Every finding on record at Regency on the Lake - Fort Gratiot

Based on observation, interview, and record review the facility failed properly store, label, and date medications for one resident (R56) of four residents reviewed for medication administration. Findings include: On 06/30/25 at 10:08 AM, Licensed Practical Nurse (LPN A) was observed to retrieve an inhaler for R56 from the cart which was unlabeled and undated. LPN A was asked if there was a date opened on the inhaler and replied, No. A review of R56's physician's order revealed, Ventolin HFA Inhalation Aerosol Solution 108 (90Base) Microgram per actuation (MCG/ACT)(Albuterol Sulfate) 2 puff inhale orally four times a day for shortness of breath. A review of R56 medical record revealed R56 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's. A review of R56's most recent Minimum Data Set assessment (MDS) revealed R56 with impaired cognition and required assistance of activities of daily living including medication administration. On 07/01/25 at 9:19 AM, the Director of Nursing (DON) was asked about the inhaler in the med cart not being labeled. The DON explained, they did not believe inhalers need a date opened on them, but would have to look at the policy. A review of facility policy titled Medication Management dated 9/22/2023 revealed, Medications are stored, dispensed and destroyed in a manner to ensure safety and conformance with state and federal laws . Medications will be dated and discarded per manufactures guidelines .

This citation pertains to Intakes MI00151561. Based on interview and record review, the facility failed to document notification of family and physician for a change in condition for one resident (R901) of three reviewed for notice of condition change. Findings include: A review of the complaint noted R901 had been seen on 01/28/25 and the resident appeared to be doing fine. It was noted that they were called on 01/30/25 and told R901 had been sent to the hospital. The complainant reported R901 appeared very ill and the emergency room physician reported that R901 had vomited and had a large amount of stool upon diagnostic examination and had sepsis (a body system wide infection). A review of the record for R901 revealed R 901 was admitted into the facility on [DATE], discharged to the hospital on 12/24/24 after and fall with fracture and readmitted [DATE]. R901 was treated for a urinary tract infection and low blood pressure. Diagnoses included Dementia, Chronic Obstructive Pulmonary Disease and Protein Calorie Malnutrition. The minimum data set (MDS) assessment dated [DATE] indicated moderately impaired cognition with an 11/15 Brief Interview for Mental Status score and the need for partial/moderate assistance with eating and personal hygiene, the need for substantial/maximal assistance for upper body dressing, oral hygiene, transfer and rolling left to right in bed. R901 was dependent for bathing. Further review revealed a progress note dated 01/30/25 at 6:12 AM revealed, At approximately 0415 (4:15 AM) CNA (certified nursing assistant) alerted that resident had labored breathing and increased lethargy .EMS (emergency medical service) arrived . and took resident to (hospital) ER. On 04/02/25 at 2:52 PM, CNA A reported during a phone interview that R901 had a complaint of stomach pain and liquid brown emesis (vomit) which did not appear to contain food. The CNA reported R901 was sick a couple of times that day and reported they told Nurse B and Nurse B gave R901 some Zofran (an anti nausea medication). On 04/02/25 at 3:07 PM, Nurse B they did not recall the specific color or type of emesis or what they had been told by the CNA. A review of the January 2025 Medication Administration Record (MAR) documented Nurse B administered a dose of Zofran on 01/29/25 at 12:30 PM. A review of the administration note for the same time documented the medication was for nausea and vomiting and patient requested. Further review of the progress notes revealed no documentation of physician or family notification related to the CNA A observation of liquid brown emesis. On 04/03/25 at 1:04 PM, during a phone interview, the Medical Director reported they were not aware of the liquid brown emesis for R901 and would have had the resident sent out to the hospital for evaluation.

Based on observation, interview, and record review, the facility failed to apply heel protector boots per physician orders for two residents (R5 and R24) out of two reviewed for skin conditions and apply positioning devices per physician orders for one resident (R1) out of two reviewed for positioning. Findings Include: R5 On 6/4/2024 at 9:15 AM, R5 was observed in their bed. Two heel protection boots were noted to be in a wheelchair. R5 was noted to have their heels resting on the mattress. R5 was asked if they wear heel boots while in bed. R5 said they sometimes do and sometimes don't. On 6/5/2024 at 9:16 AM, R5 was observed laying in bed. Two heel protection boots were noted to be in a wheelchair. R5 heels were noted to be resting on the mattress. A review of the medical record revealed that R5 admitted into the facility on [DATE] with the following diagnoses, Difficulty in Walking and Restless Leg Syndrome. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 13/15 indicating an intact cognition. R5 also required assistance with bed mobility and transfers. Further review of the physician orders noted the following, Orders: Bilateral heel boots ATC (Around The Clock) r/t (Related To) preference and pressure relief .Status: Active. On 6/5/2024 at 3:16 PM, an interview was conducted with Wound Care Nurse (WCN) A. WCN A stated that R5 usually has the boots on and they should be wearing them. WCN A stated it should be documented if they don't have them on and why. R24 On 6/4/2024 at 9:15 AM, 10:42 AM, 1:09 PM, and 2:30 PM, R24 was observed laying in bed. R24 stated they were having pain in their legs. R24 was noted to have heel boots on the floor next to their bed. A review of the medical record revealed that R24 admitted into the facility on [DATE] with the following diagnoses, Muscle Wasting and Atrophy and Muscle Weakness. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 1/15 indicating a severely impaired cognition. R24 also required assistance with bed mobility and transfers. Further review of the physician orders noted the following, Orders: Bilateral heel boots in bed .Status: Active. On 6/5/2024 at 3:14 PM, an interview was conducted with Wound Care Nurse (WCN) A. WCN A stated they did not know if R24 was resistant to wearing the boots or not, but R24 should have them on. WCN A stated R24 has had a decline in health since last hospital admission and they had just changed their mattress to a low air loss mattress. 50223 R1 A review of the medical record revealed that R1 admitted into the facility on [DATE] with the following diagnoses, Weakness and Abnormal Posture. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental status score of 8/15 impaired cognition. R1 also required assistance with bed mobility and transfers. Further review of R1's physician orders revealed an order stating Ensure resident's wheelchair has L arm bolster, rear anti-tippers, a cushioned head rest, a cushioned kyphotic back rest, a pressure reduction seat cushion and B elevating footrests to be used for increased tilting or transport. lambswool to wheelchair back r/t protection. On 06/04/24 at 10:37 AM, R1 was observed in hallway sitting in their wheelchair, leaning to their left side. An arm bolster was observed on right arm of wheelchair. No lambswool padding was noted. On 06/04/24 at 12:18 PM, R1 was observed still sitting up in their wheelchair at the nurse's station leaning to their left side and hunched over. An arm bolster remains on right arm of wheelchair. No lambswool padding noted. The same observation was made at 01:04 pm and 01:49 pm. On 06/05/24 at 09:10 AM, R1 was observed sleeping in bed. Their wheelchair was in the room with an arm bolster on the wheelchair on the right side. No lambswool padding noted. On 06/05/24 at 12:54 PM, R1 was observed sitting in their wheelchair in the dining area hunched over forward. An arm bolster was noted on the right wheelchair arm. No lambswool padding noted. On 06/05/24 at 03:26 PM, R1 was observed sitting at nurses' station in wheelchair. No lambswool padding noted. An arm bolster was noted on the right arm of the wheelchair. Further review of R1's care plan stated the following, Observe for sliding down in the chair and assist to reposition in chair as needed. Wheelchair seating and positioning: The pt is currently sitting in a tilt in space w/c, fitted with a L (left) arm bolster, rear anti-tippers, a cushioned head rest, a cushioned kyphotic back rest, a pressure reduction seat cushion and elevating footrests to be used for increased tilting or transport. On 06/06/24 09:36 AM, During an interview, the unit manager stated that the right arm bolster was discontinued and that they stopped using the lambswool when R1 received a new wheelchair. The unit manager could not confirm the date the change was made but stated it had been quite a while. A review of a facility policy titled, Physician's Order noted the following, Treatment rendered to a resident must be in accordance with the specific standing, written, verbal, or telephone order of a physician or other licensed health professional ordering within teir scope of practice and clinical privileges.

Based on observation, interview, and record review, the facility failed to secure smoking/vape pens for one sampled resident (R59) of two reviewed for accidents. Findings include: On 6/04/24 at 10:52 AM, R59 was observed lying in bed, when asked a question R59 stated, I don't feel well and I don't want to talk. Observed on R59's overbed table was one vape/smoking pen. On 6/06/24 at 9:04 AM, R59 was observed lying in bed, when asked a question R59 stated, I don't want to talk. R59 then asked to be left alone. Observed on R59's overbed table was one vape/smoking pen. On 6/06/24 at 9:18 AM, the Unit Manager and R59's assigned nurse was asked if R59 was allowed to have vape/smoking pens in their room. The Unit Manager and the nurse was observed to go to R59's room and reported, residents are not to have smoking/vape pens. The Unit Manager was observed to come out of R59's room with three unopened boxes and one open smoking/vape pen. A review of R59's medical record revealed, R59 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Atrial fibrillation. A review of R59's Minimum data set (MDS) assessment dated [DATE] noted R59 with an intact cognition and required assistance with activities of daily living. On 6/06/24 at 10:10 AM, the Director of Nursing (DON) was asked if the facility allowed vape/smoking pen at the facility. The DON reported, the resident should not have a vape pen. A review of the facility's policy titled, Non-Smoking Policy dated 5/1/2022 revealed, Policy: This facility is a non-smoking facility. Procedure: 8. Please note, all forms of E-Cigarettes, vaping material's, etc. are strictly prohibited to be in the facility .

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach of one resident (R1) out of one reviewed for call lights. Findings include: On 06/04/24 at 09:15 AM, R1 was observed in bed sleeping. The soft touch call light was hanging on the end of the bed out of reach of the resident. On 06/05/24 at 09:10 AM, R1 was observed in bed sleeping. The soft touch call light was on the floor past the end of the bed out of reach of the resident. A review of the medical record revealed that R1 admitted into the facility on [DATE] with the following diagnoses, Weakness and Abnormal Posture. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental status score of 8/15 impaired cognition. R1 also required assistance with bed mobility and transfers. Further record review of R1's care plan listed having the call light within reach as an intervention for multiple care plan problems as follows: Ensure/provide a safe environment. Call light in reach. Keep (R1's) environment as safe as possible with: even floors free from spills and/or clutter; adequate lighting; call light within reach, commonly used items within reach, avoid repositioning furniture. Put (R1) call light within reach and encourage [them] to use it for assistance as needed. Paddle call light to be used. Touch pad call light for ease of use and encouragement to use. (Name of R1) will have no evidence of noncompliance with transfers and will use call light or call bell. On 06/06/24 at 10:07 AM during an interview, the DON (Director of nursing) stated R1 is able to use the soft touch call light but is unable to use a regular call light. The DON states that the call light should be in reach at all times. A review of the facility policy titled Call Lights noted the following: Call lights will be placed within the guests/residents reach and answered in a timely manner.

This citation pertains to Intake MI00139026. Based on interview and record review, the facility failed to implement adequately supervision for one sampled resident (R901) of three residents reviewed for falls, resulting in multiple falls, and two hospital transfers. Findings include: A review of R901's census information revealed that R901 was originally admitted into the facility on [DATE] with diagnoses that included Alzheimer's Disease, Heart Failure, Gout, and History of Falling. A review of the R901's 5-Day Minimum Data Set assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status score of 8/15 indicating a moderately impaired cognition, and required extensive assistance of 2 persons for bed mobility, transfers, and toilet use. Further review of R901's admission fall risk assessment dated [DATE] categorized the resident as being at At Risk for falls with the following details noted: -Does the resident have a history of falls? Yes -Does the resident have a fear of falling, muscle weakness, decreased lower extremity joint function, balance deficit, or gait deficit? Yes -Does the resident have urinary urgency? Yes -Does the resident take medications that may increase falls (Antiarrhythmics, Anticolinergics, Antidepressants, Antiepileptics, Antihypertensives? Yes -Does the resident have impaired cognition, judgement, memory, safety awareness and/or decision making capacity? Yes A review of R901's medical record revealed that R901 sustained 13 unwitnessed falls in their room during their admission at the facility, two resulting in transfers to the hospital. Progress notes revealed the following: 12/2/2022 18:08 (6:08pm) Nurses Notes Note Text: Resident observed on floor next to bed at 0915 (9:15am). Resident stated she 'slid off of the bed'. Loose stool noted on floor surrounding resident . 1/23/2023 05:23 (5:23am) Nurses Notes Note Text: Resident had an unwitnessed fall in bathroom. Resident sustained a head gash above the right eye, complains of right hip pain and skin tare (tear) on right hand. Physician and family notified. Resident sent to [local hospital] for treatment. A review of R901's hospital documentation dated 1/23/23 revealed the following, .Presented to the emergency department via EMS (emergency medical services) from [facility] .Patient reports she had gotten up to go to the bathroom and slipped and fell landing directly on her right hip and striking her head and some of her right elbow and hand to break the fall .Assessment: Right hip pain status post mechanical fall with right acute comminuted displaced intertrochanteric fracture of right proximal femur .Plan: .patient was admitted under orthopedics for fall and is tentatively scheduled for right IT (intertrochanteric) intervention (surgery) today . Per Cleveland Clinic and [NAME] Hopkins, A comminuted fracture is a type of broken bone. The bone is broken into more than two pieces. It takes a lot of force for someone to get a comminuted fracture. A car accident or serious fall, for instance, can cause this type of break. Someone with a comminuted fracture will probably need surgery. A review of R901's census revealed that the resident was readmitted into the facility from the hospital on 1/26/23, and sustained a fall the same day according to the following progress note: 1/26/2023 22:35 (10:35pm) Nurses Notes Note Text: Resident observed on the floor in a sitting position in front of chair . Further review of R901's progress notes related to falls revealed the following: 2/18/2023 11:30 (11:30am) Nurses Notes Note Text: Called to resident's room around 0945 (9:45am). Res (resident) was observed on the floor sitting up on bilateral knees in front of recliner. Resident stated 'I forgot I needed help getting up.' No visible injuries noted and resident denies pain. 3/4/2023 18:28 (6:28pm) Nurses Notes Note Text: Called to this resident's room around 1720 (5:28pm) by CNA (certified nurse assistant) staff. Resident was observed on the floor in the middle of bathroom floor. She was sitting upright on buttocks facing toilet grab bar. Resident was barefoot and the floor was saturated in urine. It appears resident removed her brief and gripper socks at her recliner and then self transferred to the bathroom. She stated 'I was going to use the bathroom but I slipped on this wet stuff.' Resident denies any pain and stated she did not hit her head. No visible injuries to note . 3/23/2023 15:46 (3:46pm) Nurses Notes Note Text: Around 0930 CNA staff entered resident's room to observe her on the floor, sitting upright on buttocks on the floor in front of recliner, facing the bed. No visible injuries. Denies hitting her head. Denies any new pain . 4/2/2023 02:37 (2:37am) Nurses Notes Note Text: resident was observed sitting on the bathroom floor next to her wheel chair that was located next to the toilet. Resident was observed in the sitting position between the toilet and her wheel chair. Resident did not pull the light cord as instructed. No injuries were observed. Resident had socks on that were not non slip socks and wheel chair was not locked. Resident stated that she was not injured and didn't hit her head . 4/4/2023 16:42 (4:42pm) Nurses Notes Note Text: Resident was observed on the floor in her room. Resident stated that she was trying to use the BR (bathroom). Resident found on floor, on her bottom but more on her L (left) hip, sitting in front of her BR door. Stated she did not hit her head and no injuries at this time . 5/11/2023 12:01 (12:01pm) Nurses Notes Note Text: This writer was called into resident's room by aide, Resident was observed sitting on buttocks in front of recliner chair leaning on recliner towards left side, feet out. Resident stated she just slipped out of her recliner chair. 5/24/2023 06:49 (6:49am) Nurses Notes Note Text: resident observed on floor at 0545 (5:45am), skin tear noted to right arm . 6/1/2023 03:50 (3:50am) Nurses Notes Note Text: Writer entered resident's room at 03:50 (3:50am) and observed resident sitting in front of her recliner on her buttocks with both legs outstretched. Resident stated 'I just slid out.' Resident denied pain or injury . 7/8/2023 05:45 (5:45am) Nurses Notes Note Text: Writer entered resident's room at 05:45 (5:45am) after hearing resident yelling. Writer observed resident on the floor in front of her recliner on her hands & knees. Resident stated 'I don't know what I was doing .' 8/2/2023 10:56 (10:56am) Nurses Notes Note Text: resident observed laying on L (left) side of body with L arm under her, feet facing the doorway, head pointed towards window side. blood noted under resident's head. call light not in use. resident stated she attempted to get up but doesn't know why. 2 lacerations noted to L side of forehead, skin tear noted to L shoulder and back of LUE (lower upper extremity). resident c/o (complain of) head pain and pain to LUE. resident able to perform ROM (range of motion) to LUE . 8/2/2023 19:24 (7:24pm) Nurses Notes Note Text: Resident returned from the hospital around 1530pm (3:30pm) via EMS .Hospital paperwork states laceration #1 has 7 (sutures) and laceration #2 has 4. Sutures to be removed in 5-7 days . While at the hospital they offered for a CT scan and cervical spine but residents family denied it due to patients mental status and hospice status . On 9/5/23 at 2:55 PM, Unit Manager A was asked about R901's numerous falls while admitted to the facility, and she explained that a lot of R901's falls revolved around toileting, specifically stomach issues resulting in loose stools, and the resident attempting to self-transfer on their own. Regarding fall interventions, Unit Manager A explained that their fall coordinator along with the nurses on duty following a fall would implement interventions. Unit Manager A explained that one of the interventions was for the resident to move from the end of the hall the center hall where there was more traffic where the resident could be monitored more, as she preferred to remain in her room in her recliner. Regarding hourly rounds, Unit Manager A explained that hourly rounds are completed 72 hours post-fall. On 9/5/23 at 3:09 PM, the Director of Nursing (DON) was interviewed about R901's multiple falls, and he explained that the resident was having falls prior to admittance into their facility and that R901 would not stop trying to take themselves to the bathroom. The DON explained that R901's cognition would fluctuate and implemented several interventions, one which involved moving the resident to the center of the hall, closer to offices and traffic. The DON was asked how the facility determines that fall prevention interventions are effective, and he explained that evaluating effectiveness of falls is ongoing and that the IDT (interdisciplinary team) reviews and discusses falls. The DON was asked about more frequent rounding on the resident, and explained that frequent rounding is their standard of care. The DON was asked about additional supervision for the resident including bringing the resident to common areas, and he explained that the resident declined being out of their room, and was more comfortable in their recliner. A review of R901's census revealed that the resident remained in the same room for the entire length of their admission. Further review of R901's medical record revealed a fall care plan with duplicate interventions: A review of R901's care plan revealed the following: [R901] is at risk for fall related injury and falls R/T (related to) generalized weakness and history of falls, she receives antianxiety, antidepressant medication vitamin D deficient. Date Initiated: 08/02/2023. Created on: 11/29/2022 Interventions: -Keep the resident's environment as safe as possible with: even floors free from spills and/or clutter; adequate lighting; call light within reach, commonly used items within reach, avoid repositioning furniture and keep the bed in the appropriate position. Date Initiated: 11/29/2022 -Provide [R901] with activities that minimize the potential for falls while providing diversion and distraction. Date Initiated: 12/05/2022 -dycem to recliner Date Initiated: 12/06/2022 -Encourage the resident to wear appropriate footwear as needed. Date Initiated: 01/06/2023 -Encourage use of call light. Date Initiated: 01/06/2023 -Encourage resident to wear non-skid foot wear when out of bed. Assist resident as needed. Date Initiated: 01/23/2023 -Resident to have anti-slip mat in front of recliner. Date Initiated: 01/27/2023 -use touch pad call light Date Initiated: 02/19/2023 -Put [R901's] the call light within reach and encourage her to use it for assistance as needed. Date Initiated: 02/21/2023 -anti roll brakes to wc (wheelchair) Date Initiated: 02/23/2023 -Obtain UA w/C&S (urinalysis with culture and sensitivity) Date Initiated: 03/06/2023 -med review r/t loose stools Date Initiated: 03/10/2023 -complete elimination pattern assessment x 72 hours Date Initiated: 03/23/2023 -Encourage [R901] to rest [in recliner, chair or bed] when they appear fatigued. Date Initiated: 05/11/2023 -Medication Review with [physician]. UA C&S ordered Date Initiated: 05/24/2023 -placed slippers on after fall. reinforced use of call light Date Initiated: 05/24/2023 -verify grippy sock are being worn every shift Date Initiated: 05/24/2023 -call don't fall signs placed Date Initiated: 06/07/2023 -different recliner when available Date Initiated: 06/07/2023 -Administer medication supplements as ordered. Date Initiated: 06/07/2023 -Hospice consult Date Initiated: 06/07/2023 -Hourly rounding for 72 hours post fall Date Initiated: 06/07/2023 -Obtain labs as ordered, report abnormal findings to the physician. Date Initiated: 06/07/2023 -PT/OT (physical and occupational therapy) evaluate and treat as ordered or PRN (as needed) Date Initiated: 06/07/2023 -Offer/encourage [R901] to rest in her bed at night time in place of her recliner Date Initiated: 07/10/2023 -Staff to perform hourly rounding 72 hours post fall Date Initiated: 08/02/2023 A review of the facility's Fall Management policy revealed the following, Policy:The facility will identify hazards and guests/resident risk factors and implement interventions to minimize falls and risk of injury related falls. Overview: 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 progras as appropriate to minimize the risk of falls

