impaired cognition and needed extensive assistance with activities of daily living. The Resident was diagnosed with Depression, Anxiety and [CONDITION(S)]. A review of the facility policy titled Fall Management Policy revised 07/14/2021 revealed the following: .Practice Guidelines .3. When a fall occurs, the licensed nurse will evaluate the .resident for injury .4. The licensed nurse will complete incident/accident report. Review/revise care plan .Document in the medical record and on the 24 hour Report .Initiate the Post-Fall evaluation .Document in the progress notes for 72-hours following the fall .6. The licensed nurse will notify the attending physician and the responsible party of the fall, and document the notification in the medical record. 7. The nurse will communicate via the 24-hour report .to the interdisciplinary team .

Based on observation, interview, and record review, the facility failed to properly reposition a resident during incontinence care for one sampled Resident (R85) of seven residents reviewed for accidents resulting in, a fall with injury. Findings include: On 07/12/22 at 10:01 AM, R85 was observed lying in bed and asked about the activities that they attend in the facility. R85 explained that they recently began staying in their room more often and explained and they had a fall resulting in an injury to their knee cap. R85 explained that incontinence care was being provided by the CNA (certified nursing assistant, CNA B) when they rolled off the bed. A review of R85's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that include Heart Failure, Malignant Neoplasm of the Uterus, and Hypertension. A review of their most recent Minimum Data Set assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance of two persons for bed mobility, and was totally dependent for transfers. Further review of R85's medical record revealed the following progress notes: 6/1/2022 12:48 (12:48 PM) Nurses Note Text: Summoned to resident room. Observed lying on [their] back with staff present/CNA and Hospice nurse witness. Informed resident was receiving AM (morning) care when [they] rolled out of bed to the floor landing on [their] right knee as staff was trying to keep from falling. Informed resident did not hit [their] head. Limitation to right knee with C/O (complaint of) pain. VSS (vital signs stable) . 6/1/ 9:27 (7:27 PM) Nurses Note Text: Np (Nurse Practitioner) reviewed right knee xray and stated that knee is misaligned and needs to be sent out for ortho (orthopedic) consult and review. Writer went to tell resident this and resident stated [they prefer] not to be sent out explained that knee is misaligned, resident states [they have] a tiny bit of pain but not bad. Gave resident prn (a needed) tylenol. [family member] is aware of results. currently waiting on hospice to call back and further instructions from Np. A review of R85's radiology report dated 6/1/2022 revealed the following, FINDINGS: Fracture of the distal femoral shaft with malalignment. Joint space narrowing. Mild soft tissue swelling. CONCLUSION: Acute femoral fracture. A review of the Incident and Accident report for R85's fall revealed the following, During routine care, resident rolled out of the bed kneeling on right knee. X-ray showed acute femoral fracture. On 07/14/22 at 9:57 AM, CNA B was interviewed regarding the fall of R85. CNA B explained that they were cleaning R85's buttocks who was lying on their side, facing away from them and holding onto the assist bar on their bed. CNA B explained that the hospice nurse and Nurse Practitioner were also in the room at the time but were speaking to one another and not involved in providing care at that time. CNA B explained that R85 moved their leg and began to roll off the bed resulting in their fall onto the floor. CNA B was asked if R85 required one or two people to assist with the care they were providing, and they explained that R85 required two people, and that she would typically ask for help from another CNA, but they were providing a shower to another resident at the time. CNA B further explained that after the incident, she received one on one education, disciplinary action, and stated, Everyone received an in-service on checking the Kardex (plan of care). On 7/14/22 at 10:30 AM, The Director of Nursing (DON) explained that the fall of R85 had been reviewed, and the root cause was identified leading the facility to re-educate all certified nursing assistants, address disciplinary action, and systemic changes to ensure that the incident does not occur again. A review of the facility's Fall Management policy revealed the following, The facility will identify hazards, and guest/resident risk factors and implement interventions to minimize falls and risk of injury related to falls .Each guest/resident is assisted in attaining/maintaining his or her highest practical level of function by providing the guest/resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls, Guests/residents will be evaluated by the interdisciplinary team for their risk for falls, A plan of care is developed and implemented based on this evaluation with ongoing review . Facility's Corrective Actions Description of deficient practice: Nursing Assistant failed to follow Kardex for Bed mobility extensive assistance of 2-person for bed mobility and repositioning which resulted in a fall with injury. Plan of Correction: Resident [R85] was assessed by assigned nurse. [R85] was assisted to bed with the use of a Mechanical Lift. Physician assistant was in the room and an examination was completed. [R85] was administered pain medication as ordered for complaints of right knee pain. The physician assistant ordered A STAT right knee Xray. Result of the right knee x-ray dated 6/1/2022 revealed Fracture of the distal femoral shaft with malalignment. Joint space narrowing. Mild soft tissue swelling. Conclusion: Acute Femoral Fracture. Audit residents Kardex for number staff required for Bed Mobility One to one inservice with assigned CNA [CNA B], CNA on utilizing and following residents Kardex CNA Standard of Care Policy reviewed and deemed appropriate Inservice nursing assistants on utilizing and following residents Kardex as it relates to bed mobility During routine rounds nurse managers will monitor CNAs performing personal care. How the facility identified resident affected and residents having potential to be affected by the same deficient practice. In depth analysis how the deficiency occurred: On June 1, 2022, at approximately 11:30 AM physician assistant, hospice nurse and wound care nurse were in the room of [R85] to perform a skin assessment. After the skin assessment was completed wound care nurse left the room and physician assistant and hospice nurse stayed in the room. The physician assistant and hospice nurse stood away from the bed on the right side of resident [R85] as they discussed resident [R85] plan of care. [CNA B] stated [R85] was incontinent and she preceded to gather supplies to perform incontinent care. Assigned CNA [CNA B] stated [R85] was assisted to turn on [their] right side as [they] held onto the right-side assist bar. [R85] stated when lying on [their] right side assigned CNA [CNA B] pulled the bottom sheet and [their] lower body began to slide off the bed. [R85] stated as [they] slid off the bed [they were] in the kneeling position on [their] right knee. Assigned CNA summoned assigned nurse to the room as the physician assistant and hospice nurse stayed with the resident. [CNA B] failed to follow [R85] Bed Mobility Kardex of extensive assistance of 2 person for bed mobility and repositioning. How facility identified resident affected and residents having potential to be affected by the same deficient practice. Affected resident Mobility Kardex reviewed Audit Mobility Kardex for residents having the potential to be affected Corrective Action taken for resident affected One to one inservice with assigned CNA CNA Reeducation on using resident Kardex to Guide Care During routine rounds monitor staff performing resident care Assigned CNA [CNA B] received progressive disciplinary action. Measures of systemic changes made to ensure that deficient practice will not occur and affect other. DON/Designee will observe CNAs performing bed mobility weekly x4 weeks then monthly x3 months to ensure bed mobility is performed according to residents Kardex. How facility monitors its corrective actions to ensure same deficient practice is corrected and not recur. Additional education and monitoring will be initiated for any identified concerns. Audit results will be reported to the facility quality assurance committee for review and further recommendations. Date of completed of Plan of Correction. June 8, 2022

