Every finding on record at Riverside Commons Rehab and Nursing Center, LLC

This citation pertains to intake 3034793.Based on observation, interview and record review, the facility failed to lock one resident's bed and failed to stop repositioning a resident at their request during a brief change for one (R504) of three residents reviewed for falls, resulting in R504 falling from the bed, injuring their head and knee with subsequent hospitalization related to a fracture.Findings include:A review of an intake submitted to the State Agency revealed the following: Complainant (Family Member A) states that (R504) fell about two weeks ago, maybe longer. (Family Member A) states the aide (Certified Nurse Aide), (CNA D) was changing (R504) brief, rolled (R504) over, the bed wasn't locked so (R504) rolled to the floor. (Family Member A) states (R504) hit the floor hard and hit (their) head and there was no follow up to examine for injury. (Family Member A) states (R504) been complaining of a lot of pain since the fall, migraine, pain in her back, shoulder and lower legs. (Family Member A) states requested facility to send (R504) to the emergency, resident was sent to (the hospital on) 6/4/26. On 6/23/26 at 9:45AM, Family Member A was interviewed by telephone about R504's fall. Family Member A said R504 fell off the bed during care. Family Member A said R504 did not return to this facility after hospitalization. R504 was admitted to another long-term care facility after hospital discharged .A review of R504's electronic medical record revealed an admission to the facility on 3/11/25 with the diagnosis of Intracerebral Hemorrhage (bleeding inside the brain), Muscle Weakness, Falls, Cerebral Infarction (an ischemic stroke, is the pathologic process that results in an area of necrotic tissue in the brain) Hemiplegia and Hemiparesis affecting left dominant side (mean the non-dominant brain hemisphere (typically the right) has sustained damage), Progressive Vascular Leukoencephalopathy refers to the slow, progressive damage to the brain's white matter caused by the deterioration or blockage of small blood vessels), Morbid Obesity, Glaucoma, Implantable Loop Recorder (ILR) (a heart monitor) and Neuropathy. R504's has a Brief Interview for Mental Status score of 15/15 (cognitively intact with normal thinking, learning, and memory skills) dated 5/15/26.A review of R504's care plan revealed the following:Problem (R504) is at risk for falls due to generalized muscle weakness with impaired/unsteady gait with history of falls Dated 3/12/2025.A review of R504's MDS (Minimum Data Set) section GG (measures a patient's functional abilities) dated 5/15/26 revealed the following:Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed. (R504 scored Substantial/Maximal Assistance: Substantial/Maximal Assistance-Helper (staff) does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort).A record review of R504 progress note created Registered Nurse C (RN C) on 5/23/2026 at 09:29 am revealed the following: Informed by (CNA D) that while (CNA D) was changing (R504's) brief and turning (R504) to the other side (of the bed), resident slid out of bed. Writer and supv(supervisor) enter rm (room)and observed resident sitting on floor between bed and wall. Resident denies any discomfort and striking head. ROM (range of motion) to all 4 extremities without difficult.Staff used Hoyer lift to transfer resident from floor back into bed.A review of R504's progress note dated 5/26/2026 at 5:13 PM, revealed the following: Resident c/o (complain of) pain on right side of head due to a fall over the weekend. Writer reached out to resident attending NP (Nurse Practitioner) and order for x-ray to right side of face and C-spine (the neck region of the backbone) .Resident agreed.A review of R504's progress note dated 6/04/2026 at 10:57PM revealed the following: .Resident sustained a fall approximately two weeks ago. MD ordered transfer today for further evaluation related to previous fall. Resident transferred via EMS (emergency Medical Services) accompanied by two EMS personnel at 8:00 PM .A review of R504's inpatient hospitalization note, dated June 5, 2025, revealed the following: Admitting Diagnoses: Compression Fracture of the Body of Thoracic Vertebra.R504 was discharged from the hospital on 6/9/2026 and admitted to another facility.A review of the facility's CNA D investigation, signed on 6/14/2026, revealed the following: Stated at approximately 4:45 AM CNA D went into (R504's) room to give peri-care. (CNA D) notes that (R504) was close to the edge of bed to the resident's right side. (CNA D) asked (R504) to roll to left side which was toward (CNA D). The resident grabbed the mobility bar with (R504's) right hand and proceeded to roll over. The resident crossed (their) right led over the left leg to help roll over. While (R504) was rolling over, (R504) was slowly sliding out of the bed and landed on (their) bottom. (CNA D) stated that the resident did not hit (their) head. (CNA D) also stated that the bed was locked.Attempts to contact CNA D were made on 6/23 at 2:20 pm and at 4:18 pm. A third attempt was made on 6/24/26 at 1:05 pm. All attempts to contact CNA D were unsuccessful.On 6/24/26 at 8:33 AM, CNA E was interviewed about the care provided to R504, post fall on 5/23/26. CNA E stated, (R504 asked me to be careful because their head and leg hurt from falling out of bed last shift (on 5/23/26, midnight shift). (R504's) roommate (R505) said (R504) hit (their) head on the wall too. I asked (R504) why they did not tell the nurse about their pain. (R504) said they didn't want to be a problem. At that time CNA E said she told the nurse about R504's pain.On 6/24/26 at 8:42 AM R505 (R504's roommate during the time of the fall) was observed sitting on the side of their bed, wearing a hospital gown, and watching TV. R505 was asked about R504's fall from the bed. R505 stated, The Aide (CNA D) came to the room to change (R504's) brief.(R504's) bed was up against the wall (on R504's right side) .the Aide (CNA D) started rolling (R504) toward the wall (on the R504's) right side and the Aide was on the other side (R504's left side) . R504) started yelling 'I'm falling, I'm falling.that girl kept saying 'roll over, roll over, grab the bar'. R505 asked how (R505) was able to visualize that event. R505 stated, I'm nosy.I was looking at them because the curtain was open and I was at the bottom of the bed.I was looking with my own eyes the whole time.the bed was rolling because it didn't look to be locked.I saw the Aide (CNA D) kept trying to roll (R504) over and (R504) said 'stop, stop I'm falling'. R505 said R504 ended up falling on the floor. R505 said CNA D asked R504, why did you do that? R505 stated, (R504) said my leg, my leg.the bed was moved out some. R505 continued, saying R504 was yelling. R505 said, I was concerned because (R504) fell hard and I knew (R504) was hurt.they might get mad at me because I'm talking to you.but I look after people here. R505 said CNA D went to get the nurse, and they got R504 back in bed. R505 said R504 said their head and leg hit on the floor. A review of R505's EMR revealed an admission to the facility on [DATE] with the diagnosis of Atherosclerosis (blood vessels that carry oxygen and nutrients from the heart to the rest of the body become thick and stiff), Falls, Difficulty walking, and Congestive Heart Failure. A review of R505 has a Brief Interview for Mental Status score of 15/15 (cognitively intact with normal thinking, learning, and memory skills) dated 6/12/2026.On 6/24/26 at 11:03 am, R504 was interviewed via telephone to discuss their fall. R504 said, (CNA D) was changing my brief, then (CNA D) unlocked the bed and moved my bed away from the wall. R504 said the bed was against the wall because she asked staff to position it that way, thinking it would help with positioning in bed. R504 continued, (CNA D) moved the bed out and started rolling me towards the wall. (CNA D) was on the other side at my backside. (CNA D) asked me to roll over and started pushing me over.I told (CNA D) that I felt like I was falling because the bed was moving.then (CNA D) kept saying 'roll over', I kept saying 'I'm going to fall'.(CNA D) kept pushing me over and told me to hold the bar.then I fell out of the bed. I felt like (CNA D) kept pushing me and did not stop when I said stop. (CNA D) said to me, 'now why did you do that?' .I told (CNA D) I was falling but (CNA D) didn't say nothing. R504 said they did not feel the pain for a few hours, and added, My head and leg were hurting so badly. R504 explained their pain had gotten worse since the fall.On 6/24/26 at 2:25 pm, a follow-up interview was conducted with the Nursing Home Administrator (NHA) and the DON concerning R504's fall from bed during care. The DON stated that when staff are performing care, they should always consider safety first. The NHA was present for the interview but had nothing to add to the discussion.A review of the facility's policy Care and Treatment: Fall dated 07/11/2018, revealed the following: It is the policy of this facility to evaluate extent of injury after fall, prevent complications and to provide emergency care.6. Evaluate cause of fall.Document all appropriate information in the medical record.11. Note on 24- Hour Report.

This citation pertains to intake 3034793.Based on interview and record review, the facility failed to perform a post-fall assessment in a timely manner and failed to ensure a radiology exam was completed for one (R504) of four residents reviewed for a change in condition resulting in the delay of medical care/treatment.Findings include:Review of an intake submitted to the State Agency revealed the following: Complainant (Family Member A) states that (R504) fell about two weeks ago, maybe longer. (Family Member A) states the aide (Certified Nurse Aide), (CNA D) was changing (R504) brief, rolled (R504) over, the bed wasn't locked so (R504) rolled to the floor. (Family Member A) states (R504) hit the floor hard and hit (their) head and there was no follow up to examine for injury. (Family Member A) states (R504) been complaining of a lot of pain since the fall, migraine, pain in her back, shoulder and lower legs. (Family Member A) states requested facility to send (R504) to the emergency, resident was sent to (the hospital on) 6/4/26.On 6/23/26 at 9:45 AM, Family Member A was interviewed via telephone about R504's fall on 5/23/26. Family Member A said R504 fell off the bed during care. Family Member A said the facility did not send R504 to the hospital until (Family Member A) insisted they (the facility) send R504 to the hospital. Family Member A said R504 did not return to this facility after hospitalization. R504 was admitted to another long-term care facility after hospital discharged .A review of R504's electronic medical record (EMR) revealed an admission to the facility on 3/11/25 with the diagnosis of Intracerebral Hemorrhage (bleeding inside the brain), Muscle Weakness, Falls, Cerebral Infarction (an ischemic stroke, is the pathologic process that results in an area of necrotic tissue in the brain) Hemiplegia and Hemiparesis affecting left dominant side (mean the non-dominant brain hemisphere (typically the right) has sustained damage), Progressive Vascular Leukoencephalopathy refers to the slow, progressive damage to the brain's white matter caused by the deterioration or blockage of small blood vessels), Morbid Obesity, Glaucoma, Implantable Loop Recorder (ILR) (a heart monitor) and Neuropathy. R504's has a Brief Interview for Mental Status score of 15/15 (cognitively intact with normal thinking, learning, and memory skills) dated 5/15/26.A record review of R504 progress note created Registered Nurse C (RN C) on 5/23/2026 at 09:29 AM revealed the following: Informed by (CNA D) that while (CNA D) was changing (R504's) brief and turning (R504) to the other side (of the bed), resident slid out of bed. Writer and supv(supervisor) enter rm (room)and observed resident sitting on floor between bed and wall. Resident denies any discomfort and striking head. ROM to all 4 extremities without difficult.Staff used Hoyer lift to transfer resident from floor back into bed.A review of R504's progress note dated 5/26/2026 at 5:13 PM, revealed the following: Resident c/o (complain of) pain on right side of head due to a fall over the weekend. Writer reached out to resident attending NP (Nurse Practitioner) and order for x-ray to right side of face and C-spine (the neck region of the backbone) .Resident agreed.Review of R504's EMR order dated, 5/27/2026 at 10:15 PM (four days after the fall), and placed by Physician G, revealed the following: X-ray right side of face and C-spine.STAT (medical directive meaning immediately and without delay.)A review of R504's progress note dated 6/04/2026 at 10:57 PM revealed the following: .Resident sustained a fall approximately two weeks ago. MD ordered transfer today for further evaluation related to previous fall. Resident transferred via EMS (emergency Medical Services) accompanied by two EMS personnel at 8:00PM resident departed facility in stable condition.Prior to R504's transfer to the hospital on 6/4/2026 at 8 PM, the radiology exam had not been completed.A review of R504 hospital note, dated June 5, 2026, revealed the following: Admitting Diagnoses: Compression Fracture of the Body of Thoracic Vertebra.On 6/24/26 at 2:25 PM, an interview was conducted with the Nursing Home Administrator (NHA) and the DON (Director of Nursing) concerning R504's fall on 5/23/26, the absence of the post-fall assessment, and the radiology order that was not completed. The DON stated, During this transition (facility change in ownership and new EMR) we had trouble with our records and keeping track, we found out that the X-Ray was canceled by the radiology people. The DON did not respond to the absence of the post fall report. The NHA was present for the interview but had nothing to add to the discussion.A review of the facility's policy Change in a Resident's Condition or Status dated 07/11/2018, revealed the following: A significant change of condition is a major decline or improvement in the resident's status that:Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting);Impacts more than one area of the resident's health status;Requires interdisciplinary review and/or revision to the care plan; andUltimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument.A review of the facility's policy Care and Treatment: Fall dated 07/11/2018, revealed the following: It is the policy of this facility to evaluate extent of injury after fall, prevent complications and to provide emergency care.6. Evaluate cause of fall.10. Document all appropriate information in the medical record.11. Note on 24- Hour Report.

This citation pertains to intake 3034793.Based on interview and record review the facility failed to ensure an X-Ray was completed in a timely manner for one resident (R504) of three residents reviewed for physician orders, resulting in radiology orders not being executed for R504 after a fall. Findings include:On 5/23/26 at 9:45AM, Family Member A was asked about R504's fall. Family Member A said R504 fell off the bed during care. Family Member A said the facility did not send R504 to the hospital until (Family Member A) insisted they (the facility) send R504 to the hospital. Family Member A said R504 did not return to this facility after hospitalization. R504 was admitted to another long-term care facility.A review of R504's electronic medical record (EMR) revealed an admission to the facility on 3/11/26 with the diagnosis of Intracerebral Hemorrhage (bleeding inside the brain), Muscle Weakness, Falls, Cerebral Infarction (an ischemic stroke, is the pathologic process that results in an area of necrotic tissue in the brain) Hemiplegia and Hemiparesis affecting left dominant side (mean the non-dominant brain hemisphere (typically the right) has sustained damage), Progressive Vascular Leukoencephalopathy refers to the slow, progressive damage to the brain's white matter caused by the deterioration or blockage of small blood vessels), Morbid Obesity, Glaucoma, Implantable Loop Recorder (ILR) (a heart monitor) and Neuropathy. R504's has a Brief Interview for Mental Status score of 15/15 (cognitively intact with normal thinking, learning, and memory skills) dated 5/15/26.A record review of R504 progress note created Registered Nurse C (RN C) on 5/23/2026 at 09:29 AM revealed the following: Informed by (CNA D) that while (CNA D) was changing (R504's) brief and turning (R504) to the other side (of the bed), resident slid out of bed. Writer and supv (supervisor) enter rm (room)and observed resident sitting on floor between bed and wall.A review of R504's EMR order dated 5/26/2026 at 4:47 PM, ordered by Physician G revealed the following: X-ray right side of face.R504's EMR order dated 5/26/2026 at 5:26 PM, ordered by Physician G revealed the following: X-ray right side of face and C-spine.A review of R504's Order dated 5/27/2026 at 10:15 PM, ordered by Physician G revealed the following: X-ray right side of face and C-spine.STAT (medical directive meaning immediately and without delay.Prior to R504's transfer to the hospital on 6/4/2026 at 8 PM, the ordered radiology tests were not done.On 6/24/2026 at 2:25 PM, an interview was conducted with the Nursing Home Administrator (NHA) and the DON concerning R504's fall from bed during care, ordered radiology not completed, and R504's change in condition. The DON stated, During this transition (facility's change in ownership and new EMR) we had trouble with our records and keeping track, we found out that the X-Ray was canceled by the radiology people. The DON was asked who was responsible for residents' orders and the DON said the nurse manager should keep up with all orders. The DON was asked if there was documentation of when and why the X-Rays were discontinued. The DON did not respond.A review of the facility's policy Physician Orders, updated 04/09/2021, revealed the following: It is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's orders. The facility shall ensure to follow physician orders as input into the medical chart.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area and maintain cleanliness of ice machines resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 04/07/2026 at 9:17 AM observed a container with unidentified food inside and no date or label in the main walk-in cooler. Dining Director (DD) A removed the bin to be labeled.According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.On 04/07/2026 at 9:57 AM observed the drain line leading from the ice machine extended below the base of the floor drain creating an improper air gap in the skilled nursing main kitchen. DD A stated they would have it fixed immediately.According to the 2022 FDA Food Code section 5-202.13 Backflow Prevention, Air Gap. An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, or nonFOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch).On 04/07/2026 at 10:09 AM observed black specs near the top of the internal shield of the ice machine in the skilled nursing second floor kitchen. DD A confirmed seeing the spots.On 04/07/2026 at 10:24 AM observed a [NAME] countertop ice and water machine with brown buildup and mineral deposit accumulated on the internal ice shoot in B unit dining area. Further observation found red and brown dried splash marks along the upper and back side around the ice shoot. An interview with DD A at this time found they did not know about this ice machine and would have to check with maintenance about it. On 04/07/2026 at 10:27 AM an interview with Regional Operations for Maintenance C found the ice machines are cleaned every six months according to manufacturer's instructions and are due for their cleaning now.On 04/07/2026 at 10:29 AM observed brown buildup on the interior of the ice shoot and an accumulation of brown residue along the bottom and edges of the tray plate of the [NAME] countertop ice and water machine in the first floor dining room. On 04/07/2026 at 1:25 PM an interview with DD A found maintenance does deep cleans on ice machines, and dietary wipes down monthly or as needed.On 04/08/2026 at 9:57 AM observed Follet countertop ice and water machine with brown buildup and mineral deposit accumulated on the internal ice shoot in the B unit dining area.On 04/08/2026 at 10:04 AM in an interview with Maintenance Supervisor (MS) D when asked about who cleans ice machines, MS D indicated maintenance does deep cleans every six months, along with dietary and environmental services cleaning in between. When asked who would clean the inside ice shoot of the [NAME] countertop machines, MS D indicated that would be maintenance. MS D stated the first floor ice machine was being cleaned today. When asked about logging cleaning, MS D indicated maintenance does not keep cleaning logs for the ice machines, and cleaning is completed when it generates in their maintenance system.On 04/08/2026 at 11:59 AM an interview with Environmental Services and Linen Supervisor (ESLS) B found environmental services cleans ice machines daily on the exterior with a stainless steel wipe and underneath the unit. When asked about the drip tray, ESLS B stated the surface of the tray is cleaned by environmental services but not the inside of the ice machine. On 04/08/2026 at 12:03 PM an interview with DD A found dietary staff wipe the kitchen ice machines monthly and maintenance performs deep cleans every six months. However, dietary staff do not clean the [NAME] countertop ice and water machines located in the dining rooms throughout the facility. When asked if there is a policy regarding cleaning of ice machines, DD A indicated maintenance would have that.On 04/08/2026 at 12:14 PM in an interview with DD A regarding cleaning frequency of ice machines, DD A indicated having had discussions with maintenance to increase the cleaning frequency of ice machines.According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.A record review of the facility provided document entitled Cleaning of food and nonfood contact surfaces states, The food-contact surfaces of all cooking equipment shall be kept free of encrusted grease deposits and other accumulated soil. Nonfood contact surfaces of equipment, such as handles on reach- in units, sides of sinks, gaskets on cooler and freezer doors, tracks of sliding doors on equipment, and the exterior of ice machines, shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles, and other debris.A record review of the facility provided maintenance work document entitled Preventative Maintenance Work Order includes information on frequency and instructions for ice machines. PM: 6 MO - Semi-Annual Ice Machine Inspection Instructions include: 14. Remove and clean/sanitize dispensing chutes and dispensing chute covers with non- toxic ice machine cleaner and sanitizer. 15. Clean drain tray and drain gate. 16. Clean all exterior surfaces of the ice machine.

Based on observation, interview, and record review, the facility failed to store insulins in accordance with pharmacy and manufacturer's recommendation in two of six medication carts reviewed for safe storage of medications and biologicals resulting in the potential for decreased efficacy of the insulin.Findings include:On [DATE] at 8:53 AM during inspection of medication cart #3 on Unit A with Licensed Practical Nurse (LPN) M, 8 of 14 insulin Kwik Pens (disposable, prefilled, multi dose injection device to deliver insulin) in the medication cart were not stored in accordance with pharmacy recommendations labeled on the Kwik Pen. Both the Kwik Pens and the bags they were stored in had pharmacy labels that read: Keep Refrigerated and Good for 28 days after opened. Five Kwik Pens were observed to be opened and in use without any 'open date' on them. LPN M acknowledged there was no 'open date' and therefore no way to determine how long the Kwik pens had been in use.One Kwik Pen was open, had an 'open date' of [DATE] and appeared to be still in use (32 days past the expiration date).One Kwik Pen was open, had no resident's name or 'open date' on it and was approximately half empty. LPN M confirmed there was no way to determine which resident was prescribed this Kwik Pen. LPN M stated, The pens are labeled with the resident's name. I don't know whose pen this is. The label must have accidently come off this. It will be thrown out.One Kwik Pen was unopened and unrefrigerated. There was no delivery date to determine how long the Kwik Pen had been stored at room temperature. LPN M stated, I didn't know that one was not opened. Yes, unopened insulin should be in the refrigerator. On [DATE] at 11:06 A.M during inspection of medication cart #4 on Unit A with Registered Nurse (RN) P, 3 of 4 Kwik Pens were unopened and stored at room temperature. All 3 of the unopened Kwik Pens had pharmacy instructions to Keep Refrigerated and Good for 28 days after opened. The 4th Kwik pen was opened and mislabeled. The Kwik Pen's cap had a resident's name hand-written on it that did not match the resident's name on the printed pharmacy label. RN P stated, I think there was a Kwik Pen without a cap. I may have accidently switched caps on that one. RN P acknowledged that unopened insulins should be refrigerated until opened and then dated. On [DATE] at approximately 12:35 PM a request was made to the Director of Nursing (DON) was asked for the facility's policy for medication storage. During interview the DON stated, Yes, we should be storing unopened insulins in the refrigerator. We educate our nurses on that and to put the date on the pen's label when opened. I don't' know why it wasn't done. According to the facility's policy for Insulin Pen Administration effective 11/2025 in part reads: Insulin pens are to be dated when opened and discarded after 28 days. Do not use if the insulin pen manufacturer date has expired. According to the facility's policy for Medication Administration last revised on 4/2026 in part reads: step12. Medication vials/pens are to be dated when opened.

Based on observation, interview, and record review, the facility failed to assist the resident in developing and implementing an advance directive upon admission for one (R118) of five residents reviewed for advance directives. Findings include:On [DATE] at approximately 10:00 AM, R118 was observed in their room preparing for a doctor's appointment. The resident was alert and answered questions appropriately. R118's family member was at the bedside. A record review was conducted of R118's electronic health record (EHR) and revealed a most recent admission date of [DATE] with diagnoses that included chronic obstructive pulmonary disease, Parkinson's disease, hypertension, anemia, bipolar disorder, major depressive disorder, restless leg syndrome, and chronic pain. A physician order in the EHR dated [DATE] indicated Full Code (a term used to communicate to staff to start chest compressions or other life-saving measures if a person's heart or breathing stops). The EHR did not contain any documents or statements by R118 regarding their wishes or decisions for life sustaining treatment.On [DATE], a document titled, Physician Orders for Scope of Treatment was received. The document was signed and dated by R118 on [DATE] with Box A checked which read, DO NOT attempt Resuscitation/CPR/DNR/No CPR - All-Natural Death.On [DATE] at approximately 11:40 AM, Social Worker O (SW O) was queried as to the process for completing the advance directive portion of the admission process. SW O said that she was responsible for ensuring the form was presented to the resident or their responsible party upon admission. SW O continued that during off-hours and weekends, the nursing staff could also complete the advance directive portion. In addition, SW O said that the advance directive conversation could also occur during the initial 72-hour care conference held with the resident and/or their responsible party. SW O was unable to explain why the document was not completed until 12 days after R118's admission. When asked if it was concerning to them that the form was not completed timely upon admission, SW O responded yes. On [DATE] at approximately 12:14 PM, R118 was asked if they were informed about their right to formulate an advance directive. R118 said they were not informed upon admission. When asked if they would choose life-saving measures if their heart or breathing were to stop, R118 stated, I do not want chest compressions - never have. Just let me go. It would make me upset if they did chest compressions. On [DATE] at approximately 10:45 AM, the Nursing Home Administrator (NHA) was interviewed regarding advance directives. The NHA said that upon admission, the resident or their responsible party is asked about their wishes for life-sustaining treatment during the 24-48-hour admission period. If they do not want to make a decision at that time, they are advised that the facility would perform life-saving measures and that this conversation would be documented in the resident's electronic health record. A policy titled, Advance Directives dated 10/2025 revealed the following: It is the policy of the facility that the resident has the right to be fully informed of advance care and treatment and of any changes in the care or treatment that may affect the resident's well-being, and, Social Services will follow up with the resident.who wishes to formulate an Advance Directive, in providing.Orders for Scope of Treatment form on which to indicate his/her written directive(s). and, On Admission.residents will be made aware of their right to make their wishes known, and a copy of the form will be made available to them, if desired.