Based upon observation, interview and record review, the facility failed to develop a care plan for use of a right hand orthosis (hand held splint) for one (R26) of two residents reviewed for orthotics resulting in limited resident access to and application of the orthosis. Findings include: Review of the facility record for R26 revealed an initial admitted [DATE] with diagnoses that included Cerebral Infarction with Right Hemiplegia and indication of a history of falls. R26 was readmitted on [DATE] following a hospitalization with the new diagnosis of Encephalopathy. The Minimum Data Set (MDS) assessment dated [DATE] indicated R26 required supervision for eating and upper body dressing, set up for oral hygiene and primarily maximum assistance for self care tasks and transfers otherwise. On 4/2/23 at approximately 9:50 AM, R26 was observed laying in bed. It was noted that R26 appeared to have right upper extremity contractures at the elbow, wrist and hand. There were no splints or orthotics in place and none were observed in the room. When asked about the use of any splints R26 expressed non-verbally that they did not have any. On 4/3/23 at approximately 9:15 AM, R26 was observed in their bed. It was noted that there were no splints or orthotics of any kind in place on the right upper extremity. R26 gave the writer permission to check their drawers/cabinet for any orthotics. A hand carrot orthosis (splint) was located in a wash basin on top of the dresser located opposite of the foot of R26's bed. When asked if the hand carrot was being placed in R26's hand they expressed that it had been but not recently or frequently. On 4/3/23 at approximately 1 PM, Occupational Therapists (OT) H and I were interviewed regarding their evaluation findings and recommendations for R26. They both indicated that R26 was not appropriate for full splinting at this time due to the extent of the contractures and therefore a right hand carrot was initially provided to attempt to prevent further hand flexion (closing) contracture. On 4/3/23 at approximately 2:15 PM, the Facility Administrator (NHA) was interviewed regarding the facilities restorative program status and they indicated that there currently was essentially no restorative service as the restorative aides are being pulled to the floor to cover traditional nurse aide duties. The NHA indicated that they were working towards reinstatement of consistent restorative services. On 4/3/23 at approximately 2:30 PM, R26 was observed in their bedroom and the hand carrot was not in the right hand. The carrot was observed to remain in the wash basin on the dresser. Further review of the facility record for R26 revealed no physician orders, care plans or task/Kardex checklist related to use of the right hand orthosis. Review of R26's Occupational Therapy evaluations reveals that the initial evaluation dated 2/10/23 includes short-term and long-term goals (#4) related to resident tolerance of wearing a right hand resting hand splint. On 4/4/23 at approximately 9:10 AM, R26 was observed in their bed. The right hand carrot was not in place. On 4/4/23 at approximately 11:30 PM, the facility Director of Rehab (DOR) was interviewed and stated that the expectation for a resident provided with an orthosis (splint) from therapy is, that a related order and a care plan should be in place. On 4/4/23 at approximately 12:30 PM, the NHA was interviewed and stated that the expectation regarding a resident provided with an orthosis is that a related order and care plan should be in place. On 4/4/23 at approximately 1 PM, during a group interview with the NHA, DOR and occupational therapy staff members, the staff expressed that R26 had been able to apply and remove the right hand carrot without assistance however the writer noted that during the length of the survey the carrot has been stored well out of R26's reach and therefore they are not able to access it independently. Review of the facility policy titled Brace and Splint Program dated 4/26/22 revealed the following Procedure: 5: Interdisciplinary Care Plan a. A care plan will be developed that has measurable objectives and interventions and that include the following: b. Applying the brace and splint: Resident applies the brace with staff that provide verbal and physical guidance and direction that teaches the resident how to apply, manipulate and care for the appliance. c. Staff has a scheduled program of applying and removing the appliance that includes: d. Scheduled hours to be worn and when skin will be inspected for signs and symptoms of pressure areas, irritations, rashes, etc. and will be reported to the charge nurse and attending physician. e. Communicate individualized interventions to the direct care providers. Provide specific directions and training as needed. Update care plan and Kardex.

Based on observation, interview and record review, the facility failed to ensure medications were administered per order for one resident (R38) of five reviewed for medications, resulting in the potential for the exacerbation of acute or chronic health conditions. Findings include: On 4/2/23 at 9:14 AM, R38 was observed sitting up in bed with their breakfast tray in front of them. R38 was unable to respond to interview questions and appeared to have some limited use of the left side of their body. A review of R38's record and Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was admitted into the facility on [DATE] with medical diagnoses of Altered Mental Status, Unspecified Convulsions, End Stage Renal Disease, Type 2 Diabetes Mellitus, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Metabolic Encephalopathy, Dependence on Renal Dialysis, Other Seizures, Dysphagia, Oropharyngeal Phase, and Muscle Weakness. Further review revealed that the resident is severely cognitively impaired and requires supervision to extensive assistance for most activities of daily living (ADLs). A review of R38's orders revealed: Hemodialysis MWF (Monday, Wednesday, and Friday) (p/u (pick up) at 10 am) at [outpatient dialysis center] *Be sure to send hemodialysis communication form with resident - every day shift every Mon, Wed, Fri. Depakote Oral Tablet Delayed Release 500 MG (milligrams) (Divalproex Sodium) Give 500 mg by mouth one time a day every Mon, Wed, Fri for seizures -Start Date 03/13/2023 1400 (2:00) PM (Medication due at 2:00 PM). Keppra Oral Tablet 500 MG (Levetiracetam) Give 500 mg by mouth one time a day every Mon, Wed, Fri for seizures -Start Date- 03/13/2023 1400 (Medication due at 2:00 PM). Vimpat Oral Tablet 150 MG (Lacosamide) Give 150 mg by mouth one time a day every Mon, Wed, Fri for seizures -Start Date- 03/13/2023 1400 (Medication due at 2:00 PM). A review of R38's Medication Administration Record (MAR) from March 2023 revealed that the ordered 2:00 PM Depakote, Keppra, and Vimpat, were not administered on 3/22/23, 3/27/23, and 3/29/23, specifically by Licensed Practical Nurse (LPN) G. A review of the accompanying progress notes for the missed doses indicated that LPN G did not administer the medication because R38 was, at dialysis. On 4/3/23 at 8:14 AM, LPN G was interviewed at the facility and asked if R38 is sent to dialysis with any medications. LPN G indicated that the resident was not. LPN G showed this surveyor R38's dialysis communication forms, which indicated that the only medication administered to the resident at their dialysis appointments is Sensipar (used to treat high calcium levels). LPN G was asked why they did not administer R38's 2:00 PM medications, if they are not sent with the resident on dialysis days. LPN G stated that he has never personally given R38 their ordered 2:00 PM medications (Keppra, Depakote, Vimpat) on dialysis days because the resident gets back late, and he was not sure if he was supposed to give them or not. LPN G reviewed the facility's hemodialysis policy (revised 10/1/2019) in this surveyor's presence at the nurses' station, however, no guidance was noted in the policy regarding medications. On 4/4/23, a review of R38's Medication Administration Record (MAR) from April 2023 revealed that the ordered 2:00 PM Depakote, Keppra, and Vimpat, were administered on 4/3/23 by Licensed Practical Nurse (LPN) G. On 4/4/23 at 8:27 AM, LPN G was interviewed and asked what led him to administer R38's 2:00 PM medications yesterday, 4/3/23, when he had not done so previously. LPN G stated he talked with his co-workers and made sure R38 received their seizure medications when they returned from dialysis. A review of the documents scanned into R38's chart revealed lab results dated 3/22/23 which included, Valproic acid level (Depakene) = 45.2 ug/mL [therapeutic 50-120 ug/mL]. On 4/4/23 at 12:45 PM, the Director of Nursing (DON) was interviewed. The DON was asked if he could provide any rationale as to why LPN G did not administer R38's ordered 2:00 PM seizure medications on their dialysis days. The DON was unable to provide an explanation and stated he would need to follow up with R38's physician regarding the resident's medication orders. A review of the facility's policy/procedure titled, Medication Administration, revised 9/9/22, revealed, Guest/resident medications are administered in an accurate, safe, timely, and sanitary manner .Medications are administered in accordance with written orders of the attending physician. If a dose is inconsistent with the guest's/resident's age and condition or a medication order is inconsistent with the guest's/resident's 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 .

Based on observation, interview, and record review the facility failed to answer call lights in a timely manner, assist with brief changes and or failed to assist residents during meals for four residents (R1, R8, R62, R68) of seven residents reviewed for activities of daily living care (ADLs), resulting in dissatisfaction with care, dissatisfaction during meals, and the potential for compromised nutrition and weight loss. Findings include: Resident #1 (R1) On 4/2/23 at 9:00 AM, during an initial tour of the facility, R1 was interviewed about their level of satisfaction with the care that they were receiving at the facility. R1 indicated that they sometimes had to wait up to Two hours for a brief change. R1 stated, That's too long. On 4/2/23 at 10:00 AM, a review of R1's EMR revealed the following, R1 had diagnoses of Heart failure and Hemiplegia (Paralysis) affecting left non-dominate side. A review of R1's most recent quarterly MDS revealed that R1 had an intact cognition and required extensive assistance with all ADLs other than eating. On 4/3/23 at 8:57 AM, R1 was further interviewed about their brief changes and call light response time and stated, It's terrible. On 4/3/23 at 9:00 AM, R1's call light was activated. The light was observed to be on outside of R1's room and a small red light inside the room indicated that A call had been placed. On 4/3/23 at 9:15 AM, staff was observed walking past R1's room and did not respond to R1's call light. On 4/3/23 at 9:22 AM, staff was observed walking past R1's room and did not respond to R1's call light. On 4/3/23 at 9:35 AM, R1's assigned Certified Nurse Assistant (CNA) B was interviewed regarding R1's call light and their lack of response to the call light. CNA B stated, I was giving another resident a shower. CNA B indicated that any staff member could answer a resident's call light. On 4/3/23 at 9:45 AM, Nurse Manager - Registered Nurse (RN) A was interviewed about their expectations regarding staff answering resident's call lights. RN A indicated that they would like to see call lights answered within Ten minutes or less. RN A indicated that staff should be Communicating with each other to ensure that resident call lights are answered in a timely manner. On 4/4/23 at 11:00 AM, the Director of Nursing (DON) was interviewed regarding their expectation for staff when answering resident's call lights and meal set-up for residents. The DON stated, Ideally, I would like to see call lights answered within ten minutes or less. 32220 R62 On 04/02/23 at 10:56 AM, R62 was observed to be in bed. R62 had their breakfast tray on the over bed table across their lap. R62 leaned toward the right with the head of the bed up around 30-45 degrees. Muffin halves, sausage were not eaten. The cereal had a spoon in but still reached the top rim of the bowel. The drinks were open but did not appear to have been touched. On 04/02/23 at 1:13 PM, the lunch tray had been served to R62. R62 was observed to be in bed and with eyes closed. R62 leaned over to the right and the head of the bed was up around 30-45 degrees. R62 had a large selection of items. The egg salad sandwich appeared to have a couple of bites out if it. The lemonade, potato salad, onion rings and cantaloupe did not appear to have been eaten. On 04/02/23 at 3:31 PM, R62 appeared in the same position with the food items uneaten as before. On 04/03/23 at 8:22 AM, R62 was observed to be in bed. The breakfast tray was on the over bed table across the resident's thighs. R62 leaned toward the right in bed with the head of the bed up around 30-45 degrees. Around 80% of the meat was left and two slices toast and oatmeal remained to be eaten. On 04/03/23 at 1:01 PM, R62 was observed to out of bed, dressed and seated in the area around the nurse's station for lunch. R62 sat up straight and appeared to feed themselves slowly, but consistently. On 04/03/23 at 3:56 PM, the Therapy Director reported R62 had been picked up on 03/29/23 for physical (PT) and occupational therapy (OT) related to a nursing report about increased debility. This included walking, toileting, dressing and standing. R62 had five PT and three OT visits and was participating. On 04/04/23 at 8:25 AM, R62 was observed to be in bed with 50% of the breakfast eaten. R62 leaned over to right and the head of the bed was up around 30-45 degrees. A review of the record for R62 revealed, R62 was admitted into the facility on [DATE]. Diagnoses included Dementia, Alzheimer's and Heart Disease. The Minimum Data Set Assessment (MDS) dated [DATE] documented impaired cognition and the need for extensive assistance of one person for bed mobility, transfer, locomotion, dressing, toilet needs and personal hygiene. Eating was documented as independent with set up. R8 and R68 On 04/02/23 at 8:36 AM, during the initial resident screening, R68 commented that there were times when they waited for extended lengths of time to get their call light answered and their care needs met. On 04/04/23 at 8:39 AM, call lights were observed activated on the south unit. Call lights for R8 was activated and was shown on the kiosk at the nurse's station. At 8:49 AM R68 call light was activated. R8's call light remained activated. At 9:18 AM, the call light for R's 8 and 68 continued to be activated. At 9:27 two activity staff (in green scrubs) entered into room for R8 and R68 and spoke with the residents and exited. The call lights subsequently came back on. At 9:40 R8 was asked about their care needs and reported that they needed to be changed. R8 further noted that staff took the breakfast tray and turned off the light but did not return. R8 verbalized they then turned the call light back on. At 9:42 AM staff entered the room of and spoke with, R8. The staff exited the room and did not find the needed supplies in the supply closet, reported this to the resident and walked to the other end of the unit for supplies. At 9:51 AM the call light for R8's remained on. A different aide entered the room of R8. The call light for R8 went out at 9:55 AM and the call for R68 was back on. At 10:09 AM staff entered the room of R68 and assisted them. R68 waited around 80 minutes for assistance and R8 waited around 70 minutes for personal hygiene assistance. A review of the record for R8 revealed R8 was admitted into the facility on [DATE]. Diagnoses included Cerebral Palsy, Diabetes and Chronic Obstructive Pulmonary Disease. The Minimum Data Set Assessment (MDS) dated [DATE] documented intact cognition with a 15/15 Brief Interview for Mental Status (BIMS) score and the need for total assistance of two persons for bed mobility and transfer and extensive assistance of one person for dressing, toilet needs and personal hygiene. A review of the record for R68 revealed, R68 was admitted into the facility on [DATE]. Diagnoses included Stroke, Aphasia (Difficulty Speaking) and Hemiplegia (paralysis on one side). The Minimum Data Set Assessment (MDS) dated [DATE] documented intact cognition and the need for extensive assistance of one or two persons for bed mobility, transfer, dressing, toilet needs and personal hygiene. On 4/04/23 at 11:33 AM, during the Quality Assurance (QA) review the Administrator was asked about meal assistance and call light response. The Administrator reported they had not been aware of any call light concerns until about a week and half ago. The Administrator reported the facility had identified meal assistance as a concern and discussed the concerns in morning meeting along with weight loss. The Administrator reported the idea would be to provide assistive dining, having more communal dining and how to get residents to come out as some had been resistive to communal dining. The Administrator reported these activities went away with COVID and staffing has been an ongoing challenge with a decreased pool of nurse assistants and nurses. The Administrator also commented that all office staff are assigned to assist nursing with meal assistance during dining times. On 4/4/23 at 11:45 AM, a facility policy titled Call Lights Last Revised: 2/15/2022 was reviewed and stated the following, Policy: Call lights will be .answered in a timely manner .Responding To A Call Light: 1 .answer the guest/resident promptly . On 4/4/23 at 11:50 AM, a facility policy titled Routine Resident Care Last Revised: 3/7/2023 was reviewed and stated the following, Residents receive the necessary assistance to maintain good grooming and personal .hygiene .Guidelines 8. Incontinence care is provided timely according to each resident's needs. On 4/4/23 at 11:57 AM, a facility policy titled Meal Service Last Revised: 11/11/2021 was reviewed and stated the following, Policy: It is the policy of this facility to provide a dinning experience that is conducive to meal acceptance .