Based on interview and record review, the facility failed to adequately administer, monitor, and maintain oxygenation for one sampled resident (R#701) of three reviewed during an infection control focused survey, resulting in inadequate monitoring of a COVID-19 positive resident. Findings include: On 5/5/20 at 10:52 AM, the NHA was asked to provide remote access to the facility's electronic medical record (EMR) system in order to conduct record review. On 5/5/20 during an Infection Control Focused Survey, the Nursing Home Administrator (NHA) provided names of residents in the facility who had tested positive for COVID-19 (Novel Coronavirus 2019). This list included R#701, who was noted to have passed away on 5/1/20 in the facility. A review of R#701's closed medical record revealed the following: 4/21/2020 21:45 (9:25 PM) Respiratory Screen Q (every) shift .noted some occasional cough, resident has cough med order in place, T (temperature) = 98.4 (degrees Fahrenheit). 4/22/2020 05:00 (5:00 AM) resident in bed asleep, hardly awaken, SPO2 (oxygen saturation) = 97% @ (at) O2 (oxygen) 2 L/min (liters per minute) infusing well via NC (nasal cannula), normal breathing noted, non labored at this time slightly afebrile @ 99.6, will monitor. 4/22/2020 18:01 (6:01 PM) PA (Physician Assistant) here @ facility new orders as follows: Stat CXR (chest x-ray) P/A (posterioranterior view) and COVID-19 Swab and stat CMP (comprehensive metabolic panel) and CBC (complete blood count) contact/droplet isolation ordered as well, all orders carried out. Labwork for R#701 was reviewed and revealed results within normal ranges with the exception of Sodium, which was 146 (Normal 136-145), and Carbon [MEDICATION NAME], which was 32 (Normal 21-31). 4/23/2020 01:18 (1:18 AM) Respiratory Screen Q shift .patient coughing, has low grade fever T = 99.6, SPO2 = 86% RA (on room air), with O2 = 94%. Vital signs recorded on day shift for R#701 on 4/22/20 were: blood pressure (BP) 138/64, heart rate (HR) 69, respirations (RR) 18, SPO2 88%, temperature 100.3. PA A encounter note dated 4/22/20: Pt (patient) lying in bed, in no acute distress, Pt with T 100.3 F this AM. Pt also at 88% SPO2 on 2L nasal cannula, improved to 91% on 4L .patient states feels short of breath .suddenly begins to scream uncontrollably, states (their) foot hurts .CXR negative for any acute cardiopulmonary process. Labwork reviewed. Pt also swabbed for COVID d/t (due to) [MEDICAL CONDITION] (low oxygen level), pending. Pt to remain in contact precautions at this time .Stable at 4L nasal cannula, continue to monitor for any new symptoms or acute decompensation. an order for [REDACTED]. Medication Administration note dated 4/27/2020 at 13:03 (1:03 PM) Resident lethargic. Medication Administration note on 4/27/2020 at 14:21 (2:21 PM) Meds held resident not accepting PO (oral) meds/meals/fluids at this time. 4/27/2020 14:42 (2:42 PM) Resident lethargic/confused pulse ox (SPO2) down to 83%. Placed on non-rebreather slowly up to 10L (10 L/min supplemental oxygen). Pulse ox maintaining between 89/90 on 10L. (PA A) and self in room assessed resident throughout shift no changes observed. PA notified daughter of resident's condition. Agreed to continue current care and add [MEDICATION NAME] as needed. Will proceed with plan of care. PA A encounter note, Date of service: 4/27/2020, Visit Type: Acute Change of Condition .Chief Complaint / Nature of Presenting Problem: [MEDICAL CONDITION] .Pt lying in bed, in no acute distress. Pt with 100.3 F fever this AM. Writer called to hall by nurse who states pt SPO2 dropped into low 80's on 5L nasal cannula, was switched to nonrebreather mask at that time. Currently at 92% on 8L nonrebreather mask, slow respirations. Pt unable to tolerate NMT (Neuromuscular therapy) treatment, pt's daily inhalers are on order. Pt also alternating between lethargic state and uncontrollable screaming/moaning, unable to communicate needs. Pt COVID swab pending at this time. Pt is a DNR (Do Not Resuscitate) - spoke with daughter to update on condition. She would like pt kept comfortable at this time .Pt with underlying [MEDICAL CONDITIONS] .Currently on 8L nonrebreather mask, will follow SPO2 to wean back to nasal cannula. Continue to monitor for any acute decompensation . (A non-rebreather mask is an effective method for delivering high concentrations of oxygen at a flow rate of 10-15 L/min). 4/27/2020 21:43 (9:43 PM) Respiratory Screen .patient having SOB (shortness of breath), on O2, spo2 = 87%. 4/28/2020 06:00 (6:00 AM) Respiratory Screen .patient noted having SOB, [MEDICAL CONDITION] SPO2 = 80% on RA, at O2 @ 3 L/min SPO2 = 89%, noted coughing and increase temp, all PRN meds attempted given. 4/28/2020 06:13 resident in bed awake, alert yelling at times, SPO2 = 88 @ O2 3L/min, kept clean dry and comfortable, will continue to monitor. PA A encounter note dated 4/28/2020: Pt seen at 9am hanging off side of bed with no oxygen on, tank empty. (R#701) mouth is full of thick, green phlegm and (resident) also appears to have vomited on (themselves). Call light on floor out of reach. Pt begins screaming upon being repositioned. Oxygen re-applied, vitals improved to 92% on 5L nasal cannula. Pt with 100.1 F temperature - able to take small sips of water with assistance. Shifts from resting with eyes closed to screaming uncontrollably. COVID swab pending .Patient has poor ability for expressing concerns secondary to decreased cognitive abilities and age. Discussed with nursing .continue to monitor for any acute decompensation. 4/29/2020 01:19 (1:19 AM) refused meds. 4/29/2020 01:22 (1:22 AM) resident on respiratory distress, SPO2 = 86%, on O2 @ 3 l/min. 4/29/2020 06:08 (6:08 AM) patient having SOB, O2 infusing @ 3 L/min via NC, SPO2 = 85(%). PA A encounter note dated 4/29/2020: Pt seen lying in bed, in no acute distress. Nasal cannula not on, SPO2 73% presently. Re-applied cannula at 5L and improved to 89%. Pt able to take small sips of water with assistance. Low-grade fever of 99.1 F this AM. Will refrain from placing pt on non-rebreather mask temporarily today as (they) tolerated very poorly previously, starts screaming in distress and also may not keep on if not closely monitored . PA A encounter note dated 4/30/2020: Pt seen lying in bed, afebrile, in no acute distress. O2 saturation currently 86% on 5L nasal cannula. Pt placed on nonrebreather mask @ 6L and improved to 92%. Pt tolerating placement of mask at this time - will monitor and wean back to 5L cannula as vitals improve. Pt with dry mucous membranes, poor skin turgor and decreased PO intake. IV (intravenous) fluid replacement ordered as well as updated labwork. Pt expresses no physical complaints at this time. Labwork for R#701 on 4/30/2020 revealed: Sodium 167 (Normal range 136-145) Potassium 5.9 (Normal 3.5-5.3) Glucose 144 (Normal 70-100) BUN (blood urea nitrogen - test for kidney function) 105.9 (Normal 7-25) Creatinine (test for kidney function) 3.87 (Normal 0.40-1.10) White Blood Cells (fight off infection) 12.6 (Normal 3.6-11.1) Progress notes indicated R#701 passed away in the facility on the evening of 5/1/20. On 5/5/20 at 10:19 AM, during a tour of the facility, Nurse B, who was working on the designated COVID-19 unit, was interviewed. Nurse B was asked what criteria would warrant sending a COVID-19 resident out for a higher level of care. Nurse B stated, I'd say a pulse ox drop, if we have to put them on a non-rebreather. Usually sending out. Temps and coughs we control here. When queried regarding staffing at the facility, and specifically on the COVID-19 unit, Nurse B stated, It's a nursing home. (Staffing is) always hard. On 5/6/20 at 7:48 AM, access to the facility's medical records was again requested from the NHA. On 5/6/20 at 9:05 AM, the NHA stated she would contact someone to provide access. On 5/6/20 at 10:07 AM, the NHA stated, I emailed the head of IT the problems you're having with access. They are working on it. On 5/6/20 at 10:37 AM, the NHA stated she was informed that remote access to surveyors was not going to be allowed. The NHA stated she would take requests for record review and provide them via email as fast as she could. On 5/6/20 at 11:00 AM, progress notes and physician documentation for R#701 was requested from the NHA. On 5/6/20 at 3:39 PM, the NHA emailed Clinical Decision Tree guidelines related to COVID-19. A review of the document titled, COVID-19 Clinical Decision Tree, 4/30/2020, did not specify what criteria would be used for determining need for a higher level of care. On 5/6/20 at 4:16 PM, the NHA, DON, and ICP were interviewed via phone. When queried regarding the status of the progress notes for R#701, the NHA stated, You should have gotten them in the last email sent. On 5/6/20 at 4:25 PM, an email from the NHA was received containing physician notes for R#701, however, the notes did not contain any of the nurses' progress or remaining progress notes. On 5/6/20 at 4:30 PM, The NHA was interviewed via phone, along with the Director of Nursing (DON) and Infection Control Preventionist. When