Based on interview and record review, the facility failed to immediately report an injury of unknown origin to the State Agency for one vulnerable resident (R83) of one resident reviewed for abuse.Findings include:On 04/07/2026 at 12:17 PM, R83 was observed in bed with their eyes closed. R83 did not answer to name called. On 04/08/2026 at 09:45 AM, R83 was observed sitting in the dining room in their wheelchair. R83 was asked how they were feeling and if they remembered how they hurt their hip. R83 was not able to respond appropriately to questions.A review of R83's electronic medical record (EMR) revealed an initial admission to the facility on [DATE] with the diagnoses of Dementia, Dysphagia, Fracture of Right Foot, Fracture of Humerus, Seizure, Right Knee Osteoarthritis, And History of Falls. R83 was readmitted to the facility on [DATE] with the diagnosis of a Fracture of Superior Rim off the Right Pubis, (a type of break in a person's pelvis; pelvic ring break are usually caused by falls in elderly patients or high-impact trauma), and a Urinary Tract Infection. A review of R83 Brief Interview for Mental Status (BIMS)dated 12/18/2025 revealed a score of 3/15 (Severe Impairment).A review of R83's care plan revealed the following: R83 has impaired daily decision-making R/T (related to) dementia.Start Date:06/15/2022.Problem: R83 is at risk for falling R/T generalized muscle weakness with history of falls in her community and Dementia DX. poor safety awareness.Start Date 06/08/2021 Last Reviewed/Revised 03/20/2026 01:00 PMApproach: Frequent monitoring of resident activities to ensure safety measures are used when performing self-transfers Start Date 10/31/2023.A review of R83's progress note entered by License Practical Nurse (LPN) Q dated 03/03/2026 2:00PM and revealed the following: Writer was alerted by another staff member that resident was in the dining area shaking. Writer assessed resident and observed that the appeared to be trembling and restless. Resident grabbed at throat when asked where she is experiencing pain. Resident grimacing when touched, stating that it hurts all over. Emergency contact requested that resident be sent to (Hospital) for further evaluation.A review of R83's progress note entered by LPN Q dated 03/03/2026 at 10:00AM revealed the following: Resident is awake in dining area, seated upright in w/c (wheelchair). Resident deniesexperiencing any pain or discomfort. Vital signs are within resident's normal limits. Fluids within reach. No concerns at this time.A review of R83's hospital note entered by Orthopedic Physician R dated 03/04/2026 revealed the following: (R83) has dementia.Reportedly with a fall. (R83) noted to have fractures of the right superior and inferior pubic rami on x-ray. Patient does not communicate appropriately does respond but indiscernible.Imaging of pelvis reveals findings consistent with right superior inferior pubic ramus and superior ramus fractures. Osteopenia is present.On 04/08/2026 at 2:15 PM, the Director of Nursing (DON) was interviewed and queried about R83's fracture. The DON stated, We sent (R83) to the hospital because she was having pain.we assumed it was a UTI. The DON was asked when they received information that R83 had a fracture. The DON stated, I learned of a possible fracture on March 9th (2026). The DON was asked if she knew how the fracture occurred and the DON stated, We completed an investigation at that time. The DON was asked if the injury was reported to the State Agency. The DON did not provide a response. On 4/09/2026 at 12:30 PM, the DON and the Nursing Home Administrator (NHA) were interviewed and queried if R83's fracture was reported to the State Agency. The NHA stated, Once we found out that (R83) had a fracture I investigated and found that we did not need to report the injury (to the State Agency). The NHA was asked if R83's injury was observed by staff. The NHA said, The CNA (Certified Nursing Assistant) was very thorough with their explanation. The NHA was asked how did R83 sustain the injury. The NHA did not provide an explanation regarding the origin of R83's fracture.A review of the facility's policy titled Abuse Prohibition Program dated 02/22/2022 revealed the following:Reporting: The facility will file reports in accordance with State Law.Required State Survey Agency notification will be made within 2 hours or within 24 hours as required by statute to the Michigan Bureau of Health Services.

Based on observation, interview, and record review, the facility failed to provide toileting assistance in a timely manner for one (R43) of two residents reviewed for ADLs (Activities of Daily Living), resulting in R43 having an incontinence episode in the bed. Findings include:On 4/07/2026 at 9:03 AM, R43 was observed in their room, seated on the edge of their bed looking out the doorway with the call light on. R43 stated, I'm waiting for her to come back with the lift. I have to go to the bathroom. I put the light on, and they come in here turn it off and say they will be right back with the lift and another CNA, but it takes a while. I have waited about 10 minutes already, so I put the light back on. At 9:06 AM, Certified Nurse Assistant (CNA) H entered the room, turned the call light off and said, I haven't forgot about you. I have to get help. I'll be back in a minute. At 9:14 AM, CNA H came back in the room and said, Another resident is using the lift right now. Do you want to use a bed pan instead? R43 declined and said they preferred to use the toilet.At 9:25 AM, R43 was transferred to the bathroom with the sit-to-stand lift and was able to use the toilet.On 4/08/2026 at 10:47 AM R43 was observed in their room, seated on the edge of their bed with the call light on. The sit-to-stand lift was in the resident's room, but no staff were present. R43 said they had been waiting for assistance to use the bathroom for almost an hour and couldn't hold it any longer. R43 stated, It's like this almost every morning. I usually go to the toilet after breakfast because I take a water pill in the morning. They should know this. Today I've been waiting for a long time, more than usual. They come back in and tell me they are trying to find someone to help with the transfer. They always have two people. I'm not sure I can hold it.At 11:02 AM R43 was observed in the same position on the bed and stated, Well, it's too late. I already wet the bed. R43 reported they had waited for over one hour to get assistance to use the toilet today. Upon further observation it was evident that R43 had urinated in the bed. At 11:08 AM Licensed Practical Nurse (LPN) G was asked about R43's toileting needs and acknowledged that R43 required a sit-to-stand lift with two staff members for toileting. LPN G said, We try to get everyone toileted, but there are only two lifts on this hall, and we have several residents that use them right after breakfast. LPN G and CNA H proceeded to assist R43 with incontinence care. According to R43's Minimum Data Set (MDS) dated [DATE] they were cognitively intact and able to easily make their needs known. R43 was identified to require moderate assistance with toileting and was unable to walk 10 feet. R43 was not on a toileting program and was occasionally incontinent of urine. A care plan updated on 3/19/26 indicated R43 required staff assistance with all ADLs due to generalized weakness and a recent fall without injury during a transfer. On 4/09/2026 at 10:53 AM during an interview with nurse manager, LPN J acknowledged that R43 required a lift and two staff members for transfer to the bathroom. LPN J stated, The resident has recently declined to a sit-to-stand lift in the past few weeks. The staff need to plan for that resident to be toileted earlier in the morning. On 4/09/2026 at approximately 11:30 AM the Director of Nursing was requested to supply the facility's policy for ADLs and toileting a resident. During interview the DON said staff are expected to assist the residents to the toilet in a timely manner.

Based on observation, interview, and record review, the facility failed to provide nebulizer treatments as ordered for one resident (R57) of three residents reviewed for respiratory care.Findings include:On 4/07/2026 at 10:23 AM, R57 was observed in his room sitting in a wheelchair. R57's nebulizer mask was observed on the floor near the nightstand. When R57 was asked about the nebulizer mask R57 stated, They don't always give the nebulizer to me and I need it. I was taking it daily at home and in the hospital. It helps. I'm short of breath when I move around. R57 was alert and oriented to person, place, and time during the interview.On 4/08/2026 at 1:20 PM, R57 was interviewed about his nebulizer treatment and said he did not get the treatment. R57 stated, I was on the nebulizer at home for six years, I'm always short of breath I want the nebulizer it helps. They stopped giving it to me. I've asked them, I asked the nurse for it.On 4/08/2026 at 2:20 PM, Licensed Practical Nurse (LPN) N was interviewed and said R57's nebulizer treatment was switched to PRN (as needed). LPN N stated, I told him that when he asked for the nebulizer.On 4/08/2026 at 2:45 PM, R57's physician orders and medication administration record were reviewed with unit manager J. Unit Manger J confirmed a PRN order for Ipratropium-Albuterol via nebulizer every six hours as needed for shortness of breath. Review of R57's MAR revealed the medication was unavailable 11 times for March 2026 and last provided on 3/22/26. When asked if the medication was unavailable Unit Manager J said the medication is readily available and could not explain why the medication was not given.On 4/08/2026 at 3:05 PM, R57 was interviewed with Unit manager J. When Unit Manager J asked R57 if he wanted the nebulizer treatment, R57 was agreeable and said he asked the nurse, but the treatment was not provided. R57 further said that the most recent treatment he did have, the nurse did not stay with him, and the nurse did not know how to use the machine correctly. Unit manager J acknowledged facility should have provided the nebulizer treatment when the resident asked.Review of R57's Electronic Health Record (EHR) revealed he was admitted to the facility on [DATE] with diagnosis that included Heart Failure, Pneumonia, Acute respiratory disease and Chronic obstructive pulmonary disease. A Minimum Data Set assessment dated [DATE] revealed moderate impaired cognition and moderate assistance for Activities of Daily Living (ADLS). Review of R57's care plan did not reveal nebulizer and/or breathing treatments.On 4/09/2026 at 9:29 AM, the Director of Nursing (DON) was interviewed and said the expectation is for the nurses to provide PRN medications as ordered and if the residents ask for the medication and/or treatments. The DON further said the nebulizer medication is readily available in the facility medication back up.Review of the facility policy titled Nebulizer Therapy date revised 11/2025 revealed in part. Procedure: Indications for nebulizer therapyAMust have a physician order to administer nebulizer treatment. Administering a liquid medication to treat respiratory condition (i.e., COPD, CHF, Pulmonary Fibrosis, etc.). Document in the medical record (respiratory rate, heart rate, pulse oximetry, breath sounds, and any adverse effect from the nebulizer treatment). Supervision of treatment needs to be done to ensure no adverse reaction to the medication. Nebulizer machine is to be kept at bedside in a bag for administration of ordered treatment.

Based on observation, interview, and record review, the facility failed to promptly notify the health care provider of laboratory results for one (R118) of one resident reviewed, resulting in a potential delay in treatment. Findings include:On 4/7/2026 at approximately 10:00 AM, R118 was observed in their room preparing for a doctor's appointment. The resident appeared alert and communicated appropriately during the interaction. R118's family member (FM T) was at the bedside and said they thought R118 had a urinary tract infection but was unsure if an antibiotic was ordered. On 4/8/2026 at approximately 12:05 PM, R118 was asked if they were still experiencing burning with urination, and they responded yes. A record review was conducted of R118's electronic health record (EHR) and revealed a most recent admission date of 3/28/2026 with diagnoses that included chronic obstructive pulmonary disease, Parkinson's disease, hypertension, anemia, bipolar disorder, major depressive disorder, restless leg syndrome, and chronic pain. There was no physician order for an antibiotic. A nursing progress note dated 4/3/2026 revealed, CNA (certified nursing assistant) reported to writer that resident has a burning sensation when (R118) urinates. PA (Physician Assistant) ordered a UA test (a test that examines urine) with reflex culture to be done today. The EHR revealed a physician order dated 4/3/2026 which read, Order for UA with reflex to culture STAT (immediately). The EHR revealed no further documentation of the laboratory results, notification of the provider, or further monitoring of R118's symptoms. On 4/8/2026 at approximately 11:50 AM, Unit Manager J (UM J) was asked about the UA test and if the results were communicated to the ordering provider. UM J confirmed that the laboratory provider collected R118's urine specimen on 4/3/2026 and results were completed on 4/4/2026. UM J presented the laboratory results and confirmed they showed positive results indicative of a possible urinary tract infection. UM J said the results were not communicated to the ordering provider until the afternoon of 4/8/2026. On 4/9/2026 at approximately 11:15 AM, the Director of Nursing was interviewed regarding the process for notifying the ordering health care provider of laboratory results. The DON said it was their expectation that the nurse would call the provider and notify them of the results and seek any further orders for treatment. When asked if a STAT laboratory result should be communicated timely to the provider, the DON stated, yes - so there is no delay in treatment. A policy titled, Change in Condition Notification of Clinicians dated 12/15/2025 revealed the following: Purpose: To articulate communication and notification standards among clinicians when a change in the residents condition occurs., and 1) Examples of significant, unexpected, or abnormal clinical findings may include.laboratory findings (for example: abnormal or critical test results), and (a) Phone Call communication with the provider should be considered when the change in condition requires an intervention from the provider before the next time the provider is at the facility (i) Examples: Critical Laboratory or Diagnostic results.

Based on observation, interview, and record review, the facility failed to communicate transmission-based precautions for one resident (R48) of four residents reviewed for infection prevention and control, resulting in the potential for spread of infection among residents, staff, and visitors. Findings include:On 4/8/2026 at approximately 9:20 AM, R48 was observed in their room, in bed. An equipment caddy was observed mounted to R48's door which held personal protective equipment (PPE). The PPE observed in the caddy included gloves, face masks, and gowns. There was no signage on the door indicating what type of transmission-based precautions were in place or what type of PPE was to be worn to enter the room and provide care. On 4/8/2026 at approximately 1:10 PM, Licensed Practical Nurse K (LPN K) was interviewed regarding R48's transmission-based precautions. LPN K confirmed R48 had influenza A and staff were to wear PPE upon entering the room. When asked how she knew what type of precautions were needed, LPN K said there is a sign on the door that communicates the type of precaution and what PPE is needed to enter. LPN K then confirmed that no sign was present on R48's door. A record review was completed which indicated R48 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's Disease, anxiety disorder, chronic obstructive pulmonary disease, atrial fibrillation, hypertension, type II diabetes, pain, and influenza A virus (added 4/5/2026). Section C of the Minimum Data Set with an Assessment Reference Date of 3/27/2026 revealed R48 scored a 4/15 on the Brief Interview for Mental Status exam - indicative of a severe cognitive impairment. A physician order dated 4/5/2026 revealed, Droplet isolation due to Influenza A. R48's care plan approaches, dated 4/6/2026 revealed the following, Display precaution sign as directed by Infection Control and wear mask and glove while administering care. On 4/9/2026 at approximately 10:00 AM, Infection Preventionist E (IP E) was queried regarding the facility's practices related to PPE and transmission-based precautions. IP E said they follow Centers for Disease Control (CDC) guidelines and their facility policy when determining what type of isolation and PPE is to be used for communicable diseases. IP E confirmed that those with influenza A would be under droplet precautions. IP E said PPE would include mask, gown, and gloves for entering the room and providing care. IP E further said that they would place a sign on the resident's door indicating to staff and visitors what type of precautions the resident was on and what type of PPE would be donned prior to entering the room. When asked why the use of appropriate signage and PPE is important, IP E said, to stop the spread of infection among residents and others. A policy titled, Infection Prevention Policy dated March 2026 revealed, Signs- this facility will alert the staff/visitors of the type of precautions that are required by placing a sign on the door of the resident's room (Droplet and Contact Precautions).

This citation pertains to intake 2961759.Based on interview and record review, the facility failed to implement interventions and skin treatments as prescribed to prevent the development or worsening of pressure ulcers for two (R703 and R708) of five residents reviewed for pressure ulcers resulting in R703 and R705 developing stage 3 pressure ulcers (total loss of skin, exposing fatty tissue) to the coccyx area while in the facility.Findings include:The State Agency received a complaint that R708 developed a pressure ulcer at the facility.R708:According to R708's closed Electronic Health Record (EHR), R708 re-admitted to the facility on [DATE] with multiple diagnoses that included surgical repair in the cervical region of C3-C6, diabetes, and metabolic encephalopathy. On 12/12/25, the Clinical admission Assessment Section 5 - Skin Condition indicated R708 had no ulcers, no skin problems, and no skin treatments. A skin assessment dated [DATE] identified R708 to have MASD (moisture associated skin disorder) on the groin and scrotum with cicatrix (scar tissue following a healing wound). The left heel was non-blanchable (does not fade or lighten in color when light pressure applied) and discolored. Protective heel boots were ordered and Triad paste (zinc-oxide based cream) to the coccyx area. There is no documentation to support the Triad paste was applied to R708's coccyx area or the protective heel boots were applied. The Minimum Data Set (MDS) dated [DATE] indicated R708 had severe cognitive impairment, required extensive assistance for mobility, and one unstageable DTI (deep tissue injury that is a full thickness wound where depth cannot be measured because it is covered with dead tissue). The location of the DTI is not specified. Section M1200 indicated there was no pressure reducing bed or chair and no turning and repositioning program. A care plan for at-risk for skin breakdown was initiated on 12/16/25 that included floating heels while in bed, use of pressure reducing mattress to bed and cushion while in wheelchair and encourage and assist resident to turn and reposition. There are no additional progress notes or skin assessments regarding R708's skin from 12/16/25 - 12/25/25.On 12/25/25 a progress note written by Licensed Practical Nurse (LPN) B documented the following: a foam dressing was observed on the coccyx, when removed noted an area with eschar (blackened dead tissue), edges are rough, no drainage. Noted additional open areas along the bilateral buttock region at tailbone. There are no measurements or additional descriptions of R708's wounds. An order for Manuka Honey 100% was prescribed for R708's coccyx area 3 times a week; Tue, Thu, Sat. The Medication Administration Record (MAR) indicated R708 received the treatment two times; 12/25/25 and 12/27/25.During interview with LPN B on 3/27/25 at 10:20 AM they said they observed the foam dressing on R708's coccyx during incontinence care. LPN B stated, I did not know he had any wound prior to that. It alarmed me to see the foam patch. When I removed it there was eschar over the wound. LPN B said they did not know when the foam patch was applied to R708 because there was no date on it. LPN B reviewed R708's EHR and confirmed there were no progress notes, skin assessments or treatments for the coccyx area prior to 12/25/25. LPN B did not recall if R708 had any skin concerns with the left heel. During an interview with the Director of Nursing (DON) on 3/27/25 at 11:00 AM, confirmed there were no skin assessments or treatment orders for the coccyx area until 12/25/25. The DON stated, I determined who put the foam patch on. They worked on 12/23/25. There is no documentation. There are no skin treatment orders until 12/25/25. The DON confirmed this was not facility protocol. A request was made for the facility's skin care protocol/policy.On 3/27/25 at 11:47 AM LPN C said they put the patch on R708 on 12/23/25 sometime during the day shift. LPN C stated, I was doing care and saw the ulcer on the coccyx. I put a foam patch on it real quick, got too busy, and forgot to chart on it or tell the doctor. LPN C acknowledged that was not the facility protocol. They did not recall if R708 had a pressure ulcer on the left heel.On 12/30/25 the initial wound care note identified R708's coccyx wound to be an unstageable pressure ulcer that measured: length 7.0 cm (centimeter) x width 8.5 cm x 0.2 cm. 90% covered with eschar. A second pressure ulcer to R708's Left Heel was described as a DTI that measured: L 8.5 cm x W 8.5cm x D 0.0 cm. At this time an order for Low-Air-Loss Mattress was made and coccyx skin treatments were changed to Santyl (chemical debriding agent) every day.On 3/27/25 at 2:30 PM, Registered Nurse (RN) A was asked about R708's pressure ulcers and confirmed they were acquired while at the facility and there was a delay in prevention and treatment of the coccyx pressure ulcer and left heel.R703:A review of R703's closed Electronic Health Record (EHR) revealed R703 admitted to the facility on [DATE] with multiple diagnoses including osteoarthritis of the left knee with DVT (deep vein thrombosis). On 10/16/25, Registered Nurse (RN) F documented R703 had a dime sized open area on the coccyx. An order was prescribed for facility-stock barrier cream as needed after incontinence care. A care plan was initiated for at risk for skin breakdown. The approaches/interventions included the following: encourage and assist resident to turn and reposition frequently, staff may apply floor stock barrier cream as needed after incontinence care, and pressure-reducing mattress on wheelchair and bed. There was no documentation to support that barrier cream had been applied to the open area on R703's coccyx. On 10/22/25, the Minimum Data Set (MDS) indicated R703 had intact cognition, required extensive assistance with mobility, and one stage 2 pressure ulcer (partial loss of skin, presents as a shallow open crater). The care plan was not revised to indicate R703 had actual skin breakdown. There were no additional progress notes or assessments for R703's coccyx pressure ulcer until 10/24/25.On 10/24/25, (9 days after admission) the following skin treatment for R703's pressure ulcer was ordered: cleanse coccyx with wound cleanser, pat dry, remove soiled triad paste and apply a dime- thick layer of triad paste and leave open to air, twice a day. According to R703's Medication Administration Record (MAR) for 10/2025 that treatment was administered 3 of 6 prescribed treatments: only once a day on 10/24/25, 10/25/25, and 10/26/25. On 10/27/25 the order was discontinued.On 10/27/25 the skin treatment order for R703's pressure ulcer was changed to; cleanse open area to coccyx with normal saline, apply oil emulsion and alginate then apply dry dressing three times a week on Mon, Wed, and Sat. According to R703's MAR for 10/2025 that treatment was administered 1 of 2 prescribed treatments on 10/27/25. On 10/30/25 the order was discontinued.On 10/27/25 a second skin treatment for R703's pressure ulcer was ordered to include: cleanse peri wound with wound cleanser, pat dry. Remove soiled Triad paste. Apply a dime-thick layer of Triad and leave it open to air. According to R703's MAR for 10/2025 that treatment was administered 2 of 4 prescribed treatments on 10/27/25 and 10/28/25. On 10/30/25 the order was discontinued.On 10/29/25, (14 days after admission) an initial wound care note documented the following: stage 3 coccyx wound with 40 % necrotic tissue (dead blackened skin/tissue) measurements; length 3.5 cm (centimeter) x width 6.0 cm x depth 0.2 cm.On 10/30/25 the skin treatment order for R703's pressure ulcer was changed to apply Manuka Honey after coccyx cleanse with normal saline, pat dry, then apply Manuka Honey and alginate (absorbent wound covering). Cover with foam dressing 3 times a week Mon, Wed, and Friday. According to R703's MAR the treatment was administered 2 of 4 prescribed treatments on 10/31/25 and 11/3/25. On 11/8/25 the order was discontinued.On 11/8/25 the skin treatment order for R703's pressure ulcer was changed to apply Santyl (a chemical debriding agent) after cleansing coccyx with normal saline followed by alginate cover with dry dressing daily and prn (as needed). R703's MAR for 11/2025 indicated the treatment was administered 7 of 8 prescribed treatments: daily from 11/8/25 - 11/13/25. No skin treatments were administered on a prn basis. On 11/14/25 that order was discontinued and changed to; cleanse with Dakin's solution (diluted bleach to kill bacteria in wounds) apply Santyl followed by alginate cover with clean dry dressing every day and prn.On 11/19/25 R703's wound care note documented the following: coccyx pressure ulcer stage 3, length 7.6 cm x width 5.4 cm x depth 1.5 cm. R703 was transferred to the hospital for worsening of the resident's pressure ulcer.On 3/27/26 at 2:30 PM RN A acknowledged that R703 admitted to the facility with a dime-sized open area on the coccyx that developed into a larger stage 3 pressure ulcer and was hospitalized . RN A confirmed that no skin treatments had been documented until 10/24/25, 9 days after admission. RN A stated, The first skin note I can see is 10/29/25, two weeks after admission. RN A said the wound care nurse who documented the first skin assessment note on admission had abruptly resigned and no longer worked at the facility. RN A was asked to review R703's MARs and stated, Yes, there are some holes there. I don't know why they did not receive all the prescribed skin treatments.According to the facility's Wound and Skin Management Policy last revised on 5/2025 in part reads: 'The facility must ensure that a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable, and receives necessary treatment and services to promote healing, prevent infection and prevent new areas from developing. Routine preventative care shall include turning and proper positioning, application of pressure reduction or pressure relief devices, providing good skin care, clean/dry bed linens and maintaining adequate nutrition and hydration.Documentation of risks and preventative measures will be included on the resident's plan of care and in the medical record as indicated.SKIN CHECKSSkin assessments are performed daily for each resident by the CNA. Any new breakdown must be reported to the charge/staff nurse and/or treatment nurse so that the appropriate treatment can be initiated.On the resident's bath/shower days the nurse must validate the shower, complete skin assessment.