This citation has two deficient practices. This citation pertains to Intake MI00135496. Deficient practice #1. Based on observation, interview and record review the facility failed to provide sufficient staff monitoring to prevent inappropriate wandering, for one (R109) of one sampled residents reviewed for wandering, resulting and multiple unwelcome entries into residents' rooms. Findings include: On 4/02/23 at 11:13 AM, R109 was observed in bed sleeping, in the room a staff person was observed sitting in a chair near R109's bed. The staff person was asked the reason for her in R109's room and stated, Last night [R109] tried to get in bed with another resident without any clothes on. On 4/03/23 at 9:15 AM, R109 was observed with one to one (1:1) supervision from a staff person. On 4/04/23 at 12:35 PM, R109's one to one Certified Nurse Assistant (CNA) R was asked about R109's behavior and stated, [R109] has been ok today. I was able to get [R109] to sit and watch a movie, but I didn't know [R109] was legally blind, until [interested party] told me. CNA R explained that she normally works another unit but understood that [R109] had behaviors that required one to one supervision. On 4/04/23 at 12:36 PM, CNA P was asked about taking care of R109 and stated, [R109] loves to walk around. [R109] has been aggressive, will sometimes forget where the bathroom is and would just go wherever [R109] is. CNA P further explained that R109 had been aggressive with her when trying to assist the resident to the bathroom. On 4/03/23 at 3:16 PM, Social Service was asked about R109 and explained, R109's behavior had mostly been exit seeking, but in the last week R109 has been more ramped up. Social Service reported that they offered a different placement for the resident, but the family did not agree to the transfer. A review of R109's medical record revealed, R109 was admitted to the facility on [DATE] with diagnosis of Respiratory Bronchiolitis Interstitial Lung disease, Adjustment Disorder with Depressed Mood, Dementia with Behavioral Disturbance. A review of R109's Minimum Data Set Assessment (MDS) dated [DATE] noted R109 with an severely impaired cognition and required extensive assistance of one staff person for Activities of Daily Living (ADLs). Further review of R109's medical record revealed the following progress notes: 3/10/23 16:24 Social Service Note Text: Resident referred to Psych Services. 3/14/23 Behavior Note Text: Resident became agitated with staff when continuing to encourage use of walker for ambulation. Resident walked and said, (explicitive) you guys! 3/15/23 15:38 Nurse Practitioner Note Text: . Complaint: New patient-medication review/Dementia with behaviors . Todays nursing staff, reports pt (patient) wonders but states he is easy to redirect . 3/16/23 01:38 Behavior Note Text: Resident frequently ambulating in hallway w/out (without) walker and nothing on feet. Attempting to enter other patients rooms. Becomes agitated when staff attempt to redirect, states, I'm not staying here, I'm going home to my wife. Encourage resident to proper footwear on and resident refused. 3/17/2023 Nurses Note Text: Res exit seeking this evening. Activity, snack, bathroom, companionship, tv, exercise all offered with no effect . 3/17/2023 23:32 Behavior Note Text: Res (resident) continues to be redirected but is going into rooms on SE (Southeast) Resident set off exit door on SE hall. 3/18/2023 00:34 Behavior Note: Res continues to set off door alarms, and is trying to get into the SE linen closet. 3/18/23 00:53 Behavior Note Text: Res has set off alarm on SW (southwest) exit door. Res being redirected by staff. 3/18/2023 00:57 Behavior Note Text: Resident setting off door alarms and trying to get out. Resident was redirected several times. Requires one on one (1:1). 3/19/2023 19:35 Behavior Note Text: Resident continues to wander with exit seeking behaviors through out the shift. Res set off door alarms at minimum of 15 times this shift. Res is easy to redirect but very forgetful. 3/21/2023 16:14 Behavior Note Text: Resident was observed by CNA and nurse to be standing at the Center East emergency exit door with [R109's] pants and pull up down around [R109's] ankles and feces on the floor behind him. Staff assisted the resident to bathroom to get cleaned up and changed. 3/23/2023 13:00 Behavior Note Text: Resident set off door exit alarms numerous times this shift. Staff able to redirect resident easily, but res immediately begins attempting to exit facility side doors minutes later. 3/23/2023 18:02 Behavior Note Text: Resident was observed by CNA taking food off other resident's dinner tray this evening. Resident became agitated with staff when attempting to redirect to his own dinner tray. 3/24/2023 02:01 Nurses Note Text: Resident continued to wander and enter other residents rooms at start of shift. Resident given shower as ordered and prn (as needed) Ativan (antianxiety), effective. Currently resting in bed call light w/in reach. 3/24/2023 19:47 Behavior Note Text: Res into rooms 200 & 201 upsetting residents within, telling this writer to shut the (explicitive) up, when being redirected back out into hall. 3/24/2023 19:57 Behavior Note Text: Res tried to push 217-1's w/c. Res 217-1 stated- Get yr (your) hands off me you SOB (son of a explicitive). Res stated- You'll get yrs the same way honey. 3/24/2023 20:01 Behavior Note Text: Res has shut himself in w/resident of room [ROOM NUMBER]. Nurse has retrieved. 3/24/2023 20:08 Behavior Note Text: Res entered room [ROOM NUMBER] redirected out after res within yelling at [R109] to leave. 3/24/2023 20:10 Behavior Note Text: Res unzipped pants attempting to urinate on SE hall couch. Res redirected to room. 3/24/2023 Behavior Note Text: resident continues wander in and out and attempts to get into bed with other residents males and females when asked what he was doing? Response I am getting into bed resident redirected to their own room and bed several times, resident walked up behind author and exposed himself while author turned around. Resident motion when author turned around. Resident was told to stop and to put his (private parts) away. Response was I am looking for a good room and slowly stopped behaviors and put his (private parts) away and returned to wandering in and out of rooms. Resident was redirected to his room where he promptly left the room to walk the halls again. 3/25/2023 Behavior Note Text: Resident observed in hallway holding hands and rubbing another resident back. Redirected to go on walk with CAN and told that it was inappropriate behavior. When redirected, resident grabbed the CNA's arm and told her no. Continued to redirect both residents during entire shift, both refused. On call nurse notified. Has not gone further than hand holding at this time. Resident also urinated in another residents room. Redirected to use his bathroom. On four separate occasions resident opened doors and set off alarms. Redirected to walk within the unit. 3/25/2023 Behavior Note Text: resident threatened another resident stating I will whoop your (explicitive). Nurse told resident that this was inappropriate, and he walked away. 3/25/2023 Nurses Note Text: res cont. (continue) to set off door alarms and go into other res rooms beginning at shift change. 3/26/2023 11:02 Nurses Note Text: resident began wandering and exit seeking this morning. Non pharm (pharmological) interventions ineff. (ineffective). PRN Ativan admin at 0900. At around 0945 res set alarm to back hallway off (SW). CNA attempted to intervene, resident became combative and struck CNA twice. His legs became weak at that time and he fell , striking head on door frame and then floor. More staff arrived to assist. Writer observed res on floor in back hall, just before door fame. Laying on right side. Blood on floor coming from head. See risk management assessment for assessment. Wife happened to call when writer was at nurse station for fall paperwork (at 0953). She voiced understanding but was agitated that she wasn't notified yet, writer attempted to explain to her that incident just occurred . 3/26/2023 17:32 Behavior Note Text: resident has been wandering and exit seeking since returning from hospital. Entering other rooms and restrooms, while they are using restrooms. He as required almost one on one supervision. Unable to redirect. 3/30/203 13:22 Social Service Note Text: 3/26/23: Resident had titration of his Ativan from 0.5 milligram (mg) every (Q) 6 hours PRN to 0.5mg QD (everyday). 3/30/2023 18:55 Nurse Note Text: No new complaints of pain or injury from pervious fall. Neurological assessments remain WNL (within normal limits) for resident. Res continues to wander into other resident rooms and attempts to exit seek. 3/31/23 21:00 Behavior Note Text: Res has pulled wooden frame out from dry wall of nurses station. Nurse redirecting. 3/31/2023 21:35, Res entering rooms on SE hall. Res redirected back to his room. 4/1/2023 02:08 Behavior Note Text: Res cont. to go up and pat resident (in room) 217-1 on the shoulder, despite redirection. Res 217-1 began screaming Stop touching me!' Res redirected back to room. 4/1/2012 04:29 Behavior Note Text: res in room. Res in her room began screaming at res to get out CNA went in to redirect and was pushed by res. Res then directed out. 4/1/2023 18:19 Behavior Note Text: res wandering for most of the shift. He was observed entering other resident's rooms numerous times, and even attempting to get into their beds while occupied. Res was not redirectable every time and became agitated with staff when asked to leave the room. Res would leave the room eventually but quickly entered another room . 4/2/2023 08:27 Nurses Note Text: At approximately 2100 [R109] enter another residents room and began to undress and get into bed with that resident. Two aides called me into the room for assistance. I walked in and told [R109] that this was not his room and we had get out. I pulled up his pants and walked him out of that this was not his room and we had to get out. I pulled up his pants and walked him out the room. No one was harmed . A review of R109's care plan noted, [R109] is at risk for decline in cognition and has impaired cognitive function or impaired thought processes R/T: Dementia. [R109] takes Namenda and Aricept for Dementia. Date Initiated: 3/7/2023. Goal: Will remain oriented to person place, situation, time through the review date. Date Initiated: 3/7/3023. Intervention: Anticipate needs from non-verbal indicators and past preferences as known. Focus: [R109] has actual behavior problem R/T: Dementia. Noted to remove clothing, wander into other resident rooms and exit seek Due to these behaviors and there impact on the resident and others, [R109] will have a 1 on 1, 4/3/2023. Interventions: Anticipate and meet resident's needs. Ask resident the following questions when stripping behavior occurs: if they need to go to the bathroom- assist as needed, if they are hot - assist to changes clothes as needed. Date initiated: 3/7/23. On 4/04/23 at 1:04 PM, Licensed Practical Nurse (LPN E) was asked via phone about R109's behavior. LPN E stated [R109] would wander a lot we would redirect. LPN E was asked about the incident with R109 exposing themselves and stated, No other resident was in the hallway at the time. I was the only one standing there. I don't think it was in a sexual manner. On 4/04/23 at 12:44 PM, the Director of Nursing (DON) was asked about the incident and explained that they put [R109] on 15-minute checks for the behaviors, and that they now see that 15 minute wasn't enough. The DON also explained that R109 will remain on the one to one to keep him and others safe. A review of the facility's policy titled, Behavior Management dated 7/9/22 noted, Policy: The facility will provide individualized care and services that promote the highest practicable level of function by providing activity/functional programs as appropriate and safety interventions to minimize behaviors Deficient practice #2. Based on observations, interview, and record review the facility failed to secure an oxygen tank in a restraint carrier or holder, for one sample resident (R34), of one resident reviewed for accidents, resulting in the potential for the cylinder to tip over causing fire and/or explosion. Findings inculde: On 4/02/23 at 8:57 AM, R34 was observed in their room in the bed and across the room there was an oxygen tank not in a carrier or holder. On 4/02/23 at 11:12 AM, the oxygen tank was observed in the same condition. On 4/02/23 at 9:39 AM, R34 was observed in their bedroom, R34 was observed their wheelchair moving around near the oxygen tank. The oxygen tank remained free from a carrier or holder. On 4/02/23 11:41 AM, Licensed Practical Nurse (LPN S) was asked about the tank and was observed to pick up the oxygen tank and carry it to a room titled carts, placed it on the floor, not into a carrier or holder, and closed the door. On 4/04/23 at 12:51 PM, the Director of Nursing (DON) was asked about the oxygen tank and stated, It should not be sitting in the room like that. A review of the facility's polity titled, Oxygen Storage & Assembly, dated, 1/17/2022 noted, Oxygen and oxygen equipment is stored in a safe manner. Information: Oxygen Tank Safety . Secure each tank individually, by a chain, on a cart or a stand .

Based on observation, interview, and record review, the facility failed to provide thickened liquids per diet order for one resident (R38) of three reviewed for nutrition, resulting in the potential for difficulty swallowing and aspiration. Findings include: On 4/2/23 at 9:14 AM, R38 was observed sitting up in bed with their breakfast tray in front of them. R38 was unable to respond to interview questions and appeared to have some limited use of the left side of their body. R38's tray included a glass of orange juice and a glass of milk, and their meal ticket indicated that the resident's liquids were supposed to be nectar thick consistency, and that the resident was under aspiration precautions. The orange juice and milk on the tray, along with two Styrofoam cups on the resident's bedside table (one with water, one with what appeared to be apple juice) were visibly regular consistency (thin liquid). R38 then picked up their glass of milk and took a drink. The milk, again observed to be regular consistency, dripped down the resident's chin and the resident was observed holding the milk in their mouth as they attempted to swallow it. A review of R38's record and Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was admitted into the facility on [DATE] with medical diagnoses of Altered Mental Status, Unspecified Convulsions, End Stage Renal Disease, Type 2 Diabetes Mellitus, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Metabolic Encephalopathy, Dependence on Renal Dialysis, Other Seizures, Dysphagia, Oropharyngeal Phase, and Muscle Weakness. Further review revealed that the resident is severely cognitively impaired and requires supervision to extensive assistance for most activities of daily living (ADLs). On 4/2/23 at 10:19 AM, R38 remained in bed. The two Styrofoam cups on the resident's bedside table with regular consistency liquid contents were observed. A review of R38's record revealed the following active diet order: Diet: Regular diet, Level 3 Advanced (Mechanical Soft) texture, Nectar consistency. Strict Aspiration precautions, no straws, up 90 degrees with all oral intake and 30 min after, small bites, sips. A review of R38's care plan revealed: Thickened liquids as ordered Nectar, Date Initiated: 03/17/2023. On 4/3/23 at 8:42 AM, Certified Nursing Assistant (CNA) C was asked if she had passed out resident waters this shift. CNA C stated she did not, CNA C was asked to look at the water on R38's bedside table, where the resident was observed sitting in bed. The water was visibly not thickened. CNA C stirred the water and stated it looked as if some thickener may have been put into the water, but indicated it wasn't enough to thicken it. CNA C removed the water and retrieved a new one for the resident. On 4/3/23 at 10:41 AM, CNA C stated she checked the thickening packets which said one packet was to be used for every 4 oz of liquid. CNA C also indicated that the liquids may need to be monitored, because if they sit for too long, it seems that the thickener can settle to the bottom of the cup. On 4/4/23 at 12:45 PM, the Director of Nursing (DON) was interviewed. The DON was asked what staff were responsible for ensuring a resident receives thickened liquids if that is what is ordered. The DON responded that whoever passes out the liquids should be making sure they are thickened before the resident consumes them. A review of the facility's policy/procedure titled, Diet Orders, revised 11/12/21, revealed, .The goal for each diet order is to be the least restrictive to effectively manage the guest's/resident's medical condition and to assist the guest/resident in reaching their highest functioning potential .The facility will adhere to therapeutic diet parameters during food preparation and when dispensing condiments .

Based on interview and record review, the facility failed to ensure a 14-day stop date was ordered for an as-needed (PRN) psychotropic medication and failed to document attempted non-pharmacological interventions prior to administration for one resident (R271) of five reviewed for unnecessary medications, resulting in the potential for adverse reactions and the prolonged use of psychotropic medication. Findings include: A review of 271's record and Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident was admitted into the facility on [DATE] with medical diagnoses of Displaced Bimalleolar Fracture Of Left Lower Leg, Subsequent Encounter For Closed Fracture With Delayed Healing, History Of Falling, Wedge Compression Fracture Of First Lumbar Vertebra, Subsequent Encounter For Fracture With Routine Healing, Generalized Anxiety Disorder, Major Depressive Disorder, and Nicotine Dependence, Unspecified, With Unspecified Nicotine-Induced Disorders. Further review revealed that the resident is cognitively intact and requires supervision to extensive assistance for most activities of daily living (ADLs). On 4/2/23 at 9:55 AM and 3:20 PM, was interviewed in their room. The resident was observed sitting up in their wheelchair with a back brace on and a large cast that covered their left leg and foot. The resident was queried about their medications and indicated that prior to coming to the facility, they had been hospitalized for three weeks. The resident stated, The hospital just prescribed Xanax (psychotropic/antianxiety medication) to me, I didn't ask for it .Then I was transferred here .Didn't have anything ordered then the doctor started the Klonopin (clonazepam). R271 was asked if the facility was doing anything to help them with their anxiety other than giving them medication, but the resident did not provide an answer. R271 added that they thought perhaps the anti-anxiety medication was helping them because they are a smoker. R271 stated they had not smoked in a month and had not been offered any smoking alternatives (gum or nicotine patch). A review of R271's orders revealed the following: Clonazepam Tablet 0.5 MG (milligrams) Give 1 tablet by mouth as needed for anxiety BID (twice a day), Active, Start Date: 3/28/2023 (No stop date present). A review of R271's Medication Administration Record (MAR) revealed the resident had been taking the Clonazepam consistently since the initiation of the order. Further review of R271's record did not reveal any documentation indicating what non-pharmacological interventions were attempted by staff prior to administering the medication. On 4/4/23 at 8:32 AM, Registered Nurse (RN) Unit Manager D was interviewed and asked to review R271's Clonazepam order. RN D indicated that since the medication was ordered PRN, it should have a stop date, but was unsure why it didn't have one. RN D reviewed R271's MAR and stated she would speak with the physician about getting the medication scheduled, since the resident was taking it often. RN D added that she needed to add non-pharmacological intervention orders to go along with the medication. On 4/4/23 at 12:45 PM, the Director of Nursing (DON) was interviewed. When queried regarding the initiation of as needed psychotropic medication, the DON indicated that generally the medications are expected to have a stop date on the order, as well as documented non-pharmacological interventions prior to the administration of the medication. The DON added that it's possible R271's Clonazepam should have been ordered as a scheduled medication to begin with. A review of the facility's policy/procedure titled, Behavior Management, revised 7/9/21, revealed, .Guests/residents with behavioral symptoms or those receiving psychoactive medications are evaluated, monitored, and managed by an interdisciplinary behavior management team .The IDT works with the guest/resident and or family/legal representative to determine an appropriate plan of care to identify the cause of the behavior and/or treat the behavioral symptoms .The facility staff will utilize tasks in PCC to document behaviors exhibited by the guest/resident, including new, existing and escalating behaviors, as well as the effectiveness of interventions. Additional documentation may be needed in the IDT progress, behavior notes and at-risk notes regarding the behavior, interventions and changes to plan of care .Interventions will include specific non-pharmacological interventions and behavior management strategies developed specifically for the guest/resident . The policy did not specifically address limitations on PRN psychotropic medications.

Based on observation, interview, and record review, the facility failed to store and maintain nebulizer masks in a sanitary manner, for two residents (R21 and R34), resulting in masks left hanging on the side of the bed, and the potential for contamination of equipment and transmission of bacteria leading to respiratory infections from contaminated equipment. Findings include: R21 On 4/02/23 at 11:22 PM, R21 was observed in bed. Observed on the side table was a nebulizer mask sitting on the top of the machine. The nebulizer mask was also observed in the above condition on 4/3/23 and 4/4/23. A review of R21's medical record noted, R21 was admitted to the facility on [DATE] and readmitted [DATE], with diagnosis Cardiorespiratory conditions. R34 On 4/02/23 at 8:57 AM, R34 was observed in bed. A nebulizer mask was observed to hang off the bed's assist bars. The nebulizer mask was also observed in the above condition on 4/3/23 and 4/4/23. A review of R34's medical record noted, R34 was admitted to the facility on [DATE] with diagnosis Cardiorespiratory conditions. On 4/04/23 at 11:08 AM, the Infection Control Preventionist (ICP) was asked, the proper storage of nebulizer masks and explained, Technically if used it should be broken down, cleansed with warm water, put on a barrier. The ICP further explained, it's recommend a clean emesis basin with some paper towels so it can air dry unless brand new/unused, it would be covered with a barrier like a ziploc bag on it. A review of the facility's policy titled, Nebulizer therapy, small volume undated, noted, Introduction: Nebulizer therapy is an established component of respiratory care that aids bronchial hygiene by hydrating dried, retained secretions; . Implementation: Rinse the nebulizer with water and allow it to air-dry, or discard after the treatment. The policy did not reveal to procedure for the storage of a nebulizer mask.

This citation pertains to intake MI 985 Based on observation, interview, and record review, the facility failed to provide supervision during medication administration for one sampled Resident (R910) out of two reviewed for medication administration, resulting in inappropriate medication administration and the potential for missed doses. Finding Include: On 8/11/2022 at 12:30 PM, an interview was conducted with R910 regarding their stay in the facility. During the interview three pills were observed in a medicine cup on the bedside table. No nurse was observed in the room. R910 was asked if they knew what pills they were and who put them on their table. R910 stated that the nurse put them there and that they did not know what pills were in their cup. R910 stated, I am laying down still, there is no way I can take those pills. I have to be sitting up. A review of the medical record revealed that R910 was admitted into the facility on [DATE] with the following diagnoses, [CONDITION(S)], Adjustment Disorder with Anxiety, and Muscle Wasting. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 13/15 indicating an intact cognition. R910 also required extensive to total dependence of two-person physical assistant with bed mobility and transfers. A review of the care plan and assessment did not reveal anything concerning self-administration of medications for R910. On 8/11/2022 at 12:45 PM, an interview was conducted with Nurse A regarding R910 having their medications at bedside. Nurse A stated that they put the medications there and those were R910's 9:00 AM medications. Nurse A stated that R910 takes their pills when they want to and that they left them so they could talk R910 into taking them. Nurse A stated that R910 has good days and bad days and that they were going to go and get R910 some applesauce because they decided to take them. On 8/11/2022 at 2:15 PM, an interview was conducted with the Director of Nursing (DON) regarding medications being left at bedside. The DON stated that medications should never be left at bedside. The DON stated that the nurse should take the medications out of the room if someone refuses and try again at a later time, if they continue to refuse then mark refuse on the administration record. A review of a facility policy titled, Medication Self-Administration, long-term care and revised 5/20/2022 revealed the following, A standard procedure should be established for a resident to self-administer medications to ensure resident safety, promote medication effectiveness, and provide adequate documentation of adherence with the medical treatment plan.

This citation pertains to intake MI 125. Based on observation, interview, and record review the facility failed to prevent resident to resident abuse, for two sampled Residents (R901 and R902) of two reviewed for abuse, resulting in a physical altercation. Findings include: Resident #901 (R901) On 8/11/22 at 2:52 PM, R901 was asked about the incident with R902 and reported that they (R902) were having a disagreement. R901 stated, [R902] slap me once and I let that go. Then [R902] had this orange bag that [R902] kept slapping me with. I haven't had any more problems after that, we speak now but I don't trust [R902]. A review of R901's medical record revealed, R901 was admitted to the facility on [DATE] and readmitted on [DATE]. R901's Minimum Data Set (MDS) assessment dated [DATE] noted, R901 with an intact cognition and extensive to total assistance with activities of daily living. (ADLs) Further review noted, Progress Note: At approximately 2200 resident called this writer into the room and stated [R902] hit me in the face. Don't let [R902] hit me again. Assessed resident no injury or Mark, noted. resident roommate (R902) stated. I just swatted [R901] with the bag. On call, supervisor notified, physician notified, and message left with POA (power of attorney), resident roommate (R902), moved to room [ROOM NUMBER] on the center unit. Resident #902 (R902) On 8/11/22 at 3:00 PM, R902 was asked about the incident with R901. R902 stated, They kept me and [R901] separated. [R901] told people I hit [R901] so hard that [R901] couldn't walk or talk which was not true. I had two home depot aprons and [R901] hit me first saying they were [R901's] and [R901] wanted one. I said have you lost your mind and swung the apron, it barely touched [R901's] face. R902's medical record noted, Progress Notes:4/20/22 Behavior Note Text: Resident swatted [R901] roommate in the face with a bag. When this writer asked resident why, [R902] stated [R901] sinned against the lord Jesus Christ. Resident was moved to room [ROOM NUMBER] on the center unit. On 8/11/22 at 3:15 PM staff on the unit were asked about R902's behaviors and explained that they had not seen R902 display any physical aggression, but had sometimes been aggressive when talking to other residents. A review of R902's medical record revealed R902 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R902's quarterly MDS noted an intact cognition and required limited assistance with ADLs. On 8/11/22 at 2:58 PM, the Director of Nursing (DON) was interviewed and asked about the incident with R901 and R902. The DON explained that was the first time that the two residents had a altercation. A review of the facility's policy titled Abuse Prohibition Policy dated, 4/28/22 noted, Policy: Each guest/resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property . Definitions: Physical Abuse includes hitting, slapping, pinching, and kicking. It also includes controlling behavior corporal punishment. Examples: . A guest/resident picks a fight with another guest/resident and knocks him/her down .

Based on interview and record review, the facility failed to ensure that a Minimum Data Set (MDS) assessment for one Resident (R97) was transmitted to the Center for Medicare and Medicaid (CMS), within 14 days after completion, resulting in the potential for inaccurate tracking of resident assessments, admissions and discharges. Findings include: On [DATE] at 1:44 PM, a record review revealed that R97 was admitted into the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed, R97's discharge MDS was noted to be over 120 days late, because it was not transmitted to CMS. On [DATE] at 12:15 PM, an interview was conducted with Nurse A regarding the discharge MDS missing for R97 and stated that, Yes it's late, it was completed but not sent. On [DATE] at 2:50 PM, the acting Nursing Home Administrator and Director of Nursing were asked about the late submission of R97's MDS and stated, We want them to be submitted on time. A review of the facility's policy titled Submission of MDS, last revised [DATE], noted, Purpose: Long Term Care Facilities are required to submit MDS records for all residents in Medicare or Medicaid certified beds regardless of the pay source. Medicare Part A MDS's must be submitted prior to billing for Part A services. Procedure 1. Once MDS's are completed and verified for accuracy they will be readied for transmission. 2. Completed MDS's are to be transmitted to CMS Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (APAS) system in a timely manner in accordance with CMS policies .

