Every finding on record at Riverview Health & Rehab Center

This citation pertains to intakes MI00153605 and MI00153653. Based on interview and record review, the facility failed to report facial bruising and posterior nasal fracture of unknown origin for one (R702) of four residents reviewed for abuse, resulting in an unreported incident of potential abuse. Findings include: The State Agency (SA) received a complaint on 6/10/2025 that the resident (R702) had facial bruises around both eyes and posterior sinus fractures of unknown origin. According to the Electronic Health Record (EHR), R702 admitted to the facility on [DATE] with diagnoses that included acute respiratory failure, tracheostomy, morbid obesity, and required mechanical ventilation for respiratory support. R702 was identified to have intact cognition with a BIMS (brief interview for mental status) score of 14/15. A progress note dated 6/8/25 at approximately 10:00 PM documented that R702 was observed to have facial swelling and a small amount of green discharge from the right eye. The physician was notified and R702 was transferred to the hospital for further evaluation. R702 did not return to the facility. On 6/23/25 at 11:00 A.M., during an interview with the Director of Nursing (DON) they said on 6/10/25 during the evening shift R702's family member called the facility and notified Registered Nurse (RN) A that the hospital diagnosed R702 with a facial fracture. The hospital never called or notified the facility. The resident's physician, MD B was notified and reviewed the resident's chart at the hospital and did confirm there was a posterior nasal fracture. The facility should have reported R702's injury of unknown origin to the State. The DON said the Nursing Home Administrator (NHA) had initiated an investigation about R702's fracture, but did not report the incident to the SA. The NHA was not present in the facility during the survey. On 6/23/25 at 11:30 A.M., during a phone interview MD B said, The hospital's x-ray report indicated the resident (R702) had a minimally displaced left posterior sinus wall fracture. This is the back of the sinus wall, interior part of the skull. There was no trauma preceding this incident and the resident could communicate if there was an incident. There was no reason to believe this was abuse. On 6/23/25 at 11:40 A.M. the DON provided an investigation file for R702's sinus fracture. There was no evidence to support the incident was reported to the SA. The DON confirmed the facility's abuse policy included reporting any injury of unknown to the SA. According to the facility's abuse policy, last revised 8/2012 in part reads as follows 7. Reporting and Response A. The staff will report all allegations of abuse, neglect and misappropriation of property to the Administrator immediately. B. The facility will report all allegations and substantiated occurrences of mistreatment, abuse neglect, misappropriation of property or injuries of unknown source that are suspicious in nature, to the Bureau of Health Systems using the BHS-OPS-362 immediately. Immediate means as soon as possible, but not more than 24 hours after the discovery of the incident. The investigation findings will be reported to the Bureau of Health Systems within five (state) working days (of the incident using the BHS-OPS- 363)

Based on observation, interview, and record review the facility failed to follow the standards of practice for administering medications through a Gastrostomy/PEG tube (a flexible tube surgically inserted directly into the stomach through the skin of the abdomen to deliver nutrition, hydration, and medication) for two (R51 and R129) of four residents reviewed for medication administration resulting in residents not receiving the full amount of their prescribed medications and the potential for PEG tube malfunction due to clogging. Findings include: R51 On 4/8/25 at 9:10 AM during medication administration, Licensed Practical Nurse (LPN) A was observed at the medication cart to crush the following five pills and individually place into four plastic medication cups without adding any water/dilutant to the cups; 1-metoprolol 50 milligrams (mg) 2 tablets to = 100 mg. 2-plavix 75 mg 1 tablet. 3-colace 100 mg 1 tablet. 