Based on observation, interview, and record review, the facility failed to: 1. Properly clean and sanitize a thermometer stem prior to insertion into prepared food; 2. Ensure items stored in resident refrigerators were properly labeled with resident's name and expiration date; 3. Ensure pans were properly cleaned and allowed to air dry before stacking. These deficient practices had the potential to affect all the residents who consumed food from the kitchen, resulting in the increased likelihood for food borne illness. Findings include: On 3/17/25 at 11:18 AM, Dietary Aide (DA) F was observed in the facility's sub-kitchen taking the temperature of the following prepared foods in this order: turkey burger, mechanical soft turkey burger, pureed turkey burger, pureed sweet potatoes, gravy, pureed cauliflower soup, regular cauliflower soup, and sweet potato fries. DA F used a paper towel to wipe off the thermometer stem prior to inserting it into each food item. When queried about using a paper towel on the thermometer stem between taking food temperatures, DA F stated, I was told to not use alcohol wipes. On 3/19/25 at 10:46 AM, the resident refrigerator/freezer in the Unit A pantry was observed with Licensed Practical Nurse (LPN) C. A sign on the refrigerator door documented, No employee food or drink to be placed in this refrigerator! Resident's items must have date, their name and the room number. Thank You! A document titled, Refrigeration Temperature Record, dated March 2025, recorded refrigerator temperatures but not freezer temperatures. There was no thermometer in the freezer. A 12-ounce box of frozen lasagna and 7-ounce box of chicken pot pie were stored in the freezer and neither item was labeled with a resident name or dated. On 3/19/25 at 11:11 AM, the resident refrigerator/freezer on the Appoline unit was observed with LPN E. The Refrigeration Temperature Record, dated March 2025, only recorded the temperatures of the refrigerator. A thermometer was not available in the freezer. The following items, observed in the freezer, were opened, not labeled with a resident name, or dated: 1 gallon container of vanilla ice cream and 1.5-quart container of caramel delight ice cream. The following items were in the freezer unopened, not labeled with a resident name, or dated: sausage-egg-cheese croissant sandwich, 18.5-ounce bottle of unsweetened tea, and 10-ounce bottle of a hydration beverage. The refrigerator contained an unlabeled and undated plastic bag containing half-eaten pita bread and what appeared to be small blocks of soft cheese. On 3/19/25 at 11:30 AM, in a clean pot/pan storage area in the main kitchen, the surfaces of three sheet pans nestled together were observed to have droplets of water. One of the three sheet pans was not adequately cleaned and contained sticky substances. Director of Dining (DD) B stated the soiled sheet pan needs to be soaked and scrubbed. On 3/19/25 at 11:50 AM, DD B said alcohol wipes should have been used to clean and sanitize the thermometer stem prior to inserting it into each food item. DD B said the wet sheet pans should have been allowed to air dry before stacking. Regarding the resident refrigerators, DD B said maintaining the resident refrigerators was everyone's responsibility, but at the end of the day, it was dietary's responsibility. Resident food stored in the resident refrigerators should have been labeled. Food not properly labeled should have been tossed. Dietary provides stickers for the labeling and dating. The thermometers should be in the refrigerators and freezers and the temperatures of both areas should be monitored. On 3/19/25 at 2:10 PM, the Nursing Home Administrator (NHA) stated, We expect in-house policies and procedures to be followed. A review of the facility policy titled, Food for Residents Brought in from the Outside, dated April 2024 documented in part the following: -Food/beverage brought in by family/friends for resident should be consumed within 3 days. If not consumed it should be discarded by the Midnight Shift. -The resident's nurse/CNA (Certified Nurse Aide) is responsible for checking the expiration date of all food from the unit refrigerator prior to serving to the resident. The 2013 FDA Food Code was reviewed and revealed the following: Section 4-602.11. Equipment Food-Contact Surfaces and Utensils: Equipment food-contact surfaces and utensils shall be cleaned (5) at any time during the operation when contamination may have occurred. Section 4-903.11. Storing Equipment, Utensils, Linens, and Single-Service and Single-Use Articles: (B) Clean equipment and utensils shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted. On 3/19/25 at 4:30 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked.

Based on observation, interview, and record review the facility failed to provide a bedpan timely for one incontinent resident (R11) of one resident reviewed for dignity, resulting in verbalizing feelings of embarrassment and frustration. Findings include: On 3/17/2025 at 10:47 a.m. R11 reported having a bowel movement in bed after turning on the call light for assistance that took over thirty minutes for a staff to answer the call light. During an interview R11 stated, I felt nasty because I did something nasty on myself. I felt angry, frustrated, and embarrassed. I wouldn't say this if I didn't mean it. I was so upset because I don't have bowel movements on myself. On 3/17/2025 at 10:55 a.m. assigned Certified Nursing Assistance (CNA) K was interviewed regarding resident's care. CNA K was asked if R11 was upset about having a bowel movement in bed because no one provided the resident with a bedpan. CNA K stated, Yes, the resident call light was on along with others at the same time. By the time I got to her she had pooped on herself, and she was upset. CNA K said R11 call light was on for about thirty minutes before it was answered and before the resident was changed. According to the electronic medical record, R11 was admitted to the facility on [DATE] with diagnoses of anxiety, hemiplegia and hemiparesis following a cerebrovascular disease (stroke) affecting the left dominant side, contracture of right hand and left knee, overactive bladder, and a history of constipation. R11's quarterly Minimum Data Set (MDS) with a reference date of 1/11/2025, indicated R11 had intact cognition with a BIMS (brief interview of mental status) score of 15/15 and incontinent of bowel and bladder. Review of the 8/11/2020 Activity of Daily Living (ADLs) care plan documented, (R11) is at risk for self-care deficit in ADLs functional Status/Rehabilitation Potential. Interventions: Bed mobility and transfers extensive assistance times two person. On 3/19/2025 at 1:50 p.m. the Director of Nursing (DON) said during an interview regarding R11's incontinent episode that the CNA's should have assisted the resident within fifteen or twenty minutes from the time the call light was turned on. The DON understood why the resident was upset and embarrassed especially if the resident normally uses the bedpan. Review of the facility's 12/2024 Dignity and Privacy policy: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. 2. 'Treated with dignity' mean the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.

Based on interview and record review, the facility failed to notify in a timely manner the Resident Representative (RR) for one resident (R24) of a change in condition requiring treatment, resulting in the RR not having the opportunity to participate in medical decisions regarding R24's health. Findings include: A review of the clinical record for R24 documented an initial admitted [DATE]. R24's diagnoses included dementia, pressure ulcer of sacral region-stage 4, congestive heart failure, and cerebral infarction. R24's spouse was listed as the responsible party and emergency contact. R24's son was listed as the RR. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. Additional review of R24's clinical record documented in part the following: 1. Wound care progress note dated 3/11/25: (R24) present with an acute skin tear of the right midline buttock. The wound is for initial evaluation. The wound was classified as a skin tear, length 0.91 centimeter (cm) and width 3.18 cm. Cleanse the wound with cleanser or saline solution and pat dry with gauze. Apply triad (a paste wound dressing) two times a day. 2. Nursing progress note dated 3/11/25: Patient received in bed, alert and verbal. Vital signs stable, ordered medications received and tolerated well. Foley in place and patent. Wound care performed rounds and completed patients wound treatment this shift. Will continue to monitor and maintain safety. Frequent visual checks for safety. 3. Nursing progress note dated 3/17/25: Husband in facility, provided update on wound progression and plan of care was discussed. Husband expressed understanding of information provided. Denied having any questions. During an interview and record review beginning on 3/19/25 at 12:06 PM, Unit Manager (UM) G said R24 had a skin tear and treatment was recommended. The family should be notified immediately and made aware of any changes when something happens with a resident. UM G said R24's clinical record should contain documentation that the family was contacted and referenced a progress noted dated 3/17/25 as evidence of family notification. During an interview on 3/19/25 at 12:16 PM, wound care nurse H said she rounds with the wound care team. Nurse H indicated that R24 did not have treatments in place for the skin tear prior to 3/11/25. Nurse H said the facility has a weekly wound and nutrition meeting and that would be when the family is notified. Nurse H acknowledged that waiting for the weekly wound meeting to occur may result in a delay in RR notification. During an interview on 3/19/25 at 1:52 PM, the Director of Nursing (DON) said the nurse should have tried to contact R24's spouse when the wound was discovered. A review of a facility policy titled, Change of Condition Policy, undated but provided during the survey, documented in part the following: The nurse shall promptly notify the resident, his or her provider, and representative of changes in the resident's condition and/or status; and properly assess the resident for further care needs. On 3/19/25 at 4:30 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.

Based on interview and record review, the facility failed to obtain a medication for a rare cardiac condition in a timely manner for one resident (R143). Findings include: A review of the clinical record for R143 documented an admission into the facility on [DATE] with diagnoses that included sepsis due to pseudomonas (a life-threatening infection caused by bacteria), cognitive communication deficit, and organ-limited amyloidosis (abnormal buildup of insoluble, elongated proteins primarily within a single organ) congestive heart failure. The hospital discharge summary dated 3/10/25 documented that R143 was to continue taking 61 mg of tafamidis (tafamidis [Vyndamax] is an oral medication used to treat a rare and progressive heart disease) by mouth daily. Additional review of R143's clinical record documented in part the following: Progress note of 3/13/25 at 2:29 PM: Received resident in bed awake, alert with confusion present. Resident received shift medications whole tolerated well no adverse reactions observed during shift .Writer paged MD in regards to medication Vyndamax 61 mg not delivered and unavailable in the cubex (a system to secure and provide controlled substances and other medications) to pull. Per (staff at pharmacy) the medication is very expensive and not covered by insurance. Writer contacted MD to see if an alternative can be used, writer awaiting a call back . During an interview and record review on 3/18/25 at 2:32 PM, Unit Manager (UM) G acknowledged that tafamidis was a cardiac related medication. After reviewing R143's clinical record, UM G could not provide documentation to support that any follow up had occurred regarding R143's cardiac medication since 3/13/25. UM G said they would have to page the physician because there was nothing noted in the clinical record. A review of R143's March 2025 Medication Administration Record documented that tafamidis had not been administered because the drug was not available since R143's admission into the facility. During an interview on 3/18/25 at 3:21 PM, the Lead Pharmacist (LP) I at the facility's contracted pharmacy was interviewed. LP I said Vyndamax was a specialty medication, and the facility sent the order for Vyndamax on 3/1/25. LP I said we documented that we could not supply the medication and provided a number for the facility to call for more information. A progress note of 3/18/25 at 4:20 PM documented in part the following: MD rounding with resident and was informed that Vyndamax had not been given (due to) its unavailability from the pharmacy. The physician was asked if there was an alternate med for use as the pharmacy said the medication is a specialty medication and they are unable to supply it. Physician is aware that medication is a special use med and does not want to order an alternate med. MD stated to contact the resident's family and ask them to bring the medication from home and start the medication then. Resident is stable and shows no change in condition. Resident's son was notified and informed of the unavailability of Vyndamax and agreed to bring the medication in this evening. On 3/19/25 at 1:58 PM, the Director of Nursing (DON) said when nursing discovered that tafamidis was not available they should have called the doctor immediately, did a cardiac follow up, and in this case, reached out to the family sooner especially since this was such a rare medication. On 3/19/25 at 4:30 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.

Based on observation, interview, and record review the facility failed to ensure a safe wheelchair transport for one (R15) of seven residents reviewed for accident hazards, resulting in a fracture with subsequent wound, pain, and decreased activities of interest due to the inability to participate. Findings include: On 2/27/2024 at 9:58 AM R15 was observed in bed wearing a hospital gown. R15's heel boots were observed on R15's wheelchair. When R15 was asked the purpose of the heel boots, R15 stated, The boots are for my feet when I sit in my wheelchair, so my feet don't slip off the footrests. When asked have your feet slipped off the foot rests, R15 replied, Yes I broke a bone and now I can't get up. My ankle hurts. When asked what happened to her left ankle R15 replied, Activities (staff) were bringing me back to my room and my left boot fell off the footrest and pulled my ankle and foot. That was the most painful thing I have had to put up with. The bad part is I can't get out of bed now because I'm waiting for this boot (surgical boot) to protect my foot. I'm sick of lying in this bed. I haven't been able to get up or go to activities. Record review of electronic medical records revealed R15 was admitted into the facility on [DATE] with recent readmission on 12/27/2023 with a pertinent diagnosis of acute respiratory disease, pneumonia due to coronavirus, dependence on supplemental oxygen and changes in skin texture-chronic skin tear cox/crease. According to the Minimum Data Set (MDS) dated [DATE], R15 had intact cognition with a Brief Interview of Mental Status (BIMS) of 15/15 and was dependent for mobility. Record review of the Incident and Accident report dated 2/28/2024 revealed the following: On 2/6/2024 at 3:19 PM Resident A&Ox3, verbal -able to make needs known. Resident reported feels she hyperextended her L ankle, during ride in wheelchair being brought back to room by activities-foot slipped off footrest and bent downward under chair. Due to pain resident MD notified-Xray ordered via STAT. Oncoming Nurse made aware. On 2/7/2024 at 1:18 AM Left ankle x ray results faxed over. Impression: A fracture of the distal fibula. MD ordered Motrin 400 mg BID PRN for Resident due to pain/soft tissue swelling. On 2/29/24 at 8:26 AM, Activities Supervisor (AS) D was interviewed and stated While I was pushing (R15) back to her room her left foot and foam boot fell off the footrest. (R15) immediately yelled out in pain I stopped pushing her and called for the nurse. (Licensed Practical Nurse (LPN) E) was at the nurse's station and took over. AS D further revealed R15 has not participated in activities since the ankle injury on [DATE]th 2024 and that R15 did not express any left foot and/or ankle pain prior to her foot slipping off the footrest. When queried was R15's foot properly secured prior to transport, AS D, stated I don't know we (activities staff) don't transfer residents into wheelchairs we only transport them. (R15) was already in the wheelchair when she came to activities. On 2/29/24 at 9:44 AM, LPN E was interviewed and said she heard R15 yell while AS D was pushing R15 back to the room. LPN E saw R15's left foot boot was caught underneath the footrest and pulled directly onto the left foot and R15 was weeping. LPN E stated, I fixed the boot reapplied the Velcro strap and repositioned (R15's) left foot on the footrest. On 2/29/24 at 10:48 AM, LPN F was interviewed and said she was working on 2/6/2024 and heard R15 yell while being pushed in the wheelchair and observed the left foot off the footrest and left foam boot underneath the wheelchair. LPN F stated I assessed (R15's) ankle. (R15) was complaining of ankle pain so I called the doctor to get an xray. On 2/29/24 at 11:01 AM, Rehab Director G was interviewed and revealed R15 was seen by therapy services for wheelchair positioning in [DATE] due to R15's feet falling off the footrest during transportation. Therapy got R15 a wider wheelchair and adapted footrests (heel boots secured by Velcro straps to the wheelchair foot rests). Record review of the Occupational Therapy Discharge Summary dated 10/22/23 revealed 26-inch WC (wheelchair) provided Bil leg rests adapted for comfort and positioning, leg rests and foot buddy provided . Record review of R15's care plan revealed Problem date: 10/17/2023 R15 requires a 26-inch wheelchair with adequate feet support in order to optimize comfort and safety which would allow her to attend activities of choice. Record review of the wound care practitioner note dated 2/19/2024, revealed The patient has a new left ankle fracture x 1week. Consequently, her mobility has been significantly limited and she has developed increased edema in the left lower leg which has led to the formation of new blood blister x 1 week duration. Record review of the Physical Medicine and Rehab Progress Note, dated 2/8/2024, revealed in part . R15 was seen today to follow up on pain control. Unfortunately, in the interim (R15) had an event in which her foot slipped off the footrest while being transported on a wheelchair, and (R15) subsequently had acute left ankle pain. X-ray was completed which revealed a distal fibula fracture . (R15) is complaining of left ankle pain throughout the lateral and medial aspect. Pain elsewhere is stable and forgotten due to acute pain. (R15) is now agreeable to increase the frequency of tramadol (pain medication). On 2/29/24 at 11:33 AM the Director of Nursing (DON) was interviewed and agreed that R15's left fibula fracture was caused by R15's foot slipping off the footrest during wheelchair transportation and that staff should make sure R15's foot boots are secure prior to transport. Review of the facility policy titled Wheelchair Transport (undated) revealed in part . Ensure the resident's feet are on the leg rest, If the resident seating position changes or feet are not properly on the footrest, the person pushing the wheelchair should: 1. Stop pushing the wheelchair. 2. Reposition the resident to ensure safety. 3. Once the resident is positioned safely, continue transport.

Based on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen and its support spaces resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting the facility's total census of 76 residents. Findings include: 1. On 2/27/24 at 10:21 AM, the IL kitchen dish machine was observed by the surveyor being tested by Assistant Dining Director, staff B, via a temperature sensing plate. Upon the dish machine's cycle finishing the surveyor asked staff B what the final rinse temperature read to which they replied, 160 degrees F. At this time the surveyor inquired with staff B on what they would normally do in a situation like this to which they replied, test it again. On 2/27/24 between 10:23 AM - 10:32 AM, two additional tests were conducted by staff B on the dish machine via a temperature sensing plate revealing the same temperature reading as the original test. At this time Dining Services Director, staff A, stated, I'll call maintenance to contact the service company. We will use the 3-compartment sink to sanitize until we can get this fixed. On 2/28/24 at 1:41 PM, upon record review of a policy titled, dish machine temperature record (high temperature machine) dated, February 2024 revealed numerous dates that the final rinse temperature did not reach 180 degrees F upon testing, but were signed off on by staff via initialing under the checked by column. Further review of this document by the surveyor revealed that the column titled, manager weekly review was left blank throughout the document. Review of 2017 U.S. Public Health Service Food Code, Chapter 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures, directs that: (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90oC (194oF), or less than: Pf (1) For a stationary rack, single temperature machine, 74oC (165oF); Pf or (2) For all other machines, 82oC (180oF). Pf 2. On 2/27/24 at 10:10 AM, a utensil holding container was observed with an accumulation of dust and dried food debris on its interior in the IL kitchen. On 2/27/24 at 10:11 AM, upon interview with Dining Services Director, staff A, regarding the current state of the utensils and their container they stated, we keep cleaning logs, and this is part of a regular task for us. At this time the surveyor requested a copy of the cleaning logs mentioned by staff A to review. On 2/27/24 at 11:07 AM, seven water pitchers were observed with heavy sticker residue on their exterior surface while stored on the clean ready for use storage rack in the health center. At this time the surveyor inquired with staff A on the facility's expectation on the condition of equipment and utensils prior to being placed on this storage rack to which they stated, all labels and stickers should be fully removed before being placed on this rack. On 2/27/24 at 11:37 AM, the B unit's nourishment rooms refrigerator and freezer were observed in a soiled state with an accumulation of dust and debris on its interior. On 2/27/24 at 11:45 AM, the A unit's nourishment rooms refrigerator, freezer, and microwave were observed in a soiled state with an accumulation of dust and debris on each piece of equipment's interior. Upon observation the surveyor inquired with Assistant Dietary Manager, staff B, on who is responsible for the cleaning of the equipment in the nourishment rooms to which they replied, the nursing staff should be letting someone know when they get like this. On 2/28/24 at 10:13 AM, review of electronic documents dated 1/9/24, titled Master Cleaning Schedule revealed that the facility has a system in place to ensure a clean and sanitary environment in the kitchen. Review of 2017 U.S. Public Health Service Food Code, Chapter 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, directs that: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

This citation has three deficient practices. Deficient practice #1. Based on interview and record review, the facility failed to establish a comprehensive Infection Control Program that conducted annual review of policies/procedures and calculated monthly facility acquired infection (FAI) rates, resulting in the potential for staff to be unaware of current national standards of practice for infection control and prevention and missed opportunities to identify trends in FAI, resulting in the potential delay in implementing corrective actions. Findings include: On 2/29/24 at 9:21 AM, the facility's infection control program was reviewed with the Infection Preventionist (IP) and revealed the following: 1. The IP acknowledged that the following documents had not been reviewed at least annually to ensure they were current and in keeping with national standards of practice: - List of communicable diseases to report titled, Type and Duration of Isolation was last updated 8/29/2017. - Policy titled, Influenza & Pneumococcal, dated August 2019. - Policy titled, Isolation - Categories of Transmission-Based Precaution, last reviewed August 2022. - Policy titled, Standard Precautions, last reviewed May 2022. - Policy titled, COVID-19 Multi-Transmission, last reviewed May 2022. - Policy titled, COVID-19 Staff and Resident Testing, last reviewed 1/9/2022. 2. The IP provided no calculations of monthly FAI rates which could be used to determine trends of infections from month to month and to implement timely corrective measures for spikes in rates. The IP stated, I have never compared the difference in month-to-month infections. The IP said that there needs to be more concrete documentation of the analysis of infection trends. On 1/29/24 at 2:09 PM, during an interview and record review with the Director of Nursing (DON), the outdated policies as indicated above were reviewed. In response, the DON stated, So noted. The DON added that the percentages in terms of the FAI rates, quantify the changes in FAI from month to month. The DON stated, It's important to show progress or where education is needed. 47964 Deficient practice #2. Based on observation, interview, and record review the facility failed to properly store a nebulizer mask and tubing between resident use for one (R314) out of three residents reviewed for respiratory care resulting in the potential for increased risk of respiratory infections. Findings include: On 2/27/24 at 10:41 AM, R314's nebulizer mask was observed lying directly on the nightstand not stored in a bag. When R314 was asked do you use the nebulizer, R314 responded, I use the nebulizer 2-3 times per day, the nurse adds the medicine, but I do the treatment on my own. On 2/27/24 at 1:06 PM, observed the nebulizer mask lying directly on nebulizer machine not stored in a bag. On 2/28/24 at 8:28 AM observed the nebulizer mask lying directly on nebulizer machine not stored in a bag. Record review of Electronic Medical Records (EMR) revealed R314 was admitted into facility on 2/24/2024 with pertinent diagnoses of chronic respiratory failure, chronic obstructive pulmonary disease. R314 had intact cognition. On 2/29/24 at 11:12 AM the Director of Nursing (DON) was interviewed and acknowledged nebulizer masks should be stored in a bag. 49103 Deficient Practice Statement #3 Based on observation, interview, and record review the facility failed to perform hand hygiene between care for residents (R318, R39, and R312), resulting in the potential for the transmission of communicable diseases and infections. Findings include: On 02/28/24 at 9:47 AM Licensed Practical Nurse (LPN) F was observed to prepare and administer medications to R318. LPN F did not wash or sanitize hands following administration of oral medications. LPN F donned gloves to administer eye drops to R318. LPN F did not wash hands after removing the gloves and did not wash or sanitize hands prior to leaving the room. On 2/28/24 at 9:54 AM, without performing hand hygiene, LPN F was observed preparing medications for R39. LPN F administered the medications to R39. LPN F did not wash or sanitize hands prior to administration of medication and did not wash or sanitize hands prior to leaving the room. On 2/28/24 at 10:06 AM, without performing hand hygiene, LPN F was observed preparing medication for R312. LPN F administered the medications to R312. LPN F did not wash or sanitize hands prior to giving the medications and did not wash or sanitize hands prior to leaving the room. On 2/28/24 at 10:10 AM, LPN F was queried about hand hygiene practices. LPN F said there was no sanitizer on the medication cart because it had been loaned to another nurse passing medication. LPN F acknowledged that hand hygiene should be performed before and after medication administration for each resident. On 2/29/24 at 12:38 PM the Director of Nursing (DON) was interviewed and said the policy of the facility is to wash hands between each resident. The DON stated, I stand by the policy. Review of the facility policy last reviewed May 2022, titled, Infection Prevention Policy: Hand Hygiene states in part: Facility staff shall wash their hands after each direct resident contact when indicated to prevent the spread of infection from one resident to another. And under Hand Hygiene Guidelines which states in part Gloves are never a substitute for handwashing. Hands must be washed every time gloves are removed.