Based on observation, interview, and record review the facility failed to ensure an arm bolster (positioning device) was applied to a wheelchair per care plan, for one sampled Resident (R20), resulting in improper support while in a wheelchair. Findings include: On 1/24/22 at 12:20 PM, R20 was observed leaning forward, towards the left side of the wheelchair. The wheelchair's right arm was observed with a pad around it. On 1/24/22 at 1:23 PM, R20 was observed leaning forward, towards the left side of the wheelchair. The wheelchair's right arm was observed with a pad around it. On 1/24/22 at 2:21 PM, R20 was observed in the hallway near the nursing station in the same position as before. An observation made in R20's room revealed, a blue padded device on the top of the resident's wardrobe closet. On 1/24/22 at 2:25 PM, R20 was observed in the hallway and to move an overbed table to the side, they attempted to propel, but got the wheelchair stuck on the left side of the wall. R20 was unable to move forward off the wall, and then grabbed for the handlebars on the wall to try and move. An unidentified Certified Nursing Assistant (CNA) was observed to ask R20 if they wanted to go to bed, the CNA was observed to unlock the right wheel and to transport R20 to their room. A review of a progress note revealed, 1/7/21 resident fall from [R20's] recliner on 1/3 red area to left side of head. Action: ER (emergency room ) visit incontinent pad not to be in recliner. Further review revealed Physician Orders: Dysom to seat of recliner and w/c, lambs wool to wheelchair back r/t protection, left side bolster to wheelchair arm for positioning, Healbow sleeve to left elbow in wheelchair for protection. On 1/24/22 at 3:09 PM, the Occupational Therapist OT B was asked about the devices that were ordered for R20's wheelchair and explained, those orders were for R20's old chair, not the current chair. R20's device for the new chair is a left arm bolster. OT B reviewed R20's care plan and stated, 7/23/21 is when the care plan was changed, the order wasn't updated to reflect the new chair requirements. It's updated now. On 1/24/22 at 3:26 PM, OT B was shown the bolster that was observed on R20's wardrobe closet and asked if that was the device that was care planned to be on R20's chair and stated, Yes this is it. This is the left arm bolster. OT B was asked what the bolster is used for and stated, It's to help [R20] with [R20's] posture. The OT B was observed to grab it and place it on R20's wheelchair. R20 was in the bed asleep at that time. A review of R20's medical record revealed, that R20 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of R20's medical record revealed that the resident required extensive assistance for Activities of Daily Living (ADL's). On 1/25/22 at 2:49 PM, the Director of Nursing was asked the facility's expectation regarding wheelchair devices and stated, We want them in place. A review of the facility's policy titled Physical Function dated, 9/7/2021 noted, Guest's/resident's ability in activities of daily living do not diminish unless circumstances of their clinical condition demonstrate the decline is unavoidable. There activities include the guest's/resident's ability to: Transfer and ambulate, feed themselves, dress themselves, perform personal hygiene, use the toilet, and move freely in bed. Guidelines: . 3. Enablers and assistive devices/adaptive equipment determined necessary to enhance the guest's/resident's self-performance is incorporated into the guest's/resident's care plan .

This citation pertains to MI 400. Based on observation, interview and record review, the facility failed to maintain an environment free from physical abuse for one sampled Resident (R65) of three reviewed for abuse concerns, resulting in R65 grabbed around the wrist and bruised by Resident (R58) and acute feelings of fear. Findings include: On [DATE] at 11:35 PM, R58 was seated in a wheelchair backed up to the nurse station and facing toward the room of R65. R58 had a neck brace in place and wore a gray sweater. R58 was asked about the care and stated, It is what it is. When asked about any incidents with other residents, R58 indicated they did not know of any. On [DATE]/ at 2:12 PM, R58 was observed to self propel in their wheel chair from the hallway outside the room of R65 passed the nurse station, then continue into the center hallway stopped at the closed double door, turn toward the left, opened the right hand door to the dining room and entered the dining room. The door closed behind R58. R58 had lost a sock along the way. A staff member stopped to pick it up and placed it on the counter of the nurse station. On [DATE] at 2:20 PM, R65 was observed to be seated in an arm chair on the left side of the entry to their room. R65 reported they liked to get outside their room and watch TV. A large screen TV in a seating area across the hall was viewable from where R65 was sitting. R65 was asked about any incidents with other residents and reported that(R 58) had come into their room a week or so ago and tried to get R65's roommate to go to breakfast. R65 reported the roommate told R58 that it was too early and had to leave. (R58) got upset. That is when (R58) grabbed my hand and wrist. (R65 pushed up the sleeve to reveal a tan colored area on the top of the left wrist.) I was able to get up from bed and pull my hand away. (R58) had picked up that wheelchair and threw it around. That is when the nurse came in and grabbed it away. I was scared. It happened so fast. I think (R58) thought I was (my roommate). I should have said you don't belong in here. (R58) has been in here before and even used the bathroom. (R58) is lucky (they) didn't fall. (R58) had never bothered me before. (R58) does sound that (R58) is not all there. We had a stop sign up but (my roommate) takes it down. It does need to be open for the food to come through. R65 was asked how they were doing since the incident and reported they feel better and just tries to avoid (R58). R65 reported (R58) and their roommate had meetings and conversations before and after the incident. On [DATE] at 2:31 PM, R58 was observed to have removed their neck brace and sweater and made their way to the far end of the dining room and around to an adjacent dining room. At 2:33 activity staff approached R58 and subsequently returned R58 to their home area and placed (R58) into their room. On [DATE] at 3:30 PM Certified Nursing Assistant (CNA) B was asked about the incident between R58 and R65, CNA B reported they had heard bits and pieces and the R58 has has quite an attitude. CNA B reported during vitals R58 would mock what they said at times and might reach in and try to grab their shoulder causing them to step back as R58 is a big (resident). On [DATE] at 3:33 PM, Nurse C was interviewed about R58. Nurse C reported, R58 has had a progression of their Dementia in the last month and has become more combative, more resistive to care, confused and forgetful. Nurse C also reported R58 will sit for much of the day but tends to get anxious and start wandering. Nurse C further reported on query they were not surprised by the incident as R58 was getting more possessive and R65 doesn't want (R58) coming in the room at all. On [DATE] at 9:04 AM, Nurse A was asked about the incident between R65 and R58. Nurse A reported they did not see the whole thing, but noted R58 had tried to coerce the roommate of R65 to come out into the hall and became pretty demanding on the way out of the room. R58 began throwing things and attempted to pick up the footrests off the seat of the wheelchair. Nurse A reported that R58 had punched them while separating R58 from their hold on the wheelchair. At that time Nurse A reported they thought R65 had slept through the whole thing and it was not until the morning medication pass that R65 had reported R58 had grabbed their wrist and dragged (R65) out of bed. Nurse A reported they assessed the hand and wrist and observed a bruise, possibly the size of a thumb print. On query Nurse A reported R58 had frequently roamed around at night, but had never been aggressive. Nurse A also indicated there may have been some past physical and or verbal aggression by R58 toward their now deceased spouse. On [DATE] at 11:08 AM the incident between R65 and R58 was reviewed with the DON. The DON summarized they had been at home at the time and were called in to investigate. The DON reported R65 stated to them that R58 had grabbed their arm on the way out of the room so R65 kind of got up with R58 but got free and went back to bed. The DON reported R58 definitely grabbed (R65) by the arm and was bruised. On [DATE] at 2:33 PM, after notification by the DON that R65 was not afraid of R58 and sitting out in the common area R65 was observed. R65, their Roommate and R58 were observed seated in a line outside the door way of R65's room. R65 sat in their usual spot at the left side of the doorway. The roommate was to the left of R65 at the right side of the open door way and R58 sat to the left of the roommate. The three residents did not interact. No conversation and no physical contact was observed. The residents appeared focused on the TV across the hall. R65 R65 was admitted into the facility on [DATE] and readmitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] indicated moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of ,d+[DATE]. The care plan dated [DATE] indicated, Has the potential for fluctuations in mood related to [CONDITION(S)], Anxiety, History of [CONDITION(S)]. R58 R58 was admitted into the facility [DATE] and readmitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE] indicated severely impaired cognition with a ,d+[DATE] BIMS score and independent for locomotion (via a wheelchair), eating with set up and the need for supervision with dressing. The care plan initiated and revised [DATE] documented, Has potential to demonstrate verbal aggression toward others related to anger, Ineffective coping skills, poor impulse control .when resident becomes agitated intervene before agitation escalates; Guide away from source of distress. Engage Calmly . A review of a facility investigation summary revealed, On the morning of [DATE] resident (R65) reported that another resident, (R58) had grabbed (them) by the arm/wrist and tried to get them up for breakfast. (R65) said that it happened around (3 AM) 03:00. (R65) stated that (they) thought (R58) had confused (them) for (their) roommate who often eats in the hall with (R58). (R65) did have a bruise on (their) arm where (R65) said that (R58) had grabbed (R65). (R65) stated that (they) didn't blame (R58) because (R58) was confused and did not intentionally attempt to hurt (R65). (R65) was immediately offered a room change by this writer (Director of Nursing - DON). (R65) refused room change at that time [DATE]. (R65) again refused room change when offered by social services later in the day on follow up. (R65) stated that (they) loved (their) roommate and was not afraid of (R58) so (R65) did not want to move. (R65) also stated that (they) had never seen (R58) become aggressive before. Precautionary x-ray to left wrist/arm was negative for any fracture .Writer interviewed (R58) about the situation after breakfast on [DATE] and (R58) did not recall the event at all. (R58) did state that (they) would never intentionally hurt anyone. (Roommate) is a close friend of (R58). This writer interviewed (roommate) who stated that (they were) sleeping at the time of the incident and did not remember it at all. (Roommate) stated that (R58) has never been violent with (them) and is not afraid of (R58). (Nurse A) reported the incident to writer at (5:10 AM)05:10. (Nurse A) went in to give morning medications to (R65) and (R65) told (Nurse A) about it at this time. (Nurse A) told writer that at (3:40 AM) 0340 (they) had heard raised voices coming from (room of R65) and had went to (the) room at that time and found (R58) in the room trying to get (roommate) up for breakfast. There was no interaction between (R58) and (R65) at this time. (R58) was asked to leave the room so the (residents) could go back to bed and (R58) was at first compliant but then became combative with (Nurse A). (R58) did not show any aggression toward the two (residents) in the room at that time. (Nurse A) stated that (Nurse A) has not seen (R58) show any aggression toward any other resident. (R58) left the room and did not attempt to reenter for the remainder of the shift. (Nurse A) stated that (they) felt like (R58) was confused about what time it was and didn't realize that it wasn't breakfast time . A review of the facility policy titled, Abuse Prohibition Policy revised ,d+[DATE] revealed, Policy: each resident shall be free from abuse, neglect, mistreatment, exploitation and misappropriation of property. Abuse shall include freedom from verbal, mental, sexual, physical abuse .To assure residents are free from abuse, neglect, exploitation or mistreatment, the facility shall monitor resident care and treatment on an ongoing basis. It is the responsibility of all staff to provide a safe environment for the residents .Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish .Instances of abuse irrespective of any mental or physical condition, cause physical harm, pain or mental anguish .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual intended to inflict injury or harm .

This citation pertains to MI 278 and MI 281. Based on observation, interview and record review the facility failed to ensure an appropriate size brief was used for one sampled Resident, (R77) of three reviewed for Activities of Daily Living (ADLs), resulting in leakage and feelings of being wet during a meal. Findings include On 03/16/21 at 8:40 AM, R77 was observed seated at the left side of their bed eating breakfast. R77 had a blanket across their legs. R77 was asked how they were feeling and reported they were wet. R77 finished their breakfast and leaned back onto their bed. The brief worn by R77 appeared wet and R77 reported that on touching the incontinence pad that it felt wet. R77 reported they had asked to be changed during breakfast and was encouraged that staff would change them after breakfast. It was unclear which staff had talked to R77. On 03/16/21 at 8:46 AM, CNA B was asked about the wet incontinence pad and confirmed that it was wet. CNA B reported that the brief R77 had on was too big and may have slid out of the way when R77 moved around. CNA B reported they would put on a smaller brief. A review of the clinical record for R77 revealed R77 was admitted into the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented impaired cognition and the need for extensive assistance of one or two persons for bed mobility, transfer, dressing, toilet needs and hygiene. On 03/16/21 at 11:08 AM and prior to exit the care of R77 was reviewed with the Director of Nursing (DON). The DON reported there was not a specific policy for the timeliness of incontinence care, but residents are to be change every two hours and as need per standard of care. The DON further reported a conversation with CNA B who reported the brief that had been provided to R77 was too large and likely shifted causing the pad to become wet.

Based on interview and record review, the facility failed to perform and maintain documentation of ongoing infection control surveillance, monitoring, and tracking in the resident population in a timely manner for all residents residing in the facility, resulting in the potential for unidentified trends of infections within the facility. Findings include: On 2/2/2021 at 10:14 AM, the Infection Control Nurse provided all of the facility's Infection Control documentation including surveillance, line listings and policies. At that time, she explained that she had not fully documented surveillance for any other infections within the facility aside from COVID-19. A review of the documentation revealed the following: -November 2020: Incomplete Infection Control documentation pertaining to individual line listings or facility mapping of infections within the facility during the month of November. -December 2020: No Infection Control documentation pertaining to individual line listings or facility mapping of infections within the facility during the month of December. -January 2021: No Infection Control documentation pertaining to individual line listings or facility mapping of infections within the facility during the month of January. On 2/3/2021 at 1:43 PM, an interview was completed with the Director of Nursing (DON) and asked for their expectation for complete Infection Control surveillance for all Infections within the facility. The DON stated, I would expect that it should be done, as fast as it can be. She (Infection Control Nurse) does pay attention to the dashboard daily and gets it done as fast as she can. A review of the facility's Infection Prevention Surveillance dated, 9/2019 stated the following, Policy: The Infection Preventionist does surveillance of infections among guests/residents and employees II. Healthcare associated infections are reported monthly on the: A. Infection Surveillance Tracking Tool. IV. Surveillance documentation is maintained on the: A. Infection Surveillance Tracking Tool of guest/resident Infections.

This citation portains to Intake # MI 411 Based on observation, interview and record review, the facility failed to safely transfer a resident from the bed to a Geri-chair, affecting one sampled resident (R801) resulting in a [MEDICAL CONDITION] leg. Findings include: On 7/2/19 at 10:44 AM, Resident #801 was observed in bed with their eyes closed. R801 did not respond to name being called. On 7/2/19 at 10:54 AM, Certified Nurse Aide (CNA) A was interviewed about the incident with R801 that occurred on 6/29/19. CNA A said, I took (R801) into the room with another aide to change their brief. After changing (R801's) brief, I left the room and asked Nurse B to help with getting (R801) from bed and back into the Geri-chair. The back of the chair was at the foot of the bed and the seat area was facing the head of the bed. I got underneath (R801s) right arm and (Nurse B) was underneath their left arm. We grabbed the back of (R801s) pants. We lifted (R801s) up. (R801) started lifting their legs off the ground. (R801s) was agitated and started grabbing my arm. Then we hurried up and placed (R801) into the chair. We noticed that (R801s) right foot was caught in the opening of the chair's foot-rest (the right foot was caught on the chair). (R801's) foot was twisted. It was weird because I didn't understand how their foot could twist like that. (R801) gave us a dirty look. That's how you know (R801s) is agitated. Then we lifted them up and moved their foot. We placed (R801) into the Geri-chair and placed a pillow under the right leg. (Nurse B) went looking for the nurse supervisor and told me I could go finish my other work. CNA A was asked if they used any assistive devices to assist with the transfer such as a gait belt. CNA A said, We did not use a gait belt. Was I supposed to use a transfer belt? But we grabbed the back of their pants. CNA A was asked if they received training on transfers. CNA A said I was trained to use a gait belt when walking residents. Other than that, I was trained to grab the back of their (residents) pants. Am I in trouble? Was I supposed to use the gait belt? I hope I'm not in trouble. On 7/2/19 at 11:29 AM, Nurse B was interviewed about the incident with R801 that occurred on 6/29/19. Nurse B said, I was asked to help with a transfer, we went into the room to help. I've never worked with (R801). I was not familiar with this resident. (R801) was a little agitated. We both went under their arms lifting their into the Geri-chair. We grabbed the back of (R801) pants and lifted her into the chair. We had to give them a boost because we couldn't get them in a good position. (R801) was on the edge of the chair and we had to lift them to properly get (R801) in the right position. Nurse B was asked the position of (R801) legs. Nurse B said, I'm not sure of the position their feet. I don't remember where (R801's) feet were. Once we positioned (R801) into the chair, I noticed (R801's) leg was caught in the opening of the foot-rest. It looked bad. I thought their foot was fractured. I knew right away it was an awful situation. That Geri-chair is not safe. ( R801) did not yell out. That was strange that (R801) didn't yell. (R801) had a scowl on their face. If (R801) was able to call out, then we would have been able to stop. But (R801) is nonverbal. I placed a pillow underneath their leg and went for the supervisor. I told CNA A to stay with the resident. On 7/2/19 at 11:54 AM, Therapy Manager C was interview and asked the professional standards of practice for transferring a resident from the bed to a Geri-chair. Therapy Manager C said, We assess residents and we determine the safest way to transfer. Queried Therapy Manager C regarding the use of gait belts during resident transfers. Therapy Manager C said, Gait belts should be used at all times on residents that require assistance with transfers. On 7/2/19 at 12:24 PM, the Director of Nursing DON) was queried regarding the incident with (R801) on 6/29/19. The DON said, On Saturday, I received a call from the supervisor about the incident. The resident was sent to the emergency room for x-rays. The x-ray showed a fracture. (R801) was transferred back to the facility. The DON was asked regarding staff training on resident transfers. The DON said, Our staff have their yearly education on body mechanic and transfering residents. The DON was informed that CNA A and Nurse B stated that they did not use a gait belt during the transfer of R801. The DON was asked their expectations of staff using a gait belt during transfers. The DON said, They (staff) should use a gait belt to transfer. The CNAs should keep a gait belt with them at all times. On 7/2/19 at 12:05 PM, a record review revealed Resident #801 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #801 is also under hospice care. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed R801 required extensive assistance with a two person assistance with transfer's between surfaces including to or from the bed, chair, wheelchair and standing position. A review of Resident #801's care plan initiated on 1/26/2019 revealed interventions of the following: Adjust provision of activities of daily living (ADL) to compensate for resident's changing abilities. Assist as needed to promote comfort/decrease pain and prevent complications .Observed for non-verbal indicators of attempts to express self such as tears, furrowing of the brow, pursing of the lips, yelling, grabbing, reaching, gestures. The Progress Note dated 6/29/19 at 1:24 PM noted: This nurse assisted CNA with transfer. Resident brought to a sitting position on bed, both feet on the floor at this time. After getting her into the chair, it was noted that her right foot was stuck in the chair. Upon removing (their) foot from the chair, it was noted to be completely twisted around and limp. (They) did not display any distress after (they) was in the chair. (They) had received pain medications approximately a half hour before. Immediately found supervisor and reported the situation to (them). The hospice nurse notified and gave permission to go to hospital. Physician was notified and orders received to send to the hospital for eval and treatment. Family member was notified as well by on call supervisor. Ambulance called at 12:55pm and arrived at 1:55pm. The X-ray dated 6/29/19 showed a tibia/fibula fracture (lower leg fracture). R801 returned to the facility with a splint to the lower extremity. Review of policy Gait Belt Use noted the following (this policy did not have a date): The device (gait belt) provides a secure grasping surface to aid with patient transfer and ambulation .When combined with proper body mechanics, a gait belt also improves caregiver safety by preventing back injury. Review of policy Transfer noted the following (this policy did not have a date): Assess the patient's needs and abilities when making decisions about the equipment needed for transfer because patients may require varying levels of assistance with transfer .If necessary, place a gait belt over the patient's clothes around the waist, with the buckle or Velcro fasteners secured in the front and the handles on the patient's sides to allow a firm hold and to prevent injury. A review of the Incident and Accident Report dated 6/29/19 noted the following: Staff report during 2 person transfer from bed to geri chair resident's right foot became stuck in geri chair foot rest, twisting the foot. The conclusion of the investigation noted the following: After investigation and interview, it was determined that the resident was being transferred properly with a two person assist. At the completion of the transfer, the resident's foot was noted to be caught in the foot rest, twisted. The plan to avoid this situation in the future and education provided by the DON noted the following: Nurses and CNA's will be given education on ensuring that during transfers resident legs and arms are free of obstruction. The CNA Competency Evaluation for CNA A showed date of hire as 5/6/19 and noted the following competencies: Transfers and Gait Belts, validated and demonstrated on 5/7/19 with a Passing score. Follows Resident Care Guide validated and demonstrated on 5/7/19 with a Passing score. Nurse B training transcript noted the following: Dementia Care: CMS Hand in Hand Module 1: Understand the World of Dementia: The person and Disease. Was dated on 3/18/19. [MEDICAL CONDITION] and Related Disorders: Behavior Management was dated on 11/3/18 (transcript did not have a signature and date certifying education completion).