queried regarding R#701's ordered COVID-19 swab, the DON stated, Our lab did not have accessability. They told us they were totally out. We changed labs on 4/27, and got the swab on 4/28. We had to go with another company who could give us swabs and faster results. When queried regarding PA A's encounter note for R#701 on 4/27/20, the DON stated, I believe (R#701) was a DNR. There was a phone call to family and a discussion. I would have to read the progress notes. I am just going by what I was told. I didn't talk to the doctor. They said they could send (R#701) to the hospital but would not resuscitate (them). When queried regarding the documented observation of R#701 in PA A's encounter note on 4/28/20, the DON stated, That is not my expectation for any resident if they are ill. On 5/6/20 at 4:56 PM, after review of the physician notes for R#701, the NHA was asked if those were all progress notes for R#701 as requested. The NHA stated, I believe so, that's what they gave me. The NHA indicated she would check again. On 5/6/20 at 5:08 PM, policies related to change in condition, oxygen use, and transferring residents to an acute care facility were requested. These policies were not received prior to survey exit. On 5/6/20 at 5:25 PM, PA A was interviewed regarding the care of R#701. When queried regarding their note from 4/27/20, PA A indicated they had called R#701's daughter due to the resident not doing well getting oxygen via nasal cannula, and needing a non-rebreather mask. PA A stated, Because the resident was a DNR, I was concerned about the family wanting them sent out or if they just wanted to keep them here. The daughter was on board with keeping (R#701) in the facility. When asked if they had spoke with any staff, PA A indicated they had a concern about staff because there were no large oxygen tanks in the facility. PA A explained that a resident on a non-rebreather requires an oxygen tank, because the oxygen concentrators only go to 5 L/min. PA A stated, They only have small O2 tanks. When on a non-rebreather like (R#701) was at 8 L/min, the small tanks run out in about an hour. That is why I documented that. It has been an ongoing problem if it gets noticed if the tank is empty or if (the resident) is compliant with the mask. I can talk to staff about getting new tanks and educate about how long it lasts but . When queried regarding R#701 not being sent to an acute care facility, PA A indicated it was due to the resident's daughter stating she didn't wish for the resident to go to the hospital, she wanted to keep (R#701) there and comfortable. When queried regarding their encounter note from 4/28/20, PA A stated, I shouldn't be walking in to see that, with the call light out of reach and an empty tank. PA A continued to explain that by the time they are in the facility the night shift staff is gone. PA A stated, I don't have information about being monitored appropriately. I only see what I see when I come in. Do I think I should have walked in on (R#701) like that? No. When queried regarding R#701's COVID-19 swab being ordered on [DATE] but not being collected until 4/28/20, PA A confirmed they had ordered it on 4/22/20 and stated, There were problems with the tests, there are still problems. (The facility) changed the lab because of problems. On 5/6/20 at 5:52 PM, the NHA, DON, and ICP were again interviewed via phone. When queried regarding the facility's accommodations for oxygenation, the DON stated, Our concentrators go to 5 L/min, if we need more they use a tank and put on a non-rebreather. When queried if they were aware of a problem with oxygen tanks running out with use of non-rebreather masks in the facility, the DON stated, No. The DON was then queried regarding residents who exhibit a decline in condition, and what the expectation is for monitoring these residents, especially if they are suspected to have COVID-19. The DON replied, With (R#701) I know they were communicating often about (the resident). They give them a lot of attention when there is a decline. The nurse and the PA give them a lot of attention. I was called at home about (R#701). The NHA submitted the remaining progress notes for R#701 just prior to survey exit. A review of R#701's Minimum Data Set assessment dated [DATE] revealed the resident was admitted into the facility on [DATE], with medical [DIAGNOSES REDACTED]. The resident was not marked as receiving hospice services. Further review revealed the resident was severely cognitively impaired and required extensive assistance from staff for activities of daily living. A review of the facility's policy titled, CORONAVIRUS (COVID 19), revised 4/28/20, revealed, Policy: Appropriate measures will be utilized for the prevention and control of the Coronavirus (COVID 19). The Coronavirus, also known as COVID-19, is a [MEDICAL CONDITION] infection that is caused by a distinct Coronavirus. The incubation period is two to fourteen (2-14) days, with the average being four (4) - five (5) days. This virus may be mild, moderate or severe, and can be potentially life threatening .Treatment 1. Symptom Management, follow the physicians order which may include; a. Antipyretics to reduce fever b. [MEDICATION NAME] or other [MEDICATION NAME] to liquefy secretions and / or reduce viscosity of secretions c. Oxygen supplementation; ventilation assistance in severe cases (which may require acute care setting). 2. IV Fluid supplementation which may include electrolyte replacement.

This citation pertains to Intake Numbers MI 562 and MI 567. Based on interview and record review, the facility failed to follow the care plan to provide safe bed mobility assistance for one sampled resident (R#501) from a total sample of two residents reviewed for falls, resulting in a fall with injury. Findings include: On 10/18/18 at 9:22 AM, an interview with R#501 was conducted. R#501 was asked if she had fallen at the facility and stated, yep. R#501 was asked if it hurt, Nope. R#501 was asked if they cared for her safely, I guess they did. On 10/18/18 at 9:45 AM, record review of R#501's medical record was conducted. R#501 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident needed extensive two person assist with bed mobility and transfers. A Brief Interview for Mental Status (BIMS) score of 12 indicating a moderately impaired cognition. Review of R#501's care plan regarding mobility revealed the resident required two person assist for bed mobility and transfers. On 10/18/18 at 10:30 AM, Review of R#501's Incident and Accident report (I&A) with investigation was conducted. The incident occurred on 10/10/18 at 3:00 PM. Type of A/I, Roll out of bed. Type of Injury, Skin tear, Laceration, swelling back of head. Nature of A/I, Resident was lying on her side (R) as CENA (Certified Nurses Aide) was giving (R#501) a brief change and rolled out of bed . The Post Fall Evaluation, resident statement, I was on my side getting changed. Root cause of fall, Amount of assistance in effect . Initial intervention to prevent falls, Staff must follow care plan for bed positioning. Interview with staff, Certified Nurses Aide (CNA) CNA C Assigned shower giving bed bath. Bed was raised to my waist level. Did (R#501's) front side .(Rolled resident away) washed back and dried it. Started rolling dirty under back. Put clean pads half way under back then went to the other side of the bed and as I went around the bed that's when (R#501) came out of bed while I was at the foot of the bed coming to the right side of bed. On 10/18/18 at 11:55 AM, an interview with Nurse D was conducted. Nurse D was asked about the fall sustained by R#501 and stated, I wasn't in the room when it happened, when I got there there were two CNAs, I don't know if there were two CNAs when the resident fell . On 10/18/18 at 12:09 PM, an interview with CNA G was conducted. CNA G was asked how the CNAs are informed of the number of staff that are required to assist the residents with bed mobility and transfers and stated, It's in the care plan. CNA G turned on a computer and demonstrated the information on R#501's care plan page. CNA G then stated, (R#501) needs two people to roll over. On 10/18/18 at 12:32 PM, a telephone interview with CNA C was conducted. CNA C was asked if there were two people assisting R#501 during the brief change and stated, No it was just me, we were short. The other CNA was doing showers and the nurse was busy at the cart and had an attitude. On 10/18/18 at 12:55 PM, the Director of Nursing (DON) was asked about the above findings and stated, They were not short staffed. It was a new CNA and told me she didn't know how to look at the care plan. The DON was asked for the facility's policy and procedure regarding falls and provided a document titled, Fall Management, dated as Revised 8/2016. Review of the document revealed that referring to the care plan prior to assisting a resident was not addressed.