4-vitamin C 500 mg 1 tablet. At R51's bedside LPN A attached a piston syringe (large barreled syringe with straight tip that fits into a PEG tube) to the PEG tube and dumped the dry crushed medications directly into the piston syringe without diluting the medications with water or flushing the PEG tube with 50 ml of water. LPN A then added water into the piston syringe and attempted to plunge the medications through the PEG tube. Some of the crushed medication remained in the medication cups and in the piston syringe. LPN A had to apply significant force to the plunger of the piston syringe to get the medications through the PEG tube. When asked about diluting the crushed medications prior to dumping the dry medications into the piston syringe and then adding water afterwards, LPN A replied It saves time to do it this way. LPN A repeatedly added water into the piston syringe and plunge the medications through the PEG tube. All four medication cups had visible remains of the dry crushed medications inside the cups. LPN A did not add any dilutant/water to the medication cups to ensure all medications were delivered to R51. LPN A discarded the medications cups with the remains of the crushed medications into the trash. R129 On 4/8/25 at 9:50 AM during medication administration, Licensed Practical Nurse (LPN) B was observed at the medication cart to crush the following eight pills and individually place into seven plastic medication cups without adding any water/diluent to the cups; 1-escitalopram 10mg 1 tablet and 5 mg 1 tablet to = 15 mg (2 tablets). 2-eliquis 5 mg 1 tablet 3-losartan 25 mg 1 tablet 4-memantidine 5 mg 1 tablet 5-folic acid 1 mg 1 tablet 6-gabapentin 300 mg 1 capsule 7-lansoprazole 30 mg 1 tablet At R129's bedside LPN B attached a piston syringe to the PEG tube and individually dumped each of the dry crushed medications directly into the piston syringe without diluting the medications with water or flushing the PEG tube with 50 ml of water. LPN B added water into the piston syringe after each dry medication was dumped into the piston syringe. LPN B was unable to deliver the medications through the syringe into the PEG tube due to clogging of the syringe. LPN B attempted to plunge the medications through the PEG tube but was unsuccessful. LPN B removed the piston syringe from the PEG tube and the entire nozzle of the syringe was clogged with dried crushed medications. Some crushed medications remained in the medication cups and in the piston syringe. LPN B disposed of the piston syringe and obtained another one (piston syringe) and administered the remaining medications through the PEG tube. When asked about administering medications through a PEG tube, LPN B said, Yes, I was suppose to add water to the medications cups before putting the meds in the PEG tube. I was nervous and forgot. LPN B acknowledged that R129 did not receive all the prescribed medications due to clogging in the piston syringe and some crushed remains in the medication cups. On 4/08/25 at 11:43 AM the Director of Nursing (DON) was asked about the facility's policy for administering medications through a PEG tube and said, The nurses are suppose to add approximately 5 ml of water to each crushed medication in the medication cup prior to administering the medications through the PEG. I don't know why they did not do that. I'll be doing an education of this. According to the facility's (undated) Clinical Operating Procedures for Medication Administration via Gastrostomy/PEG Tube, read in part: To administer medications through a gastrostomy/PEG tube in an accurate, safe, timely, and sanitary manner . 13. Remove plug at the tip of the PEG tube. Attach (piston) syringe or funnel to tip. 14. Check for placement by auscultation or aspiration. 15. Release clamp and instill about 10 milliliters (ml) of water into tube through syringe to check for patency. 16. Do NOT mix medications. Administer each medication separately. Mix crushed tablets with diluent (water), or open capsules and pour into liquid. Pour liquid into diluent. Mix well. Attach syringe, without piston, to end of feeding tube and open clamp. Flush tube with at least 30 mi. of water. Deliver medication slowly and steadily. Pour up to 30 ml of diluted medication into syringe barrel. Hold feeding tube at a slight angle and add more medication before syringe empties Raise feeding tube slightly higher to increase flow rate, if necessary. Monitor resident's reaction throughout instillation and stop procedure if signs of discomfort are noted. Flush tube by adding 30 ml to 50 ml of water. 17. Repeat above steps (I through 15) for each medication administered. 18. Replace plug or reconnect to administration set as indicated.