This citation pertains to MI 190 Based on interview and record review, the facility failed to accurately transcribe/reconcile an oral hypoglycemic medication ([MEDICATION NAME]), follow prescribed parameters for the administration of the oral hypoglycemic medication, and inform the doctor of extremely low blood sugars ([DIAGNOSES REDACTED]) for 1 (# 107) of 9 residents reviewed for unnecessary medications and/or diabetes management, resulting in extremely low blood sugars (BS), altered mental status, inability to fully participate in therapy, a transfer to acute care and a [DIAGNOSES REDACTED]. On 1/28/18 at 17:55 (5:55 p.m.), the glucometer registered a reading of low bgm. On 2/6/18 at 08:55 (8:55 a.m.), the glucometer registered a reading of low bgm (blood glucose meter). On 2/6/18 at 18:06 (6:06 p.m.), the glucometer registered a reading of low bgm. On the morning of 2/7/18, the resident received [MEDICATION NAME] in error for a blood sugar of 119. On the same day, the resident was transferred out to the hospital and upon arrival the resident's blood sugar was 37. The IJ was identified on 1/28/18. The Administrator was notified of the Immediate Jeopardy on 6/13/18 and was instructed to submit a plan of correction to remove the immediacy. The IJ was removed on 6/13/18 based on the provider's implementation of the plan of removal and verified onsite on 6/13/18. Although the IJ was removed, the facility deficient practice remains a pattern with actual harm that is not immediate jeopardy. In addition, based on interview and record review, the facility failed to ensure accurate transcription of health care provider orders and failed to monitor blood glucose levels per health care provider order for three (#'s 49, 356, and 507) of nine Residents reviewed for diabetic monitoring, from a total sample of 27, resulting in incorrect transcription and entry of blood glucose monitoring orders and lack of blood glucose monitoring. Findings include: On 6/6/18 at 9:00 a.m., a confidential associate of resident #107 reported during an interview that for two days Resident #107 was confused while at the facility due to low blood sugar levels. The associate went on to report that the facility was administering the medication [MEDICATION NAME] (a medication used to lower blood sugars) on a regular basis without first ensuring that Resident #107 consumed all of her meals. The last day she was at the facility, she was confused. The associate stated, When she became confused no one checked her blood sugar. That was my concern. This had been going on for the last two days that she was there. A family member requested and insisted that she be transferred out to the hospital for treatment. A reading of her (#107) blood sugar was requested at the time of the noted confusion, but the facility would not disclose the reading of the blood sugar. When she (#107) arrived to the hospital, her blood sugar was 37 (extremely low). While at the hospital she was diagnosed with [REDACTED]. Lab work was performed on arrival to the emergency room (2/7/18) and she had a glucose level of 37. On 6/6/18 at 10:20 a.m., review of Resident #107's face sheet revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #107's Minimum Data Set (MDS) assessment, dated 2/8/18, indicated an intact cognition and an intact memory with minimal queuing required. There was no mental status change noted on the MDS. Limited assistance was required for all activities of daily living (ADLs). The admission note, dated 1/25/18 at 4:45 p.m., indicated that resident #107 was admitted into the facility due to a fractured left arm and was alert and oriented at the time. A physician's note, dated 2/3/18 at 1:40 p.m., revealed: admitted for rehab (rehabilitation) after left arm fracture and surgical repair . On 6/6/18 at 12:30 p.m., the Director of Nursing (DON) was queried regarding diabetes management for Resident #107. Resident #107's blood sugars were reviewed with the Director of Nursing (DON). Review of the blood sugars revealed incidents where the glucometer could not measure the exact blood sugar due to the levels being extremely low. Review of the nurses' notes and the medical record with the DON revealed no notification of the abnormal readings to the doctor, documentation of treatment for [REDACTED]. The abnormal blood sugars were noted on the following times: 1. 1/28/18 at 17:55 (5:55 p.m.), the glucometer registered a reading of low bgm. 2. 2/6/18 at 08:55 (8:55 a.m.), the glucometer registered a reading of low bgm. 3. 2/6/18 at 18:06 (6:06 p.m.), the glucometer registered a reading of low bgm. On 6/6/18 at 12:37 p.m., the DON stated, There is no documentation of the doctor being called. The parameters should have been followed according to the standing orders. The standing orders/protocol for low blood sugars for Resident #107 were reviewed with the DON and revealed the following instructions: A. Alert resident - Blood sugar below 50 mg/dl (milligrams per deciliter), give Insta-Glucose, re-check blood sugar in 15 minutes. B., Unresponsive resident - Blood sugar below 50 mg/dl, give 1 mg [MEDICATION NAME] SQ (subcutaneous) or IM (intramuscularly), re-check blood sugar in 15 minutes, C. Notify the attending physician. When the DON was queried regarding the readings of low bgm, the DON stated, They probably forgot to document the level. The facility's glucometer manual was requested at this time. On 6/6/18 at 12:40 p.m., Resident #107's record review continued with the DON. The following was revealed: Resident #107's nurses' progress notes were reviewed with the DON. The DON stated, She was transferred to the hospital on [DATE]. At this time the nurse's note dated 2/7/18 at 15:47 (3:47 p.m.), revealed the following documentation: Continued confusion and lethargy noted. Family reporting since [MEDICATION NAME] (antidepressant) was D/C'd (discontinued) there has been no improvement. PT (physical therapy) also reporting res (resident) is more weak and declining in therapy .Call placed to doctor who stated to transfer to ER (emergency room ) for evaluation .Ambulance paged for non-emergent transfer at 2:10 p.m .Resident transferred from facility by EMS (emergency medical services) at 2:40 p.m. Upon review (with the DON) of the physician's orders [REDACTED]. Additionally, an error had occurred at the time of admission into the facility when Resident #107's medication order for the administration of [MEDICATION NAME] was not transcribed as ordered from the hospital. Review of Resident #107's Discharge Medication List from the hospital revealed the following order: [MEDICATION NAME] (Repaglinide), 1 mg oral twice a day PRN (as needed), 1 mg tablet, as needed for CBG (capillary blood glucose) > (greater than) 120. On the day of admission into the facility, on 1/26/18, the facility transcribed the order as: [MEDICATION NAME] Tablet 1 mg (Repaglinide), give 1 tablet by mouth two times a day for Diabetes, hold if BGM is <120. The DON reported that the [MEDICATION NAME] was not transcribed correctly. Per the MAR, dated 2/7/18 at 7:30 a.m., Resident #107 received a dose of [MEDICATION NAME] 1 mg despite her blood sugar of <120. The documented blood sugar was 119 at 8:07 a.m. on 2/7/18. There was no documentation of the consumed amount of breakfast and lunch for Resident #107. On 1/26/18 at 7:30 a.m., [MEDICATION NAME] was administered without a documented blood sugar reading. On 1/28/18 at 8:15 a.m., Resident #107's blood sugar was 104. The nurse still administered the [MEDICATION NAME] per the MAR, despite the medication's parameters. Later, that same day, at 17:55 (5:55 p.m.), Resident #107's blood sugar, per the glucometer read, Low BGM. A copy of Resident #107's care plan for diabetes management was requested. The DON reported not having one. On 6/6/18 at 3:05 p.m., review of the manufacturer's manual for the facility's glucometer revealed the following regarding readings: A reading of LO indicates your blood glucose (sugar) reading is below 20 mg/dl. Test result is lower than 20 mg/dl. Wash and dry your hands and repeat the test on your fingertip with a new test strip. If the result is still 'LO,' contact your physician or a healthcare professional immediately. On 6/6/18 at 3:50 p.m., review of Resident #107's hospital records, a Neurology Consult Note, 2/7/18, revealed the following documentation: This patient was admitted to the hospital on [DATE] with symptoms of increasing confusion and altered mental status .In the emergency room she was found to have severe [DIAGNOSES REDACTED] requiring D 50 ([MEDICATION NAME]) fluid bolus to correct her low sugar readings. She has a known history of underlying diabetes mellitus. She had not been eating prior to her admission .She likely had some degree of metabolic [MEDICAL CONDITION] due to severe [DIAGNOSES REDACTED]. Per the hospital's record, Resident #107's primary [DIAGNOSES REDACTED]. On 6/6/18 at 3:55 p.m., review of the facility's policy entitled Diabetic Management, revised 3/2013, revealed the following documentation: Diabetic Management involves both preventative measures and treatment of [REDACTED]. Upon admission the IDT evaluates the diabetic resident and implements a plan of care to ensure orders are received and are accurate related to blood glucose monitoring and anti-diabetic agents. Blood glucose orders should include parameters to follow and when to notify the physician. The facility's plan of correction: 1. Resident identified to be affected by the alleged deficient practice. Resident # 107 was transfer to the hospital on [DATE] and has not returned to the facility. Upon investigation nurse transcribed order for [MEDICATION NAME] incorrectly when admitted . The order was [MEDICATION NAME] 1 mg BID, PRN for blood sugars greater than 120. It was transcribed [MEDICATION NAME] 1 mg, BID hold for blood sugar less than 120. During residents stay at Regency 2 nurses document Low BGM instead of documenting the results of the BGM. On 2/7/18 a nurse gave the medication with a blood sugar of 119. On 2/7/2018 resident # 107 became confuse her nurse checked her blood sugar and it was 119 and she administered 1 mg of [MEDICATION NAME], due to the residents continued confusion the nurse call the physician who requested she be sent to the hospital. 2. Residents with the potential to be affected by the alleged deficient practice. The facility currently has 25 diabetic residents receiving diabetic medications as of 6/13/2018. On 6/13/18 all residents receiving medication for diabetic management have been assessed by the nurse managers, audits were also completed by Nurse Managers, to ensure that orders are transcribed properly, medications are given as ordered/parameters followed, physicians are notified as ordered for low BS, to ensure that progress notes are present for low BS, glucometer's are calibrated and that DM management care plans are in place. If necessary, deficient practices have been corrected. 3. Systematic Measures Effective immediately, 6/13/2018 the facility will follow the following policies: Admin Vol 1:503.00 physician's orders [REDACTED]. Licensed nurses will be immediately inserviced by the Staff Development Nurse on the facilities Diabetic Management policy, physician's orders [REDACTED]. Blood Glucose Monitoring Lippincott Procedures; Admin Vol 1:503.00 physician's orders [REDACTED]. As of 6/13/18 at 2:15 PM 19 out of 50 Licensed Nurses were re-educated 06/13/2018. The remaining nurses will be re-educated prior to working their next shift, all nurses have been notified by telephone regarding needing immediate education. This will be on-going until one hundred percent of the licensed nurses have been re-educated. The nurse who gave the medication out of parameters received corrective action 6/13/2018. The 2 nurses who documented low for BS results had 1 on 1 education 6/13/2018 regarding proper documentation of BS by the Director of Nursing. The nurse who transcribed the medication incorrectly was given corrective action on 6/13/18. 4. Quality Assessment and Assurance Nursing management will complete random weekly audits to ensure that diabetic medications are transcribed properly, that the medication is given as ordered following ordered parameters, and that physicians are notified for high or low blood sugars levels as ordered. The administrator and DON will review the audit tools daily Monday thru Friday beginning 6/14/18 to ensure residents are being monitored per policy. In the event of a weekend, holiday or late evening admission the scheduled facility manager will ensure diabetic medication orders are in place and transcribed properly. The audits will be conducted on 20% of diabetic residents on each unit weekly x 4 weeks, and then monthly for 2 months to ensure compliance. Audits will continue until compliance has been maintained. Results of the audits will be taken to the QA meeting monthly by the Director of Nursing for review until compliance has been obtained and maintained. The Director of Nursing is responsible for continued compliance. 5. Corrective Action will be completed 6/13/2018. Resident #49 Record review on 6/13/18 at 11:40 AM, revealed Resident #49 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 4/30/18, revealed the Resident was cognitively intact and required supervision to extensive assistance to perform Activities of Daily Living (ADL's). Record review on 6/13/18 at 11:45 AM of Resident #49's physician orders [REDACTED]. -Check BGM (Blood Glucose Measurement) daily at noon (Order Date: 5/30/17, Discontinued date: 6/13/18) -Check Blood Glucose Daily (Order Date: 6/10/18) Review of Resident #49's blood glucose monitoring documentation and laboratory studies at this time revealed 11 documented blood glucose levels for Resident #49 since 5/30/17 on 5/30/17, 6/1/17, 6/17/17, 7/3/17, 12/29/17, 12/30/17, 1/3/18, 6/10/18, 6/11/18, 6/12/18, and 6/13/18. Review further revealed only five of the blood glucose measurements on 6/10/18, 6/11/18, 6/12/18, and 6/13/18 were obtained at noon as ordered. The other six blood glucose measurements were obtained between 5:04 AM and 6:25 AM. Review of Resident #49's laboratory studies revealed the Resident had Hemoglobin A1C (blood test utilized to determine the average blood glucose concentration in the blood and control of blood glucose levels over a three month time frame) testing completed on 10/27/17. The result of the test was high which indicated poor glucose control. An interview and record review were completed with the Director of Nursing (DON) on 6/13/18 at 2:15 PM. When queried regarding Resident #49's blood glucose monitoring orders and documented results, the DON stated, You would expect to see over 400 results and you don't see any. I know. I saw that and talked to them (staff) and we changed the order today. When queried regarding laboratory testing related to glucose monitoring for the Resident, further explanation was not provided by the DON. Resident #356 Record review on 6/13/18 at 3:00 PM revealed Resident #356 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required limited assistance to perform Activities of Daily Living (ADL's). Review of Resident #356's medical record revealed a health care provider order dated 6/3/18 which stated, BGM in AM before breakfast, one time a day for DM (Diabetes Mellitus). Review of documented blood glucose measurements at this time revealed no blood glucose measurement was documented on 6/4/18 and 6/6/18. Additional review revealed all measurements were documented between 7:54 AM and 10:30 AM. Review of Resident #356's care plans at this time revealed the Resident's care plan related to diabetes mellitus was created on 6/13/18. The care plan was titled, (Resident #356) is at risk for hypo/[MEDICAL CONDITION] and other complication r/t (related to) [DIAGNOSES REDACTED]. On 6/13/18 at 3:30 PM, an interview was conducted with the DON. When queried regarding no documentation of Resident #356's blood glucose on 6/4/18 and 6/6/18 as well as the times the measurements were documented, the DON was unable to provide an explanation. Resident #507 Record review on 6/13/18 at 1:50 PM revealed Resident # 507 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Resident's admission assessment, dated 5/31/18, revealed the Resident was cognitively intact and required assistance to perform Activities of Daily Living (ADL's). Record review of Resident #507's medical record on 6/13/18 revealed a physician order [REDACTED]. Review of documented blood glucose monitoring results at this time revealed the Resident's blood glucose level had been obtained six times since the Resident was admitted to the facility. Dates and times of blood glucose monitoring documentation included: -5/31/18 at 6:27 PM, Blood Glucose 141 (high) -6/1/18 at 5:54 AM, Blood Glucose 133 (high) -6/1/18 at 12:07 PM, Blood Glucose 212 (high) -6/1/18 at 4:52 PM, Blood Glucose 192 (high) -6/2/18 at 12:27 PM, Blood Glucose 269 (high) -6/2/18 at 4:49 PM, Blood Glucose 162 (high) Review of Resident #507's care plans at this time revealed the Resident's care plan related to diabetes mellitus was created on 6/11/18. The care plan was titled, (Resident #507 is at risk for hypo/[MEDICAL CONDITION] and other complication r/t (related to) [DIAGNOSES REDACTED]. An interview and record review were completed with the Director of Nursing (DON) on 6/13/18 at 2:20 PM. When queried regarding Resident #507's blood glucose monitoring order and documented measurements, the DON reviewed the medical record and stated, The order was entered wrong. It (Order) was entered by administrations instead of days. (Order entered as having a frequency of seven administrations instead of seven days). Should have been ordered for 21 administrations. When asked why there were only six documented measurements, not seven, with the order being entered incorrectly, the DON reviewed the medical record and stated, The order was entered right. No further explanation was provided. An interview was conducted with the DON and facility Administrator on 6/13/18 at 3:35 PM. When queried regarding blood glucose monitoring and documentation for Resident #'s 49, 356, and 507, the Administration did not provide further explanation. On 6/13/18 at 5:00 PM, record review of facility policy entitled Diabetic Management (Release Date: 3/2013), revealed, Routine Care: Blood glucose measurements are taken per the physician order.