This citation pertains to intake # Based on observation, interview, and record review, the facility failed to respond timely and appropriately to an alarming fire door when 1 (#701) of three sampled residents, reviewed for elopement risks, from a total sample of three, exited the building and crossed the street to a nearby gas station (located approximately an eighth of a mile from the facility), resulting in the potential for residents to become injured, lost or harmed when crossing a street and wandering to a gas station. Findings include: On 3/29/18 at 9:30 AM, the Administrator was interview regarding Resident #701 elopement from the facility on 3/9/17. The Administrator stated, He (Resident #701) got out a door that wasn't alarmed with the wanderguard system (a system that alarms when a resident wearing a wanderguard bracelet comes near an open door), because we can't have those on the fire doors. He got out a fire door, the ones where you have to push on it for 15 seconds and then it releases, and he got out. He was in activities (previous to elopement), they were doing karaoke, we watched the video, he just got up out of his wheel chair and went to the door and got out. My staff started to look for him about a minute after it happened. A staff member came to me and said she thinks someone got out. My Minimum Data Set (MDS) Nurse went outside to look and a lady stopped in the car and said she thinks one of our residents is across the street. The MDS nurse looked and seen him. The lady in the car picked him up and brought him back. The nurse redirected him back in the facility. He is confused, but lucid sometimes. He has a Brief Interview of Mental Status( BIMS) of 3 (indicating severe cognitive impairment). He told the lady in the car that he was going to a baseball game but then told the nurse he was going home. He does have a wanderguard bracelet on. We had the maintenance guy change the fire door delay time to 30 seconds (instead of 15). I have to meet with the family to transfer him to a locked down unit because it would be safer for him. At first they agreed, but then they changed their mind and want him to stay here because they like it here. The whole incident took about 10 minutes, but four of it was getting him back to the facility. We currently have a 1:1 on him (a staff member watching over him 24/7). He has not attempted to elope since the incident, he can't because he has a 1:1. On 3/29/18 at 9:50 AM, an observation was made of the building lay out and area where the incident occurred. The activity room was near the MDS office but tucked in a small corridor that lead into a hallway. To the right, down that same hallway was a door way with a red exit sign, just passed that doorway to the left was the fire door in question. The main hallway where the MDS office and activity room was located, was quiet, without a nurses station. There was a housekeeping room and an employee locker room also located in the hallway. There were very few resident rooms located in this area of the hall. On 3/29/18 at 9:56 AM, an interview was completed with the MDS Nurse A. MDS Nurse A stated, I work contingent, so I heard an alarm but wasn't sure where it was coming from. So, I went out of the office and then went out the door that was alarming to look around when a lady in a car told me a resident was across the street, I looked and seen him (Resident #701) walking and we went to go get him (in the car). He was fine, at first he said he was going to a ball game and then he told me home. When we got back to the facility me and his nurse did a head to toe skin assessment on him (to make sure there were no injuries). On 3/29/18 at 10:10 AM, an interview was completed with the Social Worker (SW) B. SW B stated, We have elopement books at each nurses station and at the front reception area with picture of residents at risk for elopement. We have a communication board that tells us if a resident is at risk for elopement. Then I take a picture of the resident and put it in each book, then create a care plan and put in in the medical record. The elopement assessments are done on admission, and then we watch them for four weeks. We also do the elopement assessments quarterly and with significant changes. On 3/29/18 at 10:14 AM, Resident #701 was observed resting in bed with his eyes closed. A 1:1 staff member was in the room watching the resident. On 3/29/18 at 10:26 AM, a record review of the Investigation Form dated 3/9/18 revealed that Resident #701 had exited the building at 2:40 PM through the business office exit door. A review of the Incident Report revealed the same information stating, Alarm sounding writer (MDS Nurse A) exited the facility through business hallway door and returned resident (#701) to facility, through front door. A record review of the camera footage times revealed the following: 14:35:10 (2:35 PM) Resident #701 exits the building 14:35:33 (2:35 PM) Dietary Aide C comes around the corner with a cart and goes into the business office. 14:35:54 (2:35 PM) Dietary Aide C comes out of the business office and does not go to exit door. 14:36:09 (2:36 PM) Medical Records Employee E comes into business office hallway from main hall and goes to exit door. 14:36:28 (2:36 PM) Medical Records Employee E reaches exit door and looks out the window. 14:36:40 (2:36 PM) Medical Records Employee E walks away and passes MDS Nurse A in the hallway. 14:37:10 (2:37 PM) MDS Nurse A goes to exit door and looks out the window. 14:37:14 (2:37 PM) MDS Nurse A walks away from the door and meets Housekeeping Manager D in hallway and they both go to exit door. 14:38:01 (2:38 PM) MDS Nurse A and Housekeeping Manager D open the door and MDS Nurse A exits the door to go outside. 14:43:46 (2:43 PM) A car is seen pulling up right at the front lobby entrance door. 14:45:00 (2:45 PM) MDS Nurse A brings Resident #701 back in the facility with the help of Good Samaritan. On 3/29/18 at 10:35 AM, a review of the face sheet and MDS assessment revealed that Resident #701 was admitted into the facility on [DATE] with the [DIAGNOSES REDACTED]. The initial MDS assessment dated [DATE] revealed that Resident #701 had a BIMS score of 03, needed limited assist with ambulation and had wandering behaviors (1-3 days/week) and was at significant risk of getting to a dangerous place. On 3/29/18 at 11:05 AM, an interview was completed with the Director of Nursing (DON) in regards to the delay in reaction by the mentioned employees with the alarming exit door. The DON stated, Medical Records Employee E responded to the door, but she was newer (a newer employee) and didn't know what to do so she went to get help, then Housekeeping Manager D responded and that is where the MDS Nurse A and her met and then looked out the door. During this time, the Administrator had walked in and then was queried about what was done in response to the elopement of Resident #701. The Administrator stated, We educated all the staff about what to do when the alarms are going off. We also had the maintenance guy change the delay of the release of the fire door to 30 seconds instead of 15 seconds. Then we had the door company come in and check all the doors just to make sure they were all working correctly, and they were. The Activities Director is also doing two elopement drills per month instead of one. On 3/29/18 at 11:23 AM, a record review was completed of the elopement drills for the following dates: 3/26/18, 3/2/18, 2/22/18, 1/18/18, 12/31/17, and 11/22/17. There were no deficiencies identified in the comments. On 3/29/18 at 11:25 AM, an observation was made of Resident #701 lying in bed resting with his eyes closed. There was a 1:1 nurses aide with the resident. On 3/29/18 at 12:12 PM, a record review was completed of the Progress Notes for Resident #701 and revealed the following: 2/16/18- .Frequent walker/wanders. Unstable gait. Requires redirection. 