Based on interview and record review, the facility failed to ensure two residents (R17 and R31) out of five residents reviewed for immunizations, were currently educated and offered a pneumonia immunization, resulting in the potential for development and spread of pneumonia among vulnerable residents in the facility. Findings include: On 2/29/24 at 2:10 PM during an interview and record review with the Director of Nursing (DON), the following residents did not have documentation of a current pneumococcal immunization or refusal: - The Electronic Health Record (EHR) for Resident #17 (R17), most recently admitted on [DATE] and was over [AGE] years of age, documented the pneumococcal vaccine was offered on 10/26/20 and it was declined. No other offer for pneumococcal immunization was documented. - The EHR for Resident #31 (R31), most recently admitted on [DATE] and was over [AGE] years of age, provided no documentation that pneumococcal education and/or immunization was offered or refused. On 2/29/24 at 3:05 PM, the DON stated regarding R17, I guess we can offer the pneumo vaccine every year. The facility provided no documentation that the pneumococcal vaccine was contraindicated for R17 or R31. A review of the facility's policy titled, Influenza & Pneumococcal, dated August 2018, .pneumococcal vaccination are offered year round .(Staff are to) assure documentation in the resident's medical record of the information/education provided regarding the benefits and risk of immunization and the administration or refusal of or medical contraindications to the vaccine

This citation pertains to MI 226. Based on observation, interview, and record review, the facility failed to provide appropriate transfer assistance for one (#601) resident reviewed for accidents, resulting in Resident #601 sustaining a right humerus (long bone in the arm that runs from the shoulder to the elbow) fracture and experiencing pain. Findings include: The complainant reported to the State Agency that facility staff failed to transfer resident safely resulting in a fracture. On 7/14/2020 at 12:00 PM, Resident #601 (R601) was observed awake in her bed. When R601 was queried if she had a recent fall, she said, No. R601 then added, My arm got broke. That was a while back. The girl (Certified Nurse Aide (CNA) F) went to get someone to help transfer me. The guy (CNA C) lifted me and my arm snapped. He no longer works here. They took an x-ray and that's when they knew it was broke. A review of R601's clinical record documented admission into the facility on [DATE]. Her [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] documented intact cognition. A MDS dated [DATE] documented R601 was totally dependent upon staff for transfers which required two+ person physical assistance. Additional record review documented in part the following clinical notes: --3/15/2020 at 3:31 AM (nursing): received resident awake in bed watching TV with no acute distress noted .Resident complained of general pain, PRN (as needed) Tylenol given. --3/16/2020 at 2:37 PM (Physician): Resident says she has been having right shoulder and upper arm pain since she was transferred from her bed yesterday. Right side is paralyzed but now hurts since being moved. No recent falls. Right upper extremity pain. Obtain right shoulder and humeral x-ray. Continue present medications. --3/16/2020 at 2:58 PM (nursing): Patient received this morning in her room alert and awake. Patient has complaints of pain in her right shoulder .X-ray results came back showing fracture is present .Family, patient, and Nurse Practitioner notified. Patient ordered to follow up with ortho. --3/16/2020 at 3:08 PM (restorative CNA): resident received AROM (active range of motion) 15 reps x 2 for 15 minutes to both (lower and upper extremities) to restore her strength and mobility. Resident stopped after a few minutes stated her arm was hurting. Notified the nurse and they ordered an x-ray. --3/17/2020 at 2:19 PM (nursing): Resident alert and able to make needs known to staff .Medicated for pain in right arm as ordered with effectiveness. --3/17/2020 at 11:04 PM (nursing): resident alert and able to make needs known to staff. PRN [MEDICATION NAME] (medication used to relieve moderate to severe pain) administered for shoulder pain with effectiveness. --3/18/2020 at 4:08 AM (nursing): Resident complained of right arm pain at 1:00 AM. PRN [MEDICATION NAME] administered with positive results. --Radiology report of 3/16/2020 documented: Impressions: Impacted fracture surgical neck of the right humerus. On 7/14/2020 at 3:03 PM, the facility's investigation into R601's fractured humerus was reviewed with the Director of Nursing (DON). --CNA C's written statement indicated in part the following: I was asked to assist with a transfer of a resident .I went in and sat the patient up on the bedside. I had already placed her wheelchair at the side of the bed. Once I placed the bed at the same level of the wheelchair, I lifted and slid the resident over into the wheelchair. The aide thanked me for my help and I went on to finish rounding. --The following was noted in the facility summary: While lifting (R601) (CNA C) lost his gripping and shifted with a short jerking motion during the transfer. When queried about the facility summary that CNA C lost his gripping, the DON said, The (former) Administrator talked with (CNA C) and got that info from him. It was not part of his statement. When queried if the former Administrator's interview with CNA C was documented or if there was a written statement from CNA F, the DON stated that neither were part of the investigation packet. On 7/14/2020 at 3:15 PM, CNA F was queried about R601's transfer. CNA F said she asked for assistance because (R601) is a two person assist. (CNA C) picked (R601) up by himself. CNA F added, I'm not sure why he picked her up by himself. When queried if she saw CNA C slip or lose his footing, CNA F said, No. CNA F stated she saw R601's elbow hit the arm rest. On 7/14/2020 at 3:30 PM, the DON produced a written statement from CNA F which indicated the following: He (CNA C) picked her up and put her in the chair. When she went in the chair, her elbow hit the arm rest. The chair and bed were level. This statement was dated 7/14/2020. On 7/14/2020 at 4:35 PM, R601's plan of care related to her transfer status between 3/10/2020 and 3/25/2020 was reviewed with MDS Coordinator, Nurse D. On 3/12/2020 CNA F documented that R601's transfer status was extensive two-person assist. When queried about how the CNAs know a resident's transfer status, Nurse D said, There is a Kardex in their room. On 7/14/2020 at 5:11 PM, the DON stated that CNA C no longer works at the facility. He was an agency employee. The DON said, We did not do a disciplinary. I feel the disciplinary was not to let him come back. When queried about what CNA C did wrong, the DON said, The MDS showed (R601) was a two-person (assist), she should have been a two-person assist. (CNA C) did it himself. The DON provided documentation that indicated CNA C's last day of employment at the facility was 3/17/2020 related to being under investigation for fall and playing games in patient's room. The facility policy titled, Transfer Policy, undated, was reviewed and revealed in part the following: --Check the resident's Kardex to see what kind of transfer the resident is (i.e. 1 person, 2 person, hoyer lift).

Based on observation, interview and record review the facility failed to provide an environment free of abuse and neglect, affecting one resident (R#1) out of three residents sampled , resulting in R#1 falling while being forcibly pulled by staff backwards into the resident's room ,resulting in R#1 receiving a laceration (cut) to right forehead and Traumatic Subarachnoid Hemorrhage. (collection of blood outside of brain). Findings Include: On 10/24/19 at 9:30 a.m., during observation of a time and date stamped video from 10/05/19 provided by facility, R#1 is seen at 9:10:42 p.m. standing in doorway of room. CNA (Certified Nursing Assistant) A approaches resident and puts left hand on R#1's chest and pushes resident with force backwards into room. At 9:11:00 p.m., R#1 is seen at doorway and then is pulled back into room with force by holding resident's clothing. Nurse B is observed at medication cart in front of resident's room and was seen turning around and reacting to situation that was occurring and not shown on camera. After watching the video with Assistant Director of Nursing (ADON), when asked if it was ever appropriate to push any resident or patient of any age backwards, ADON stated, No. When asked if R#1 had been redirected correctly, ADON stated, No. On 10/24/19 at 11:30 a.m., during a phone interview with Nurse B, when asked if the video of incident was reviewed, Nurse B stated, No. When asked to give an account what happened, Nurse B replied, I was at my medication cart and R#1 was in the doorway. CNA A came to change R#1 and I heard some commotion. CNA A was saying to R#1, you can't do that, you can't do that. I went to room to see what was going on. I then went to medication cart to get resident's medication and I happened to turn around and saw R#1 being pulled and falling. When asked if he/she saw CNA A pull the resident into the room resulting in her falling, Nurse B, states, Yes. When asked what happened when R#1 fell , Nurse B stated, R#1 hit her head and there was so much blood. On 10/24/19 at 12: 05 p.m., during interview and observation of R#1 was seen to be cognitively impaired and was unable to answer questions appropriately. R#1 was seen to be elderly, frail and shuffled feet when walking. On 10/24/19 at 2:30p.m., during interview with Nurse Supervisor D leading shift on 10/5/19, when asked if CNA A continued to work after the incident, Nurse Supervisor D replied, When I left for the night she was still here. When asked how he/she felt about this incident, Supervisor D replied, I am just sick about it. When asked if she interviewed the staff regarding the incident, Supervisor D replied, CNA A said R#1 was trying to go back into hall and was naked and was trying to redirect her. (Video observation revealed resident was fully clothed) and Nurse B made a comment that Maybe she fell or was pulled, when asked to elaborate she did not. On 10/24/19 at 3:15 p.m., during interview via phone with Administrator, when asked if tape was reviewed, Administrator stated, Yes. When asked if CNA A caused harm to R#1 when the resident was pulled back into room and fell , Administrator stated, On the camera I cannot see if CNA A clearly pulled the resident in room causing the fall. When asked if R#1 had been diagnosed with [REDACTED].#1 was sent out to the emergency roiagnom on [DATE], Administrator stated, Yes. On 10/24/19, record review revealed R#1 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to Minimum Data Set ((MDS) dated [DATE], R#1 had severe impaired cognition and was extensive assist with most Activities of Daily Living (ADLS). 10/24/19, review of Abuse Prohibition Program- effective (MONTH) (YEAR)- Policy Statement- Beaumont Rehabilitation and Continuing Care will maintain an environment free from abuse and neglect. 10/24/19 review of hospital records revealed on 10/6/19 a [DIAGNOSES REDACTED].

Based on observation, interview, and record review, the facility failed to maintain sanitizing temperatures of the dish machine, and continued to distribute food on un-sanitized dishware, resulting in the high likelihood of spreading communicable diseases among residents, resulting in an immediate jeopardy affecting 144 residents that receive food from the kitchen. Immediate Jeopardy was identified: 10/15/18 at 10:18 AM and began on 10/12/18. The Administrator was notified of the Immediate Jeopardy: 10/15/2018 at 2:59 PM The Facility was requested for a written plan of correction for removal: 10/15/2018 at 2:59 PM Facts Supporting Immediate Jeopardy: On 10/15/18 at 10:18 AM, during an observation of the dish washing room, the surveyor requested for Director of Dining Services (DDS) C to place an irreversible temperature sensitive test strip through the dish machine to ensure that the rinse cycle of the dish machine is reaching a sanitizing temperature of a minimum of 160 degrees Fahrenheit. DDS C placed a test strip on a plastic tray and ran the dish machine cycle. The test strip was observed to not change color to indicate that the dishware was reaching a sanitizing temperature of 160 degrees. Another test strip was placed on a plastic plate, ran through the dish machine, and no color change occurred. The surveyor had a different brand of irreversible temperature sensitive test strips, one of which was placed on a metal lid and ran through the dish machine with no color change, showing that the dish machine was consistently not providing a rinse cycle with hot enough water to properly sanitize dishware. On 10/15/18 at 10:22 AM, during a review of the facility's BACK OF DISHMACHINE TEMPERATURE FORM, it had two dates where the dish machine was tested with temperature sensitive test strips. On 10/1/18, the machine was tested using the test strips by a dietary employee identified by their initials. The test strip for 10/1/18 had only a partial color change, indicating that the temperature of the dishware that the test strip was placed on, was only just narrowly reaching 160 degrees. The next time that the dish machine was tested using the test strips was on 10/12/18 by a dietary employee, identified by the same initials as the test that was performed on 10/1/18. The test strip on the record for 10/12/18 showed no color change to indicate that the dish machine is adequately sanitizing. On 10/15/18 at 10:28 AM, DDS C stated that the dish machine technician was notified and that residents will be served lunch on single-use kitchenware (paper and Styrofoam products). On 10/15/18 at 11:43 AM, DDS C was queried on if the dish machine temperature monitoring records are reviewed by management. DDS C stated, We look through (the records) and check these, employees write the temperature in red ink if it's not right, referring to the dish machine temperature gauge log. The surveyor asked DDS C if it was a problem that the test strip on 10/12 did not change colors, and DDS C stated, Absolutely. The surveyor inquired on what the protocol is for the staff members who observed the dish machine in poor repair and DDS C stated, They are supposed to let us know. On 10/15/18 at 12:35 PM, multiple residents were observed to be drinking coffee from plastic mugs and drinking juice and water from plastic cups that are used on a daily basis. On 10/15/18 at 12:36 PM, during an interview, DDS C was asked if she was aware that residents were drinking from plastic mugs and cups and stated that she was aware and that the facility doesn't typically use any Styrofoam or paper cups for the residents. DDS C was then asked by the surveyor when the cups and mugs were washed and DDS C stated, They would have been washed last night. The surveyor then asked DDS C if she believed the dish machine would have been properly sanitizing last night, and DDS C then stated, Probably not. DDS C then proceeded to retrieve all the cups and mugs. On 10/15/18 at 9:10 a.m., during a tour of the first and second floor nursing stations observation was made of R#'s 138 and 385 in contact precaution (an isolation precaution to prevent the spread of infection) for [MEDICAL CONDITION] (C. diff.-a contagious microorganism that causes inflammation of the colon causing diarrhea and intestinal infection. [DIAGNOSES REDACTED]. can be spread from person-to-person by touching or by direct contact with contaminated objects and surfaces). Both residents breakfast trays were on glass dishware and served to them in their respective isolation rooms. Record review revealed that R#138 was admitted into the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review revealed that R#385 was admitted into the facility on [DATE] with a [DIAGNOSES REDACTED]. During an interview on 10/15/18 at 1:54 PM, Infection Control Nurse H was asked if there have been any increase of gastrointestinal infections and stated that there has not been any increase of gastrointestinal infections but there have been two residents admitted with [MEDICAL CONDITION] (a potentially life-threatening bacterial infection). Infection Control Nurse H was queried on if there was any single-use kitchenware used for residents with isolation precautions and stated that residents with isolation precautions use the same dishware as the other residents and there was no special handling of the dirty dishes after mealtime. Infection Control Nurse H was asked why paper and styrofoam dishware is not used for residents with contagious infections and stated it was because of the high water temperature of the dish machine. Infection Control Nurse H stated that she was not aware of the dish machine not sanitizing until today (10/15/18). On 10/16/18, during an interview at 3:37 PM, Dietary Service Employee (DSE) I verified that she tested the dish machine with the temperature sensitive test strips on 10/1/18 and 10/12/18. DSE I was queried on if the facility has provided any training on how to use the dish machine test strips and stated, I don't recall if we had any training or not. The surveyor then asked DSE I if the dish machine was reported to management when the temperature sensitive test strip did not change color, who then stated, I don't remember, I usually notify them when it's not working. During a review of the facility's policy #F019, titled Section: SANITATION AND INFECTION CONTROL; Subject: DISH MACHINE TEMPERATURES, revised on 1/15, it noted, .High Temperature Machine: Single-tank, stationary-rack, dual-temperature machine: Wash temperature 150(Deg)F - Final rinse temperature 180(Deg)F-194(Deg)F . PR[NAME]EDURES: Supervisor/Food and Nutrition Associate as assigned oHigh Temperature Dishmachine - record on Dishmachine Temperature Record form: - Wash and final rinse temperatures during each period of use. - Once a day, run a test strip through the dishmachine to verify the surface temperature of the dish. Attach the used test strip to a temperature log. The test strip must verify that the surface temperature of the plate reached 160(Deg)F . o Immediately brings any substandard temperature to the attention of management. Supervisor o If documentation of the temperatures and test strips results has been assigned to a Food and Nutrition Associate, confirms that it is completed at each meal period. Director (in the event of inappropriate temperature) o Determines if reading is due to malfunctioning temperature gauge or inappropriate temperatures. o Makes management decision concerning adequacy of sanitation of service ware. If due to inappropriate water temperature (high temperature machine), or inappropriate concentration of sanitizer solution (low temperature machine), implements disposable service ware. o Contacts sources of repairs. o Documents actions taken on back of form . According to the 2013 FDA Food Code Section 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90(Deg)C (194(Deg)F), or less than: (1) For a stationary rack, single temperature machine, 74(Deg)C (165(Deg)F); or (2) For all other machines, 82(Deg)C (180(Deg)F). (B) The maximum temperature specified under (A) of this section, does not apply to the high pressure and temperature systems with wand-type, hand-held, spraying devices used for the in-place cleaning and SANITIZING of EQUIPMENT such as meat saws Although the immediate jeopardy was removed on 10/15/18, the facility remained out of compliance with a scope and severity of wide spread, no actual harm with potential for more than minimal harm that is not immediate jeopardy after acceptance and on site verification of the following plan for removal: Immediate Jeopardy Removal Plan Deficient practice based on observation included failing to maintain sanitizing temperatures of the dish machine. 1) Upon notification the dish machine was not working the facility immediately stopped using the dish machine at approximately 10:18 am. 2) The facility served the residents lunch meal at approximately 12:20 on (MONTH) 15, (YEAR) using Styrofoam containers, trays, plastic utensils, and plastic cups. 3) Residents in isolation received the same trays and their trays were bagged for the dietary staff to sanitize using the repaired dish machine. 4) The Dietary manager sanitized all the dishes after lunch at approximately in the dish room using the repaired dish machine, all dishes were sanitized by 3:30 pm. 5) The dish room surfaces were sanitized using the sanicloth-bleach wipes.

Based on observation, interview and record the facility failed to adequately assess/investigate, document and report to the State Agency an injury of unknown origin for one (#408) of three sampled Residents reviewed for incidents in a total sample of 24, resulting in the root cause of an ulna (bone in the lower arm) fracture to remain inconclusive and the potential for instances of neglect, mistreatment, and abuse to occur and go undetected. Findings include: On 9/12/17 at 12:25 p.m., R#408 who resided within the facility's secured unit (code required to exit the unit) was observed attempting to self-propel a wheelchair just outside of the dining room. When staff attempted to assist so that the Resident didn't go into the wall, R#408 became aggressive and swung his left arm towards the staff in an attempt to hit. On 9/13/17 at 8:10 a.m., R#408 was observed awake in bed using a straw to drink from a milk container. At that time, an interview was attempted with the Resident regarding the fall and fracture. R#408 responded Thank you, but did not make any further response to the questions asked. Review of the clinical record included a face sheet record which identified R#408 was initially admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 7/18/17 documented R#408 had cognitive deficits with moderately impaired decision making skills, required extensive assistance of two people for transfers and dressing, had no falls since the previous assessment, and had range of motion limitations to both upper and lower extremities. Review of radiology report dated 8/8/17 2:14 AM documented, XR (x-ray) Wrist Right 2 Views .Suggestion of [MEDICATION NAME] fractures of the base of the styloid is suspected. There is small bone fragment adjacent to the distal end of the radius toward the ulnar aspect. This actually appears to be corticated (thickened and hardened more than usual) and represent a 4 mm (millimeter) loose body .Impression: Ulnar styloid fracture . Review of the interdisciplinary progress notes from 8/2/17 - 9/13/17 included: 8/4/17 3:05 pm .Fall-CENA reported to writer & 'off-shift going nurse' that resident fell .Dr. alerted, via telephone conversation . (There was no documented evidence or indication of pain or injury related to this fall). 8/4/17 5:21 Recorded as Late Entry on 08/11/2017 01:53 PM haD A FALL MET WITH NIECE I received a call this morning that the patient fell from bed (inaccurate - R#408 fell from wheelchair in the dining room) .He is aware that he fell and he says that he hit the side of his head .Assessment: Fall without any loss of consciousness. The history and physical examination [REDACTED]. 8/5/17 3:37 am .Singing. No behaviors. 8/6/17 11:46 am .No indications of pain or discomfort . (There was no progress note documented on 8/7/17.) 8/8/17 3:00 am .STAT xray ordered for pain in right wrist. Results of xray show fracture .Patient left via stretcher with three EMTs at 0319 . 8/8/17 3:44 pm .Returned via ambulance, stretcher .no c/o pain .Brace to RLE at wrist area intact . Review of R#408's Physician orders [REDACTED].>Biofreeze to Rt (right) shoulder/lower back when guarding or expressing nonverbal s/s (signs and symptoms) of pain/discomfort as needed. Review of the Medication Administration Records (MARs) included an entry on 8/7/17 9:12 pm which read, Biofreeze gel 4% .PRN reason: Pain; Comment: rt (right) wrist. Review of R#408's incident report investigations provided by the facility included a fall in April 2017 and a fall on 8/4/17 with no injury. There was no investigation or documentation provided for the Resident's change in condition (increased pain and identification of the ulna fracture identified by x-ray on 8/8/17). On 9/13/17 at 3:50 p.m., an interview and record review was completed with the Safety Manager/Assistant Director of Nursing (Nurse A) and the Director of Nursing (DON). At that time, when asked about the facility's documentation regarding whether an investigation had been completed upon the Resident's identified fracture on 8/8/17 and whether it had been reported to the State Agency as required since it was an injury of unknown origin and the Resident was unable to provide any explanation or details of the injury, both Nurse A and the DON reported they were unsure and would have to look further. At that time, review of the documentation of R#408's fall on 8/4/17 was confirmed by both Nurse A and the DON that there was no documented correlation of the fracture identified on 8/8/17 with the fall on 8/4/17. The DON reported Nurse I was no longer employed at the facility. When asked if the facility's policy was to investigate and report any injury of unknown origin, the DON reported, Yes. Neither were able to explain why this had not occurred and if abuse had been ruled out as a possible cause. Also, when asked why the investigation had not been signed off by the Medical Director, Administrator, or DON as directed on the form, both were unable to offer any explanation. At that time, Nurse A and the DON reported they would investigate further and provide additional information if available. On 9/14/17 at 9:40 a.m., the DON and Administrator requested to review some additional information regarding R#408. At that time, the Administrator reported the facility had no documentation of an investigation of the Resident's injury of unknown origin and confirmed the incident had not been reported to the State Agency. The Administrator provided documentation of a post fall meeting which occurred on 8/7/17 which identified new interventions, however there was no investigation or identification provided of the Resident's change in condition/injury of unknown origin. When asked if the facility's process was to complete a report for a change in status such as an SBAR (Situation, Background, Assessment, Recommendation - a tool to facilitate prompt assessment and investigation), the Administrator reported Yes and indicated she would look to see if there was any other information or documentation to provide for review. There was no SBAR provided for R#408 and the only further information provided was a facility policy titled, Acute Condition Changes - Clinical Protocol dated November 2016 which documented: .the Nurse shall assess and document/report the following baseline information .Current level of pain, and any recent changes in pain level .The staff will monitor and document the resident's progress and responses to treatment . Review of the facility's policy titled, Abuse Prohibition Program dated November 28, 2016 documented: .Injuries of suspicious origin: An injury should be classified as an injury of unknown source when both the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury .Identification - The facility will identify and investigate all suspicions or allegations of abuse .and investigate .Investigation - The facility will identify and investigate all suspicions or allegations of abuse .The investigation will include a statement from staff involved in the resident's care as well as from resident and /or visitors who may have information regarding the suspected abuse Required State Survey Agency notification will be made within 2 hours or within 24 hours as required by statute to the Michigan Bureau of Health Services .

Based on observation, interview and record review the facility failed to honor a refusal of care for one sampled resident (#703) out of five residents reviewed for self determination and accommodation of needs from a total sample of six, resulting in resistance to care from staff leading to a fractured left humerus (arm bone). Findings include: On 8/30/17 at 9:15 a.m., review of the facility's investigation report dated 6/7/17 documented, (On 6/7/17) Certified Nurse Assistant (CNA B) was caring for R#703 and while trying to change her clothing, R#703 was fighting, flailing her arms when she was attempting to put her dress on while CNA B was holding her (R#703's) left arm. CNA B was trying to get R#703 ready for her to leave with her family for an outing, and proceeded to finish the care. When she heard R#703 yell out and saw that her arm was swelling she immediately went out and asked her nurse to come help. R#703 has osteoarthtitis ([MEDICAL CONDITION] joint disease), muscle weakness, brittle bones and limited mobility in her shoulders to maneuver her arms around. This causes difficulty with performing activities of daily living care (ADL). Review of a written statement from CNA B documented, On 6/7/17 I went to get (R#703) dressed because her daughter was coming to take her out for an outing .I proceeded to get her undressed and (R#603) was fighting me. I was able to get her undressed then I proceeded to dress her and she was still fighting as I was pulling her arm through the sleeve of her dress. R#703 yelled out, I seen her arm swelling so I immediately went and got the nurse . Review of a Nurses Note dated 6/7/17 at 4:20 p.m., documented, Reportedly client was supposed to go on a Leave of Absence (LOA). CNA B was made aware. Care was being provided. When this nurse was informed there's an emergency .her arm is swollen. Client was seen yelling and thrashing about. Closer observation revealed signs of swelling at left bicep (upper arm muscle between the shoulder and the elbow). Approximately the size of an orange encircling whole arm. Skin color reddish pink .Client yelled with guarding of left extremity .Order was given to sent to (local hospital) emergency room . Review of the hospital emergency room records dated 6/7/17 documented, (R#703) was found to have a displaced, angulated comminuted distal diphyseal fracture in the left forearm (left forearm fracture). On 8/30/17 at 10:00 a.m., observation was made of R#703 laying in bed with a left arm full cast from the wrist to the elbow. The cast was in a sling and propped up onto a pillow. R#703 was asked a simple question, and responded in Arabic language. Record review reveal that R#703 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set Assessment ((MDS) dated [DATE] indicated the residents cognition was severely impaired, had no verbal or physical behaviors and required extensive, one person physical assistance with dressing. Review of the care plan history back to 5/15/17 for R#703 revealed no care plan for resistive behavior for R#703. The Communication care plan dated 5/15/17 revealed that R#703 had difficulty making herself understood due to Arabic being her primary language. The ADL Function/Rehabilitation care plan dated 1/18/17 had approach's of Allow sufficient time to perform tasks and display patience when resident moves slow and determine current capabilities and barriers to participate in care. Review of the Resident Plan of Care guide (A guide to assist the CNA on care to be provided to a resident) dated 3/23/17 documented no evidence of R#703 being resistive to care. On 8/30/17 at 3:05 p.m., CNA B was interviewed regarding the incident with R#703. CNA B stated the she was familiar with R#703 and she at times the resident could be resistive to care, but I could always talk her through it. CNA B said that on 6/7/17 she was told by the nurse to get R#703 ready for an outing later that day. CNA B stated she started to undress the resident, but she (R#703) didn't want to get undressed. She was pulling (her arms) away from me, resisting, fighting and yanking her left arm away from me. She just wasn't having it. She was speaking in Arabic and couldn't understand what she was saying. I kept telling her, 'your daughter wants you dressed'. I was finally able to undress her. While attempting to put on a clean dress, she kept yanking her left arm back and speaking in Arabic. I pushed her left arm through the sleeve of the dress while pulling on her left hand guiding the left arm through the sleeve. She yanked her left arm back real hard and then yelled out (in pain) and I saw swelling of her arm. I immediately went and got the nurse. CNA B was asked if during her training she was instructed on what to do when a resident was resistive to care. CNA B stated, If a resident is resisting like R#703 was, I have been taught to leave them alone, let them calm down, come back a little later, go get someone to help intervene, and report it to the nurse. CNA B was asked why in this instance she continued to undress and subsequently dress R#703 when she was resisting and fighting the care being provided, to which the CNA responded, I know how her daughter can be. She wanted her mother dressed, so I was just trying to get her dressed. On 8/30/17 at 3:35 p.m., the facility's Director of Nursing (DON) was queried regarding the incident with R#703. The DON was asked what the facility's policy was regarding resident's that were resisting care. The DON stated, The CNA should have stopped when a resident began resisting care and go get the nurse. On 8/30/17 at 4:00 p.m., review of the facility's Patient's Rights and Responsibilities policy dated 11/2016 documented, Resident's have the right to understand and participate in their care, treatment, and services.