Based on observation, interview, and record review, the facility failed to provide timely and appropriate care to a supra-pubic (s/p) catheter (flexible tube surgically inserted into the bladder through the skin of the abdominal wall) for one (R97) of one resident reviewed for catheter care resulting in delayed assessment and treatment of R97's s/p catheter. Findings include: On 4/07/25 at 10:28 AM, R97 was observed lying on their back in bed with an incontinence pad tucked under the right side of their abdomen with a dinner-plate sized dried yellow stain on it. The resident had urinary catheter tubing with a collection bag positioned on the left side of their body. There was no anchoring device to secure the s/p catheter. The s/p catheter tubing was taut and pulling down off the left side of the bed. The urinary catheter tubing had no urine in it. The collection bag had a small amount of amber urine in it and was attached to the bed frame. R97's was wearing one brief with a second brief tucked inside the first brief with the inside facing toward the resident's abdomen. R97 was unable to be interviewed due to severe cognitive impairment. At 10:30 AM R97's assigned nurse, Licensed Practical Nurse (LPN) A was at bedside and observed the resident's double brief and incontinence pad that had the yellow stain on it. LPN A said they were unaware the resident's s/p catheter had been leaking. LPN A said, I didn't get any report about this. We do not double brief. I don't know who put the double brief on like that. Yes, the catheter should have an anchoring device on it as well. LPN A removed both briefs from R97 to assess the s/p catheter's insertion site and stoma (surgically created opening on the abdomen used to reroute urine through s/p catheter). R97 had visible urine leaking out of the s/p catheter insertion site, traveling along an abdominal fold and onto the incontinence pad tucked underneath the right side the resident's abdomen. LPN A said, Yes this has been leaking for a while and needs to be irrigated. There is a standing order for that. LPN A reviewed R97's Electronic Health Record and said There is no note that the resident's catheter had been leaking or that it had been irrigated. At 10:50 AM Certified Nursing Assistant (CNA) C came in to R97's room and was asked about the double brief and incontinence pad underneath the resident. CNA C said they noticed the resident's s/p catheter was leaking and just put a double brief over it and forgot to tell the nurse about it. CNA C was unable to explain why the resident did not have a anchoring device on the s/p catheter. CNA C said, I don't know where they anchoring tape is. LPN A said, The nurses have the anchoring devices. I will get one. The resident was checked for incontinence at this time with both LPN A and CNA C. R97 was observed to be free from stool. R97's skin was intact without rash or irritation. The resident's catheter had leaked to the right side of the resident's abdomen and not underneath. At 10:55 AM LPN A irrigated R97's s/p catheter without difficulty. During the irrigation a moderate about of urine leaked through the catheter tubing and also out through the insertion/stoma site. LPN A said the doctor would be notified. On 4/08/25 at 8:58 AM R97 was observed lying in bed on his left side. The s/p catheter was draining cloudy yellow into the collection bag. There was a small amount of liquid around the s/p catheter insertion site. There was no stain or indication of leaking in the resident's bed or brief at this time. The s/p catheter was not anchored to the resident's thigh and was hanging straight down from the resident's abdomen with tension. On 4/08/25 at 9:05 AM during an interview with the Director of Nursing (DON) and nurse manager Registered Nurse (RN) D it was reported that R97 had a history of the s/p catheter leaking and the nurse should have irrigated the catheter when the leaking was noticed. The DON said, The resident has a monthly appointment with urology to have his supra-pubic catheter changed. It was last done on 3/17/25. RN D said, The resident does this all the time and irrigating the catheter fixes the leakage. It (the catheter) should have been irrigated as soon as the leakage was noted. I can't explain why it wasn't. We do not double brief or just put a pad underneath the resident. I will anchor the catheter now. According to the resident's Electronic Health Record (EHR) R97 admitted to the facility on [DATE] with multiple diagnoses that included acute respiratory failure and cerebral vascular accident (stroke) that required a tracheostomy with full mechanical ventilation for breathing and s/p catheter for urinary elimination. R97 had severe cognition deficit and required a feeding tube for all nutrition, hydration, and medication administration. The physician's order dated 10/8/24 reads as follows: Irrigate plugged catheter PRN ( as needed) If no urine flow through catheter call MD (medical doctor). Ensure the catheter anchor is in place every shift, check for kinks, hematuria, and sediment. Notify the MD with any concerns. A care plan for supra-pubic catheter lasted edited on 2/26/25, included the following interventions; irrigate catheter if obstruction is suspected, change catheter per MD order and prn (as needed), use catheter strap to anchor catheter. The facility's Clinical Operation Procedure for Suprapubic Catheter Care (undated) in part read: Purpose: proper care of the catheter site reduces skin irritation and/or infection. 8. If these is drainage that would soil clothing, apply a dry dressing; secure with paper tape. 10. Secure the catheter tubing with a catheter strap, if desired.