2/17/18- .Wanders a lot. Redirected numerous times. Compliant with care. 3/9/18-At approximately 2:40 PM, writer (MDS Nurse A) heard business hallway door alarm sounding. Writer exited facility through the business hallway door and observed resident (#701) ambulating outside stating he was going home and returned resident back in to facility through front doors. On 3/29/18 at 12:20 PM, a record review was completed of the Physician Orders and Care plans for Resident #701 and revealed the following: 2/28/18 order stated:Wanderguard bracelet, confirm placement . 2/19/18, revised 2/27/18 Elopement Care Plan- Focus (Resident #7010 is at risk for elopement and/or wandering r/t (related to) cognitive impairment and being mobile. Goal (Resident #701) will not leave facility unattended through the review date. Interventions 1:1 Supervision Apply wanderguard per order Distract resident while wandering . Identify pattern of wandering . Observe resident for fatigue . Observe wandering behavior and attempt diversional interventions . Provide reassurance/Redirect . Use Calm approach. Provide structured activities . On 3/29/18 at 12:27 PM, a request was made to the Administrator to view the video. The Administrator stated, The recording only goes back for two weeks, so I don't have it anymore. On 3/29/18 at 12:30 PM, a record review of the facility policy titled, Elopement Policy with a revision date of 5/2017 was completed and revealed the following: It is the policy of this facility to prevent to the extent reasonably possible, the elopement of residents from the facility. Elopement occurs when a resident who needs supervision leaves a safe area without authorization . Procedure 5. All employees will be educated on the Elopement Policy and Procedure upon hire, annually and as needed. Elopement Alarm Activation 1. If an employee hears a door alarm, he or she should: a. Immediately go to the site of the alarm; 2. In situations where the alarm sounds and a resident is not found to have exited: a. Notify the charge nurse immediately, and b. Ensure that a head count is completed to ensure that all residents are accounted for. Missing Resident 5. Charge nurse will notify the other unit(s) of the missing resident. All staff members will thoroughly search the building immediately room-by-room, resident areas, non-resident areas, and facility grounds as directed by the search coordinator. On 3/29/18 at 12:37 AM, an interview was completed with Medical Records Employee E. Medical Records Employee E stated, I go up front to relieve the receptionist every day from 1:30 PM-2:30 PM. I heard a slight ringing. I figured it was a door alarm. I didn't see anyone. I tried to hit the door to go out and circle the building. I tried to put in a code, it didn't work, I went to the MDS Nurse to look for someone and then (Housekeeping Manager D) came out and opened the door. At that time I did not realize someone (Resident #701) had gotten outside. I went and told (Administrator) and she started a headcount and then realized (Resident #701) got out. I thought I had to put in a code for the wanderguard system, but the maintenance guy came around and explained to us what code it was (after elopement). On 3/29/18 at 12:40 PM, an interview was completed with Housekeeping Manager D. Housekeeping Manager D stated, I heard an alarm and saw (MDS Nurse A). I went over there to pushed the code to silence the alarm. (MDS Nurse A) then went outside. During the interview, Housekeeping Manager D demonstrated how the fire door in question works. Once the door handle is pushed, an alarm sounds and gradually gets louder, if the handle is held for the appropriate amount of seconds, the door opens and then a second, louder alarm sounds. According to Housekeeping Manager D, once the door sounds initially, each nurses station also alarms to alert the staff that the door has opened. On 3/29/18 at 12:53 PM, an interview was completed with Dietary Aide C. Dietary Aide C stated, I went out in the hallway and walked passed the door. My mind was on work so I didn't even hear it. They (the facility) gave me a 1:1 (discipline) for it. If I would have heard it, or seen the lights flashing on it (the door) what I should have done was went outside and looked around for any residents. On 3/29/18 at 1:00 PM, a Facility Past Non Compliance was reviewed and accepted, and stated the following: Date of incident: 3/9/2018 Concerns: 1. Resident (#701) got up from wheelchair in the activity room while Karaoke activity was going on and exited out the Business Office hallway emergency door. 2. The activity staff did not immediately realize he was gone, as he ambulates ad lib (as tolerated). 3. Staff failed to follow Elopement Policy when they went to the alarming door. Investigation: On (MONTH) 9, (YEAR) at approx. (approximately) 2:35 pm resident (#701) exited the building through the Business Office hallway emergency exit door. The alarm immediately sounded; however, staff did not immediately announce the elopement. Although staff went to the alarming door within one minute, they did not initially open the door, go outside and circle the building, checking for residents, but waited a few minutes. Meanwhile, other staff was conducting an internal head count. (Resident #701) is an [AGE] year old white male who was admitted to the facility on [DATE], with several [DIAGNOSES REDACTED]. The following plan was put in place to prevent reoccurrence of this concern: Element 1: Multiple staff members were interviewed in an effort to determine process gaps. The resident has no ill effects from the experience and has no recollection. The resident has since been on 1:1 monitoring 24 hours a day. The family and physician were notified. The residents care plan was reviewed and the elopement assessment has been updated. The family was in agreeance with Social Worker finding alternate placement for resident, possibly a facility with a locked unit. Element 2: Other residents at risk have been assessed to assure appropriate measures are in place, such as Wander Guard placement and operating properly; care plans reviewed, and review of elopement assessments. Element 3: (Door company), the company that installs our door alarms came in the following Monday, 3/12/2018 and assessed every emergency exit door alarm to assure proper operation. A random trigger of the door alarms was completed the next day to determine level of response. Response was appropriate. The facility Elopement Policy has been reviewed and deemed appropriate. Although monthly elopement drills take place, staff from all departments is being re-educated on the Elopement policy, focusing on the 'immediate' response to door alarms, and the procedure for exiting the door and walking (around) the building in the event the resident is not actually seen exiting. This education is being completed by the Staff Development Coordinator and will be completed by 3/16/2018. Element 4: The facility will increase frequency of drills to twice monthly and will cover all shifts. Activity Director is responsible for completing elopement drills and will monitor response times of staff and assure that all processes are followed. The Elopement Policy is reviewed in New Hire Orientation and we will begin orientating them on the actual residents that are at elopement risk. During activities when there is a large participation of residents; facility will assure there are at least 3 staff members. The findings of these drills will be reported to the Administrator for discussion and review at monthly QAPI (Quality Assurance Performance Improvement). The document was signed by the Administrator.