This citation pertains to MI 636. Based on interview and record review the facility failed to ensure medication was administered by a qualified professional for one (resident #701) of three residents reviewed for medication administration from a total sample of three, when a nurse aide had Resident #701 ingest two denture tablets for complaints of gastrointestinal distress, resulting in nausea, tarry stools, a blood transfusion and hospitalization related to the denture cleanser ingestion. Findings include: On 4/25/2014 at 8:30 a.m., an unannounced abbreviated survey was conducted in response to a facility reported incident involving the administration of denture tablets by a certified nurse assistant (CNA) to Resident #701. On 4/25/2014 at 9:00 am, review of Resident #701's medical record revealed the following: A medical record face sheet documented Resident #701 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] documented Resident #701 had intact cognition but required two person assistance with activities of daily living. Nursing notes dated 4/16/2014 at 6:50 p.m. documented, "Resident (#701) alert verbally responsive...denies pain or discomfort." Nursing notes dated 4/17/2014 at 12:16 a.m. documented, "Notified by CNA and staff RN that resident accidently chewed and swallowed two denture tabs." Nursing notes dated 4/17/2014 at 10:50 a.m. documented, "Physical Therapy exercises interrupted. Patient reported needing to use restroom." Nursing notes dated 4/17/2014 at 12:39 p.m. documented, "Resident had bowel movement times one this shift, was soft and muddy in appearance." Nursing notes dated 4/18/2014 at 11:00 a.m. documented, "Emesis times one of undigested food. Complaints of nausea and upset stomach. Resident taken to bathroom with large bowel movement, black/tarry in color. Upon sitting on toilet resident became clammy." Nursing notes dated 4/18/2014 at 11:20 a.m. documented, "Staff reported that resident had emesis time one with the appearance of undigested food and tarry stools. Nurse stated that resident's skin was clammy...Resident stated...did not feel well. Resident complained of abdominal pain...Bowel sounds hypoactive...orders were given to transfer to...Hospital." On 4/25/2014 at 9:30 a.m., review of the facility's investigation that included hospital records dated 4/18/2014 with the time of 3:27 p.m. revealed: "Resident experienced nausea and diarrhea and abdominal pain. Hemoglobin was low-transfused with two units of blood. (Resident #701) states that two days ago she was given two denture tablets. The resident stated "gas" medication was requested but the nurse's aide brought denture tablets. (Resident #701) stated she tried to inform the nurse aide that it was in fact denture tablets but the nurse's aide insisted that it was gas medication so (Resident #701) swallowed the tablets." Continued review of the facility investigation revealed: "CNA mistakenly gave denture tablets to resident thinking that they were for gas." According to a statement dated 4/16/14, made by CNA "A" as part of the facility's investigation, "Another CNA and I (CNA "A") went to answer (Resident #701's) call light and she said that she needed gas medication...I went up to the front desk...and told the nurses she needed gas medication. The nurse told me she has some (gas medication) in her side drawer and I could give her two tablets that she can chew...I went in the room and only saw a package of tablets. I picked them up and showed them to her (Resident #701) and asked her if these are the tablets she takes. She told me yes. I opened the package and gave her two of them which she chewed. After the second one she said it didn't taste right. I went to the nurse with the remaining four tablets...She (Registered Nurse/RN "B") told me it was denture wash and I had given her the wrong medication." On 4/25/2014 at 12:35 p.m., the Director of Nursing (DON) was asked to explain why RN "B" informed CNA "A" there was gas medication in Resident #701"s drawer. The DON stated the nurse was "thinking out loud. The nurse didn't expect the CNA to give the med (medication)." When the DON was asked why the nurse did not assess Resident #701 when the abdominal complaints were verbalized, the DON stated "I can't speak on that." According to the DON, Resident #701 "was stabilized and went to another hospital." The DON further added "We assess residents here and only nurses medicate residents. On 4/25/2014 at 1:05 p.m. during an interview, RN "B" denied telling CNA "A" to give Resident #701 any medications. RN "B" stated, "I was on the phone with another resident's family member. I spoke out loud where I saw the gas medication. I thought she (would tell her nurse, RN "C". I assumed she (CNA "A") would inform the nurse. I didn't know she (Resident #701) couldn't have medications at the bedside. I saw (Resident #701's) daughter bring in gas medication and leave them in the bedside. It happened in a matter of two minutes. " During an interview on 4/25/2014 at 12:40 p.m., when Unit manager "D" was asked about the facility's policy for medications at the bedside, Unit manager "D" stated, "It is not the facility's policy for meds to be at the bedside without a physician's order. On 4/25/2014 at 3:00 p.m., review of the facility's policy titled "Medication Administration" dated 6/2011 indicated, "The licensed nurse is responsible for administering medications in accordance with the physician's order and facility policy." On 4/25/2014 at 3:15 p.m., review of the facility policy titled "Self Administration of Medication" dated 7/2010 indicated, "If a resident verbalizes a desire to self-administer his/her own medications the facility will: assess the ability of the resident to perform the task...a locked box secured with a key must be placed in the resident's room." According to the Pfizer (manufacturer) drug company "material data sheet" for denture tablets, dated 9/19/2001, ingestion of denture tablets is "hazardous...ingestion of large amounts may [MEDICAL CONDITION] the...stomach and may cause nausea, vomiting, diarrhea, abdominal discomfort..." ( )

REFER TO INTAKE MI 502. BASED ON OBSERVATIONS, INTERVIEWS, AND RECORD REVIEW, THE FACILITY FAILED PREVENT ABUSE FOR 1 (#501) OF 4 SAMPLED RESIDENTS REVIEWED FOR ABUSE FROM A TOTAL SAMPLE OF 11, RESULTING IN LACERATIONS TO THE FACE, LIP, AND FINGER AS WELL AS HUMILIATION, ANGER, AND FEAR OF FUTURE PUNISHMENT, PER A REASONABLE PERSON WHO HAD BEEN PHYSICALLY ABUSED. FINDINGS INCLUDE: RESIDENT #501, [AGE] years OLD, WAS INITIALLY admitted to the facility on [DATE], PER THE ADMISSION RECORD. ACCORDING TO THE MINIMUM DATA SET (MDS) assessment dated [DATE], RESIDENT #501 HAD SEVERE COGNITIVE AND MEMORY IMPAIRMENT. SHE REQUIRED EXTENSIVE ASSISTANCE FOR MOST ACTIVITIES OF DAILY LIVING, INCLUDING BATHING AND DRESSING. SHE DID HAVE BEHAVIORS WHICH OCCURRED EVERY 1 TO 3 DAYS. RESIDENT #501'S BEHAVIORS INCLUDED HITTING, KICKING, YELLING, SPITTING, AND PACING. IN AN INTERVIEW ON 7/26/13, SOCIAL WORKER #3 STATED THAT RESIDENT #501 SPOKE ONLY ARABIC. THE SOCIAL WORKER SAID THAT ONE OF THE OTHER SOCIAL WORKERS SPOKE ARABIC AND AS WELL AS SEVERAL NURSES. ACCORDING TO THE SOCIAL WORKER, THERE WAS ALWAYS SOMEONE AVAILABLE WHO COULD TRANSLATE FOR THE RESIDENTS WHO SPEAK ONLY ARABIC. IN THE 7/26/13 INTERVIEW, SOCIAL WORKER #3 STATED THAT RESIDENT #501'S BEHAVIORS OF HITTING, KICKING, YELLING, SPITTING, AND PACING WERE NO LONGER PROBLEMS. RESIDENT #501 DID CONTINUE TO STAND UNASSISTED, WHICH WAS A SAFETY HAZARD. PROGRESS NOTES FROM APRIL, 2013 TO JULY, 2013 DOCUMENTED ONLY THAT RESIDENT #501 ATTEMPTED TO STAND UNASSISTED. NO OTHER BEHAVIORS WERE DOCUMENTED IN THE PROGRESS NOTES. AN ACTIVITIES OF DAILY LIVING (ADL) CARE PLAN, DATED 5/13/13, INDICATED THAT RESIDENT #501 REQUIRED TWO STAFF PERSONS AT TIMES BECAUSE OF OCCASIONAL AGITATION AND DEMENTIA. CERTIFIED NURSING ASSISTANT (CNA) #5 WAS INTERVIEWED ON 7/29/13 AT 9:20 A.M. CNA #5 SAID SHE WAS ASSIGNED TO RESIDENT #501 DURING THE 7 A.M. TO 3:30 P.M. SHIFT ON 6/17/13. CNA #5 SAID SHE HAD CARED FOR RESIDENT #501 IN THE PAST AND HAD GIVEN HER SHOWERS PRIOR TO 6/17/13. ON THE DAY OF 6/17/13, CNA #5 SAID SHE ASKED CNA #7 TO ASSIST HER IN SHOWERING RESIDENT #501. ACCORDING TO CNA #5, RESIDENT #501 WAS USUALLY VERY CALM WHEN RECEIVING SHOWERS. ON 6/17/13, HOWEVER, RESIDENT #501 WAS YELLING IN ARABIC ON THE WAY TO THE SHOWER, AND HER YELLING CONTINUED WHEN RESIDENT #501 WAS TAKEN INTO THE SHOWER. CNA #5 SAID THAT RESIDENT #501 "MUST HAVE BEEN TELLING US (CNA #5 AND CNA #7) SOMETHING BY YELLING, BUT WE DIDN'T UNDERSTAND HER (#501), BECAUSE WE DIDN'T SPEAK ARABIC." PER CNA #5, WHILE REMOVING RESIDENT #501'S BRIEF, THE RESIDENT SPIT IN CNA #7'S FACE. CNA #7, ACCORDING TO CNA #5, WITH ONE HAND GRABBED RESIDENT #501'S FACE ON BOTH SIDES OF THE MOUTH. CNA #5 SAID THAT RESIDENT #501 TRIED TO REMOVE CNA #7'S HAND FROM HER (#501) FACE, BUT CNA #7 HELD ON. WHEN CNA #7 RELEASED HER HAND, THERE WERE RED MARKS ON RESIDENT #501'S FACE. RESIDENT #501'S LIP WAS TORN AND BLEEDING. CNA #7, PER CNA #5, DROPPED THE TOWEL SHE WAS HOLDING IN HER HAND AND LEFT THE SHOWER ROOM. CNA #5 SAID THAT SHE (#5) WASHED RESIDENT #501 AND THEN THE NURSE ON-DUTY CAME INTO THE SHOWER ROOM. THE NURSE COMPLETED A BODY ASSESSMENT ON RESIDENT #501 AND QUESTIONED CNA #5 ABOUT THE INJURIES ON THE RESIDENT #501'S FACE, LIPS, AND FINGER. CNA #5 SAID SHE LIED AND TOLD THE NURSE THE INJURIES WERE THERE PRIOR TO THE SHOWER. CNA #5 SAID SHE KNEW CNA #7 HAD DONE SOMETHING WRONG, BUT SHE FEARED RETALIATION FROM CNA #7 IF SHE (#5) TOLD THE NURSE WHAT HAD HAPPENED. CNA #5 SAID SHE ALSO FEARED PEOPLE WOULD THINK SHE HAD ABUSED THE RESIDENT. CNA #5 WENT ON TO SAY THAT LATER, SHE (#5) CALLED THE ABUSE HOT LINE BUT NO ONE ANSWERED. CNA #5 SAID THAT SHE THEN CALLED A FRIEND AND TOLD HER WHAT HAPPENED. CNA #5 THEN SAID SHE (#5) WROTE AN ACCURATE STATEMENT OF WHAT HAD HAPPENED AND GAVE IT TO HER FRIEND TO GIVE TO SOCIAL WORKER #3. CNA #7 WAS INTERVIEWED BY TELEPHONE ON 8/1/13 AT 11 A.M. CNA #7 SAID SHE AGREED TO ASSIST CNA #5 IN SHOWERING RESIDENT #501 ON 6/17/13. CNA #7 SAID SHE HAD PROVIDED CARE FOR RESIDENT #501 IN THE PAST. CNA #7 SAID SHE ACCOMPANIED CNA #5 AND RESIDENT #501 TO THE SHOWER. ONCE IN THE SHOWER, PER CNA #7, THE RESIDENT STARTED SWINGING HER ARMS, KICKING, AND SPITTING. AS THE CNAS WERE UNDRESSING RESIDENT #501, THE RESIDENT SPIT IN CNA #507'S FACE. CNA #7 SAID SHE RAISED HER HAND AND ARM, PLACING IT BETWEEN RESIDENT #501 AND HERSELF. CNA #7 SAID SHE DID NOT PLACE HER HAND ON RESIDENT #501 AT ANY TIME. CNA #7 SAID SHE LEFT THE SHOWER TO GET SOCKS FOR RESIDENT #501. CNA #7 STATED, "WHEN I (#7) LEFT THE SHOWER, THE RESIDENT (#501) WAS STILL HITTING." CNA #7 SAID SHE DIDN'T KNOW IF RESIDENT #501'S CARE PLAN SAID ANYTHING ABOUT INTERVENTIONS TO USE WHEN RESIDENT #501 BECAME AGGRESSIVE. CNA #7 SAID, "NORMALLY YOU WOULD LEAVE THE RESIDENT ALONE, NOTIFY THE NURSE, AND RETURN TO THE RESIDENT AT A LATER TIME TO ATTEMPT CARE." ACCORDING TO CNA #7, SHE AND CNA #5 DID NOT DISCUSS WHAT TO DO WHEN RESIDENT #501 BECAME AGGRESSIVE. CNA #7 SAID SHE (#7) DID NOT KNOW HOW THE INJURY TO RESIDENT #501'S FACE, LIP, AND FINGER OCCURRED. THE CNA SAID SHE DID NOT NOTICE ANY INJURY TO RESIDENT #501 BEFORE THE SHOWER. CNA #7 SAID SHE DID NOT SEE CNA #5 CAUSE ANY INJURY TO RESIDENT #501. CNA #7 SAID THE NURSE WAS IN THE SHOWER WHEN SHE (CNA #7) RETURNED WITH THE RESIDENT'S SOCKS, AND THAT RESIDENT #501 WAS STILL AGITATED. CNA #7 SAID THAT SHE SAID, "I'M OUT OF HERE." CNA #7 LEFT THE SHOWER ROOM. CNA #7 SAID SHE WAS FIRED FOR "SUPPOSED ABUSE ...I (#7) DON'T KNOW WHAT (CNA #5) TOLD THE NURSE, BUT I GUESS SHE FINGERED ME." LICENSED PRACTICAL NURSE (LPN) #4 SAID SHE WAS CALLED TO THE SHOWER ROOM ON 6/17/13 TO DO RESIDENT #501'S BODY ASSESSMENT, NORMALLY REQUIRED WITH THE SHOWER. LPN #4 SAID SHE ASKED CNA #5 ABOUT THE SCRATCHES ON THE RESIDENT #501'S FACE AND HER BLEEDING LIP. CNA #5 TOLD HER (#4) THAT THE SCRATCHES WERE THERE WHEN SHE (#5) ARRIVED ON DUTY THAT DAY. CNA #5 SAID THAT RESIDENT #501 PULLED AT SOME LOOSE SKIN ON HER LIP, CAUSING IT TO BLEED. LPN #4 SAID RESIDENT #501 WAS NOT USUALLY AGITATED AND HAD NO BEHAVIORS PRIOR TO THE SHOWER. HOWEVER, WHEN LPN #4 ENTERED THE SHOWER, RESIDENT #501 WAS "REALLY AGITATED." ACCORDING TO LPN #4, RESIDENT #501 WAS SPEAKING IN ARABIC VERY LOUDLY AND VERY FAST, BUT THAT RESIDENT #501 WAS NOT PHYSICALLY AGGRESSIVE AT THAT TIME. LPN #4 SAID AFTER RESIDENT #501 CALMED DOWN, SHE DID NOT REMEMBER THE SHOWER OR THE AGGRESSIVE BEHAVIOR. LPN #4 SAID, "I (#4) HAVE NEVER SEEN THE RESIDENT (#501) LIKE THAT BEFORE. I HAVE PLACED HER ON THE TOILET. I'VE SEEN HER GET SHOWERS BEFORE, AND I'VE NEVER OBSERVED ANY BEHAVIORS." ACCORDING TO SOCIAL WORKER #3, INTERVIEWED ON 7/26/13 AT 8:30 A.M., CNAS #5 AND #7 WERE SUSPENDED AND LATER TERMINATED, HOWEVER CNA #5 WAS RETURNED TO WORK AFTER INTERVENTION FROM HER UNION. SOCIAL WORKER #3 SAID RESIDENT #501 WAS INTERVIEWED BY AN ARABIC SPEAKING SOCIAL WORKER ON 6/17/13. RESIDENT #501 COULD NOT REMEMBER THE SHOWER OR THE INCIDENT. SOCIAL WORKER #3 SAID THERE HAD BEEN NO FURTHER AGGRESSIVE BEHAVIORS BY RESIDENT #501. ACCORDING TO A POLICE CASE REPORT, AN INVESTIGATION WAS BEGUN ON 6/17/13. THE POLICE REPORT INDICATED THAT THE RESIDENT (#501) HAD "SEVERAL SMALL ABRASIONS TO HER LEFT CHEEK AREA, AND SMALL CUTS ON HER LIPS" AS WELL AS "FAINT CUTS/ABRASIONS ON HER LEFT INDEX FINGER." A WARRANT WAS COMPLETED FOR CNA #7 AND FORWARDED TO THE PROSECUTOR'S OFFICE. RESIDENT #501 WAS OBSERVED ON 7/26/13 AT 2:45 P.M. SITTING IN HER WHEELCHAIR IN THE HALLWAY NEAR THE NURSE'S DESK. THE RESIDENT WAS SITTING QUIETLY, OBSERVING ACTIVITY ON THE UNIT. RESIDENT #501 WAS OBSERVED AGAIN ON 7/30/13 EATING HER LUNCH IN THE DINING ROOM. THE RESIDENT WAS SMILING, HAPPILY EATING HER LUNCH. ACCORDING TO STAFF, THE RESIDENT ASKED THAT THE SURVEYOR SIT DOWN BESIDE HER AT THE TABLE. ( )