Based on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting the facility's total census of 138 residents who receive meal services. Findings include: 1. On [DATE] at 9:46 AM, Cook, staff B, was observed rinsing out a cloth towel at the three compartment sink and then wiping off a stainless steel countertop. Upon observation the surveyor inquired with staff B on the purpose of the cloth towel to which they replied, it's our sanitizer. On [DATE] at 9:54 AM, the surveyor asked the Certified Dietary Manager, staff A, how the facility cleans and sanitizes work surfaces to which they stated, we have our red and green buckets. One has soapy water in it, and one has our sanitizer. At this time the surveyor asked staff A if they could test the sanitizing compartment of the three compartment sink to verify its concentration to which they replied, of course. On [DATE] at 9:57 AM, testing of the sanitizer concentration by staff A via a test strip, and comparing its color to the wall mounted chemical manufacturers reference sign, revealed a concentration of zero. Upon observation staff A stated, We will remake it now. On [DATE] at 9:59 AM, testing of the sanitizer concentration by staff A via a test strip again revealed a concentration of 0 ppm to which they stated, We'll switch to bleach, and I'm going to call my chemical rep right now to fix this. At this time staff A was observed by the surveyor instructing staff B to, re-do everything you just cleaned in this sink, and use the dish machine. There's a problem with our wall dispenser. We are also going to need to change out all our buckets to bleach water. Review of 2017 U.S. Public Health Service Food Code, Chapter ,d+[DATE].11 Sanitizers, Criteria, directs that: Chemical SANITIZERS, including chemical sanitizing solutions generated on-site, and other chemical antimicrobials applied to FOOD-CONTACT SURFACEs shall: (A) Meet the requirements specified in 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (Food-contact surface sanitizing solutions)P 2. On [DATE] at 9:29 AM, the surveyor approached the dish room's designated hand washing sink to wash their hands when Certified Dietary Manager, staff A, stated, that one doesn't work. You'll need to use one in the kitchen. At this time the surveyor inquired with staff A on the length of time the sink has not been operational to which they replied, it's been like that for years, I don't know why it was shut off. On [DATE] at 10:09 AM, the walk-in cooler's refrigeration equipment was observed dripping onto the floor. Upon observation the surveyor inquired with staff A, on the current state of this equipment to which they replied, Yes, it's been like that for a while. Maintenance knows about it. We use a towel once in the morning and in the afternoon to clean the water from the floor. On [DATE] at 10:27 AM, the walk-in freezer's refrigeration equipment and surrounding area was observed partially iced over, and with its entry door unable to latch shut. At this time staff A stated, Same. It's been like that for a while now. The door does latch, just not all of the time. Review of 2017 U.S. Public Health Service Food Code, Chapter ,d+[DATE].11 Good Repair and Proper Adjustment, directs that: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts ,d+[DATE] and ,d+[DATE]. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, 3. On [DATE] at 10:12 AM, a milk bin containing individual cartons of milk with the expiration date of, [DATE] was observed by the surveyor. Upon observation they surveyor inquired with Certified Dietary Manager, staff A, on the current state of the milk in this bin to which they stated, I have no idea why these are expired, they just delivered these to us. I'll get rid of them now. Review of 2017 U.S. Public Health Service Food Code, Chapter ,d+[DATE].18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition, directs that: (A) A FOOD specified in ,d+[DATE].17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in ,d+[DATE].17(A), except time that the product is frozen; P

Based on observation, interview, and record review the facility failed to maintain an effective pest control program to ensure that the facility is free of pests, resulting in an increased potential for contamination of food, both food and non-food contact surfaces, and foodborne illness potentially affecting staff, visitors and all 138 residents. Findings include: On 5/14/24 at 9:23 AM, two live flies were observed in the basement hallway. On 5/14/24 at 9:42 AM, four live flies were observed in the kitchen's dishwashing area. On 5/14/24 at 10:07 AM, three live flies were observed near the kitchen's walk-in cooler. Upon observation the surveyor inquired with Certified Dietary Manager, staff A on the current state of the insects in this area to which they responded, it used to be worse. It has gotten much better. On 5/14/24 at 10:45 AM, the surveyor requested the facility's pest control policy to review to which staff A responded, I am not the best one to talk to about that, but the front desk has a book. On 5/15/24 at 11:23 AM, record review of the facility's most recent pest control service record dated, 4/10/24 revealed that the facility is currently being treated for gnats and cockroaches. On the bottom portion of this document the pest control technician recommended that the facility, get trash with food waste out of the building nightly to reduce gnat problems. Review of 2017 U.S. Public Health Service Food Code, Chapter 6-501.111 Controlling Pests, directs that: The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: (B)Routinely inspecting the PREMISES for evidence of pests;