This citation pertains to intake MI 454 Based on interview and record review, the facility failed to provide two-person assistance during incontinence care for one (#801) of three sampled residents reviewed for falls from a total sample of three, resulting in a fall with injury requiring hospital transfer for medical treatment. Findings include: The clinical record review on 6/29/15 at 10:00 a.m. revealed that Resident #801 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #801 had severe cognitive impairment and required extensive 2 person physical assistance with bed mobility and positioning. A nursing Progress Note, dated 6/7/15, documented, At approximately 5:40 a.m., this writer in hallway heard a noise from resident's (#801) room, met CNA (Certified Nursing Assistant A) in hallway who verbalized to writer, that the resident is on the floor. Followed the CNA into room. Observed the resident lying on the right side of bed, close to window. Resident positioned face down on stomach, her forehead up against electrical outlet. When resident rolled over two wounds were observed to the forehead one in the middle of the forehead area cleaned and a dry pressure dressing was applied. ROM (Range of motion) initiated resident can move extremities but complained of right leg pain when moved. Resident's niece notified. Physician notified. New orders to transfer to hospital. DON (Director of Nursing) notified. The nursing plan of care for activities of daily living (ADL) dated 4/24/12 and revised 6/8/15 documented, Resident #801 has an ADL Self Care Deficit and requires assistance with ADLs and mobility. Resident requires two person assist with bed mobility and positioning. Review, on 6/29/15 at 11:30 a.m., of a Post Fall Evaluation, dated 6/7/15, revealed, Assigned CNA turned Resident (#801) away from her (assigned CNA) instead of toward her (assigned CNA) causing Resident's legs to slip out of the bed and then the upper part of Resident's body followed. Root cause of this fall- amount of assistance in effect. Review, on 6/29/15 at 1:00 p.m., of the transfer records from when Resident #801 was readmitted back into the facility on [DATE] from the hospital, revealed that Resident #801 was admitted into the hospital with a Closed Head Injury and Laceration of Scalp. The transfer records read, skin tear to left forehead intact with glue, laceration left forehead intact with sutures no active bleeding. During an interview with Resident #801's roommate, on 6/29/15 at 2:15 p.m., Resident #57 said, I (#57) didn't physically see (Resident #801) fall, but I do know that there was only one CNA in the room. The CNA was new, but should have known what (Resident #801) needed. When the Director of Nursing (DON) was interviewed on 6/29/15 at 1:50 p.m., the DON reported that the incident was caused by staff not providing the proper amount of assistance during ADLs (Activities of Daily Living). She went on to explain that Resident #801 required the assistance of two staff members for bed mobility and transfers. During incontinence care with Resident #801, CNA A tried to roll the resident over without assistance and Resident #801 fell out of bed. Since then, the entire staff underwent inservice training to follow the Resident Care Guides, which designate the type and amount of assistance that each resident required according to their care plans. The DON indicated that CNA A no longer worked at the facility as of 6/11/15. The Resident Care Guide for Resident #801 was reviewed, on 6/29/15 at 3:00 p.m., and noted two person assistance for bed mobility was required with full staff performance 7 days a week. The facility policy for Routine Resident Care, undated, was reviewed on 6/29/15 at 4:00 p.m. and read, Residents receive the necessary assistance to maintain good grooming and personal/oral hygiene Care is taken to ensure resident safety at all times. The facility was determined to be noncompliant with regulatory requirement F323 as a result of the facility failing to provide two-person assistance as assessed during incontinence care for Resident #801 resulting in a fall with injury requiring hospital transfer for medical treatment. However, the facility identified a past noncompliance in regard to the incident with documentation, and a plan of correction date of 6/8/15. Therefore, although cited, no further action is necessary. During the onsite visit of 6/29/15, the surveyor verified that the following plan of correction had been implemented: Element #1 Resident #801 was immediately assessed by the nurse; attending physician notified and gave orders to transfer resident to hospital for further evaluation. The CNA received 1:1 inservice on the importance of following residents' care plan. The CNA was immediately suspended pending completion of the investigation. Element #2 Residents who required assistance with turning when rendering care have a potential for being affected by this deficient practice and were identified. Element #3 Comprehensive Plan of Care Policy was reviewed and deemed appropriate. CNAs were inserviced on facility's Care Planning Policy. As of 6/9/15 41 of 50 CNAs have been inserviced. This will be ongoing until one hundred percent of CNAs have been re-educated. The remaining CNAs will receive education on the above policy upon reporting for duty on their next scheduled day and will not be allowed to work until the inservicing is completed. Nurse Managers will monitor staff during Quality Rounds to ensure staff is properly reviewing the resident's care guide prior to providing care and document findings on Quality Rounds tool. Tool will be reviewed at the Morning Stand Up Meeting Monday through Friday. Element #4 DON/designee will randomly audit staff providing care 2 times a week times 4 weeks then monthly times 3 months to ensure staff is properly reviewing the resident's care guide prior to rendering care. Audits will forward to the DON. Audits will be summarized by the DON and forwarded to the monthly QA&A Committee for further review and recommendations. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO SUPERVISE AND ENSURE PROPER SEATING TO PREVENT FALLS FOR ONE (#206) OF THREE RESIDENTS REVIEWED FOR FALLS OUT OF A TOTAL OF 21 SAMPLED RESIDENTS, RESULTING IN A FALL WITH A HIP FRACTURE AND hospitalization . FINDINGS INCLUDE: ON 7/16/13 AT 12:45 P.M., RESIDENT #206 WAS OBSERVED SEATED IN A SMALL LOW WHEELCHAIR. RESIDENT #206 WAS ASSISTED TO THE UNIT FROM THE DINING AREA BY A FACILITY CNA. ON 7/18/13 AT 2:00 P.M., RESIDENT #206'S MEDICAL RECORDS WERE REVIEWED WITH THE DIRECTOR OF NURSING (DON). REVIEW OF THE MEDICAL RECORD FACE SHEET REVEALED AN ORIGINAL admission date of [DATE] AND A REadmission date of [DATE] WITH [DIAGNOSES REDACTED]. THE INCIDENT AND ACCIDENT AND INVESTIGATION FOR THE EVENT WAS REQUESTED. THE DON WAS IMMEDIATELY QUERIED REGARDING THE ORIGIN OF RESIDENT #206'S HIP FRACTURE. THE DON STATED "I'M NOT SURE OF THE EXACT DATE, I'LL HAVE TO LOOK IN THE RECORD. THERE WERE THREE NURSES ON. THE CNA (CERTIFIED NURSING ASSISTANT) BROUGHT THE RESIDENT TO THE NURSE'S STATION BECAUSE THE RESIDENT KEPT TRYING TO GET UP. IT WAS WHEELCHAIR WASHING NIGHT SO THE CNA TRANSFERRED THE RESIDENT INTO A CHAIR WITH ARM SUPPORT. NURSE "E" CAUGHT THE RESIDENT AS THE RESIDENT WAS FALLING. ACTUALLY, STAFF "E" COULD NOT PREVENT THE RESIDENT FROM FALLING. THE RESIDENT fell FROM THE CHAIR AFTER NODDING OFF TO SLEEP. THE STAFF REPORTED THE RESIDENT STAYED UP LATE MANY NIGHTS." ON 7/19/13 AT 8:40 A.M., RESIDENT #206'S MEDICAL RECORD AND INCIDENT AND ACCIDENT REPORT DATED 4/5/13 AT 3:45 A.M. WAS REVIEWED AND REVEALED, THE RESIDENT EXPERIENCED A FALL FROM THE CHAIR. "RESIDENT WAS SITTING IN THE CHAIR AND STARTED TO NOD OFF TO SLEEP RESULTING IN A FALL ON LEFT SIDE." THE DOCUMENTED INTERVENTION IMPLEMENTED WAS "DO NOT ALLOW RESIDENT TO SLEEP IN CHAIR." REVIEW OF THE FACILITY'S "SBAR" (A COMMUNICATION TOOL USED FOR RESIDENT UNUSUAL OCCURRENCES) FOR RESIDENT #206, DATED 4/5/13 AT 4:30 A.M. "SITUATION:FALL, BACKGROUND: LEFT HIP PAIN, APPEARANCE:HIP FRACTURE AND REQUEST: ORDERS TO SEND TO HOSPITAL." THE SBAR PROGRESS NOTES DOCUMENTED "DURING THE EVENING RESIDENT ATTEMPTED TO GET UP BY SELF RESULTING IN THE CNA BRINGING THE RESIDENT TO THE NURSE'S STATION FOR FURTHER OBSERVATION." WHILE THE RESIDENT WAS SITTING IN A CHAIR, A NURSE ON THE UNIT OBSERVED THE RESIDENT "NOD OFF TO SLEEP AND LEAN" TO THE LEFT SIDE. " THE NURSE WAS UNSUCCESSFUL IN STOPPING THE RESIDENT'S FALL TO THE FLOOR. COULDN'T GET TO RESIDENT IN TIME. RESIDENT HIT THE FLOOR ON HER LEFT HIP." ON 7/19/13 AT 8:50 A.M., STAFF "C" WAS INTERVIEWED REGARDING THE FALL RESIDENT #206 EXPERIENCED ON 4/5/13. STAFF "C" STATED THE TWO NURSES WERE SITTING, CHARTING ON THE A WING BEHIND THE NURSE'S STATION. STAFF "C" "WAS MAYBE TWO ARMS LENGTHS" FROM THE RESIDENT "WHEN I NOTICED THE RESIDENT HAD SLID FROM THE CHAIR." STAFF "C" WAS DOING PAPERWORK AND SHE WAS SCHEDULED EXTRA THAT NIGHT." ON 7/19/13 AT 9:30 A.M., STAFF "D" WAS INTERVIEWED REGARDING THE FALL RESIDENT #206 EXPERIENCED 4/5/13. STAFF "D" STATED "RESIDENT #206 WAS BROUGHT TO THE NURSES STATION BECAUSE THE RESIDENT CONTINUED TO ATTEMPT TO CLIMB OUT OF THE BED. THE RESIDENT WAS TRANSFERRED TO A REGULAR CHAIR BECAUSE IT WAS WHEELCHAIR CLEANING NIGHT. THE CHAIR DID NOT HAVE ARMS. THE RESIDENT WAS PLACED IN FRONT OF THE PARTITION AT THE NURSE'S STATION. THE NURSES WERE BEHIND THE NURSES STATION". ON 7/19/13 AT 11:30 A.M., STAFF "E" WAS INTERVIEWED REGARDING THE FALL RESIDENT #206 EXPERIENCED ON 4/5/13. STAFF "E" STATED TWO NURSES WERE SEATED BEHIND THE NURSE'S STATION. STAFF "E" WAS STANDING AT THE NURSE'S STATION. STAFF ''E" OBSERVED THE RESIDENT FALLING FROM THE CHAIR, AND COULDN'T GET TO THE RESIDENT IN TIME BEFORE THE RESIDENT fell TO THE FLOOR ON THE LEFT SIDE. STAFF "E" DENIED KNOWLEDGE OF THE TYPE OF CHAIR THE RESIDENT WAS SEATED IN. ON 7/19/13 AT 12:30 P.M., THE DON WAS INTERVIEWED REGARDING THE TYPE OF CHAIR RESIDENT #206 WAS IN PRIOR TO THE FALL ON 4/5/13 AT 3:45 A.M.. THE DON STATED "WHEN I ARRIVED to the facility on THE DAY SHIFT, I ASSESSED THE CHAIRS THAT WERE AT THE A WING NURSE'S STATION AT THAT TIME. THE RESIDENT HAD FALLEN ON THE MIDNIGHT SHIFT. THERE WAS A RED LEATHER CHAIR THERE WITH ARMS. THAT WAS THE ONLY CHAIR THERE." WHEN QUERIED WHETHER THE STAFF HAD REPORTED WHETHER THAT WAS THE CHAIR THE RESIDENT WAS SEATED IN, THE DON STATED "I HAVE TO GO BY WHAT THEY REPORT TO ME." WHEN QUERIED WHETHER RESIDENT #206 WAS ASSESSED TO SAFELY SIT IN A REGULAR CHAIR WITH NO ARM SUPPORT AND IF A CHAIR ALARM WAS ORDER WHEN THE RESIDENT WAS UP IN THE CHAIR, THE DON AGAIN STATED "I'LL HAVE TO CHECK THE RECORD." REVIEW OF THE FACILITY "PATIENT TRANSFER FORM" TO THE HOSPITAL DATED 4/5/13, DOCUMENTED "LEFT HIP PAIN/FALL." REVIEW OF THE HOSPITAL DISCHARGE SUMMARY FOR DISCHARGE OF 4/9/13 DOCUMENTED RESIDENT #206 "WHO SUFFERS FROM DEMENTIA, fell FRACTURING...LEFT HIP...SEEN IN MEDICAL CONSULTATION AND CLEARED FOR SURGERY...UNDERWENT OPEN REDUCTION AND INTERNAL FIXATION (ORIF) OF THE LEFT HIP. discharged TO A SUBACUTE NURSING FACILITY FOR CONTINUING RECOVERY." REVIEW OF RESIDENT #206'S MDS (MINIMUM DATA SET) DATED 5/5/13 DOCUMENTED RESIDENT #206 REQUIRED EXTENSIVE ONE PERSON ASSISTANCE WITH TRANSFERS AND WAS COGNITIVELY IMPAIRED. REVIEW OF RESIDENT #206'S FALL CARE PLAN DATED 3/10/13, DOCUMENTED RESIDENT WAS "AT RISK FOR FALLS RELATED TO DECREASED MOBILITY, BALANCE SECONDARY TO GENERALIZED WEAKNESS SECONDARY TO [DIAGNOSES REDACTED]. REVIEW OF THE PHYSICAL THERAPY CARE PLAN DATED 3/6/13 DOCUMENTED RESIDENT #206 EXPERIENCED: DECREASED FUNCTIONAL MOBILITY, FAIR SITTING BALANCE, AND POOR STANDING BALANCE. REVIEW OF THE REHABILITATION SCREEN FOR RESIDENT #206 DATED 3/6/13 DOCUMENTED RESIDENT #206 WAS RECOMMENDED A REGULAR WHEELCHAIR FOR SEATING. ON 7/19/13 AT 1:30 P.M., THE DON WHEN QUERIED REGARDING 1) RESIDENT #206'S SLEEPING IN A REGULAR CHAIR DURING THE NIGHT 2) THE 4/5/13 I/A DOCUMENTED AS AN INTERVENTION "DO NOT ALLOW RESIDENT TO SLEEP IN THE CHAIR" 3) THE CARE PLAN DOCUMENTED "ALLOW RESIDENT TO SLEEP IN CHAIR WHEN FATIGUED" AND WAS UNABLE TO EXPLAIN OR CLARIFY. REVIEW OF THE POLICY TITLED "FALL MANAGEMENT" DATED 5/2010, DOCUMENTED "THE FACILITY WILL IDENTIFY HAZARDS AND RESIDENT RISK FACTORS AND IMPLEMENT INTERVENTIONS TO MINIMIZE FALLS." ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO CONSISTENTLY MONITOR ANTICOAGULANT LEVELS AS ORDERED FOR ONE RESIDENT (#206) OF ONE REVIEWED FOR ANTICOAGULANT THERAPY, FROM A TOTAL OF TWENTY ONE SAMPLED RESIDENTS, RESULTING IN ANTICOAGULANT TOXICITY, NEW ONSET [MEDICAL CONDITION] AND hospitalization RELATED TO COMPLICATIONS OF ANTICOAGULATION MEDICATIONS. FINDINGS INCLUDE: ON 7/16/13 AT 12:45 P.M., RESIDENT #206 WAS OBSERVED IN A SMALL LOW WHEELCHAIR. RESIDENT #206'S SKIN WAS PALE IN APPEARANCE. ON 7/19/13 AT 9:10 A.M., RESIDENT #206'S MEDICAL RECORDS WERE REVIEWED WITH THE DIRECTOR OF NURSING (DON). THE MEDICAL RECORD FACE SHEETS REVEALED AN ORIGINAL admission date of [DATE] AND REadmitted S OF 4/9/13 AND 4/23/13. [DIAGNOSES REDACTED]. THE FACESHEET FROM THE REadmitted D 4/9/13 ALSO INCLUDED COGNITIVE DEFICITS AND ABNORMALITY OF GAIT. THE LAST admitted D 4/23/13 ADDED [DIAGNOSES REDACTED]. REVIEW OF THE HOSPITAL DISCHARGE SUMMARY FOR DISCHARGE OF 4/9/13 DOCUMENTED RESIDENT #206 "WHO SUFFERS FROM DEMENTIA, fell FRACTURING...LEFT HIP...SEEN IN MEDICAL CONSULTATION AND CLEARED FOR SURGERY...UNDERWENT OPEN REDUCTION AND INTERNAL FIXATION (ORIF) OF THE LEFT HIP...POSTOPERATIVELY...WAS ANTICOAGULATED...THERE WERE NO COMPLICATIONS...discharged TO A SUBACUTE NURSING FACILITY FOR CONTINUING RECOVERY." REVIEW OF THE FACILITY'S PHYSICIAN ORDERS FOR RESIDENT #206 DATED 4/9/13, DOCUMENTED "[MEDICATION NAME] 3 MG (MILIGRAMS) BY MOUTH EVERY DAY FOR 14 DAYS, AND INR (INTERNATIONAL NORMALIZED RATIO-A TEST USED TO MEASURE CLOTTING OF THE BLOOD) EVERY THREE DAYS." A PHYSICIAN'S ORDER WRITTEN 4/10/13 DOCUMENTED "PT ([MEDICATION NAME] TIME)/INR NEXT DRAW, AND THEN THREE TIMES A WEEK WHILE ON [MEDICATION NAME]." THE PHYSICIAN'S ORDERS FOR 4/18/13 DOCUMENTED "HOLD ANTICOAGULANT TIMES ONE DAY. HOLD ASPIRIN WHILE PT IS ON [MEDICATION NAME]. VITAMIN K 5 MG INTRAMUSCULARLY NOW...SEND TO emergency room ; RULE OUT GI BLEED." (VITAMIN K IS A MEDICATION GIVEN TO CLOT BLOOD IN CASES OF SEVERE BLEEDING AND AN INTERFERING SUBSTANCE IN AN ANTICOAGULANT STUDY). REVIEW OF THE NURSES NOTES FOR RESIDENT #206 DATED 4/18/13 8:00 P.M., DOCUMENTED "SMALL AMOUNT OF BLOOD IN STOOL." NURSE'S NOTE FOR 4/19/13 12:30 A.M. DOCUMENTED, "NURSE NOTED ACTIVE BLEEDING FROM RECTUM. PHYSICIAN NOTIFIED. ORDERS RECEIVED TO TRANSFER TO emergency room ." NO OTHER DOCUMENTATION OF RECTAL BLEEDING WAS DOCUMENTED. THERE WAS NO BOWEL AND BLADDER TRACKING SHEETS AVAILABLE TO TRACK BOWEL AND BLADDER STATUS SINCE ADMISSION ON 4/9/13. REVIEW OF THE FACILITY "PATIENT TRANSFER FORM" TO THE HOSPITAL SIGNED 4/19/13, DOCUMENTED "GI BLEED,VITAMIN K 5 MG (MILLIGRAMS) INTRAMUSCULARLY 2:20 P.M. [MEDICATION NAME] 3 MG HELD ON 4/18/13." REVIEW OF THE NURSES NOTES DATED 4/19/13 12:15 A.M. DOCUMENTED "LAB CALLED TO FACILITY CONCERNING PT/INR. LAB WAS UNABLE TO READ RESULTS DUE TO INTERFERING SUBSTANCES...LAB WILL DO RE-DRAW IN AM. 4/19/13 LABS WERE CANCELLED DUE TO RESIDENT TRANSFER TO emergency room ." REVIEW OF THE FACILITY'S "PT/INR [MEDICATION NAME] FLOW SHEET" USED TO TRACK PT/INR HISTORY ONLY CONTAINED A BLOOD DRAW ON 4/11/13. REVIEW OF THE PT/INR LAB RESULTS FOR RESIDENT #206 REVEALED THE FOLLOWING: 4/11/13 COLLECTED 5:50 A.M. (SCHEDULED DRAW) PT- 22.9/INR-2.2 (THE LAB RESULTS REGISTERED AS HIGH RANGE FOR THE PT AND INR. THE PT LAB RESULTS PARAMETERS = REFERENCE RANGE 0.9-1.1 SECONDS. THE INR RESULTS=MODERATE-INTENSITY [MEDICATION NAME] THERAPY 2.0-3.0). THESE RESULTS WOULD VARY WHEN A RESIDENT WAS ANEMIC WITH A LOW BLOOD CONCENTRATION). 4/16/13 NOT DRAWN/NOT MONITORED 4/18/13 THIS LAB DRAW WAS NOT SCHEDULED AS ORDERED. IT WAS COLLECTED AT 6:20 P.M. IT WAS A "STAT" (AS SOON AS POSSIBLE) DRAW. THE SCHEDULED DRAWS FOR THE LAB WERE AT 5:00 A.M. THE LAB WAS "UNABLE TO REPORT RESULTS DUE TO POSSIBLE INTERFERING SUBSTANCES (VITAMIN K)." REVIEW OF THE INITIAL CARE PLAN FOR RESIDENT #206 READMISSION INto the facility on [DATE] DID NOT INCLUDE ANTICOAGULATION INSTRUCTIONS TO THE NURSES UNTIL 4/18/13, THE DAY RESIDENT #206 WAS TRANSFERRED AND readmitted INTO THE HOSPITAL. REVIEW OF THE HOSPITAL DISCHARGE SUMMARY DATED 4/23/13 DOCUMENTATION INCLUDED "Diagnoses: [REDACTED]. DISCHARGE COMMENTS: DO NOT TAKE [MEDICATION NAME] ANY LONGER." REVIEW OF THE FACILITY'S HISTORY AND PHYSICAL DATED 4/25/13 DOCUMENTED hospitalized "4/19/13-4/23/13. WENT OUT FOR GI BLEED DUE TO [MEDICATION NAME] TOXICITY...RECENT ORIF LEFT HIP. GI BLEED SECONDARY TO ANTICOAGULANTS. HEMOGLOBIN 8 (NORMAL FOR RESIDENT #206 RANGE 11.7-13.8)." WHEN QUERIED REGARDING THE INCONSISTENT ANTICOAGULATION MONITORING AND THE NEW [DIAGNOSES REDACTED]. THE DON FURTHER EXPLAINED, "THE ONLY LAB DRAW THAT WAS MISSED WAS ON THE 16 TH. WHEN I REALIZED THAT, I IMMEDIATELY IN-SERVICED THE STAFF AND PUT A PLAN IN PLACE SO THIS WOULD NOT BE REPEATED. ANTICOAGULATION MEDICATIONS REQUIRE CLOSE MONITORING AND WE ARE AWARE. ALSO, WE ATTEMPTED A STAT LAB ON THE 18TH WHEN WE REALIZED IT HAD NOT BEEN DRAWN. THERE IS NOTHING ELSE I CAN SAY." REVIEW OF THE FACILITY POLICY TITLED "ANTICOAGULANT PT/INR MONITORING" UPDATED 4/18/13, DOCUMENTED "IT IS THE POLICY OF THIS FACILITY THAT THE RESIDENTS ON ANTICOAGULATION THERAPY WILL BE MONITORED TO ENSURE THE MAINTENANCE OF SAFE LABORATORY PARAMETERS AS ESTABLISHED BY THE PHYSICIAN. THE PROTOCOL FOR MANAGING ANTICOAGULANT THERAPY WILL ENSURE RESIDENT SAFETY AND PREVENT NEGATIVE EFFECTS FROM THE USE OF ANTICOAGULANTS. RESIDENTS RECEIVING ANTICOAGULANT THERAPY REQUIRE MONITORING AND WILL HAVE ANTICOAGULANT INR TRACKING INFORMATION PLACED IN THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]." ( )