THIS CITATION PERTAINS TO INTAKES MI 087 AND MI 170. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO PREVENT THE SEXUAL ASSAULT OF ONE (RESIDENT#105) OF 7 SAMPLED RESIDENTS REVIEWED FOR ABUSE AND NEGLECT FROM A TOTAL SAMPLE OF 8 RESIDENTS, RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #105, WHEN TWO NURSING EMPLOYEES (EMPLOYEES #5, AND #15) WITNESSED A MAINTENANCE TECHNICIAN, KNOWN AS EMPLOYEE #17, IN RESIDENT #105'S ROOM, WHILE RESIDENT #105 WAS IN BED, WITH HER DISPOSABLE BRIEF NEATLY UNFASTENED ON THE LEFT SIDE FULLY EXPOSING HER GENITALIA AND HER FACILITY GOWN ROLLED BACK TO FULLY EXPOSE HER LEFT BREAST. THIS DEFICIENT PRACTICE PLACED AN ADDITIONAL 25 FEMALE RESIDENTS LIVING ON THE SAME UNIT AT RISK FOR SEXUAL ABUSE. FINDINGS INCLUDE: ON 4/14/13, AT 7:40 A.M., THE NURSING HOME COMPLAINT INVESTIGATION INTAKE UNIT RECEIVED A FACILITY REPORTED INCIDENT OF ALLEGED SEXUAL ABUSE. THE REPORT INDICATED THAT RESIDENT #105 WAS FOUND IN HER ROOM, WITH HER DISPOSABLE BRIEF OPENED, EXPOSING HER GENITALIA AND LEFT BREAST, AS WITNESSED BY TWO CERTIFIED NURSING ASSISTANTS (CNAS), KNOWN RESPECTIVELY AS EMPLOYEES #15 AND #37. THE CNAS ALSO WITNESSED A MALE MAINTENANCE WORKER KNOWN AS EMPLOYEE #17 EXITING OUT OF THE RESIDENT'S BATHROOM AND IMMEDIATELY REPORTED THEIR SUSPICION OF SEXUAL ABUSE TO THE DAY SHIFT LICENSED NURSE MANAGER ON B-WING, KNOWN AS EMPLOYEE #5. REVIEW OF THE CLINICAL RECORD FOR RESIDENT #105 INDICATED ON THE "RESIDENT ADMISSION RECORD FORM" THAT SHE WAS admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED].; AND [MEDICAL CONDITION] ARTHRITIS. THE COMPREHENSIVE assessment dated [DATE], INDICATED THAT RESIDENT #105 WAS NON- AMBULATORY AND TOTALLY DEPENDENT ON STAFF FOR HER PERSONAL CARE NEEDS INCLUDING POSITIONING. FURTHER REVIEW OF THE COMPREHENSIVE ASSESSMENT INDICATED THAT THE RESIDENT HAD SEVERELY IMPAIRED COGNITION AND WAS NOT ABLE TO COMMUNICATE. ON 4/16/13, AT 9:30 A.M., OBSERVATION REVEALED THAT RESIDENT #105 WAS LYING IN BED IN A SUPINE POSITION. RESIDENT #105 EXHIBITED HAND TREMORS. AN INTERVIEW WAS ATTEMPTED WITH THE RESIDENT, BUT WAS UNSUCCESSFUL DUE TO THE RESIDENT'S SEVERELY IMPAIRED COGNITION AND HER INABILITY TO COMMUNICATE. ON 4/16/13, AT 11:35 A.M., AN INTERVIEW WITH EMPLOYEE #15 REVEALED THAT ON 4/14/13, AT APPROXIMATELY 7:45 A.M., SHE WAS MAKING ROUNDS ON UNIT "B' AND OBSERVED THAT THE DOOR WAS CLOSED TO THE ROOM OCCUPIED BY RESIDENT #105. EMPLOYEE #15 STATED THAT THIS CONCERNED HER SINCE THE RESIDENT WAS UNABLE TO CLOSE THE DOOR AND NURSING WAS NOT IN THE ROOM WITH RESIDENT #105. EMPLOYEE #15 STATED THAT WHEN SHE ATTEMPTED TO OPEN THE DOOR, IT WAS BLOCKED BY AN OVER-BED TABLE THAT HAD BEEN PLACED BEHIND THE DOOR. EMPLOYEE #15 SAID THAT SHE WAS ONLY ABLE TO OPEN THE DOOR ABOUT ONE THIRD OF THE WAY. EMPLOYEE #15 EXPLAINED THAT SHE LOOKED INSIDE THE ROOM AND SAW A SHADOW AND SOMEONE RUN BRISKLY INTO THE ADJOINING BATHROOM. EMPLOYEE #15 STATED THAT SHE WAS STARTLED AND SUMMONED A CO-WORKER, EMPLOYEE #37, TO ASSIST HER. EMPLOYEE #15 STATED THAT WHEN SHE AND EMPLOYEE #37 PUSHED THE DOOR OPEN, SHE IMMEDIATELY OBSERVED RESIDENT #105 LYING IN BED ON HER BACK WITH HER BLANKET PUSHED BELOW HER WAIST AREA. EMPLOYEE #15 STATED THAT RESIDENT #105'S BRIEF WAS NEATLY UNFASTENED ON THE LEFT SIDE AND HER GENITALIA WAS FULLY EXPOSED. EMPLOYEE #15 STATED THAT SHE ALSO OBSERVED THAT RESIDENT #105'S HOSPITAL GOWN HAD BEEN NEATLY FOLDED BACK, LEAVING HER LEFT BREAST FULLY EXPOSED. EMPLOYEE #15 STATED THAT AS SHE AND EMPLOYEE #37 ENTERED THE ROOM, THE BATHROOM DOOR OPENED AND EMPLOYEE #17 CAME OUT OF THE RESIDENT'S BATHROOM. EMPLOYEE #15 STATED THAT EMPLOYEE #17 GREETED THEM, SAYING "HELLO" AS HE PASSED, AND QUICKLY LEFT THE ROOM. EMPLOYEE #15 STATED THAT SHE AND EMPLOYEE #37 IMMEDIATELY SUMMONED EMPLOYEE #5, THE DAY SHIFT NURSE MANAGER, TO RESIDENT #105'S ROOM. ON 4/19/13, AT 1:30 P.M., INTERVIEW WITH EMPLOYEE #37 REVEALED THAT ON 4/14/13, "SOMETIME BEFORE 8:00 A.M.", SHE WAS SUMMONED BY EMPLOYEE #15 TO THE ROOM OCCUPIED BY RESIDENT #105. EMPLOYEE #37 STATED THAT EMPLOYEE #15 INFORMED HER THAT SHE HAD DIFFICULTY OPENING THE DOOR TO THE ROOM BECAUSE SOMETHING WAS PLACED BEHIND THE DOOR. EMPLOYEE #37 STATED THAT EMPLOYEE #15 SAID THAT SHE SAW A SHADOW OF SOMEONE RUN INTO THE BATHROOM. EMPLOYEE #37 STATED THAT AFTER SHE ASSISTED EMPLOYEE #15 PUSH THE DOOR OPEN SHE ENTERED THE ROOM AND OBSERVED RESIDENT #105 LYING IN BED ON HER BACK WITH HER BRIEF NEATLY UNFASTENED ON THE LEFT SIDE AND HER GENITALIA FULLY EXPOSED. EMPLOYEE #37 STATED THAT SHE ALSO OBSERVED THE RESIDENT'S LEFT BREAST FULLY EXPOSED. EMPLOYEE #37 STATED THAT AT THE SAME TIME THE BATHROOM DOOR THAT WAS CLOSED WAS OPENED AND EMPLOYEE #17, ACKNOWLEDGED THEM, SAID HELLO AND EXITED OUT OF THE RESIDENT'S ROOM. EMPLOYEE #37 STATED THAT SHE AND EMPLOYEE #15 IMMEDIATELY SUMMONED EMPLOYEE #5 TO THE RESIDENT'S ROOM AND REPORTED THEIR SUSPICIONS. ON 4/17/13, AT 1:00 P.M., AN INTERVIEW WITH EMPLOYEE #5 REVEALED THAT ON 4/14/13, AT APPROXIMATELY 8:00 A.M., HE WAS SUMMONED BY EMPLOYEES #15 AND #37 TO THE ROOM OCCUPIED BY RESIDENT #105. EMPLOYEE #5 STATED THAT HE IMMEDIATELY WENT TO THE RESIDENT #105'S ROOM AND OBSERVED RESIDENT #105 LYING IN BED, ON HER BACK WITH THE BED COVERS PULLED BELOW HER WAIST. EMPLOYEE #5 STATED THAT HE OBSERVED THE LEFT SIDE OF HER DISPOSABLE BRIEF WAS "NEATLY UNFASTENED AND FOLDED BACK" AND HER GENITALIA WAS FULLY EXPOSED. EMPLOYEE #5 FURTHER REPORTED THAT THE RESIDENT #105'S HOSPITAL GOWN WAS ALSO FOLDED SO HER LEFT BREAST COULD BE FULLY EXPOSED. EMPLOYEE #5 SAID THAT RESIDENT #105 WAS AGITATED AND "EXHIBITING JERKING MOTIONS WITH HER ARMS AND HANDS MORE THAN USUAL." EMPLOYEE #5 STATED THAT RESIDENT #105 WAS NON- COMMUNICATIVE AND TOTALLY DEPENDENT ON STAFF FOR POSITIONING AND UNABLE TO FASTEN HER GARMENTS DUE TO HAND TREMORS ASSOCIATED WITH [MEDICAL CONDITION]. EMPLOYEE #5 SAID BOTH EMPLOYEES #15 AND #37 HAD RETURNED TO THE RESIDENT #105'S ROOM AND INFORMED HIM THAT THEY HAD WITNESSED EMPLOYEE #17 IN THE ROOM WITH RESIDENT #105. EMPLOYEE #5 SAID THAT "THEY (EMPLOYEES #15 AND #37) WERE CONCERNED SOMETHING BAD HAD OCCURRED." EMPLOYEE #5 STATED THAT AFTER HE OBSERVED RESIDENT #105 EXPOSED AND HEARD THE STATEMENTS OFFERED BY EMPLOYEES #15 AND #37, HE BECAME SUSPICIOUS THAT RESIDENT #105 HAD BEEN SEXUALLY ABUSED BY EMPLOYEE #17. REVIEW OF THE RESIDENT'S CLINICAL RECORD REVEALED A "RESIDENT PROGRESS NOTE" ENTRY, DATED 4/14/13, AT 9:15 A.M., AND COMPOSED BY THE DAY SHIFT, B-WING, NURSE MANAGER ALSO KNOWN AS EMPLOYEE #5 THAT DOCUMENTED, "AT APPROXIMATELY 8 AM ALLEGATION OF POSSIBLE SEXUAL ASSAULT REPORTED TO UNIT MANAGER. PER PROTOCOL DON (DIRECTOR OF NURSING), ADMINISTRATOR, AND SOCIAL WORK NOTIFIED. (PROPER NAME OF PHYSICIAN) NOTIFIED OF RESIDENT STATUS. ORDERED TRANSFER TO (PROPER NAME OF AREA HOSPITAL) emergency room FOR EVALUATION FOR POSSIBLE SEXUAL ASSAULT. ALL BEDDING AND CLOTHING GATHERED AND SENT WITH RESIDENT. RESIDENT'S SISTER NOTIFIED OF RESIDENT'S STATUS AND TRANSFER. REMAINS ALERT AND NON VERBAL." A FURTHER INTERVIEW WITH EMPLOYEE #5 VERIFIED THAT HE IMMEDIATELY INITIATED TELEPHONE NOTIFICATION TO THE DIRECTOR OF NURSING (DON) TO REPORT AN INCIDENT OF SUSPECTED SEXUAL ABUSE. EMPLOYEE #5 STATED THAT FOLLOWING HIS CONTACT TO THE DIRECTOR OF NURSING, HE INITIATED TELEPHONE CONTACT TO THE PHYSICIAN AND RESIDENT'S RESPONSIBLE RELATIVE. A REVIEW OF THE RESIDENT'S CLINICAL RECORD REVEALED A physician's orders [REDACTED]. REVIEW OF THE "MEDICAL TRANSPORT SERVICE" FORM, DATED 4/14/13, INDICATED THAT RESIDENT #501 WAS TRANSPORTED FROM THE FACILITY TO THE HOSPITAL emergency room AT APPROXIMATELY 10:09 A.M., ON 4/14/13. EMPLOYEE #5 FURTHER STATED THAT FOLLOWING THESE CONTACTS, HE IMMEDIATELY INTERVIEWED EMPLOYEE #17. EMPLOYEE #5 REPORTED THAT WHEN HE QUESTIONED EMPLOYEE #17 REGARDING THE REASON HE WAS IN THE ROOM OCCUPIED BY RESIDENT #105, EMPLOYEE #17 INFORMED HIM THAT WHEN HE ARRIVED THAT MORNING, A FEMALE EMPLOYEE REQUESTED THAT HE PLUNGE THE TOILET IN RESIDENT #105'S BATHROOM, BECAUSE IT WAS CLOGGED. EMPLOYEE #5 FURTHER REPORTED THAT EMPLOYEE #17 WAS UNABLE TO PROVIDE THE NAME OF THE FEMALE AND DESCRIBED HER AS BEING OF CAUCASIAN ETHNICITY. EMPLOYEE #5 STATED THAT EMPLOYEE #17 WAS INFORMED THAT HE WAS SUSPENDED FOR SUSPICION OF INAPPROPRIATE CONTACT WITH A RESIDENT AND EMPLOYEE #17 WAS ASKED TO LEAVE THE PREMISE. EMPLOYEE #5 STATED THAT HE DID NOT INITIATE CONTACT TO THE LOCAL LAW ENFORCEMENT AGENCY. REVIEW OF THE HOSPITAL emergency room REPORT INDICATED THAT RESIDENT #105 HAD AN ADMISSION ARRIVAL TIME OF 10:30 A.M., ON 4/14/13. THE HOSPITAL REPORT INDICATED THAT THE CHIEF COMPLAINT WAS TO "RULE OUT SEXUAL ASSAULT." THE HOSPITAL REPORT INDICATED THAT THE RESIDENT'S CLOTHING AND BRIEF WERE PACKAGED AND ACCOMPANIED HER TO THE HOSPITAL. REVIEW OF THE HOSPITAL RECORD REVEALED THAT NURSING PERSONNEL, "TALKED TO (PROPER NAME OF EMPLOYEE #5) WHO REPORTED THAT PATIENT FOUND WITH LEFT SIDE OF BRIEF OPEN AND GOWN UP ON CHEST EXPOSING LEFT BREAST WITH AN EMPLOYEE LOOKING ON. UNSURE IF PATIENT WAS TOUCHED AT THE TIME. WILL NOT GIVE EMPLOYEE'S NAME BUT STATED THEY HAVE SUSPENDED AND SOCIAL WORK HAS BEEN NOTIFIED. THEY DID NOT CONTACT POLICE." FURTHER REVIEW OF HOSPITAL RECORDS REVEALED THAT RESIDENT #105 DID NOT PRESENT WITH ANY VAGINAL TRAUMA AND A SEXUAL ASSAULT NURSE EXAMINER (SANE) COMPLETED AN EXAM. THE RAPE KIT WAS SEALED AND SENT FOR FORENSIC TESTING. THE HOSPITAL RECORD ALSO INDICATED THAT RESIDENT WAS ADMINISTERED [MEDICATION NAME] 250 MG AND [MEDICATION NAME] 1 GRAM PRIOR TO BEING TRANSFERRED BACK TO THE NURSING HOME LATER THE SAME DAY. ON 4/17/13 AT 9:30 A.M., PHONE INTERVIEW WITH A LOCAL LAW ENFORCEMENT OFFICER KNOWN AS OFFICER "A" REVEALED THAT ON 4/14/13, AT APPROXIMATELY 11:00 A.M., POLICE DISPATCH WAS CONTACTED BY HOSPITAL emergency room PERSONNEL WHO REPORTED THE INCIDENT OF SUSPECTED SEXUAL ASSAULT FOR RESIDENT #105. OFFICER "A" FURTHER REPORTED THAT HE ARRIVED TO THE NURSING HOME AT APPROXIMATELY 11:15 A.M., ON 4/14/13. OFFICER "A" FURTHER REPORTED THAT HE WAS INFORMED BY EMPLOYEE #5 THAT EMPLOYEE #17 HAD BEEN PLACED ON SUSPENSION STATUS AND LEFT THE FACILITY. ON 4/18/13, AT 10:45 A.M., INTERVIEW WAS CONDUCTED WITH EMPLOYEE #17. EMPLOYEE #17 VERIFIED THAT HE WAS SCHEDULED TO WORK ON THE DAY SHIFT ON 4/14/13. REVIEW OF THE EMPLOYEE'S TIME CARD REVEALED AN ARRIVAL TIME OF 7:23 A.M., ON 4/14/13. EMPLOYEE #17 STATED THAT "SOMETIME BETWEEN 7:30 AND 8:00 A.M.," HE WENT TO UNIT "B" TO CHECK WORK ORDER REQUESTS AND WAS VERBALLY REQUESTED BY A FEMALE EMPLOYEE TO GO TO THE ROOM OCCUPIED BY RESIDENT #105 AND PLUNGE A CLOGGED TOILET IN THE BATHROOM. EMPLOYEE #17 STATED THAT HE WENT TO THE HOUSEKEEPING CLOSET ON THE UNIT AND OBTAINED A PLUNGER AND PROCEEDED TO THE RESIDENT'S ROOM. EMPLOYEE #17 STATED THAT BECAUSE THE ROOM WAS DARK, HE DID NOT CLOSE THE DOOR TO THE ROOM. EMPLOYEE #17 SAID HE OBSERVED RESIDENT #105 LYING IN BED 1. EMPLOYEE #17 STATED THAT HE DID NOT PAY ATTENTION TO THE RESIDENT'S APPEARANCE SINCE THE ROOM WAS DARK. EMPLOYEE #17 STATED THAT HE WENT INTO THE BATHROOM TO PLUNGE THE TOILET AND CLOSED THE BATHROOM DOOR. EMPLOYEE #17 STATED THAT AFTER HE PLUNGED THE CLOGGED TOILET HE LEFT THE RESIDENT'S ROOM. EMPLOYEE #17 STATED HE HAD NO RECOLLECTION OF EMPLOYEES #15 AND #37 BEING IN RESIDENT #105'S ROOM WHEN HE EXITED THE BATHROOM. DURING THE INTERVIEWS WITH EMPLOYEES #5, #15, AND #37, ALL REPORTED THAT EMPLOYEE #17 DID NOT HAVE A PLUNGER OR ANY WORK EQUIPMENT IN HIS POSSESSION AT THE TIME OF THE INCIDENT. ON 4/22/13 AT 2:30 P.M., THE ADMINISTRATOR WAS PROVIDED NOTIFICATION OF IMMEDIATE JEOPARDY THAT BEGAN ON 4/14/13, FOR THE FACILITY'S FAILURE TO PREVENT SEXUAL ABUSE, WHEN EMPLOYEES #5 AND #15 ENTERED THE OBSTRUCTED DOORWAY TO RESIDENT #105'S ROOM AND FOUND EMPLOYEE #17 IN THE ROOM, WHILE RESIDENT #105 WAS IN BED, WITH HER GENITALIA AND HER LEFT BREAST EXPOSED. THIS DEFICIENT PRACTICE PLACED AN ADDITIONAL 25 FEMALE RESIDENTS LIVING ON THE SAME UNIT AT RISK FOR SEXUAL ABUSE. ON 4/22/13, AT 4:15 P.M., THE SURVEYOR VERIFIED THAT THE FACILITY IMPLEMENTED THE FOLLOWING MEASURES TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON 4/14/13, AT 9:00 A.M., MAINTENANCE TECHNICIAN KNOWN AS EMPLOYEE #17 WAS SUSPENDED PENDING INVESTIGATION. EMPLOYEE #17 LEFT THE PREMISE AND REMAINS ON SUSPENSION. 2. ON 4/15/13, THE DON AND UNIT MANAGER PUT A QUALITY ASSURANCE PLAN IN PLACE TO ASSESS 25 OUT OF 25 FEMALES ON THE DEMENTIA UNIT. THE EIGHT MALE RESIDENTS ON THE UNIT WILL BE ASSESSED ON 4/22/13. FACILITY HAD NURSING STAFF GO TO EVERY FEMALE'S ROOM WITH A MAINTENANCE MAN TO SEE IF THERE WAS ANY TYPE OF REACTION. THERE WAS NO CATASTROPHIC REACTION OR ANY REACTIONS AT ALL. THIS WAS DONE DAILY APRIL 15 THROUGH APRIL 19, 2013. 3. ON 4/15/13, 25 OF THE 25 FEMALE RESIDENTS ON B-WING WERE ASSESSED. THE OTHER WINGS, A, C, D WERE ASSESSED ON 4/16/13, 4/17/13, AND 4/18/13. THE TOTAL NUMBER OF FEMALE RESIDENTS ASSESSED WAS 117 OUT OF A TOTAL OF 117 FEMALE RESIDENTS. 4. ON 4/22/13, 138 OUT OF 305 EMPLOYEES FROM ALL DEPARTMENTS WERE IN-SERVICED ON ABUSE PROHIBITION POLICY AND ELDER JUSTICE ACT. THIS IN-SERVICE IS DONE ON A YEARLY BASIS. THE IN-SERVICE WILL INCLUDE THE DIFFERENT TYPES OF ABUSE SUCH AS PHYSICAL, PSYCHOLOGICAL, SEXUAL, MISAPPROPRIATION OF FUNDS, AND INVOLUNTARY SECLUSION. THERE WILL BE A FOCUS ON SEXUAL ABUSE AND IF ANY RESIDENT IS FOUND TO BE EXPOSED, THE STAFF WILL IMMEDIATELY REPORT TO THE NURSE ON THE UNIT. ABUSE PROHIBITION AND ELDER JUSTICE ACT IN-SERVICING WILL CONTINUE UNTIL ALL THE STAFF HAS BEEN IN-SERVICED. STILL WILL NOT BE ABLE TO WORK UNLESS THEY HAVE COMPLETED THE IN-SERVICE. THE IMMEDIATE JEOPARDY THAT BEGAN ON 4/14/13 WAS REMOVED ON 4/14/13, WHEN EMPLOYEE #17 WAS PLACED AND REMAINED ON SUSPENSION. THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF "ISOLATED" AND SEVERITY AT " NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY," DUE TO NOT ALL STAFF HAVING BEEN IN-SERVICED ON THE ABUSE PROHIBITION PROTOCOL AND ELDER JUSTICE ACT AND UNTIL SUSTAINED COMPLIANCE CAN BE VERIFIED.