This citation pertains to MI 190 Based on interview and record review, the facility failed to prevent neglect when necessary services and treatment for [REDACTED].#'s 107, 49, 356, and 507) of nine residents reviewed for diabetes management did not receive necessary treatment for [REDACTED]., and a new [DIAGNOSES REDACTED]. On 6/6/18 at 9:50 a.m., review of the complaint intake for Resident #107 revealed the following documentation: On 2/7/18 the facility checked blood sugar in a.m. and the resident received the [MEDICATION NAME] .The facility could not tell the family what the BS was in a.m. At 12:00 noon the resident was staring at the wall and babbling very confused the staff were unaware and never checked BS (blood sugar) again. Family Dr. sent to ER .the resident was transferred to a local hospital for confusion for [DIAGNOSES REDACTED] BS was 34 checked in ER hospital. On 6/6/18 at 10:20 a.m., review of Resident #107's face sheet revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #107's Minimum Data Set (MDS) assessment, dated 2/8/18, indicated an intact cognition and an intact memory with minimal queuing required. There was no mental status change noted on the MDS. Limited assistance was required for all activities of daily living (ADLs). The admission note, dated 1/25/18 at 4:45 p.m., indicated that resident #107 was admitted into the facility due to a fractured left arm and was alert and oriented at the time. A physician's note, dated 2/3/18 at 1:40 p.m., revealed: admitted for rehab (rehabilitation) after left arm fracture and surgical repair . On 6/6/18 at 12:30 p.m., the Director of Nursing (DON) was queried regarding diabetes management for Resident #107 and revealed the following: Review of the blood sugars revealed incidents where the glucometer could not measure the exact blood sugar due to the levels being extremely low. Review of the nurses' notes and the medical record with the DON revealed no notification of the abnormal readings to the doctor, documentation of treatment for [REDACTED]. The abnormal blood sugars were noted on the following times: 1. 1/28/18 at 17:55 (5:55 p.m.), the glucometer registered a reading of low bgm. 2. 2/6/18 at 08:55 (8:55 a.m.), the glucometer registered a reading of low bgm. 3. 2/6/18 at 18:06 (6:06 p.m.), the glucometer registered a reading of low bgm. On 6/6/18 at 12:37 p.m., the DON stated, There is no documentation of the doctor being called. The parameters should have been followed according to the standing orders. The DON had no explanation when queried about the neglect of treatment for [REDACTED]. The standing orders/protocol for low blood sugars for Resident #107 were reviewed with the DON and revealed the following instructions: A. Alert resident - Blood sugar below 50 mg/dl (milligrams per deciliter), give Insta-Glucose, re-check blood sugar in 15 minutes. B., Unresponsive resident - Blood sugar below 50 mg/dl, give 1 mg [MEDICATION NAME] SQ (subcutaneous) or IM (intramuscularly, re-check blood sugar in 15 minutes, C. Notify the attending physician. When the DON was queried regarding the readings of low bgm, the DON stated, They probably forgot to document the level. The facility's glucometer manual was requested at this time. On 6/6/18 at 12:40 p.m., Resident #107's record review continued with the DON. The following was revealed: Resident #107's nurses' progress notes were reviewed with the DON. The DON stated, She was transferred to the hospital on [DATE]. At this time the nurse's note dated 2/7/18 at 15:47 (3:47 p.m.), revealed the following documentation: Continued confusion and lethargy noted. Family reporting since [MEDICATION NAME] (antidepressant) was D/C'd (discontinued) there has been no improvement. PT (physical therapy) also reporting res (resident) is more weak and declining in therapy .Call placed to doctor who stated to transfer to ER (emergency room ) for evaluation .Ambulance paged for non-emergent transfer at 2:10 p.m .Resident transferred from facility by EMS (emergency medical services) at 2:40 p.m. Upon review (with the DON) of the physician's orders [REDACTED]. Additionally, an error had occurred at the time of admission into the facility when Resident #107's medication order for the administration of [MEDICATION NAME] was not transcribed as prescribed from the hospital. Review of Resident #107's Discharge Medication List from the hospital revealed the following order: [MEDICATION NAME] (Repaglinide), 1 mg oral twice a day PRN (as needed), 1 mg tablet, as needed for CGB > (greater than) 120. On the day of admission into the facility, on 1/26/18, the facility transcribed the order as: [MEDICATION NAME] Tablet 1 mg (Repaglinide), give 1 tablet by mouth two times a day for Diabetes, hold if BGM is <120. The DON reported that the [MEDICATION NAME] was not transcribed correctly. Per the Medication Administration Record [REDACTED]<120. The documented blood sugar was 119 at 8:07 a.m. on 2/7/18. There was no documentation of the consumed amount of breakfast and lunch for Resident #107. On 1/26/18 at 7:30 a.m., [MEDICATION NAME] was administered without a documented blood sugar reading. On 1/28/18 at 8:15 a.m., Resident #107's blood sugar was 104. The nurse still administered the [MEDICATION NAME] per the Medication Administration Record [REDACTED]. Later, that same day, at 17:55 (5:55 p.m.), Resident #107's blood sugar, per the glucometer read, Low BGM. A copy of Resident #107's care plan for diabetes management was requested. The DON reported not having one. On 6/6/18 at 1:25 p.m., review of Resident #107's nurses' notes revealed a decline in her cognition/mental status. The admission nursing summary note, dated 1/25/18 at 4:35 p.m., revealed, Resident is alert and oriented. The nurse's note dated 2/7/18 at 12:35 a.m., revealed, Resident's daughter expressed concern about resident's increased confusion and lack of improvement .Writer also noticed slight increase in confusion from admit . On the day of transfer to the ER there was the following documentation dated 2/7/18 at 3:47 p.m., that revealed, Continued confusion and lethargy noted .PT also reporting res (resident) is more weak and declining in therapy . On the day before, 2/6/18, Resident #107 had two critically low blood sugars in which the facility's glucometer could not measure due to the blood sugars being so low. Again, there was never any documented treatment and or interventions for the critically low blood sugars. There was no documentation from the facility, in the least, acknowledging the critically low blood sugars which may have lead to the change in mental status/confusion and lethargy. On 6/6/18 at 3:05 p.m., review of the manufacturer's manual for the facility's glucometer revealed the following regarding readings: A reading of LO indicates your blood glucose (sugar) reading is below 20 mg/dl. Test result is lower than 20 mg/dl. Wash and dry your hands and repeat the test on your fingertip with a new test strip. If the result is still 'LO,' contact your physician or a healthcare professional immediately. On 6/6/18 at 3:50 p.m., review of Resident #107's hospital records, a Neurology Consult Note, 2/7/18, revealed the following documentation: This patient was admitted to the hospital on [DATE] with symptoms of increasing confusion and altered mental status .In the emergency room she was found to have severe [DIAGNOSES REDACTED] requiring D 50 ([MEDICATION NAME]) fluid bolus to correct her low sugar readings. She has a known history of underlying diabetes mellitus. She had not been eating prior to her admission .She likely had some degree of metabolic encephlopathy due to severe [DIAGNOSES REDACTED]. Per the hospital's record, Resident #107's primary [DIAGNOSES REDACTED]. On 6/6/18 at 3:55 p.m., review of the facility's policy entitled Diabetic Management, revised 3/2013, revealed the following documentation: Diabetic Management involves both preventative measures and treatment of [REDACTED]. Upon admission the IDT evaluates the diabetic resident and implements a plan of care to ensure orders are received and are accurate related to blood glucose monitoring and anti-diabetic agents. Blood glucose orders should include parameters to follow and when to notify the physician. Resident #49 Record review on 6/13/18 at 11:40 AM, revealed Resident #49 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 4/30/18, revealed the Resident was cognitively intact and required supervision to extensive assistance to perform Activities of Daily Living (ADL's). Record review on 6/13/18 at 11:45 AM of Resident #49's physician orders [REDACTED]. -Check BGM (Blood Glucose Measurement) daily at noon (Order Date: 5/30/17, Discontinued date: 6/13/18) -Check Blood Glucose Daily (Order Date: 6/10/18) Review of Resident #49's blood glucose monitoring documentation and laboratory studies at this time revealed 11 documented blood glucose levels for Resident #49 since 5/30/17 on 5/30/17, 6/1/17, 6/17/17, 7/3/17, 12/29/17, 12/30/17, 1/3/18, 6/10/18, 6/11/18, 6/12/18, and 6/13/18. Review further revealed only five of the blood glucose measurements on 6/10/18, 6/11/18, 6/12/18, and 6/13/18 were obtained at noon as ordered. The other six blood glucose measurements were obtained between 5:04 AM and 6:25 AM. Review of Resident #49's laboratory studies revealed the Resident had Hemoglobin A1C (blood test utilized to determine the average blood glucose concentration in the blood and control of blood glucose levels over a three month time frame) testing completed on 10/27/17. The result of the test was high which indicated poor glucose control. An interview and record review were completed with the Director of Nursing (DON) on 6/13/18 at 2:15 PM. When queried regarding Resident #49's blood glucose monitoring orders and documented results, the DON stated, You would expect to see over 400 results and you don't see any. I know. I saw that and talked to them (staff) and we changed the order today. When queried regarding laboratory testing related to glucose monitoring for the Resident, further explanation was not provided by the DON. Resident #356 Record review on 6/13/18 at 3:00 PM revealed Resident #356 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required limited assistance to perform Activities of Daily Living (ADL's). Review of Resident #356's medical record revealed a health care provider order dated 6/3/18 which stated, BGM in AM before breakfast, one time a day for DM (Diabetes Mellitus). Review of documented blood glucose measurements at this time revealed no blood glucose measurement was documented on 6/4/18 and 6/6/18. Additional review revealed all measurements were documented between 7:54 AM and 10:30 AM. Review of Resident #356's care plans at this time revealed the Resident's care plan related to diabetes mellitus was created on 6/13/18. The care plan was titled, (Resident #356) is at risk for hypo/[MEDICAL CONDITION] and other complication r/t (related to) [DIAGNOSES REDACTED]. On 6/13/18 at 3:30 PM, an interview was conducted with the DON. When queried regarding no documentation of Resident #356's blood glucose on 6/4/18 and 6/6/18 as well as the times the measurements were documented, the DON was unable to provide an explanation. Resident #507 Record review on 6/13/18 at 1:50 PM revealed Resident # 507 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Resident's admission assessment, dated 5/31/18, revealed the Resident was cognitively intact and required assistance to perform Activities of Daily Living (ADL's). Record review of Resident #507's medical record on 6/13/18 revealed a physician order [REDACTED]. Review of documented blood glucose monitoring results at this time revealed the Resident's blood glucose level had been obtained six times since the Resident was admitted to the facility. Dates and times of blood glucose monitoring documentation included: -5/31/18 at 6:27 PM, Blood Glucose 141 (high) -6/1/18 at 5:54 AM, Blood Glucose 133 (high) -6/1/18 at 12:07 PM, Blood Glucose 212 (high) -6/1/18 at 4:52 PM, Blood Glucose 192 (high) -6/2/18 at 12:27 PM, Blood Glucose 269 (high) -6/2/18 at 4:49 PM, Blood Glucose 162 (high) Review of Resident #507's care plans at this time revealed the Resident's care plan related to diabetes mellitus was created on 6/11/18. The care plan was titled, (Resident #507 is at risk for hypo/[MEDICAL CONDITION] and other complication r/t (related to) [DIAGNOSES REDACTED]. An interview and record review were completed with the Director of Nursing (DON) on 6/13/18 at 2:20 PM. When queried regarding Resident #507's blood glucose monitoring order and documented measurements, the DON reviewed the medical record and stated, The order was entered wrong. It (Order) was entered by administrations instead of days. (Order entered as having a frequency of seven administrations instead of seven days). Should have been ordered for 21 administrations. When asked why there were only six documented measurements, not seven, with the order being entered incorrectly, the DON reviewed the medical record and stated, The order was entered right. No further explanation was provided. An interview was conducted with the DON and facility Administrator on 6/13/18 at 3:35 PM. When queried regarding blood glucose monitoring and documentation for Resident #'s 49, 356, and 507, the Administration did not provide further explanation. On 6/13/18 at 5:00 PM, record review of facility policy entitled Diabetic Management (Release Date: 3/2013), revealed, Routine Care: Blood glucose measurements are taken per the physician order.

Based on observation, interview and record review the facility failed to ensure appropriate interventions were in place to prevent severe weight loss for 1 (#508) of 3 residents reviewed for weight loss from a total sample of 20, resulting in the resident experiencing a severe weight loss in 6 months. Findings include: On 8/7/17 at 8:35 AM, during the initial tour, nurse B was queried if Resident #508 gets out of bed. Nurse B responded Not as often as (they) used to. On 8/7/17 at 10:00 AM, a record review revealed that Resident #508 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], indicated Resident #508 required limited assistance with transfer and ambulation; supervision with meals and personal hygiene, and always continent of bowel. The MDS dated [DATE] indicated Resident #508 required extensive assistance with transfers, does not ambulate, supervision with meals, required limited assistance in hygiene and is occasionally incontinent of bowel. On 8/9/17 at 9:40 AM, review of the dietary note dated 4/20/17 revealed resident being offered Ensure plus three times per day (TID) and refusing it often, will change it to [MEDICATION NAME] extra On 8/9/17 at 10:00 AM, a review of Resident #508's weights revealed: 7/11/17 112.3 lbs (pounds); 6/3/17 111 lbs 5/30/17 110.6 lbs 5/5/17 118.5 lbs 4/27/17 118.6 lbs 4/6/17 112.1 lbs 3/24/17 112.6 lbs 2/2/17 126.2 lbs. A review of the resident's lab results dated 5/12/17 revealed a total protein of 5.5 ( normal range ---- and an [MEDICATION NAME] of 2.9. A review of Resident #508's food acceptance record revealed an average intake of meals was 51 percent (% ) to 75% with no record of supplements being offered. On 8/9/17 at 10:50 AM, a review of the resident's physician orders [REDACTED]. an order for [REDACTED]. On 8/9/17 at 11:00 AM, a review of the resident's care plan for pressure ulcers revealed the following interventions: .Monitor nutritional status, serve diet as ordered and monitor effectiveness with an initiation date of 2/7/14 and no revision noted. .Encourage good nutrition and hydration in order to promote healthier skin . with an initiation date of 1/30/14 and a revision date of 7/28/17 with no change noted to care plan. A review of the resident's diet care plan revealed .able to feed self . with an initiation date of 2/6/14 which states declines supplements, have retried them and she accepts at times. An intervention was in place to provide and serve supplements as ordered: Ensure plus refusing with an initiation date of 8/11/16 with a revision date on 7/31/17 with no change in care plan. On 8/9/17 at 1:50 PM, observed Resident #508 lying on there back in there bed. When queried how they were feeling. Resident stated I've been waiting since lunch and I'm wanting to be turned. On 8/9/17 at 1:50 PM, An interview with Medical Director (MD) K in the residents room, regarding the resident's nutritional status, no response provided. The MD offered the resident has hydro[DIAGNOSES REDACTED](swelling on the kidney). On 8/9/17 at 2:00 PM, The Certified Dietary Manager (CDM) I was queried how residents get offered supplements and who orders them, They let me know to add extra protein, ensure clear or shakes. When queried if resident #508 received extra supplements Yes it should be on their meal ticket if it's ordered. On 8/9/17 at 2:10 PM, a review of resident #508's meal ticket indicated no supplements, ensure or protein shakes listed. On 8/9/17 at 2:50 PM, a review of the physician progress notes [REDACTED]. A review of the physician progress notes [REDACTED]. A record review of the physician progress notes [REDACTED]. A record review of the physician progress notes [REDACTED]. There were no corresponding orders noted. On 8/9/17 at 3:30 PM, the Director of Nursing ( DON) was queried on expectations of staff when weight loss was recognized an stated, I would expect the staff to alert the dietician, order supplements, possibly downgrade diet or have speech therapy evaluate and I would go to weekly weights. When queried if supplements would need to be ordered by a physician, There would be an order for [REDACTED].>On 8/9/17 at 4:20 PM, a review of the facility weight management policy revealed Residents determined to be at risk or have significant weight changes will be weighed on a weekly basis including residents with insidious weight loss, Once an insidious weight loss is identified, the RD further assesses the resident and makes recommendations as indicated to prevent/treat unintended weight loss, Dietary manager, and/or RD are to communicate weight changes to the attending physician and resident's responsible party.

Based on observation, interview and record review, the facility failed to provide effective interventions to prevent falls and serious injury for 3 (#'s 509, 513, and 517) of 6 sampled residents reviewed for falls from a total sample of 20, resulting resident #509 and #517 obtaining hip fractures, and resident # 513 obtaining contusions, bruises, and lacerations, and the potential for additional injuries. Findings Include: Resident # 517 On 8/8/17 at 2:30 PM, a review of the face sheet revealed that resident # 517 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident's had an intact cognition and required one person assistance for transfers and bed mobility. On 8/8/17 at 2:45 PM, a review of the Care Plan revealed that the resident was at risk for falls from a recent right total hip arthroplasty, history of falls with injury. On 8/8/17 at 3:10 p.m., a review of Resident #517's fall incident reports revealed the following: On 6/7/17 at 5:20 p.m., Resident's spouse observed her on the floor when walking into the room. Resident was in front of the dresser on right buttock. Both legs tucked to the side of resident. Resident indicated attempting to self transfer and pant leg got caught on the wheel chair. An X-ray was completed to resident's right hip which revealed a fracture around resident's right hip replacement. Resident #517 was transported to the hospital for evaluation and treatment. Resident # 517 returned to the facility from the hospital on [DATE]. No new interventions were added to the fall care plan, upon the resident's return to the facility on [DATE]. On 6/25/17 at 11:35 PM, Resident was observed on the floor next to the bed. The resident indicated needing to use the bathroom. There were no injuries. Interventions were listed as: Sensor mat to exit side of bed. Bed against wall. On 8/8/17 at 4:45 PM, Resident #517 and the spouse were queried on the falls which occurred involving the resident on 6/7/17 and 6/25/17. Resident #517's spouse indicated, that resident's fall on 6/7/17 caused the resident to re-injure their hip, resulting in a longer then anticipated stay at the facility. Resident's spouse indicated that they (staff) were letting the resident do to many things that resident should not have been doing. When queried on what those things were, the resident's spouse mentioned allowing her to self transfer. On 8/9/17 at 11:37 a.m , The Director of Nursing (DON) was interviewed and Resident #517's falls on 6/7/17 and 6/25/17 were reviewed. The DON was queried on why no new interventions were put in place following Resident #517's fall with injury on 6/7/17 and return to the facility on [DATE]. The DON indicated that an intervention was put in place on 6/19/17, to encourage resident to keep the room door open. The DON was further queried on why this intervention was not put in place on 6/12/17, upon resident's return from the hospital. The DON indicated, It should have been. That is not typical. That was an oversight. Resident #509 On 8/7/17 at 12:30 PM, record review revealed that resident # 509 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment, dated 7/22/17, revealed a Brief Interview for Mental Status (BIMS) score of 4 which indicated severe deficit in cognition and the resident required assistance with activities of daily living and transfers. On 8/8/17 at 10:30 AM, a review of the resident's incident and accident reports revealed the following: On 9/29/16 at 8:40 PM, the Resident was found in the bathroom lying on stomach face down, legs straight, arms bent to sides, w/c (wheelchair) behind (Resident), head on floor at base of toilet. The Resident obtained a skin tear. Blood pressure (Bp) was 85/60. Resident #509 was transferred to the hospital for evaluation. The Incident and Accident Report stated, Interventions Implemented. Non skid footwear wasn't in place. Do not leave Resident unattended in bathroom. Bp documentation added to noon med pass r/t (related to) low Bp. On 5/11/17 at 9:50 PM, Resident was observed sitting on the floor by nightstand, feet bare and under the bed, no injuries noted. The Incident and Accident Report stated, Interventions Implemented. Anti slip mat to exit side of bed. Encourage grippy socks, PT (physical therapy) referral. On 6/9/17 at 3:44 AM, Resident was observed lying on the floor on (their) left side complaining 'My hip hurts like hell'. The Resident was sleeping in bed prior to falling. The Resident was sent to the emergency room . The medical record revealed Resident #509 sustained a left femur (hip) fracture. The Incident and Accident Report stated, Interventions Implemented. Anti rolls brakes, Anti shock rug to exit side of bed/until Resident becomes mobile then replace with anti slip rug. Move room closer to nurses station when bed comes available. On 6/24/17 at 7:45 PM, When chair was in lift position, the pillows resident was sitting on and pillow at right side all slid with resident to floor- lying on right side, head toward window, pillow under head, pillow partway under right hip. No injury was noted. The Incident and Accident Report stated, Interventions Implemented. Daughters do not want (Resident) left alone in room when up in recliner. Alarm mat to exit side of bed (replaces antishock rug) or to foot of recliner. On 8/8/17 at 11:15 AM, an interview with Resident #509's family member revealed the resident sustained [REDACTED]. The family member revealed the resident had slipped out from the recliner chair after coming back to the facility from having surgery on his leg. The family member revealed that was when the alarm mat was placed on the floor and stated, When he puts his feet down it alarms and he stops and sometimes use the call light or it gives the staff enough time to get down here and help him. On 8/8/17 at 12:30 PM, review of the Resident #509's care plan for risk of falls, revealed a goal of (Resident) will be free of injury related to falls through the review date, initiated on 2/27/17 and revised on 6/3/17. There was no revision of the Resident's goals after the fall on 6/9/17 that resulted in a femur fracture. The Interventions for the care plan did not include the following interventions that were listed on the Incident and Accident Reports: move room closer to nurses station when bed comes available and Resident not to be left alone while in the recliner chair. On 8/9/17 at 2:00 PM, an interview with the Director of Nursing (DON) was conducted regarding Resident #509. When queried if interventions listed on the Incident and Accident Reports should appear on the care plan, the DON stated, They should be in place, yes. When queried why the alarm mat was not instituted earlier, the DON stated, We use alarms as a last resort. The DON further explained that the family did not want to move the Resident closer to the nurses station indicating too much activity in the area. On 8/9/17 at 3:00 PM, a review of Resident #509's medical record progress notes, did not reveal a refusal from the family to have the Resident's room closer to the nurses station. At the time of the survey, rooms were available closer to the nurses station that were not directly near the the nurses station. Surveyor: Howard, Brender Resident #513 On 8/8/17 at 2:30 p.m., a review of the Care Plan revealed, Resident #513 had a history of [REDACTED].#513, also had an Activity of Daily Living (ADL) self-care performance deficit and required assistant with all ADLs and mobility. Do not leave in rest room unattended. On 8/8/17 at 3:00 p.m. Resident #513 was observed in room walking self to the bathroom. The Certified Nursing Assistant (CNA) came in the room to assist Resident #513 into the bathroom and left, leaving the resident in the bathroom alone. The CNA went to another resident's room. After several minutes, the CNA came back to Resident #513's room to assist resident out of the bathroom. On 8/8/17 at 3:30 p.m., a review of the Minimum Data Set (MDS) revealed Resident #513 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS dated [DATE] revealed, that Resident #513 had an intact cognition. On 8/8/17 at 4:30 p.m., a review of the Incident and Accident Reports for resident #513 revealed the following: On 11/14/16 at 3:30 a.m., resident slid out of bed landing on buttock on alarm mat, leaning against bed. Resident stated that she was trying to reach her wheel chair to go to the restroom. Alarm mat malfunction. No injury noted. Intervention: Maintain proper function of alarm mat. New intervention after IDT review: Alarm not replaced. On 11/18/16 at 2:30 a.m., resident was sitting on buttock on floor mat, legs straight in front of resident, arms to sides with palms on floor, resident was facing side of bed. Resident stated they rolled out of bed. No injuries. Floor mat did not initially alarm. On 11/27/16 at 11:55 p.m., a fell ow nurse was walking past resident's room and heard resident moaning and calling for help. Resident was on the floor with her left leg was inside the spoke of the wheelchair. Resident kept stating get me up. No gripper socks. Alarm wasn't in place. Intervention: 1:1 given to Certified Nursing Assistant for education who didn't put mat in place. On 2/17/17 at 4:55 a.m., resident was observed lying on the floor in front of the bed with alarm mat under bed. Resident stated she rolled out of (their) bed. No injury noted. Intervention: Nursing to check placement and function of alarm mat every 4 hours. On 3/3/17 at 1:30 a.m., resident was observed sitting on the floor, leaning against her bed with all of her blankets wrapped around lower body. On 4/28/17 at 12:11 a.m., resident observed on floor beside bed after alarm mat sounded. Resident on knees facing toward bed. Resident stated, trying to get back into bed. No injury noted. On 6/25/17 at 12:45 a.m., resident observed on floor face down after alarm sounded. Resident laying prone in front of bed with legs extended straight against night stand with right arm bent at 45 degrees above head. Blankets on floor mat under resident. Skin tear located on left hand centimeter by 1 centimeter in size. Bruise top of head on left side with some swelling, bruise on left eye, bridge of nose bleeding along with slight bleeding of left nostril. Resident complained of headache. Doctor called and order to send to hospital for treatment and evaluation. On 8/9/17 at 12:08 p.m., a record review revealed following: The Care Plan revealed, resident is at risk for injury/complication of seizure disorder. The Nurses Comprehensive Evaluation dated 5/24/17 showed the Resident scored 5 which indicated no risk for falls. No neurological checks were observed in the Resident's record. On 8/9/17 at 9:50 a.m., Director of Nursing (DON) was interviewed. When queried about assessments and fall of Resident #513, stated, We do fall assessments for all falls. We don't have a system like our sister facility that gives us an actual number. We do neuro checks after resident hit their head. We do incident reports and record everything on it. We also do Fall Huddle where we come up with an intervention. All interventions are care planned. No other information was given regarding the repeated falls. A review of the Facility's Policy Fall Management with the revision date of August 2016 documented the following: If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls .If a potential head injury is present, complete the Neurological Record.