Based on observation and interview the facility failed to provide a safe, functional, and sanitary environment for the facilities census of 138 residents and its staff resulting in an increased potential for harm. Findings include: On 5/15/24 between 1:02 PM, and 2:28 PM, during an environmental tour of the facility with Environmental Services Manager, Staff C, the following observations were made: Both dryers in the laundry room were observed with a variety of melted/baked on debris varying in color and texture on the interior drums of the units. Upon observation the surveyor inquired with Staff C on the current state of the interior of the dryers to which they stated, all clothes should be checked when they are being sorted for anything in pockets. It should be done before going into the washing machines, so this doesn't happen. We'll get this cleaned up. The clean linen supply room in the six south memory care wing was observed unlocked. Upon entering the room the surveyor inquired with staff C on if this room was always used for this purpose to which they replied, no, not always. It used to be a patient room years ago when this was a hospital. At this time the surveyor asked staff C if they thought a room such as this should have restricted access, such as a locked door based upon the resident population in this area to which they replied, it makes sense. I guess we wouldn't want anyone coming in here and using the bathroom. I can get some keys made and give them to staff. The fifth south soiled utility room's hopper was observed soiled. Personal protective equipment (PPE) was observed not available for use in the fifth south and three south floor's soiled utility rooms. On 5/15/24 at 1:13 PM, the surveyor inquired with staff C, on who oversaw replenishing the PPE in the soiled utility rooms to which they replied, the nursing staff I think. Lift batteries and charging stations were observed being stored in all the soiled utility rooms. On 5/15/24 at 2:16 PM, the surveyor inquired with staff C on if the lift batteries and charging stations would normally be stored in a soiled utility room to which they replied, I think they always have been, but we can move them to a cleaner area.

Based on interview and record review, the facility failed to ensure one (R70) of four residents reviewed for advance medical directives (AMD) had their code status/treatment preferences documented in their Electronic Health Record (EHR). Findings include: A review of R70's Electronic Health Record (EHR) on 5/14/24 at 3:41 PM revealed there was no AMD form to indicate code status or treatment preferences for the resident. The resident's face sheet (a document that gives pertinent medical information at a glance) indicated R70 was a 'full code' (all life saving measures to be provided, including cardiac-pulmonary resuscitation). R70 admitted to the facility on [DATE] with multiple diagnoses that included traumatic brain injury and respiratory failure with dependency on mechanical ventilation. A progress note dated 3/18/24 written by Social Worker (SW) F indicated that an AMD form was sent out to the resident's Legal Guardian (LG). There was no additional progress notes regarding follow-up to R70's AMDs. On 5/15/24 at 11:30 AM during an interview, R70's family member said they were the resident's Legal Guardian and had provided the appropriate paperwork to the facility, including a completed AMD form. R70's LG reported that the resident was a 'full code'. On 5/15/24 at 2:34 PM, SW F said the AMD form was given to the ward clerk and did not get scanned into the resident's EHR. At this time a paper copy of the AMD form was provided and reviewed. The AMD form was dated 3/8/24, not signed by the resident or the resident's LG, and indicated R70 was a full code 'by default'. Upon further inquiry SW F said R70 did not have a LG and therefore the resident was a full code by default. SW F said R70's family member said they were the resident's LG, but did not provide any paperwork to legally indicate that. SW F said she did not follow-up with R70's family member about the AMD form. On 5/15/24 at 3:45 PM, during further review with the Director of Nursing (DON), it was determined that R70's LG had sent the facility a signed AMD form indicating the resident was a 'full code'. The DON said R70's family member had also submitted valid LG paperwork for the resident. The DON said the AMD form should have been scanned into the resident's EHR at this time. The DON could not say why the documents were not in the resident's EHR. According to the facility's Advance Directive Policy and Procedure (undated) documented in part; A. Upon admission, identify if the resident has an Advance Directive and if not, determine if the resident wishes to formulate an advance directive . D. A copy of all Advance Directive documents will be obtained and located in the resident's medical record.