THIS CITATION PERTAINS TO INTAKES MI 106, MI 078 AND MI 501 AND CONTAINS MULTIPLE DEFICIENT PRACTICE STATEMENTS. THIS REFERS TO INTAKE MI 106. BASED ON OBSERVATION, INTERVIEWS, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE A SAFE ENVIRONMENT FOR ONE RESIDENT (RESIDENT #102) OF 4 SAMPLED RESIDENTS REVIEWED FOR ENVIRONMENTAL HAZARDS FROM A TOTAL SAMPLE OF 8 RESIDENTS, RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #102, A RESIDENT RESIDING ON THE DEMENTIA UNIT, WHO INGESTED AN UNDETERMINED AMOUNT OF A TOXIC SUBSTANCE, NAIL POLISH REMOVER, ON 3/19/13. RESIDENT #102 PICKED UP AN UNATTENDED BOTTLE OF ACETONE NAIL POLISH REMOVER FROM AN OPEN PLASTIC TUB USED AS A NAIL KIT, REMOVED THE BOTTLE LID AND DRANK AN UNDETERMINED AMOUNT OF THE NAIL POLISH REMOVER. RESIDENT #102 SUBSEQUENTLY SUSTAINED GASTRIC UPSET AND VOMITED SEVERAL HOURS LATER. THIS DEFICIENT PRACTICE PLACED ALL 34 RESIDENTS LIVING IN THE DEMENTIA UNIT AT RISK FOR SERIOUS HARM, INJURY AND/OR DEATH. FINDINGS INCLUDE: RESIDENT #102 DURING AN INTERVIEW ON 4/16/13 AT 4:45 P.M., RESIDENT #102'S DAUGHTER SAID SHE WAS NOTIFIED BY THE FACILITY STAFF ON 3/19/13 AT APPROXIMATELY 3:30 P.M., THAT RESIDENT #102 HAD DRANK SOME NAIL POLISH REMOVER THAT HAD BEEN ACCIDENTLY LEFT OUT ON THE TABLE. RESIDENT #102'S DAUGHTER ARRIVED AT THE FACILITY WITHIN 30 MINUTES AND CONFERRED WITH EMERGENCY MEDICAL STAFF (EMS) WHO WERE ALREADY ON THE SCENE, THE FACILITY'S PHYSICIAN, AND THE POISON CONTROL CENTER STAFF (PCC) BY PHONE. IT WAS DETERMINED THAT THE RESIDENT WAS NOT CONSIDERED "POISONED," BECAUSE SHE HAD ONLY DRANK A SMALL AMOUNT OF THE ACETONE. THE PCC AND THE PHYSICIAN RECOMMENDED MILK AND ADDITIONAL FLUIDS BE GIVEN TO THE RESIDENT, ALONG WITH FREQUENT MONITORING FOR ANY ADDITIONAL SIDE EFFECTS. RESIDENT #102'S DAUGHTER SAID THAT SHE LEFT THE FACILITY AT APPROXIMATELY 4:30 P.M., BUT RETURNED AT 6:30 P.M. TO CHECK ON HER MOTHER AND FOUND RESIDENT #102 SEATED IN THE DEMENTIA UNIT'S ACTIVITY ROOM WITH VOMIT ALL OVER THE FRONT OF HER SHIRT AND ON HER LAP. DURING AN OBSERVATION ON 4/18/13 AT 9:00 A.M., THE FACILITY'S SECURED DEMENTIA UNIT (B WING) WAS OBSERVED TO HAVE ONE COMMUNITY ROOM THAT WAS LOCATED JUST ACROSS FROM THE NURSING STATION. THIS COMMUNITY ROOM SERVED AS THE DINING ROOM, THE DAY ROOM, AND THE ACTIVITY ROOM FOR THE RESIDENTS LIVING IN THE SECURED DEMENTIA UNIT (B WING). THIS ROOM WILL BE IDENTIFIED AS THE ACTIVITY ROOM FOR PURPOSES OF THIS CITATION. THE ACTIVITY ROOM WAS OBSERVED TO HAVE VARIOUS ACTIVITY ITEMS SUCH AS MAGAZINES, BINDERS, AND CASINGS FOR VIDEO AND MUSIC RECORDINGS LOCATED ON TABLES, AND ON A RACK, WHICH DID NOT HAVE ANY SAFE MEANS OF SECURING ITEMS FROM RESIDENTS' REACH. THERE WAS NO CABINET WITH DOORS, OR ANY TYPE OF SECURITY MEASURES FOR STORAGE OF SUCH ITEMS. RESIDENT #102 WAS OBSERVED TO BE SEATED AT THE CENTER TABLE, NEXT TO AN ACTIVITY STAFF MEMBER, ENGAGED IN THE CURRENT ACTIVITY. RESIDENT #102 WAS CLEAN, APPEARED COMFORTABLE AND FREE FROM ANY DISTRESS OR ANXIETY. RESIDENT #102 COULD NOT PARTICIPATE IN ANY MEANINGFUL DIALOGUE REGARDING THE INCIDENT DUE TO HER LIMITED COGNITIVE STATUS. DURING AN INTERVIEW ON 4/18/13 AT 9:30 A.M., THE DEMENTIA UNIT'S NURSE MANAGER, LICENSED PRACTICAL NURSE (LPN) #5 SAID THAT AT THE TIME OF THE INCIDENT WITH RESIDENT #102 ON 3/19/13, THE UNIT'S NAIL KIT HAD BEEN STORED ON A RACK IN THE ACTIVITY ROOM, AND NOT INSIDE ANY LOCKED OR SECURED CABINET. LPN #5 SAID THAT ALL THE RESIDENTS IN THE DEMENTIA UNIT WERE POTENTIALLY AT RISK TO HAVE INGESTED THE NAIL POLISH REMOVER. AT THE TIME OF THE ABBREVIATED SURVEY, THE UNIT'S NAIL KIT WAS BEING STORED IN A LOCKED CLOSET, INSIDE A CABINET. DURING AN INTERVIEW ON 4/18/13 AT 9:45 A.M., THE FACILITY'S ACTIVITY DIRECTOR (STAFF #43) SAID THAT THE DEMENTIA UNIT WAS THE ONLY UNIT WITH THEIR OWN NAIL KIT, KEPT IN A CLEAN PLASTIC TUB. THE FACILITY HAD OTHER NAIL KITS, BUT THEY WERE KEPT IN LIDDED TOTES, AND KEPT IN THE ACTIVITY STAFF'S SECURED OFFICE. THE FACILITY'S ACTIVITY STAFF BRING THE NAIL KIT TOTES WITH THEM FOR THE ASSIGNED MANICURE ACTIVITY AND RETURN THE NAIL KIT TOTES TO THE OFFICE WHEN THEY COMPLETE THE MANICURE ACTIVITY. ACCORDING TO MEDICAL RECORD, RESIDENT #102 WAS AN [AGE] year OLD FEMALE WHO HAD BEEN admitted to the facility on [DATE] WITH MULTIPLE [DIAGNOSES REDACTED]. RESIDENT #102 WAS IDENTIFIED TO BE ORIENTED TO SELF AND REQUIRED ASSISTANCE AND SUPERVISION FOR ALL TASKS OF DAILY LIVING DUE TO POOR SAFETY AWARENESS AND LIMITED COGNITION STATUS. RESIDENT #102 RESIDED IN THE FACILITY'S SECURED DEMENTIA UNIT. DURING AN INTERVIEW ON 4/18/13 AT 2:40 P.M., CERTIFIED NURSING ASSISTANT (CNA) #25 SAID THAT ON 3/19/13 AT APPROXIMATELY 3:30 P.M., SHE WAS SUPERVISING RESIDENTS IN THE ACTIVITY ROOM WHEN SHE LOOKED OVER AT RESIDENT #102 AND SAW HER TAKE A DRINK FROM A NAIL POLISH REMOVER BOTTLE AND THEN IMMEDIATELY SET IT BACK ON THE TABLE. CNA # 25 SAID SHE YELLED, "NO," AND IMMEDIATELY REMOVED THE NAIL POLISH REMOVER BOTTLE FROM RESIDENT #102'S HAND WHILE ANOTHER CNA (CNA #27) NOTIFIED THE REGISTERED NURSE (RN #24). CNA #25 SAID THAT RESIDENT #102 WAS KNOWN TO GRAB AT THINGS WITHIN HER REACH AND PUT THEM IN HER MOUTH, WHICH INCLUDED ITEMS ON THE TABLE, OR FOOD FROM OTHER RESIDENTS' MEAL TRAYS. CNA # 25 SAID SHE DID NOT KNOW HOW LONG THE NAIL KIT WAS ON THE TABLE IN THE ACTIVITY ROOM, BECAUSE USUALLY THE NAIL KIT SAT ON AN OPEN RACK AT THE OTHER SIDE OF THE ROOM, AND NOT ON THE TABLE. CNA #25 SAID THAT NO RESIDENT HAD THEIR NAILS DONE ON 3/19/13, BECAUSE MANICURES WERE USUALLY DONE ON THURSDAYS AND 3/19/13 WAS A TUESDAY. DURING AN INTERVIEW ON 4/18/13 AT 11:30 A.M., CNA #27 SAID THAT ON 3/19/13 AT APPROXIMATELY 3:30 P.M., HE WALKED PAST THE ACTIVITY ROOM AND HEARD SOMEONE YELL, "NO." CNA #27 LOOKED INTO THE ACTIVITY ROOM AND SAW RESIDENT #102 WITH A BOTTLE OF NAIL POLISH REMOVER IN HER HAND, JUST SETTING IT DOWN ONTO THE TABLE. CNA #27 SAID THAT CNA #25 AND STAFF #33 WERE ALREADY MOVING TOWARD RESIDENT #102 AND REMOVING THE NAIL POLISH REMOVER BOTTLE FROM HER HAND. CNA #27 SAID HE IMMEDIATELY GOT THE NURSE (RN #24). CNA #27 SAID HE DID NOT KNOW HOW LONG THE NAIL KIT WAS ON THE TABLE BECAUSE IT USUALLY WAS STORED ON A RACK. CNA #27 CONFIRMED THAT THE NAIL KIT HAD NOT BEEN LOCATED IN A SECURED CABINET, BECAUSE THERE WAS NO SECURED CABINET IN THE ACTIVITY ROOM, ONLY A STORAGE RACK. DURING AN INTERVIEW ON 4/19/13 AT 11:00 A.M., RN #24 SAID SHE WAS NOTIFIED BY CNA #27 ON 3/19/13 AT APPROXIMATELY 3:30 P.M., THAT RESIDENT #102 HAD SWALLOWED SOME NAIL POLISH REMOVER. RN #24 SAID SHE IMMEDIATELY ASSESSED RESIDENT #102, AND DETERMINED THAT RESIDENT #102 HAD, IN FACT, SWALLOWED SOME OF THE NAIL POLISH REMOVER BECAUSE SHE (RN #24) COULD SMELL ACETONE ON HER BREATH. RN #24 SAID THAT AFTER SHE ASSESSED RESIDENT #102, SHE IMMEDIATELY NOTIFIED THE PHYSICIAN, CALLED 911 (EMERGENCY MEDICAL SERVICES), THE INFECTION CONTROL NURSE, AND RESIDENT #102'S FAMILY. RN # 24 CONFIRMED THAT RESIDENT #102 WAS KNOWN TO GRAB AT FOOD AND OTHER ITEMS WITHIN HER REACH AND PUT THEM IN HER MOUTH. RN #24 SAID THAT RESIDENT #102 WAS QUICK, AND CAPABLE OF UNSCREWING LIDS AND OPENING BOTTLE TOPS. RN #24 SAID THE NAIL KIT WAS AN OPEN PLASTIC TUB THAT WAS SEEN SITTING ON THE TABLE DURING THE INCIDENT ON 3/19/13. RN #24 COULD NOT SAY HOW LONG THE NAIL KIT HAD BEEN ON THE ACTIVITY ROOM TABLE BECAUSE SHE COULD NOT RECALL THE LAST TIME ANYONE HAD THEIR NAILS DONE. DURING AN INTERVIEW ON 4/18/13 AT 1:20 P.M., THE INFECTION CONTROL NURSE (RN #32) SAID THAT SHE WAS CALLED TO THE DEMENTIA UNIT'S ACTIVITY ROOM ON 3/19/13 AT APPROXIMATELY 3:30 P.M., TO DETERMINE TO POSSIBLE SIDE EFFECTS RESIDENT #102 MAY HAVE AFTER INGESTING NAIL POLISH REMOVER. RN #32 SAID THAT THE NAIL POLISH REMOVER'S #1 INGREDIENT WAS ACETONE. THE MATERIAL SAFETY DATA SHEET (MSDS) FOR ACETONE INDICATED THAT ACETONE IS "HARMFUL OR FATAL IF SWALLOWED, AND AFTER INGESTION MAY ENTER THE LUNGS AND PRODUCE DAMAGE. (ACETONE) MAY PRODUCE CENTRAL NERVOUS SYSTEM EFFECTS, WHICH MAY INCLUDE DIZZINESS, LOSS OF BALANCE AND COORDINATION, UNCONSCIOUSNESS, COMA, AND EVEN DEATH." THE ADMINISTRATOR WAS NOTIFIED ON 4/19/13 AT 10:10 A.M., OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 3/19/13, WHEN STAFF FAILED TO PROVIDE A SAFE ENVIRONMENT AND ADEQUATE SUPERVISION FOR RESIDENT #102, WHEN RESIDENT #102 INGESTED A TOXIC SUBSTANCE, ACETONE NAIL POLISH REMOVER, WHEN THE BOTTLE HAD BEEN LEFT UNSECURED, ON A TABLE IN THE DEMENTIA UNIT'S ACTIVITY ROOM. THIS DEFICIENT PRACTICE PLACED 34 ADDITIONAL RESIDENTS WHO RESIDED ON THE DEMENTIA UNIT AT RISK FOR SERIOUS HARM, INJURY AND/OR DEATH. ON 4/19/13 AT 4:00 P.M., THE SURVEYOR CONFIRMED THAT THE FACILITY HAD IMPLEMENTED THE FOLLOWING MEASURES TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON 3/19/13 AT 4:00 P.M., THE NAIL POLISH REMOVER WAS IMMEDIATELY REMOVED FROM THE DEMENTIA UNIT'S ACTIVITY ROOM, AND THE DEMENTIA UNIT WAS ASSESSED FOR ANY ADDITIONAL POTENTIALLY HAZARDOUS CHEMICALS OR MATERIALS. 2. ON 3/20/13, RESIDENT #102 WAS RE-EVALUATED FOR POOR SAFETY AWARENESS. HER CARE PLAN AND ACTIVITY PREFERENCE SHEET WERE UPDATED TO REQUIRE 1-TO-1 SUPERVISION DURING ACTIVITIES AND DINING. 3. ON 3/20/13, THE FACILITY'S SHOWER ROOMS, AND DINING ROOMS WERE ASSESSED AND DETERMINED TO BE FREE FROM ANY ADDITIONAL POTENTIALLY HAZARDOUS CHEMICALS. DAILY ROUNDS BY MANAGERS WERE IMPLEMENTED TO ENSURE THAT POTENTIALLY HAZARDOUS CHEMICALS WERE SECURED. 4. ON 3/20/13, THE FACILITY'S NAIL CARE POLICY WAS UPDATED AND INCLUDED THE SECURING OF POTENTIALLY HAZARDOUS CHEMICALS AND MATERIALS, WHICH INCLUDED NAIL POLISH REMOVER. THE FACILITY WILL NO LONGER UTILIZE LIQUID NAIL POLISH REMOVER DURING THE MANICURE ACTIVITY AND HAS ORDERED NAIL POLISH REMOVER WIPES. 5. ON 3/20/13, 4 OF 4 ACTIVITY STAFF MEMBERS WERE IN-SERVICED ON THE POTENTIAL FOR SAFETY HAZARDS AND THE UPDATED NAIL CARE POLICY. 6. ON 4/19/13 AS OF 4:00 P.M., 49 OF 72 LICENSED NURSES, 59 OF 94 CERTIFIED NURSING ASSISTANTS, AND 32 OUT OF 41 THERAPY STAFF MEMBERS HAD RECEIVED TRAINING ON THE UPDATED NAIL CARE POLICY AND SECURING OF POTENTIALLY HAZARDOUS CHEMICALS. 7. ON 4/19/13 AS OF 4:00 P.M., FACILITY STAFF WERE NOTIFIED THAT THEY WILL NOT BE ALLOWED TO WORK AT THE FACILITY UNTIL THEY RECEIVE THEIR IN-SERVICE REGARDING THE NEW NAIL CARE POLICY THAT INCLUDES THE SECURE STORAGE OF ALL POTENTIALLY HAZARDOUS CHEMICALS. THE IMMEDIATE JEOPARDY (IJ) WHICH BEGAN ON 3/19/13 WAS REMOVED ON 4/19/12. THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF "ISOLATED" AND SEVERITY OF "NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY" DUE TO NOT ALL FACILITY STAFF HAVING BEEN IN-SERVICED ON THE NEW POLICIES FOR NAIL CARE AND THE SECURING OF POTENTIALLY HAZARDOUS CHEMICALS AND UNTIL SUSTAINED COMPLIANCE CAN BE VERIFIED. THIS REFERS TO INTAKE MI 501. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE ASSISTANCE TO PREVENT AN ACCIDENT FOR 1 (#103) OF 4 SAMPLED RESIDENTS REVIEWED FOR FALLS AND ACCIDENTS FROM A TOTAL SAMPLE OF 8, WHEN RESIDENT #103 fell DURING AN IMPROPER TRANSFER FROM SHOWER CHAIR TO BED, RESULTING IN INJURY, A SPIRAL FRACTURE THE FEMUR. FINDINGS INCLUDE: REVIEW OF THE FACILITY'S INCIDENT REPORT DATED 2/11/13, AND COMPLETED BY A REGISTERED NURSE (RN) KNOWN AS EMPLOYEE #19, REVEALED THAT AT 10:15 A.M., ON 2/11/13, RESIDENT #101 fell WHILE IN THE SHOWER ROOM WITH A CERTIFIED NURSING ASSISTANT (CNA) KNOWN AS EMPLOYEE #20. REVIEW OF A NURSING PROGRESS NOTE DATED 2/11/13, AND COMPLETED BY EMPLOYEE #19 INDICATED, "WRITER (EMPLOYEE #19) PULLED TO SHOWER ROOM BY CNA (EMPLOYEE #20) AT 10:15 A.M., ON 2/11/13. RESIDENT OBSERVED LYING ON FLOOR. WHEN ASSESSED HAND GRIPS STRONG, ROM (RANGE OF MOTION) COMPLETE, SHORTENING OF LEFT EXTREMITY NOTED. RESIDENT ASSISTED BY STAFF INTO BED. PHYSICIAN NOTIFIED AND AGREED TO ORDER XRAY OF BILATERAL KNEES, SKIN TEAR NOTED TO RIGHT FOREARM, AND TREATMENT NURSE NOTIFIED. SON NOTIFIED TO RETURN CALL, HE IS AT WORK AND WILL CALL BACK. RESIDENT RESTING IN BED, PRN MEDICATION ADMINISTERED FOR PAIN. WILL CONTINUE TO MONITOR." EMPLOYEE #19 STATED THAT THE RESIDENT'S RADIOLOGICAL REPORTS TAKEN AT THE FACILITY REVEALED BILATERAL FEMORAL FRACTURES. REVIEW OF RESIDENT #103'S "RESIDENT ADMISSION RECORD," PRINTED 4/16/13, WITH AN admission date of [DATE], REVEALED THAT THAT RESIDENT #103 HAD MULTIPLE [DIAGNOSES REDACTED]. THE COMPREHENSIVE assessment dated [DATE], INDICATED THAT RESIDENT #103 HAD MODERATELY IMPAIRED COGNITION AND REQUIRED EXTENSIVE ASSISTANCE WITH HIS PERSONAL CARE ACTIVITIES. THE MINIMUM DATA SET INDICATED THAT THE RESIDENT WAS CODED A "3" FOR TRANSFER SUPPORT THAT DENOTED RESIDENT #103 NEEDED TWO STAFF MEMBERS PRESENT TO PHYSICALLY ASSIST DURING TRANSFERS. FURTHER REVIEW OF THE CLINICAL RECORD FOR RESIDENT #103 REVEALED A PHYSICAL THERAPY EVALUATION DATED 11/15/12. CONTINUED REVIEW OF THE PHYSICAL THERAPY PROGRESS NOTES INDICATED THAT THE RESIDENT WAS DISCONTINUED FROM PHYSICAL THERAPY ON 12/14/12, AND INDICATED "DISCHARGE SECONDARY TO MAXIMAL POTENTIAL ACHIEVED." ON 4/16/13, AT 11:00 A.M., OBSERVATION REVEALED THAT RESIDENT #103 WAS OBSERVED IN HIS ROOM LYING IN BED. INTERVIEW WAS ATTEMPTED WITH THE RESIDENT; HOWEVER, RESIDENT #103 WAS UNABLE TO RECALL ANY DETAILS ASSOCIATED WITH THE FALL INCIDENT ON 2/11/13. REVIEW OF RADIOLOGICAL REPORTS DATED 2/11/13, AT 1:42 A.M., REVEALED THAT THE resident sustained [REDACTED]. ON 4/18/13, AT 1:45 P.M., INTERVIEW WITH EMPLOYEE #19 REVEALED THAT EMPLOYEE #20 HAD TRANSFERRED THE RESIDENT ALONE WHEN IN THE SHOWER ROOM. EMPLOYEE #19 COULD NOT EXPLAIN WHY EMPLOYEE #20 TRANSFERRED RESIDENT #103 BY HERSELF, WHEN HIS COMPREHENSIVE ASSESSMENT INDICATED HE NEEDED 2-PERSON ASSISTANCE. ON 4/19/13, AT 9:00 A.M., INTERVIEW WITH EMPLOYEE #20 REVEALED THAT SHE TRANSFERRED RESIDENT #101 ALONE WHEN IN THE SHOWER ROOM. EMPLOYEE #20 STATED THAT WHEN SHE ATTEMPTED TO PIVOT TRANSFER THE RESIDENT FROM THE SHOWER CHAIR INTO HIS WHEELCHAIR, HIS LEGS COLLAPSED AND THEY fell TO THE FLOOR TOGETHER. SHE REPORTED THAT SHE IMMEDIATELY ALERTED EMPLOYEE #19 FOR HELP IN THE SHOWER ROOM AND TO ASSESS RESIDENT #103. EMPLOYEE #20 STATED THAT SHE REQUESTED ASSISTANCE EARLIER FROM A PEER TO ASSIST HER TRANSFER RESIDENT #101 FROM HIS BED INTO THE WHEELCHAIR, BUT FAILED TO GET HELP WHILE IN THE SHOWER ROOM. FURTHER REVIEW OF THE CLINICAL RECORD REVEALED THAT THE PHYSICIAN ORDERED FOR THE RESIDENT TO BE TRANSFERRED TO AN AREA HOSPITAL FOR FURTHER EVALUATION AND TREATMENT FOLLOWING NOTIFICATION OF THE RADIOLOGICAL FINDINGS. THIS REFERS TO INTAKE MI 078. BASED ON OBSERVATION, INTERVIEW AND INTERVIEW, THE FACILITY FAILED TO ENSURE THAT 1 (#101) OF 5 SAMPLED RESIDENTS REVIEWED FOR BEHAVIOR FROM A TOTAL SAMPLE OF 8 WAS PROTECTED FROM ELOPEMENT, WHEN RESIDENT #101 EXITED OUT OF A SECOND FLOOR EMERGENCY EGRESS FIRE DOOR THAT FAILED TO ALARM, RESULTING IN THE POTENTIAL FOR SUCCESSFUL ELOPEMENT AND/OR THE POTENTIAL FOR A SERIOUS ACCIDENT. FINDINGS INCLUDE: REVIEW OF AN INCIDENT/ACCIDENT REPORT DATED 2/20/13, INDICATED THAT AT 6:35 A.M., ON 2/20/13, A LICENSED PRACTICAL NURSE (LPN) KNOWN AS EMPLOYEE #7, DOCUMENTED IN THE NURSING PROGRESS NOTES AT 6:27 A.M., ON 2/20/13, "RESIDENT (#101) UP IN WHEELCHAIR PROPELLING SELF AROUND UNIT. RESIDENT OPENING EXIT DOOR ON "D" WING. WRITER (EMPLOYEE #7) REMOVED RESIDENT FROM DOOR AND PLACED RESIDENT IN DINING ROOM WITH A 1:1 (ONE-TO-ONE) CNA (CERTIFIED NURSING ASSISTANT) FOR SAFETY. WILL INFORM UNIT MANAGER THAT RESIDENT IS NOT A CANDIDATE FOR EARLY GET UP AND NEED FOR CLOSER SUPERVISION." REVIEW OF THE "RESIDENT ADMISSION RECORD" PRINTED 4/16/13, REVEALED THAT RESIDENT #101 WAS admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. AT THE TIME OF THE ABBREVIATED SURVEY, RESIDENT #101 NO LONGER RESIDED IN THE FACILITY. REVIEW OF THE COMPREHENSIVE ASSESSMENT FOR RESIDENT #101 DATED 1/25/13, INDICATED HE HAD BOTH SHORT AND LONG TERM MEMORY IMPAIRMENT AND PROPELLED HIMSELF INDEPENDENTLY IN A WHEELCHAIR. THE RESIDENT HAD LIMITED SPEECH SECONDARY TO A HISTORY OF CEREBRAL VASCULAR ACCIDENT WITH APHASIA. ON 4/16/13, AT 2:00 P.M., INTERVIEW WITH EMPLOYEE #7 REVEALED THAT SHE WITNESSED RESIDENT #101 OPEN THE EMERGENCY FIRE EGRESS DOOR LOCATED ON "D" WING SHORT HALL. EMPLOYEE #7 STATED THAT THE RESIDENT WAS IN HIS WHEELCHAIR AND PROPELLED HIMSELF THROUGH THE DOOR TOWARD THE STAIRWELL. EMPLOYEE #7 STATED THAT SHE IMMEDIATELY INTERCEPTED RESIDENT #101 AND REDIRECTED HIM BACK ONTO THE "D" WING. EMPLOYEE #7 STATED THAT SHE "AT NO TIME HEARD AN ALARM SOUND ON THE DOOR WHICH IS AN EMERGENCY EXIT DOOR." ON 4/16/13, AT 1:30 P.M., INTERVIEW WITH THE DIRECTOR OF FACILITY SERVICES KNOWN AS EMPLOYEE #6 REVEALED THAT FROM FEBRUARY 19, 2013 TO MARCH 8, 2013, CONSTRUCTION ON A NEW SHOWER ROOM WAS BEING COMPLETED ON "D" SHORT HALL. EMPLOYEE #6 REPORTED TO THE SURVEYOR THAT THE ALARM FOR THE EMERGENCY FIRE EGRESS DOOR WAS DISARMED WHEN CONSTRUCTION WORKERS WERE IN THE BUILDING WHEN CONSTRUCTION WORKERS ARRIVED IN THE MORNING AND LEFT AT THE END OF THE DAY. EMPLOYEE #6 STATED THAT HE WAS RESPONSIBLE FOR RESETTING THE ALARM AT THE END OF EACH DAY DURING THE CONSTRUCTION PERIOD. ACCORDING TO EMPLOYEE #6, HE WAS CERTAIN THAT HE HAD RESET THE ALARM ON 2/20/13, BUT COULD NOT EXPLAIN WHY THE ALARM DID NOT SOUND.