Based on observation, interview and record review, the facility failed to provide interventions, assessment and monitoring to prevent facility acquired pressure ulcers for 2 (#'s 503 and 508) of 5 sampled residents reviewed for pressure ulcers from a total sample of 20 residents, resulting in development of Stage 3 pressure ulcers. Findings Include: Resident #503 On 8/7/17 at 11:55 am, a record review revealed that Resident #503 was admitted into the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] indicated the resident required extensive 1 person assistance with dressing, extensive 2 person assistance with bed mobility, toileting and bathing and total 2 person assistance with transfers. Resident #503 was able to feed themselves and did not walk. An interview with Nurse J on 8/7/17 at 12:27 PM provided, The resident has a new wound, a Stage 3 pressure ulcer (Full thickness loss of skin), on the left leg from an immobilizer. On 8/7/17 at 12:30 PM Resident #503 was observed lying in bed watching TV with a foam boot /brace on the left lower leg residual limb. The resident was grimacing and stated, I have muscle spasms. I didn't get my pain pill until about 10:30 am. On 8/7/17 at 2:20 PM, wound care to the resident's left lower leg and sacrum was observed performed by Nurse P, with assistance from a Certified Nursing Assistant (CNA). A stretchy wrap with dried blood was covering the resident's left lower leg residual limb and a gauze dressing soaked with dark thick bloody drainage was observed. The wound was round, approximately 2 cm (centimeters) by 2 cm, red, with some dark and yellow necrotic (dead tissue) areas. The resident was moaning and grimacing throughout the procedure. After the wound care was completed, Nurse P was queried on who inspects the resident's skin under the Left boot/brace and stated, I would think it would be documented on the TAR (treatment administration record), but I didn't see anything. I've only had (Resident #503) for 2 days. Nurse P indicated sometimes the resident wears the immobilizer and sometimes the boot/brace. On 8/7/17 at 3:00 PM, a review of a Nurse's note dated 6/21/17 provided, Had Left BKA continues to wear brace. There was no documentation of inspection of the skin under the brace. Review of the May and June 2017 TAR's revealed there was no order or documentation to monitor the left leg immobilizer or skin under the immobilizer, until after the wound was noted on 6/23/17 and provided Remove the left BKA below the knee immobilizer for 30 to 90 minutes at a time as tolerated by resident while in bed for pressure relief every shift, the order was discontinued on 6/30/17. Review of the August 2017 TAR provided, Left BKA immobilizer lined with lamb's wool to left BKA residual limb ATC (around the clock) remove for 30 to 90 minutes a shift and monitor skin integrity, date initiated 7/7/17. There was no documentation that this was performed on 8/7/17 during the 7 am - 7pm shift. Nurse P had indicated that she was not aware of this treatment. Review of the Wound Skin/Healing Record dated 6/23/17 indicated, the resident developed a suspected Deep Tissue Injury to the left medial residual limb measuring 2.6 centimeters (cm) length by 1.5 centimeters width with no drainage and dark red/purple in color. The Care Plan was updated to include Foam boots to right heel and left BKA. On 6/28/17: the wound began to have serosanguinous (yellowish drainage). The Care Plan was not updated with any new interventions. On 7/6/17: the wound had increased serosanguinous drainage and was Unstageable (covered by necrotic tissue or eschar (stringy dead tissue) and the Care Plan was updated on 7/7/17. On 7/12/17: the wound measured 1.9 cm length by 0.8 cm width by 0.3 cm depth and was a Stage 3 pressure ulcer. The Care Plan was not updated. On 7/19/17: the wound measured 1.1 cm by 0.7 cm by 0.2 cm, Stage 3 pressure ulcer. The Care Plan was not updated. On 7/26/17: the wound measured 1.4 by 1.2 by 0.3, Stage 3 pressure ulcer. The Care Plan was not updated. On 8/2/17: the wound measured 1.3 by 1.1 by 0.2, Stage 3 pressure ulcer. The Care Plan was not updated. On 8/7/17 the Skin Care Plan for Resident #503 was updated to include, Roho cushion to wheelchair. Check inflation every shift and re-inflate as necessary. An interview with Nurse B and Nurse J on 8/8/17 at 2:35 PM provided, Resident #503 had been wearing a left leg immobilizer to aid in comfort related to muscle spasms. Neither could identify any documentation to indicate monitoring of the immobilizer or the skin underneath the immobilizer on the left lower residual limb prior to identification of the pressure ulcer on 6/23/17. Nurse J stated, We usually have something in the chart that says monitor the skin under the immobilizer each shift. They are supposed to be monitored underneath. I don't know why it's not there. An interview with the Director of Nursing (DON) on 8/9/17 at 3:30 PM revealed, Nursing staff would be responsible for that, when queried who monitors the residents skin beneath a device such as an immobilizer. On 8/9/17 at 4:15 PM, a review of the facility policy titled, Skin Management, dated 8/2016, provided, It is the policy of the facility that a resident does not develop pressure injury unless clinically unavoidable .Appropriate preventative measures will be implemented on residents identified at risk and the interventions are documented on the care plan. On 8/9/17 at 4:25 PM, a review of the facility policy titled, Brace and Splint Program, dated 1/2012, revealed, Staff has a scheduled program of applying and removing the appliance that includes: Scheduled hours to be worn and when skin will be inspected for signs and symptoms of pressure areas . On 8/7/17 at 10:00 AM, a record review revealed, that resident #508 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimal Data Set ((MDS) dated [DATE] indicated that the resident required limited assistance with transfer and ambulation; supervision with meals and personal hygiene, and always continent of bowel. The MDS dated [DATE] indicated the resident required extensive assistance with transfers, does not ambulate, supervision with meals, requires limited assistance in hygiene and is occasionally incontinent of bowel. On 8/7/17 at 2:15 PM, resident #508 was observed lying in bed on her back with head of bed elevated. The resident was asked if she has been up and out of her bed lately and stated, It's been awhile. On 8/8/17 at 8:50 AM, the resident was observed lying in her bed on her back. When queried if she was getting up and out of bed today, the resident stated, I don't think so. On 8/8/17 at 10:40 AM, the resident was observed lying her bed on her back with her left leg raised on a pillow with head of bed elevated. When queried why her leg was raised because it relieves the pressure. On 8/9/17 at 9:25 AM, the resident was observed lying in bed on her back with both legs raised on pillow. On 8/9/17 at 10:00 AM, a record review of resident #508 revealed weight on 7/11/17 of 112.3 pounds and weight on 2/217 of 126.2 pounds. Which is an 11% weight loss in 6 months. On 8/9/17 at 11:00 AM, a record review of resident #508 care plan for pressure ulcers revealed the following interventions: Monitor nutritional status, serve diet as ordered and monitor effectiveness with an initiation date of 2/07/14 with no revision noted, Apply pressure relieving/reducing mattress, pillows, sheepskin padding etc to protect the skin while in bed with an initiation date of 5/09/17 with a revision date of 7/31/17 with no change noted to care plan, Encourage good nutrition and hydration in order to promote healthier skin with an initiation date of 1/30/14 with a revision date of 7/28/17 with no change noted to care plan. On 8/9/17 at 1:50 PM, the resident was observed lying on her back with her legs raised on pillows and stated I've been waiting since lunch and I want to be turned. The doctor ( MD K) entered the resident's room for assessment and stated It is very important to turn her. On 8/9/17 at 2:20 PM, queried wound care nurse (J) on what type of mattress resident 508 has she has an air LTC mattress. Observed resident #508 on her back in bed with a pillow under her right side. Attempt made by wound care nurse (J) to assess resident #508's skin with refusal noted. On 8/9/17 at 4:10, a review of the resident's weekly skin assessment dated [DATE] reveals coccyx pink, intact, blanchable. A review of the resident's progress note dated 4/18/17 revealed small open area to coccyx with small amt of slough. peri skin is macerated and red. Stage 3 pressure injury. A review of wound/skin healing record dated 4/18/17 reveals measurements to coccyx stage 3 pressure injury 1.2 centimeters (cm) Length x 1.1 cm Width x 0.2 cm Depth with serosanguinous exudate of small amount with no odor. A review of the resident's wound/skin healing record dated 5/10/17 reveals measurements to coccyx stage 3 pressure injury 0.6 cm Length by 0.3 cm Width and 0.2 cm depth. A review of the resident's weekly skin assessment dated [DATE] reveals open area to coccyx, treatment in place. A review of the resident's skin assessment dated [DATE] revealed open area, treatment in place Site noted to be sacrum. No other wound measurements found in record.

This citation pertains to intake number MI 867 Based on observation, interview and record review, the facility failed to provide effective interventions and monitor residents to maintain safety and prevent falls and serious injuries for 3 (#'s 701, 702, and 703) of 3 residents reviewed for safety and falls, resulting in Resident #701 sustaining multiple falls leading to a skull fracture and death; Resident #702 with multiple falls resulting in soreness and pain and Resident #703 with a history of falls and fracture, did not receive assistance with care per the care plan, with the potential for additional falls . Findings include: On [DATE] at 9:15 AM, a review of the facility's policy titled, Fall Management was reviewed and it revealed the following. . The IDT (interdisciplinary team) will review all resident falls within ,[DATE] hours at the morning stand up meeting to evaluate/investigate the circumstances and probable cause for the fall. The IDT will review/modify the plan of care to minimize repeat falls and update the resident care plan/kardex as needed. The IDT will assure the Post-Fall Evaluation is completed within ,[DATE] hours . On [DATE] at 9:30 AM, record review revealed that Resident #701 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set (MDS) Assessment, dated [DATE], Resident #701 had severe cognitive impairment and requires limited assist and one person assist for transfers, toileting and dressing. The Resident requires supervision and set up only for ambulation. On [DATE] at 9:40 AM, a review of Resident #701's Medication Administration Record (MAR) showed the Resident was prescribed the following medications: [REDACTED]. On [DATE] at 12 PM, a review of Resident #701's incident and accident reports and Post Fall Evaluations were completed. The Resident fell on [DATE] at the facility and suffered a skull fracture and subdural hematoma and died . There were no Post Fall Evaluations provided for falls on [DATE] and [DATE] as per facility policy. There were no new interventions added for Resident #701 after falls that occurred on [DATE] and [DATE]. Fall #1: [DATE]: Found in bathroom sitting on floor facing wall beside toilet. Towel rack was pulled from wall and was on the floor. Resident had injury to right posterior head. Intervention: Very confused- reinforced the use of walker & signal device for help. [DATE] Post Fall Evaluation: The resident's mental status was described as, confused. Interventions: Psychiatric consult ordered and Nudexta (for mood and behavior disorder) ordered. Under the heading, Care Plan/Kardex Updated stated, No. Interventions after IDT (interdisciplinary team) review, the description box is blank. Fall # 2: [DATE]: Resident walking in hallway with walker and fell into doorway of room. Had left knee bruising. Bilateral knee X-ray completed, with no fracture identified at this time. Post Fall Evaluation form was not provided. Fall #3: [DATE]: Resident observed on floor, lying supine at foot of bed. Legs were extended out in front. Resident was trying to wheelchair to go to bathroom. Sustained fracture of the right patella (knee cap). [DATE] Post Fall Evaluation: New Interventions after IDT review: IDT discussed usage of perimeter mattress, body pillow and anti -shock rug. No new interventions were added. Fall # 4: [DATE]: Resident found lying on right side of floor next to bed. No injuries were noted. Resident first explained was doing the dishes then said was attempting to get into the bed. Intervention: When resident awake and in w/c (wheelchair), don't leave in room. Post Fall Evaluation Form was not provided. Fall # 5: [DATE]: Resident found on floor next to bed by CNA (Certified Nursing Assistant). Resident had large hematoma with moderate amount of blood noted to left forehead. Due to this fall the Resident was transferred to emergency room with a diagnosed skull fracture and severe subdural hematoma (bruising with bleeding in the brain) that lead to death within 5 hours of the fall. [DATE] Post Fall Evaluation: Root Cause for this fall: Review of contributing factors, Medical status/Physical Condition/ [DIAGNOSES REDACTED]. There are no interventions provided given the Resident died at the hospital. On [DATE] at 1:30 PM, Resident #701's Care Plan was reviewed and the following was revealed: After the Resident's fall on [DATE] (fracture of the knee cap) a care plan was implemented for the bed to be against the wall. After the fall on [DATE] an addition to the care plan was made on [DATE], to not leave Resident alone in the room when in wheelchair. There were no additions to the care plan after the fall on [DATE] and [DATE]. On [DATE] at 1:40 PM, an interview was conducted with Confidential Person B in regards to the fall of Resident #701 and any concerns they may have had about the care the resident was receiving. Confidential Person explained they do believe more could have been implemented to prevent the multiple falls the Resident had at the facility. They met Resident #701 at the emergency room and the doctor there specializing in trauma pulled the Confidential Person aside and explained Resident #701's brain was displaced to the side due to the trauma sustained. In addition there was lots of hemorrhaging (bleeding on the brain) and the Resident would not survive. They were put in a room to be with the Resident until the Resident passed around 3 AM on [DATE]. On [DATE] at 1:45 PM, contact was attempted with CNA (staff assigned to care of Resident #701 the night of fall) F. There was no answer and voicemail was left requesting return phone call. On [DATE] at 3:10 PM, an interview was conducted with the Administrator, Unit Manager C and the Medical Director about the multiple falls and interventions for Resident #701. The Administrator reported the IDT spoke extensively about perimeter mattress, body pillow and shock mat. The facility chose not to implement these options. The Administrator reported there were no alarms for this Resident. Resident was not receiving 1 to 1 monitoring on a daily basis. It was explained Resident #701 would receive 1 to 1 depending on the behaviors the Resident exhibited that day. The facility chose not to implement 1 to 1 monitoring for this Resident. The Unit Manager and Administrator stated Resident #701 was checked on about every hour. There was no documentation to support this. On [DATE] at 10:00 AM, a document titled Incident Detail, was reviewed for Resident #701 and indicted, at 10:00 PM the Resident was observed on the floor on the right side facing the bed. There was a large hematoma with moderate amount of bleeding noted to the Resident's left forehead. On [DATE] at 11:00 AM, a document titled, Recent Psych Notes, were reviewed. The documents stated the following, . (Resident) is calm at this time. Confused, poor memory. Poor judgement, impaired cognition. (Resident) is poor historian . Unable to state date, time, where (Resident) is or why (Resident) is here. Poor safety awareness . This citation pertains to Intake #MI 867 Resident #702 A record review on [DATE] at 10:15 am indicated Resident #702 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident had moderately impaired cognitive abilities and needed supervision by 1 staff member with: transfers, ambulation, dressing, eating, hygiene and toileting. The resident's had moderately impaired cognitive abilities. The resident received the following medications: [REDACTED]. An observation on [DATE] at 11:05 am revealed, Resident #702 was sitting in the bedside recliner. A rolling walker was next to the resident. The call light was tied to the bed rail and a silver ding bell was on the bedside table next to the chair. There was a non-slip mat beside the low bed. Resident #702 stated I'm sore: 2 legs, 2 arms and my back. I fell twice. The time before last was the worst. The one time I was sitting on the pot and fell in the bathroom. They gave me a new call bell to ring. When asked if the resident was taking themselves to the bathroom, Resident #702 responded, Yes, I take myself. On [DATE] at 10:45 am, a review of the Incident and Accident (I&A) reports revealed Resident #702 had 5 falls while being unsupervised, between February and June, 2017: 1. [DATE] at 9:40 PM, Resident #702 fell beside the bed, the resident stated they were going to the bathroom, the resident began Effexor on [DATE] and the dose was increased on [DATE], the resident complained of headaches and vision is getting worse. [DATE] Post Fall Evaluation, New Interventions after IDT (interdisciplinary team) review: None were noted. 2. [DATE] at 4:45 am, Resident #702 fell in the bathroom with one shoe on and one shoe off, bumped top of head, resident fell asleep on the toilet. [DATE] Post Fall Evaluation, New Interventions after IDT review: Add assist bars to toilet. 3. [DATE] at 12:45 am, Resident #702 fell while transferring self between bed and wheelchair, bumped head on night stand, suggested resident call for help at night. [DATE] Post Fall Evaluation, New Interventions after IDT review: orthostatic blood pressure checks every shift for 72 hours, therapy referral. 4. [DATE] at 5:00 am, Resident #702 fell beside the bed, bumped right side back of head, Patient states trying to go to the restroom and feeling weak. Patient is independent with transfers. [DATE] Post Fall Evaluation, New Interventions after IDT (interdisciplinary team) review: None noted. Initial intervention: Patient needs to not self-transfer, patient needs alarms, recently restarted on therapy. 5. [DATE] at 4:00 PM, fell in the bathroom, bumped right cheek, trying to toilet self and was incontinent. Undated Post Fall Evaluation, New Interventions after IDT review: None were noted. On [DATE] at 10:55 am, a review the care plans for Resident #702 revealed the following: ADL (activities of daily living) Care Plan reviewed [DATE], ADL self -care performance deficit, requires assistance with ADL's and mobility, Assist with toileting at night, supervision with transfers, toileting, dressing and personal hygiene. Fall Care Plan, initially dated [DATE], reviewed [DATE] and [DATE]: No new interventions added since [DATE]: [DATE] check side effects of medications. Previous interventions: [DATE] anti-slip rug by bed, [DATE] assist bars to toilet, [DATE] keep environment safe, call light in reach. Other Fall care plan interventions: rolling walker [DATE], ask to use bathroom every 2 hours [DATE], footwear [DATE]. A review of the progress notes on [DATE] at 11:00 am, indicated the following: [DATE]: Nursing Summary, .receives supervision/setup with adl's and mobility. Extensive assist with showers .ambulatory with (the) walker through the facility with slow gait .has had multiple falls this quarter monitoring vs (vital signs) and frequency of headaches. Dr (doctor) aware and no new orders for medication changes . Nurses notes: [DATE] at 5:48 am: patient was observed on floor on back by side of table in room states hit head .Patient does have a egg size bump on right side of back of head .states (the resident) was going to the restroom like (they) always (do). independent with transfers . [DATE] at 11:09 am, .independent with transfers and toileting. [DATE] at 12:53 PM: ambulatory with wheeled walker, needs minimal assistance with dressing/toileting . [DATE]:02 PM: .heard a scream, went into residents bathroom observed resident sitting on buttocks . [DATE] at 7:45 PM: .sore upper right arm, complains of pain to right upper arm. [DATE] at 2:17 PM: X-rays of right arm, hand and shoulder are all negative, results faxed to doctor. An interview with Nurse J, on [DATE] at 1:45 PM, provided the following when queried on what preventive fall measures were in place for the residents, Depends on an individual; gripper socks, CNA's (certified nursing assistants) check on them, provide activities, place them in common areas, toilet them, they can lay down if they want, one resident has a floor sensor. When asked if Resident #702 was a fall risk, Nurse J responded, (The resident) may possibly be, but in general no. I would have to check. I don't normally work down here. An interview with CNA K, on [DATE] at 1:50 PM, provided, I think they have (the resident) as a fall risk. (The resident) falls often. I usually go in like every 10 minutes to check on (the resident). Most of the time it is (the resident) falling out of bed. When queried if there was documentation to show 10 minute checks, CNA K responded, No. On [DATE] at 2:45 PM, a review of the physician progress notes [REDACTED]. [DATE], No concerns brought up by nursing today .not on any anticoagulation given her history of recurrent falls and risk of bleeding. [DATE] No concerns brought up by nursing today .not on any anticoagulation given her history of recurrent falls and risk of bleeding. [DATE] No concerns brought up by nursing today .not on any anticoagulation given her history of recurrent falls and risk of bleeding. No further mention of specific falls or interventions to prevent falls. On [DATE] at 3:05 PM, an interview with Nurse I, provided Resident #702 received, .Therapy for strengthening. (The resident) likes to be independent, but is supervision and should have someone with (them). We try to stay away from alarms. It is a transferring issue (with the resident). When queried if Resident #702 had a toileting plan, as the resident had fallen multiple times in the bathroom alone or while in the processing of trying to take themselves to the bathroom, Nurse I responded, No. A review of the therapy progress notes on [DATE] at 3:35 PM revealed, Fall risk, SBA(stand by assist) provided with transfers and ambulation. Resident #703 An observation on 11:25 am on [DATE], revealed Resident #703 was walking around their room without anyone else present and stated, I'm here for therapy I had a revision on my left shoulder. The resident showed the left shoulder incision with staples intact. I fell at home outside on the grass last year. A record review on [DATE] at 12:55 PM, revealed Resident #703 was initially admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had full cognitive abilities and needed 1 person minimal assistance with transfers, ambulation, dressing, hygiene and toileting. The resident received the following medications: [REDACTED]. On [DATE] at 1:10 PM, a review of the care plans for Resident #703 indicated the resident required minimal 1 person assistance with transfers, ambulation, dressing, hygiene and toileting. An interview with the Director of Nursing on [DATE] at 1:40 PM provided, Let me check on that, when queried why Resident #703 was walking independently in their room and providing their own care, when the care plan stated the resident was a fall risk and needed 1 person assistance. On [DATE] at 3:50 PM, Nurse H was queried on how much assistance Resident #703 needed with care and replied, (The resident) had surgery and has a sling on the left upper extremity. I would look at the Kardex (a guide to show the amount of care needed). It says limited assistance-1 person. I could help (the resident). Transfers-limited assistance and ambulation 1 staff with a gait belt to make sure (the resident) doesn't fall. On [DATE] at 4:05 PM, the Administrator was queried on what preventive measures were provided for residents who were at risk for falls and stated, When they first come in they are assessed for falls, there are rounds at least every 2 hours, activities or the area around the nurses station are available. If they have had a fall, we assess for interventions to prevent falls. We try not to use alarms, but we have 2 alarms in the building. One on a door and 1 on a mat. When asked if they have been effective in preventing falls for the 2 residents, the Administrator responded, Yes, that has been effective for those residents. The Administrator was further queried on what measures were in place for Residents # 701 and #702 and stated, (Resident #702 did not want assistance and became upset with the floor mat. When asked if either resident had an alarm the Administrator responded, No. The Administrator was further queried on if it was safe for Resident #702 and #703 to transfer, ambulate and toilet themselves, when the MDS and care plan said they needed assistance and replied, In my estimation, no it is not. On [DATE] at 4:15 PM, a review of the facility policy titled, Fall Management, dated ,[DATE], revealed, The facility will identify hazards and resident risk factors and implement interventions to minimize falls .a Plan of Care is developed and implemented .If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls .Residents identified at risk for falls will have a care plan developed and implement appropriate fall prevention interventions.