Based on interview and record review, the facility failed to ensure the Preadmission Screening (PAS)/ Annual Resident Review (ARR) form for Mental Illness/ Intellectual Disability/ Related Conditions Identification (DCH-3877) document was accurate, complete, and sent to the local state agency for an evaluation for a Level II determination for one (R70) of three residents reviewed for PASSARs, resulting in the potential for unmet intellectual/ developmental disability care needs. Findings include: A review of R70's Electronic Health Record (EHR) on 5/14/24 at 3:41 PM revealed there was no current PAS/AAR form (DCH-3877) or Level ll evaluation in progress for the resident. The DCH-3877 form that was in the resident's EHR was dated 3/7/24 and indicated it was a 'Hospital Exempt Discharge' form, valid for 30 days only. R70 had a diagnosis of mental illness and was receiving treatment for mental illness that included antipsychotic and antidepressant medications. A progress note dated 4/24/24 written by psychiatric services confirmed R70 had multiple mental illness diagnoses and was being treated with multiple antipsychotic medications. According to the DCH-3877 form, R70 should have the form sent to the local Community Mental Health Services Program for a level ll evaluation. On 5/15/24 at 1:50 PM during an interview with Social Worker (SW) G it was confirmed that R70 did not have an accurate or current DCH-3877 form in the EHR. SW G said, I used the one form (DCH-3877) from the hospital. Yes, it is past due. The resident should have had a new one (DCH-3877). He needs a level ll evaluation. On 5/15/24 at 2:35 PM the Director of Nursing (DON) acknowledged that R70 did not have a DCH-3877 form that was current. The DON said. The resident should have a level ll evaluation.

This citation pertains to intake MI00140641 and MI00139226. Based on observation, interview, and record review, the facility failed to provide adequate ADL (Activities of Daily Living) care for one resident (R41) of six residents reviewed for ADLs, resulting in debris-filled and odorous feet. Findings Include: On 5/14/2024 at 2:40 p.m., R41 was observed lying in bed alert unable to be interviewed. R41's feet were observed with yellowish thick dry debris between all toes with an odor. Unit Manager/Licensed Practical Nurse UM/LPN D agreed R41's feet had an unpleasant odor. UM/LPN D said it shouldn't have been that much of debris between the resident's toes especially if routine showers was completed. According to the electronic medical record, R41 was initially admitted into the facility on [DATE] with diagnoses of acute respiratory failure, gastrostomy status, tracheostomy status, obesity, neuromuscular dysfunction of bladder, and hypertension. R41's annual Minimum Data Set (MDS) with a reference date of 2/17/2024 revealed no BIMS (brief interview for mental status) score. Further review of the medical record revealed R41 was unable to make needs known. Review of the 3/4/2021 ADLs care plan revealed, R41 need total one-two person assist with ADLs and mobility related to cognition due to respiratory failure, vent dependent and a trach. Staff must anticipate my needs. Interventions as follows: -Provide daily am and pm care total assist. On 5/17/2024 at 2:25 p.m. the Director of Nursing (DON) was informed of the odor and the yellowish thick dry debris between R41's toes. The DON said, R41 feet should not have had an odor and dry skin between the toes. According to the facility's undated ADL Care policy: Resident will receive ADL care per their Personalized care plan. Each resident is designated to have at least two showers per week. On non-shower days, resident will receive AM and HS (bedtime) care, apply moisture barrier cream or lotion to skin to decrease dryness.

Based on observation, interview, and record review, the facility failed to consistently implement interventions (a low-air-loss specialty mattress) for one (R114) of thirteen residents reviewed for pressure ulcer care resulting in the potential for continued impaired skin integrity. Findings include: On 5/14/24 at approximately 1:30 PM, R114 was observed in his room lying on his bed with a regular mattress in place. R114 had a tracheostomy connected to a ventilator and was unable to be interviewed due to impaired cognition. According to R114's Electronic Health Record (EHR) the resident readmitted to the facility on [DATE] with a stage 4 pressure ulcer (full-thickness skin and tissue loss exposing tendon, muscle, or bone) on his sacral area that was present upon initial admission. The Minimum Data Set (MDS) dated [DATE] indicated the resident had a pressure relieving device for the bed. A wound care note dated 5/13/24 indicated that R114 had a stage 4 sacral pressure ulcer that was not resolved, stable, and measured 3.6 centimeter (cm) x 5.0 cm x 0.3 cm with minimal amount of drainage and no signs of infection. Recommended treatment included the continuation of a low-air-loss (LAL) mattress. On 5/14/24 at 1:36 PM Licensed Practical Nurse (LPN) L was asked if R114 should be on a LAL mattress and replied yes. LPN L observed R144's bed/mattress and confirmed the resident was not on a LAL mattress. LPN L said R114 had been on a LAL mattress before and could not explain why he did not have one (LAL mattress) now. LPN L reviewed the resident's EHR and said, The resident is definitely suppose to have a low-air-loss mattress. I think when the resident went to the hospital they took the mattress off and did not replace it when the resident returned. On 5/15/24 at 9:15 AM the Director of Nursing (DON) said, Yes I was made aware the resident (R114) did not have a low-air-loss mattress in place. We think it got swapped out when the resident was hospitalized . The pressure ulcer has not deteriorated. According to the facility's Pressure Ulcer and Skin Care Management policy revised on 8/30/21, in part; A resident having pressure ulcers receives the necessary treatment and services to promote healing, prevent infection, and reduce the risk of new pressure ulcers developing.