THIS CITATION PERTAINS TO INTAKE # MI 005. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO IMPLEMENT ADEQUATE SUPERVISION AND ASSISTIVE DEVICES TO PREVENT ACCIDENTS FOR 2 (#102 AND #103) OF 4 SAMPLED RESIDENTS REVIEWED FOR FALLS, FROM A TOTAL SAMPLE OF 4, RESULTING IN A CLOSED HEAD INJURY FOR RESIDENT #102 AND THE POTENTIAL FOR SERIOUS INJURY FOR RESIDENT #103. FINDINGS INCLUDE: RESIDENT #102: ACCORDING TO THE FACE SHEET DATED 1/4/2013, RESIDENT #102 WAS admitted to the facility on [DATE]. THE MINIMUM DATA SET ((MDS) dated [DATE], INDICATED THAT RESIDENT #102 WAS AN [AGE] year OLD MALE WITH HIGHLY IMPAIRED VISION AND DISORGANIZED THINKING. RESIDENT #102 REQUIRED THE PHYSICAL ASSISTANCE OF 1 STAFF MEMBER WITH BED MOBILITY, TRANSFERS, AMBULATION, AND TOILETING. ACCORDING TO THE MDS, RESIDENT #102 WAS UNSTEADY MOVING FROM A SITTING TO STANDING POSITION, AND WAS UNSTEADY WALKING OR TURNING. HE REQUIRED STAFF ASSISTANCE FOR BALANCE AND STABILIZATION WHILE PERFORMING ALL TESTS. RESIDENT #103 HAD SEVERAL DIAGNOSES, WHICH INCLUDED ANEMIA, CONSTIPATION AND HIGH CHOLESTEROL. ACCORDING TO THE FALLS RISK assessment dated [DATE], RESIDENT #102 SUFFERED FROM IMPAIRED VISION AND INTERMITTENT CONFUSION. HE REQUIRED THE USE OF ASSISTIVE DEVICES AND ASSISTANCE WITH TOILETING. THE FALLS RISK ASSESSMENT ASSIGNED A NUMERICAL SCORE TO ALL AT RISK INDICATORS AND DETERMINED RISK ACCORDING TO THE SUM OF THE INDIVIDUAL INDICATORS. A TOTAL SCORE OF 10 OR HIGHER INDICATED A HIGH RISK FOR FALLS. ACCORDING TO THE FALLS RISK assessment dated [DATE] RESIDENT #102'S FALLS RISK TOTAL SCORE WAS 16 (HIGH RISK) AND A BED ALARM WAS IMPLEMENTED TO REDUCE THE RISK OF INJURY. ACCORDING TO THE OCCUPATIONAL THERAPY assessment dated [DATE], RESIDENT #102 HAD POOR SITTING AND STANDING BALANCE AND REQUIRED ASSISTANCE OF STAFF WITH TRANSFERS AND VERBAL CUES TO ENSURE HIS SAFETY. ACCORDING TO THE PHYSICAL THERAPY assessment dated [DATE], RESIDENT #102 HAD POOR SITTING AND STANDING BALANCE AND REQUIRED MIN (MINIMAL) PHYSICAL ASSISTANCE OF STAFF WITH ALL TRANSFERS. ACCORDING TO THE PHYSICAL THERAPY ASSESSMENT, RESIDENT #102 WAS ONLY ABLE TO WALK 10 FEET, AND THAT WALKING REQUIRED THE USE OF A ROLLING WALKER FOR SUPPORT AND REQUIRED MIN (MINIMAL) PHYSICAL ASSISTANCE OF STAFF. ACCORDING TO "INTRODUCTION TO PHYSICAL THERAPY FOR PHYSICAL THERAPIST ASSISTANTS," BY OLGA DREEBEN, PUBLISHED BY JONES & BARTLETT PUBLISHERS, 2006, MINIMAL ASSISTANCE REQUIRES THE STAFF TO CONSISTENTLY PROVIDE ASSISTANCE TO THE RESIDENT IN THE FORM OF ASSISTANCE WITH BALANCE, MOVING EXTREMITIES OR ASSISTIVE DEVICES, PROVIDE ASSISTANCE WITH APPROXIMATELY 25 % OF THE TOTAL WORK INCLUDING WEIGHT BEARING, AND GUARD THE RESIDENT FROM PROBABLE ACCIDENTS. ACCORDING TO THE CLINICAL RECORD REVIEWED, THERE WAS NO PLAN OF CARE IMPLEMENTED TO SPECIFICALLY ADDRESS RESIDENT #102'S SAFETY RELATED TO HIS HIGH RISK FOR FALLS. A PHYSICIAN ORDER [REDACTED].#102 AND REQUIRED THAT THEY (STAFF) CHECK THE ALARM EVERY SHIFT TO ENSURE IT WAS IN PLACE AND FUNCTIONING. ACCORDING TO THE NURSE'S NOTE DATED 12/25/2012, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND ASSISTANCE WITH TRANSFERS AND AMBULATION WHEN AT 3:47 A.M., RESIDENT #102 TRIED TO GET OUT OF BED AND fell . RESIDENT #102 WAS FOUND ON THE FLOOR BY FACILITY STAFF NEXT TO HIS BED. RESIDENT #102 STATED THAT HE "...WAS SLEEPING THEN DECIDED TO MOVE TO THE COUCH..." RESIDENT #102 SAID HE BUMPED HIS HEAD, AND COMPLAINED OF HEAD DISCOMFORT. ACCORDING TO THE NURSE'S NOTE, RESIDENT #102 WAS ASSISTED BACK TO BED, HIS BED WAS LOWERED AND A BED ALARM WAS PUT IN PLACE. ACCORDING TO THE EVENT REPORT DATED 12/25/2012, RESIDENT #102 SUFFERED A SMALL SKIN TEAR ON HIS RIGHT LOWER LIP AND IMMEDIATE MEASURES TAKEN INCLUDED " ...NONE OF THE ABOVE ..." ACCORDING TO THE EVENT REPORT OUTCOMES OF THE INTERVENTIONS LISTED, "...NO INTERVENTIONS USED..." DESPITE THE PHYSICIAN ORDER [REDACTED]. DURING AN INTERVIEW ON 1/4/2013 AT 1:58 P.M., THE CERTIFIED NURSE ASSISTANT (CNA) #1 SAID THAT ON 12/25/2012, BEFORE RESIDENT #102 fell , SHE WAS WALKING DOWN THE HALL BECAUSE SHE HEARD AN ALARM. CNA #1 SAID IT WAS NOT RESIDENT #102'S ALARM SHE HEARD, IT "...WAS A ROOM NEARBY..." CNA #1 SAID SHE WENT INTO THAT OTHER ROOM TO TAKE CARE OF SOMEONE ELSE'S NEEDS AND WHEN SHE CAME OUT SHE "...LOOKED INTO (RESIDENT #102'S) ROOM AND DID NOT SEE HIM IN THE BED..." CNA #1 SAID RESIDENT #102'S ALARM WAS NOT SOUNDING AS SHE WENT INTO THE ROOM AND FOUND RESIDENT #102 ON THE FLOOR. CNA #1 SAID SHE CALLED FOR A NURSE, AND WITH THE HELP OF CNA #2 AND THE NURSE, HELPED HIM BACK INTO BED. CNA #1 CLARIFIED AGAIN THAT NO ALARMS WERE IN PLACE FOR RESIDENT #102 PRIOR TO THE FALL, DESPITE THE PHYSICIAN ORDER, BUT THAT AN ALARM "...WAS PUT ON HIM (#102) AFTER THE FALL...(WE) HAD TO GO GET SOMETHING FOR HIM, (THE) ALARM PAD OR THE WHOLE ALARM, DON'T REMEMBER WHICH..." IN AN INTERVIEW ON 1/7/2012 AT 9:35 A.M., CNA #2 SAID THAT ON 12/25/2012, SHE WAS CALLED TO RESIDENT #102'S ROOM BY CNA #1. CNA #2 SAID RESIDENT #102'S ALARM WAS NOT SOUNDING AS SHE WENT INTO THE ROOM AND SHE SAW THAT RESIDENT #102 WAS STILL ON THE FLOOR. CNA #2 SAID SHE HELPED STAFF GET RESIDENT #102 BACK INTO BED AND HELPED PUT A BED ALARM ON RESIDENT #102'S BED. CNA #2 SAID, "...WE HAD TO GO GET A NEW PAD FOR HIM..." FOR HIS BED ALARM TO WORK CORRECTLY. DURING AN INTERVIEW ON 1/7/2013 AT 12:50 P.M., THE LICENSED PRACTICAL NURSE (LPN) #1 SAID THAT SHE WAS CALLED TO RESIDENT #102'S ROOM ON 12/25/2012 BY CNA #1. LPN #1 SAID THAT AS SHE WENT INTO THE ROOM, RESIDENT #102 WAS ON THE FLOOR AND SHE ASSESSED HIM. LPN #1 SAID THAT RESIDENT #102 HIT HIS HEAD, BUT SHOWED NO OBVIOUS SIGNS OF INJURY, BUT LATER COMPLAINED OF A HEADACHE. LPN #1 SAID THAT AFTER PUTTING RESIDENT #102 BACK TO BED, SHE ENSURED HE HAD HIS CALL LIGHT AND ENGAGED HIS BED ALARM. LPN #1 SAID SHE HAD TO CHANGE RESIDENT #102'S ALARM. LPN #1 SAID SHE COULD NOT REMEMBER IF IT WAS ALARMING, WHEN SHE ENTERED THE ROOM, BUT REMEMBERED NEEDING TO CHANGE THE SENSOR PAD "...SO THAT IT WOULD WORK..." LPN #1 SAID THAT IF RESIDENT #102'S ALARM WAS WORKING, "...THE PAD WOULD NOT HAVE NEEDED TO BE CHANGED...A LOT OF THE TIME THE SMALLER SENSOR PADS DON'T WORK RIGHT IF A RESIDENT MOVES A LOT...WE HAD TO GO GET A NEW SENSOR PAD SO THAT IT WOULD WORK RIGHT..." ACCORDING TO THE NURSE'S PROGRESS NOTE DATED 12/25/2012 AT 7:09 A.M., RESIDENT #102 WAS SENT TO A LOCAL AREA HOSPITAL FOR EVALUATION OF AN ELEVATED HEART RATE (130 BEATS PER MINUTE) AFTER A FALL WITH A "...SUSPECTED HEAD INJURY..." ACCORDING TO THE HOSPITAL RECORDS, RESIDENT #102 WAS COMPLAINING OF A HEADACHE INITIALLY ON ARRIVAL, AND THEN BECAME UNRESPONSIVE. TESTING COMPLETED AT THE HOSPITAL REVEALED "...A LARGE RIGHT FRONTAL PARIETAL SUBDURAL HEMATOMA (A COLLECTION OF BLOOD ON THE SURFACE OF THE BRAIN) WITH A MASSIVE AMOUNT OF...HERNIATION (A DANGEROUS SIDE EFFECT OF VERY HIGH PRESSURE INSIDE THE SKULL THAT OCCURRED WHEN A PART OF THE BRAIN TISSUE WAS SQUEEZED ACROSS STRUCTURES WITHIN THE SKULL)" RESIDENT #102 WAS admitted to the hospital with [REDACTED]. IN AN INTERVIEW ON 1/7/2013 AT 12:36 P.M., THE DIRECTOR OF NURSING (DON #1) REVIEWED RESIDENT #102'S CLINICAL DOCUMENTATION AND SAID THAT SHE WAS NOT SURE WHY THERE WAS NOT A CARE PLAN IN PLACE TO ENSURE RESIDENT #102 ' S SAFETY. DON #1 SAID THAT RESIDENT #102 "...UNFORTUNATELY CAME IN OVER THE HOLIDAY WEEKEND..." AND STAFF "...MUST NOT HAVE PUT IT (ALARMS) IN THE CARE PLAN..." DON #1 SAID THAT ACCORDING TO THE MEDICATION ADMINISTRATION RECORD, RESIDENT #102'S ALARM WAS IN PLACE ON THE DAY HE fell , BUT SHE WAS UNABLE TO EXPLAIN WHY IT WAS NOT IN PLACE AT THE TIME HE fell . DON #1 SAID THAT FACILITY STAFF ARE RESPONSIBLE FOR ENSURING ALARMS ARE IN PLACE AND FUNCTIONING AT SOME POINT DURING EVERY SHIFT. DON #1 SAID THAT THE STAFF'S ALARM CHECKS WERE DOCUMENTED ON THE ELECTRONIC MEDICATION ADMINISTRATION RECORD. AT 1:11 P.M., ON 1/7/2013, DON #1 PROVIDED THE ELECTRONIC MEDICATION ADMINISTRATION DOCUMENTATION AND REVIEWED IT WITH THE SURVEYOR. ACCORDING TO RESIDENT #102'S ELECTRONIC MEDICATION ADMINISTRATION RECORD, HIS BED ALARM WAS CHECKED ON THE AFTERNOON SHIFT OF 12/25/2012 AND WAS FUNCTIONING. ACCORDING TO RESIDENT #102'S CLINICAL RECORD, RESIDENT #102 WAS TRANSFERRED OUT OF THE FACILITY DURING THE MORNING SHIFT OF 12/25/2012 AT APPROXIMATELY 7:09 A.M. ACCORDING TO RESIDENT #102'S ELECTRONIC MEDICATION ADMINISTRATION RECORD, RESIDENT #102'S BED ALARM WAS IN PLACE UNDER RESIDENT #102 AND WAS tested TO BE FUNCTIONING APPROPRIATELY DURING THE AFTERNOON SHIFT ON 12/25/2012, HOURS AFTER RESIDENT #102 LEFT THE FACILITY. DON #1 WAS ASKED TO EXPLAIN HOW RESIDENT #102'S BED ALARM WAS CHECKED AS IN PLACE AND APPROPRIATELY FUNCTIONING IF HE WAS NOT IN THE FACILITY. DON #1 SAID, "...I DON'T KNOW, THE NURSE COULD HAVE JUST CHECKED THE BOX...I DON'T KNOW HOW TO TELL IF A RESIDENT'S ALARM IS ACTUALLY CHECKED BY THE STAFF, AND THEY DON'T JUST CHECK A BOX..." ( ) RESIDENT #103: ACCORDING TO THE FACE SHEET (UNDATED), RESIDENT #103 WAS LAST REadmitted to the facility on [DATE]. THE MINIMUM DATA SET (MDS) assessment dated [DATE], INDICATED THAT RESIDENT #103 WAS A [AGE] year OLD MALE WITH IMPAIRED VISION. RESIDENT #103 HAD SEVERAL DIAGNOSES, WHICH INCLUDED CORONARY ARTERY DISEASE, HEART FAILURE, HIGH BLOOD PRESSURE, ARTHRITIS AND ANXIETY. RESIDENT #103 REQUIRED THE PHYSICAL ASSISTANCE OF 1 STAFF MEMBER WITH TRANSFERS, AND TOILETING, REQUIRED SUPERVISION WITH AMBULATION, AND WAS UNSTEADY MOVING FROM A SITTING TO STANDING POSITION, WALKING, AND/OR TURNING. ACCORDING TO THE FALLS assessment dated [DATE], RESIDENT #103 SUFFERED FROM A "...BALANCE PROBLEM WHILE STANDING... (A) BALANCE PROBLEM WHILE WALKING..." AND SHOWED EVIDENCE OF A "...CHANGE IN GAIT PATTERN WHEN WALKING THROUGH (THE) DOORWAY..." THE FALLS ASSESSMENT FURTHER DOCUMENTED THAT RESIDENT #103 HAD "...DECREASED MUSCULAR COORDINATION...(WAS) JERKING OR UNSTABLE WHEN MAKING TURNS..." AND REQUIRED THE USE OF ASSISTIVE DEVICES FOR BALANCE AND WALKING. ACCORDING TO THE FALLS assessment dated [DATE] RESIDENT #103 WAS "...TOTALLY UNABLE TO AMBULATE WITHOUT ASSIST..." THE FALLS RISK ASSESSMENT ASSIGNED A NUMERICAL SCORE TO ALL AT RISK INDICATORS AND DETERMINED RISK ACCORDING TO THE SUM OF THE INDIVIDUAL INDICATORS. A TOTAL SCORE OF 10 OR HIGHER INDICATED A HIGH RISK FOR FALLS. ACCORDING TO THE FALLS RISK assessment dated [DATE] RESIDENT #103 ' S FALLS RISK TOTAL SCORE WAS 12 (HIGH RISK) AND " ...CARE PLAN ACTIONS TAKEN..." INCLUDED INITIATION OF A CARE PLAN; HOWEVER, ON 9/28/2012, NO CARE PLAN INTERVENTIONS WERE IMPLEMENTED. A CARE PLAN WAS IMPLEMENTED ON 10/1/2012 WITH INTERVENTIONS INTENDED TO ENSURE RESIDENT #103'S SAFETY INCLUDING ENCOURAGE RESIDENT TO PARTICIPATE IN DAILY ACTIVITIES; ENCOURAGE RESIDENT TO PARTICIPATE IN THERAPY; ENCOURAGE THE USE OF ASSISTIVE DEVICES; REMIND NOT TO AMBULATE OR TRANSFER WITHOUT ASSISTANCE; KEEP BED IN LOWEST POSITION WITH BRAKES LOCKED; KEEP CALL LIGHT AND PERSONAL ITEMS WITHIN REACH; PROVIDE TOILETING ASSISTANCE EVERY 2 HOURS AND AS NEEDED; ALARMS TO BED AND WHEELCHAIR AT ALL TIMES. ACCORDING TO THE NURSE'S NOTE DATED 10/8/2012, RESIDENT #103 WAS "...VERY CONFUSED AND CONTINUALLY TRIED TO GET UP DESPITE BEING ASKED...NOT TO GET UP WITHOUT HELP..." ACCORDING TO THE NURSE'S NOTE AT 12:30 A.M., RESIDENT #103 WAS GIVEN MEDICATION USED TO TREAT ANXIETY AND PAIN, BUT "...CONTINUED TO BE RESTLESS AND TRIED TO GET UP..." AND WAS NOTED TO BE "...HEARING AND SEEING PEOPLE..." WHO WERE NOT PRESENT. DESPITE THESE OBSERVATIONS AND ASSESSMENTS, NO EVIDENCE COULD BE FOUND TO INDICATE ANY NEW INTERVENTIONS WERE IMPLEMENTED TO ENSURE THE REQUIRED SUPERVISION WAS RECEIVED TO PREVENT AVOIDABLE ACCIDENTS FOR RESIDENT #103. ACCORDING TO THE SAFETY EVENT REPORT DATED 10/8/2012, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND ASSISTANCE WITH TRANSFERS AND AMBULATION WHEN AT 3:00 A.M., RESIDENT #103 TRIED TO GET OUT OF BED WITHOUT ASSISTANCE AND fell . RESIDENT #102 WAS "...FOUND ON (THE) FLOOR IN FRONT OF HIS BED AFTER (THE) BED ALARM DID NOT SOUND..." RESIDENT #103WAS ASSESSED WAS FOUND TO HAVE SUSTAINED SKIN TEARS ON HIS LEFT ELBOW, LEFT LOWER BACK, AND RIGHT LOWER BACK. IMMEDIATE MEASURES TAKEN TO PREVENT REOCCURRENCE OF THE ACCIDENT INCLUDED THE USE OF A BED ALARM, AN INTERVENTION ALREADY CARE PLANNED TO BE IN PLACE. THE SAFETY EVENT REPORT SECTION, "...OUTCOME OF INTERVENTIONS..." DESCRIBED RESIDENT #103'S ALARM AS "...SOMEWHAT EFFECTIVE..." ALTHOUGH THE "...BED ALARM DID NOT SOUND EVEN WHEN INTACT..." NO EVIDENCE COULD BE FOUND TO INDICATE ANY NEW INTERVENTIONS WERE IMPLEMENTED TO ENSURE THE REQUIRED SUPERVISION WAS RECEIVED TO PREVENT AVOIDABLE ACCIDENTS FOR RESIDENT #103. ACCORDING TO THE NURSE'S NOTE DATED 10/11/2012 AT 2:49 A.M., RESIDENT #103 WAS "...RESTLESS AND CONFUSED AND HAS BEEN TRYING TO GET UP APPROXIMATELY EVERY 30 MINUTES ..." DESPITE THESE OBSERVATIONS AND ASSESSMENTS, NO EVIDENCE COULD BE FOUND TO INDICATE ANY NEW INTERVENTIONS WERE IMPLEMENTED TO ENSURE THE REQUIRED SUPERVISION WAS RECEIVED TO PREVENT AVOIDABLE ACCIDENTS FOR RESIDENT #103. ACCORDING TO THE NURSE'S NOTE DATED 10/11/2012 AT 6:35 A.M., RESIDENT #103 "...PRESENTS A STATE OF INCREASED CONFUSION AND REQUIRES MAX (MAXIMUM) REDIRECTION..." DESPITE THIS ASSESSMENT, NO EVIDENCE COULD BE FOUND TO INDICATE ANY NEW INTERVENTIONS WERE IMPLEMENTED TO ENSURE THE REQUIRED SUPERVISION WAS RECEIVED TO PREVENT AVOIDABLE ACCIDENTS FOR RESIDENT #103. ACCORDING TO THE NURSE'S NOTE DATED 10/11/2012, THE NURSE ENTERED RESIDENT #103'S ROOM AND OBSERVED HIM "...WALKING TOWARDS HIS WHEELCHAIR...LOCATED AT (THE) SIDE OF THE BED..." RESIDENT #103 REACHED OUT FOR THE WHEELCHAIR AND "...fell TO HIS KNEES..." ACCORDING TO THE SAFETY EVENT REPORT DATED 10/11/2012 THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND ASSISTANCE WITH TRANSFERS AND AMBULATION WHEN AT 10:54 A.M., RESIDENT #103 fell WHEN HE "...GOT OUT OF BED TO GET IN (THE) WHEELCHAIR..." WITHOUT STAFF ASSISTANCE. THE SECTION OF THE REPORT FOR "...IMMEDIATE MEASURES TAKEN..." TO PREVENT REOCCURRENCE HAD BEEN LEFT BLANK. NO EVIDENCE COULD BE FOUND TO INDICATE ANY NEW INTERVENTIONS WERE IMPLEMENTED TO ENSURE THE REQUIRED SUPERVISION WAS RECEIVED TO PREVENT AVOIDABLE ACCIDENTS FOR RESIDENT #103. ACCORDING TO THE NURSE'S NOTE DATED 10/13/2012 AT 10:52 P.M., RESIDENT #103 WAS CONFUSED, GOT OUT OF BED WITHOUT ASSISTANCE, "...WALKED TO (THE) BATHROOM BY (HIM) SELF AND URINATED ON (THE) FLOOR..." DESPITE THIS OBSERVATION, NO EVIDENCE COULD BE FOUND TO INDICATE ANY NEW INTERVENTIONS WERE IMPLEMENTED TO ENSURE THE REQUIRED SUPERVISION WAS RECEIVED TO PREVENT AVOIDABLE ACCIDENTS FOR RESIDENT #103. ACCORDING TO THE SAFETY EVENT REPORT DATED 10/14/2012, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND ASSISTANCE WITH TRANSFERS AND AMBULATION WHEN AT 10:54 A.M., RESIDENT #103 WAS FOUND ON THE FLOOR AFTER HE fell . ACCORDING TO THE NURSE'S NOTE DATED 10/14/2012, RESIDENT #103 SUSTAINED TWO SKIN TEARS FROM THE FALL, A 1 INCH SKIN TEAR ON THE LEFT HAND AND A SKIN TEAR ON THE SIDE OF THE FOREARM. ACCORDING TO THE SAFETY EVENT REPORT, THE "...IMMEDIATE MEASURES TAKEN ..." TO PREVENT REOCCURRENCE OF THE INCIDENT INCLUDED A BED ALARM AND WHEELCHAIR ALARM, WHICH WERE INTERVENTIONS THAT WERE ALREADY IN PLACE. NO EVIDENCE COULD BE FOUND TO INDICATE ANY NEW INTERVENTIONS WERE IMPLEMENTED TO ENSURE THE REQUIRED SUPERVISION WAS RECEIVED TO PREVENT AVOIDABLE ACCIDENTS FOR RESIDENT #103. ACCORDING TO THE NURSE'S NOTE DATED 10/17/2012 AT 10:03 P.M., RESIDENT #103 WAS CONFUSED, AND WAS ATTEMPTING TO GET OUT OF BED WITHOUT ASSISTANCE. DESPITE THIS ASSESSMENT, NO EVIDENCE COULD BE FOUND TO INDICATE ANY NEW INTERVENTIONS WERE IMPLEMENTED TO ENSURE THE REQUIRED SUPERVISION WAS RECEIVED TO PREVENT AVOIDABLE ACCIDENTS FOR RESIDENT #103. ACCORDING TO THE NURSE'S NOTE DATED 10/18/2012, RESIDENT #103 WAS AGAIN FOUND LYING ON THE FLOOR NEXT TO THE BED AFTER HE fell . ACCORDING TO THE SAFETY EVENT REPORT DATED 10/18/2012, THE FACILITY DID NOT PROVIDE SUPERVISION AND ASSISTANCE WITH TRANSFERS AND AMBULATION WHEN RESIDENT #103 fell DURING AN UNASSISTED ATTEMPT TO TRANSFER AT APPROXIMATELY 5:03 A.M., BUT SUFFERED NO OBVIOUS INJURIES. ACCORDING TO THE REPORT, THE SAFETY INTERVENTIONS WERE "...EFFECTIVE..." AND NO CHANGES OR ADDITIONAL MEASURES WERE IMPLEMENTED TO RESIDENT #103'S PLAN OF CARE TO PREVENT AVOIDABLE ACCIDENTS. ACCORDING TO THE NURSE'S NOTE DATED 11/5/2012, RESIDENT #103 WAS FOUND STANDING, UNASSISTED IN FRONT OF THE NURSE'S STATION. AS THE NURSE ATTEMPTED TO TALK TO RESIDENT #103, HE LOST HIS BALANCE AND fell TO THE FLOOR, LANDING ON HIS RIGHT HIP AND SUSTAINED A SKIN TEAR ON HIS LEFT HAND. ACCORDING TO THE SAFETY EVENT REPORT DATED 10/18/2012, RESIDENT #103 fell DURING AN UNASSISTED ATTEMPT TO TRANSFER AT APPROXIMATELY 8:45 P.M. ACCORDING TO THE REPORT, THE SAFETY INTERVENTIONS WERE "...EFFECTIVE..." AND NO CHANGES WERE MADE TO RESIDENT #103'S PLAN OF CARE. DURING AN INTERVIEW ON 1/7/2013 AT 1:58 P.M., THE DIRECTOR OF NURSING (DON #1) REVIEWED RESIDENT #103'S CLINICAL DOCUMENTATION AND SAID THAT RESIDENT #103 "...WAS CONSTANTLY TRYING TO GET UP..." AND NOTHING COULD BE DONE TO HELP HIM STAY SAFE. DON #1 SAID THAT "...SOME PEOPLE HAVE ALL THE INTERVENTIONS, THE BELL AND WHISTLES, THAT WE CAN POSSIBLY OFFER, SO SOMETIMES THERE ARE NO INTERVENTIONS TO ADD..." DON #1 SAID ALL INTERVENTIONS POSSIBLE WERE IN PLACE BEFORE RESIDENT #103 fell THE FIRST TIME, SO THEY (FACILITY STAFF) "...CONTINUED WITH THE SAME PLAN OF CARE..." EVEN THOUGH IT (THE PLAN OF CARE) "...WAS NOT WORKING..." DON #1 WAS UNABLE TO EXPLAIN HOW IT WAS DETERMINED THAT "EVERYTHING" WAS IN PLACE AND NO OTHER SUPERVISION OR ASSISTIVE DEVICES COULD POSSIBLY BE IMPLEMENTED BEFORE ANY EVALUATION OF THE PLAN OF CARE COULD BE COMPLETED. DON #1 WAS UNABLE TO EXPLAIN HOW THE FACILITY HAD MONITORED THE EFFECTIVENESS OF RESIDENT #103'S SAFETY PLAN. DON #1 REVIEWED RESIDENT #103'S CLINICAL RECORD AND WAS UNABLE TO FIND EVIDENCE IN THE RESIDENT'S CHART TO INDICATE THAT THE FACILITY HAD MODIFIED INTERVENTIONS WHEN NECESSARY TO PREVENT AVOIDABLE ACCIDENTS FOR RESIDENT #103, AFTER FALLS KEPT OCCURRING. ACCORDING TO THE CLINICAL RECORD RESIDENT #103 WAS REadmitted to the facility on [DATE]. THE SAME FALLS RISK ASSESSMENT WHICH ASSIGNED A NUMERICAL SCORE TO ALL AT RISK INDICATORS AND DETERMINED RISK ACCORDING TO THE SUM OF THE INDIVIDUAL INDICATORS WAS AGAIN COMPLETED. ACCORDING TO THE FALLS RISK assessment dated [DATE], RESIDENT #103'S FALLS RISK TOTAL SCORE WAS 19 (HIGH RISK) AND MEASURES TAKEN TO ENSURE RESIDENT #103'S SAFETY INCLUDED ALARMS ON HIS BED AND WHEELCHAIR. A CARE PLAN WAS IMPLEMENTED ON 12/11/2012, BUT WAS NOT UPDATED AFTER THE FALLS RISK ASSESSMENT ON 12/12/2012 WAS COMPLETED AND DID NOT INCLUDE THE USE OF THE RECOMMENDED ALARMS. DURING THE INTERVIEW ON 1/7/2012 AT 1:59 P.M., DON #1 REVIEWED RESIDENT #103'S FALLS RISK ASSESSMENT AND CARE PLAN AND SAID THE FALL RISK ASSESSMENT COMPLETED BY THE FACILITY'S SAFETY MANAGER "...MAY NOT BE ACCURATE..." DON #1 SAID THAT RESIDENT #103 WAS IDENTIFIED AT HIGH RISK FOR FALLS ACCORDING TO THE ASSESSMENT. DON #1 DECLINED TO ANSWER WHAT WAS INACCURATE ABOUT THE ASSESSMENT AND WAS UNABLE TO EXPLAIN WHY INTERVENTIONS INTENDED FOR USE WERE NOT CARE PLANNED AND WERE NOT IN USE. ( )