This citation pertains to M 1253 Based on interview and record review, the facility failed to transfer a resident with a two person assist for one (#701) of three sampled Residents reviewed for Activities of Daily Living (ADL) care from a total sample of three "3" resulting in a right hip periprosthetic fracture. Findings include: On 3/11/15 at 10:00 a.m., during an initial tour of the facility, Resident #701 was observed sleeping in an oversized bed. Resident was asleep with a nasal canula with Oxygen at 2 liters. The Resident's roommate stated, " she sleeps all day. It's like she just has given up. You probably won't be able to talk to her... She seems to be declining every day." On 3/11/15 at approximately 11:00 a.m. the clinical record for Resident #701 was reviewed and revealed an initial admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Per the Minimum Data Set assessment ((MDS) dated [DATE] Resident #701 was cognitively intact and able to make herself understood and understand others. Resident #701 most recent weight was 291 pounds. An updated Care Plan for transferring dated 1/24/2015 revealed the following: Transfers: Resident #701 requires two "2" staff participation with transfers with gait belt and non-skid foot wear and use of walker. Authored by Registered Nurse (RN) "B". A Care Plan for toileting dated 7/8/13 revealed the following: Toilet Use: requires 1 staff participation to use toilet needs. Assist with briefs, clothing, wiping transfers and perihygene." Further review of the clinical records on 3/11/15 revealed that on 1/31/2015 an incident occurred resulting in a right hip fracture. Nursing progress notes dated 1/31/15 revealed the following: "Heard Resident yell from the room. Resident on floor with back on the toilet, but head was supported by the aides leg. Right leg was inverted. Resident was yelling in pain. Aide was trying to transfer Resident from toilet to wheelchair. Aide states that Resident's legs were weak while transferring resident from wheel chair to toilet and was lowered to the floor. Aide tried to prevent Resident from falling. Aide yelled for help, but nurse was too late and Resident was on floor. Resident was a one person assist per Kardex, but since last week with Urinary Tract Infection (UTI), Resident is more weaker now." On 3/11/15 at 2:51 p.m. a telephone interview was conducted with Register Nurse (RN) "B" regarding the updated Care Plan and the injury that occurred on 1/31/2015. RN "B" stated, " I am aware of the incident. Resident #701 should have been a two person assist that day. I changed her care plan when some aides came to me and let me know that Resident #701 was weak from a UTI and that it would NOT be safe to transfer with a one person assist. I then changed her careplan for transfers." RN "B" was asked for his definition of transfer. RN "B" stated, " Any change in position. Example: Bed to wheelchair. Wheelchair to toilet etc.." On 3/11/15 at 3: 00 p.m., a phone interview was conducted with Certified Nursing Assistant (CNA) "A" regarding the incident that occurred on 1/31/15. CNA "A" was queried about the incident and stated the following, "... I was trying to transfer her from the toilet to the wheelchair. I went to help her stand and she said, "I can't move". I was pinned between her wheelchair and the sink. I screamed for help. I pulled the call light to get a nurse. I couldn't hold her. I let her slide to the floor." When further queried as to whether she was aware that Resident #701's care plan for transfer required a two person assist, CNA "A" stated, " I am now. However at the time I thought our Kardex (electronic careplan) for toileting stated she was a one person assist." On 3/11/15 at 3:30 p.m., an interview was conducted with the Director of Nursing regarding the incident that occurred on 1/31/2015. The DON was queried as to whether he was aware of the change in status pertaining to the Resident's transfer care plan. The DON stated, " We did do an investigation on what happened that day. I am aware that her care plan for transfers was revised prior to the incident and that she was a two person assist. I know CNA "A" was fairly new to the Facility. I believe when she looked at our Kardex she looked at the toileting section and thought the Resident was a one person assist. However, to me I know toileting refers more toward the cleanliness needs of a resident. For example wiping the resident. I think there was an error in transferring information on to our Kardex. I understand that Resident #701 was a two person assist and now the Kardex has been changed to reflect the care plan revision (dated 1/24/15) so that staff know her current transfer status. At this time her current careplan requires a two person assist with a Hoyer lift." On 3/11/15 at 4:15 p.m. the Facility's Comprehensive Plan of Care Policy dated 5/13 was reviewed and revealed in part: Purpose: Every Resident in the facility with have a Plan of Care based on the comprehensive assessment. Additional resources will also be utilized to ensure that any additional needs or risk areas are identified. ... 3. In addition, the Resident Care Guide/MDS Kardex must be completed to match the plan of care and placed in a designated location.

THIS DEFICIENCY HAS TWO STATEMENTS OF DEFICIENT PRACTICE. BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT WATER TEMPERATURES WERE WITHIN A SAFE TEMPERATURE RANGE BETWEEN 105 AND 120 DEGREES FAHRENHEIT. THE HOT WATER TEMPERATURES RANGED FROM 122.2 DEGREES FAHRENHEIT TO 126.9 DEGREES FAHRENHEIT, FOR RESIDENT ROOMS #108, 121, 204, 205, 228, AND THE FIRST FLOOR SOUTH SHOWER ROOM HAND WASHING SINK. THESE HOT WATER TEMPERATURES HAD THE POTENTIAL TO AFFECT SEVEN OF 88 RESIDENTS (#6, 19, 20, 35, 36, 37 AND 75), IN THE FACILITY, RESULTING IN THE POTENTIAL FOR SERIOUS HARM, INJURY, OR DEATH FROM SCALDING. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 9/27/11 AT 10:15 A.M. THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 9/27/11 AT 4:30 P.M. THE IMMEDIATE JEOPARDY WAS CORRECTED ON 9/28/11 AT 10:57 P.M. ALTHOUGH THE IMMEDIATE JEOPARDY WAS CORRECTED, THE FACILITY'S DEFICIENT PRACTICE REMAINED AS ISOLATED, ACTUAL HARM THAT IS NOT IMMEDIATE JEOPARDY. FINDINGS INCLUDE: ON 9/27/11 AT 10:15 A.M. DURING THE INITIAL TOUR OF THE SOUTH UNIT, THE WATER TEMPERATURES WERE OBSERVED AT THE HAND WASHING SINKS OF RESIDENT #75 IN ROOM 228 TO BE 125.6 DEGREES FARENHEIT, 126 DEGREES FARENHEIT FOR RESIDENTS #36 AND #37 IN ROOM 205 AND 126.9 DEGREES FARENHEIT FOR RESIDENT #20 IN ROOM 121. ON 9/27/11 AT 10:30 A.M., THE HOT WATER TEMPERATURE OF THE HAND WASHING SINK AFFECTING RESIDENT #19 AND #20 IN ROOM 121 WAS MEASURED TO BE 123 DEGREES FAHRENHEIT AND 124 DEGREES FARENHEIT FOR RESIDENT #6 IN ROOM 108. ALL RESIDENTS IDENTIFIED HAD ACCESS TO THE HAND WASHING SINKS. AT THE HAND WASHING SINK IN THE "NORTHEAST DINING ROOM/RECREATION ROOM", A SIGN WAS POSTED THAT STATED: "CAUTION, WORKING ON WATER TEMPERATURES, WATER COULD BE EXTREMELY HOT". ON 9/27/11 AT 12:15 P.M., THE WATER TEMPERATURE LOGS WERE REQUESTED FROM THE ENVIRONMENTAL/MAINTENANCE SUPERVISOR. AT THAT TIME, THE ENVIRONMENTAL SUPERVISOR WAS QUERIED REGARDING THE HOT WATER TEMPERATURES IN THE FACILITY. HE STATED THAT THEY HAD BEEN HAVING ISSUES WITH INCONSISTENT WATER TEMPERATURES IN THE FACILITY. HE STATED THAT WHENEVER THEY WOULD ENCOUNTER A WATER TEMPERATURE THAT WAS OUT OF RANGE (105-120 DEGREES FAHRENHEIT), THAT THEY WOULD ADJUST THE TEMPERING VALVES TO GET THE TEMPERATURE BACK INTO THE PROPER RANGE. WHEN ASKED IF THE FACILITY HAD HIRED AN OUTSIDE PROFESSIONAL TO LOOK AT THE PROBLEM, HE STATED THAT THEY HAD NOT. THE FACILITY'S POLICY "PROCEDURE FOR TAKING WATER TEMPERATURES", DATED 2/1/11 NOTED THE FOLLOWING: "THESE ARE SOME OF THE ACTIONS THAT MAY BE TAKEN BY THE FACILITY TO PROTECT RESIDENTS TO PREVENT INJURY FROM EXCESSIVELY HOT TAP WATER: "SHUT OFF THE WATER TO AREAS IN WHICH PERSONS RECEIVING SERVICES MAY HAVE CONTACT WITH. INFORM THE DIRECT CARE STAFF NOT TO BATHE PERSONS RECEIVING SERVICES. INFORM THE PERSONS RECEIVING SERVICES AND VISITORS NOT TO USE THE HOT WATER. POST NOTICES ABOUT THE DANGER OF HOT WATER. CALL FOR OUTSIDE CONSULTANTS TO CORRECT THE PROBLEM (i.e. PLUMBER)." THE IMMEDIATE JEOPARDY WAS REMOVED ON 9/28/11 AT 10:57 P.M. WHEN THE FACILITY TOOK THE FOLLOWING STEPS; 1. RESIDENT IDENTIFIED TO BE AFFECTED BY THE ALLEGED DEFICIENT PRACTICE. BEGINNING ON 9/27/11 AT 6:30 PM HOT WATER MIXING VALVES WERE ASSESSED AND ADJUSTED BY A LICENSED PROFESSIONAL CONTRACTOR ON 9/27/11 TO MEET A SAFE RANGE (105-120 DEGREES FAHRENHEIT) FOR THE FOLLOWING OFF-SAMPLED RESIDENT # 6,19,20,35, 36, 37 & 75. ON 9/28/11 A LICENSED CONTRACTOR REASSESSED THE JANITOR CLOSET SINKS AND CORRECTED THE CROSS CONNECTION. SAMPLE RESIDENTS #6, 19, 20, 35, 36, 37 & 75 WERE ASSESSED BY LICENSED NURSES ON 9/28/11 AND DETERMINED TO HAVE SUSTAINED NO BURNS RELATED TO THE HOT WATER TEMPERATURES. 2. RESIDENTS WITH POTENTIAL TO BE AFFECTED BY THE ALLEGED DEFICIENT PRACTICE. ALSO ON 9/28 /11 THE LICENSED PROFESSIONAL CONTRACTOR REVIEWED TEMPERATURES ON BOTH DOMESTIC HOT WATER HEATERS THAT SERVICE THE REMAINING RESIDENT ROOMS. HE IDENTIFIED THAT THE MIXING VALVE ON THE DOMESTIC HOT WATER HEATER FEEDING ROOMS 108, 121, 204, 205, 228 AND THE FIRST FLOOR SOUTH SHOWER ROOM WAS NOT FUNCTIONING PROPERLY, AND HE MADE APPROPRIATE ADJUSTMENTS. ALSO, ON 9/28/11 THE LICENSED CONTRACTOR IDENTIFIED THAT THE JANITOR CLOSET SINKS HOT AND COLD WATER LINES WERE CROSSED AND THIS WAS CORRECTED AT 1:00 PM. ON 9/28/11, THE LICENSED CONTRACTOR ADJUSTED THE HOT WATER HEATER TEMPERATURES TO MAINTAIN A SAFE TEMPERATURE RANGE. ADDITIONAL MIXERS WERE ADJUSTED OR REPLACED TO MAINTAIN WATER TEMPERATURES BELOW 120 DEGREES. ALL HOT WATER HEATERS WERE INSPECTED BY THE LICENSED CONTRACTOR AND NO OTHER CONCERNS WITH HOT WATER TEMPERATURES WERE IDENTIFIED. AT APPROXIMATELY 10:57 PM ON 9/28/11 THE MAINTENANCE DIRECTOR RE-CHECKED ALL RESIDENT BATHROOM SINKS AND SHOWER ROOM SINKS, AND VERIFIED THAT THE HOT WATER TEMPERATURES WERE LESS THAN 120 DEGREES FAHRENHEIT. 3. SYSTEM MEASURES THE MAINTENANCE STAFF/DESIGNEE WILL MONITOR HOT WATER TEMPERATURES IN ALL SHOWER ROOM SINKS AND RESIDENT BATHROOM SINKS HOURLY FOR TWENTY FOUR HOURS, THEN EVERY SHIFT FOR 24 HOURS, THEN RANDOM DAILY. THEN THE FACILITY WILL COMPLETE RANDOM DAILY WATER TEMPERATURE CHECKS FIVE TIMES WEEKLY. ANY NOTED IRREGULARITIES WILL BE ADJUSTED IMMEDIATELY. THE FACILITY HAS IN-SERVICED THE MAINTENANCE SUPERVISOR AND THE MAINTENANCE ASSISTANTS 9/28/11 ON PROPER PROCEDURE FOR TAKING HOT WATER TEMPERATURES AND THE IMPORTANCE OF MAINTAINING SAFE HOT WATER TEMPERATURES. AS OF 9/28/11 130 OUT OF 149 LICENSED AND NON LICENSED STAFF HAVE BEEN IN SERVICED ON HOW TO REPORT UNSAFE/IRREGULAR WATER TEMPERATURES. THE REMAINING LICENSED AND NON LICENSED PERSONNEL WILL BE IN-SERVICED ON THE IMPORTANCE OF REPORTING IRREGULAR WATER TEMPERATURE PRIOR TO RETURNING TO WORK ON THEIR NEXT SCHEDULED DAY. ALL NEW EMPLOYEES WILL BE IN-SERVICED ON THE IMPORTANCE OF REPORTING IRREGULAR WATER TEMPERATURE. 4. QUALITY ASSESSMENT AND ASSURANCE THE MAINTENANCE SUPERVISOR OR DESIGNEE WILL PERFORM RANDOM DAILY WATER TEMPERATURES ON SHOWER ROOM SINKS AND RESIDENT BATHROOM SINKS FIVE TIMES WEEKLY TO ENSURE THE TEMPERATURES ARE WITHIN A SAFE RANGE. ANY AREAS OF CONCERN WILL BE ADDRESSED IMMEDIATELY. THE AUDITS WILL BE REVIEWED AND FORWARDED TO THE QUALITY ASSURANCE COMMITTEE. THE ADMINISTRATOR OR DESIGNEE WILL REPORT FINDINGS TO THE QUALITY ASSESSMENT AND ASSURANCE COMMITTEE ON A MONTHLY BASIS UNTIL THE COMMITTEE DETERMINES THAT COMPLIANCE WITH THIS PLAN HAS BEEN MAINTAINED. THE ADMINISTRATOR IS RESPONSIBLE FOR OVERALL SUSTAINED COMPLIANCE. COMPLIANCE DATE IS 9/28/11. ( ) ( ) ( ) DEFICIENT PRACTICE #2 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO IMPLEMENT MEASURES TO PREVENT FALLS AND INJURIES, FOR ONE (#821) OF 11 SAMPLED RESIDENTS REVIEWED FOR FALLS, OUT OF A TOTAL SAMPLE OF 21, RESULTING IN A FRACTURE WRIST, AND A HEMATOMA. IN ADDITION, THE FACILITY FAILED TO ENSURE THAT AN UNATTENDED MEDICATION CART WAS LOCKED, RESULTING IN THE POTENTIAL FOR ACCIDENTAL INGESTION OF MEDICATIONS. FINDINGS INCLUDE. ON 9/28/11 AT 11:00 A.M., RESIDENT #821 WAS OBSERVED SITTING IN A WHEELCHAIR IN FRONT OF THE NURSE'S STATION WITH BRUISING AND ABRASIONS ABOVE THE RIGHT EYE AND EXTENDING DOWN THE FACE TO THE LOWER FACIAL CHEEKS. RESIDENT #821 ALSO HAD A SPLINT ON THE LEFT WRIST. THE RESIDENT WAS NON VERBAL BUT SMILING. THE SOUTH UNIT MANAGER, STAFF "A", WHEN QUERIED HOW RESIDENT #821 SUSTAINED THE INJURIES, STATED RESIDENT #821 HAD A FALL IN THE SHOWER ROOM WHILE BEING TOILETED BY CERTIFIED NURSE ASSISTANT (CNA) "B" . STAFF "A" CONTINUED TO EXPLAIN RESIDENT #821 fell FORWARD, FACE FIRST WHILE ATTEMPTING TO DISROBE. STAFF "A" FURTHER ADDED RESIDENT #821 "GIGGLES AND SMILES" WHEN NERVOUS OR DO NOT KNOW AN ANSWER. ON 9/30/11 AT 12:30 P.M., REVIEW OF A FACILITY INCIDENT AND ACCIDENT REPORT (I/A), DATED 9/25/11 5:00 A.M., REVEALED RESIDENT #821 WAS "TAKEN BY WHEELCHAIR TO THE SHOWER ROOM, ASSISTED TO THE TOILET AND WAS LEANING FORWARD TO PULL HER PANTS DOWN AND JUST KEPT GOING HEADFIRST AND HIT THE FLOOR." THE I/A REPORT ALSO DOCUMENTED RESIDENT #821 SUSTAINED A "REDDEN RIGHT KNEE" AND "HEMATOMA ON FOREHEAD ABOVE RIGHT EYE." REVIEW OF THE NURSE'S NOTES DATED 9/25/11 AT 10:55 A.M., DOCUMENTED RESIDENT #821 "LEFT WITH EMERGENCY MEDICAL SERVICE (EMS) FOR THE HOSPITAL. THE NURSES NOTE, NO TIME IDENTIFIED, DOCUMENTED "RESIDENT RETURNED FROM ...HOSPITAL...X-RAY RESULTS SHOWED SUSPICIOUS LEFT WRIST FRACTURE." REVIEW OF AN BONE SPECIALIST CONSULTATION REPORT DATED 9/27/11 DOCUMENTED "THUMB SPICA SPLINT...DIAGNOSIS-FRACTURE OF LEFT WRIST." REVIEW OF RESIDENT #821'S FACE SHEET DOCUMENTED AN admission date of [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF RESIDENT #821'S PHYSICAL DEVICE EVALUATION DATED 5/6/11 DOCUMENTED RESIDENT # 821 HAS POOR SAFETY AWARENESS, WEAKNESS AND A HISTORY OF FALLS AND SYNCOPE. REVIEW OF RESIDENT #821'S ACTIVITIES OF DAILY LIVING (ADL) CARE PLAN UPDATED 8/25/11, DOCUMENTED "ASSIST WITH DRESSING LOWER EXTREMITIES...TRANSFER WITH ONE ASSIST USING A GAIT BELT." REVIEW OF RESIDENT #821'S FALL RISK assessment dated ,[DATE] DOCUMENTED A FALL RISK SCORE OF FIVE OUT OF SEVEN INDICATING THE NEED TO PROCEED TO A FALL RISK CARE PLAN. REVIEW OF THE ORIGINAL FALL RISK CARE PLAN DATED 3/10/11, DOCUMENTED "GAIT BELT USED WITH TRANSFERS". ON 9/30/11 AT 3:00 P.M., STAFF "A" WAS AGAIN QUERIED REGARDING THE I/A AND FALL RESIDENT #821 EXPERIENCED ON 9/25/11. STAFF "A" STATED THE GAIT BELT WAS NEW TO RESIDENT' #821'S ORDERS AND STAFF "A" WAS NOT AWARE A GAIT BELT WAS ON THE PREVIOUS CARE PLANS. WHEN QUERIED HOW MUCH ASSISTANCE SHOULD BE PROVIDED TO RESIDENT #821 WITH LOWER EXTREMITY DRESSING, STAFF MEMBER "A" WAS NOT ABLE TO EXPLAIN. THE NURSE AND CNA INVOLVED IN THE 9/25/11 I/A WITH RESIDENT #821 WAS UNAVAILABLE FOR INTERVIEW DURING THE SURVEY. REVIEW OF THE FACILITY'S POLICY TITLED "FALL MANAGEMENT" DATED 5/2010 DOCUMENTED, "THE FACILITY WILL IDENTIFY HAZARDS AND RESIDENT RISK FACTORS AND IMPLEMENT INTERVENTIONS TO MINIMIZE FALLS." ( ) ON 9/28/11 AT 11:30 A.M., DURING OBSERVATIONS ON THE SOUTH UNIT, A MEDICATION CART WAS OBSERVED UNLOCKED AND UNATTENDED. STAFF "D" THE NURSE ASSIGNED TO THE MEDICATION CART WHEN QUERIED WHY THE MEDICATION CART WAS UNLOCKED AND UNATTENDED STATED, "I GOT DISTRACTED. I NEVER LEAVE MY CART UNLOCKED." ON 9/29/11 AT 12:30 P.M., STAFF "A", THE UNIT MANAGER FOR THE SOUTH UNIT, WAS QUERIED WHY STAFF "D" LEFT THE MEDICATION CART UNATTENDED AND UNLOCKED. STAFF "A" STATED "I AM AWARE OF THE UNLOCKED MEDICATION CART. IT IS OUR POLICY TO LOCK MEDICATION CARTS AND NEVER LEAVE THEM UNATTENDED. I CAN'T EXPLAIN WHY THE NURSE DIDN'T LOCK IT". REVIEW OF THE FACILITY'S POLICY TITLED "GENERAL DOSE PREPARATION AND MEDICATION ADMINISTRATION" DATED MAY, 2010 DOCUMENTED "FACILITY SHOULD ENSURE THAT MEDICATION CARTS ARE ALWAYS LOCKED WHEN OUT OF SIGHT OR UNATTENDED." ( )