Based on observation, interview, and record review, the facility failed to effectively clean and maintain the physical plant effecting 131 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, decreased illumination, and reduced indoor air quality. Findings include: On 02/28/23 at 02:40 P.M., A common area environmental tour was conducted with Director of Environmental Services C. The following items were noted: 3rd Floor (South) Soiled Utility Room: Nine 12-inch-wide by 12-inch-long vinyl flooring tiles were observed etched, scored, and missing. Small Television Lounge: The wallpaper was observed loose-to-mount, adjacent to the staff telephone. The wallpaper adjacent to the sofa loveseat was also observed etched, scored, and particulate. The damaged wallpaper measured approximately 30-inches-wide by 18-inches-long. Large Television Lounge: 2 of 3 return air exhaust ventilation grills were observed heavily soiled with accumulated dust and dirt deposits. Lounge: The return air exhaust ventilation grill was observed heavily soiled with accumulated dust and dirt deposits. 2 of 6 windows were also observed leaking water from the exterior rainstorm event. Excessive water was further observed pooling on the window ledge and sofa arm rest. The damaged windows measured approximately 42-inches-wide by 60-inches-long. Staff Restroom (346): The commode base seat was observed etched, scored, and particulate. The drywall surface was also observed bubbled, raised, and moist, directly in front of the commode base. The damaged drywall surface measured approximately 2-feet-wide by 3-feet-long. Staff Restroom (347): The commode base seat was observed etched, scored, and particulate. Housekeeping Closet (348): The mop sink basin was observed soiled with accumulated dust, dirt, and grime. Miscellaneous items (plastic bottle, cloth, etc.) were also observed stored directly on the floor. 3rd Floor (North) Small Television Lounge: The wallpaper was observed missing on 1 of 4 wall partition corners. Nursing Station: 1 of 3 chairs were observed worn, torn, and particulate, creating a non-cleanable and non-sanitizable surface. The arm rests were both observed worn, torn, and particulate, exposing the inner foam padding. Director of Environmental Services C indicated he would have staff discard and replace the damaged chair as soon as possible. Large Television Lounge: 1 of 3 return air exhaust ventilation grills were observed heavily soiled with accumulated dust and dirt deposits. Staff Restroom (383): The commode base seat was observed etched, scored, and particulate. Spa Shower (381): The drywall ceiling surface was observed etched, scored, and particulate, directly above the shower stall. The damaged drywall surface measured approximately 6-inches-wide by 36-inches-long. 4th Floor (South) Supply Room (438): 1 of 2 overhead light assemblies were observed non-functional. Small Television Lounge: The drywall surface adjacent to the sofa loveseat was observed etched, scored, and particulate. The damaged drywall surface measured approximately 3-inches-wide by 36-inches-long. Nursing Station: The wall/floor vinyl coving strip was observed loose-to-mount, directly beneath the desk area. The damaged wall/floor vinyl coving strip measured approximately 6-feet-long. Large Television Lounge: 3 of 6 overhead light assemblies were observed non-functional. Lounge (415): The return air exhaust ventilation grill was observed heavily soiled with accumulated dust and dirt deposits. Staff Restroom (446): The commode base seat was observed etched, scored, and particulate. Housekeeping Closet (448): The mop sink basin was observed heavily soiled with accumulated dirt and grime deposits. The drywall surface adjacent to the entrance door was also observed cracked, dented, and broken. The damaged drywall surface measured approximately 12-inches-wide by 36-inches-long. Dining Room (427): The hand sink faucet assembly was observed loose-to-mount. 4th Floor (North) Soiled Utility: One 24-inch-wide by 24-inch-long acoustical ceiling tile was observed stained and bubbled from a previous moisture leak. Dining Room (475): The hand sink faucet hot water supply valve was observed non-functional. Small Television Lounge: 1 of 2 return air exhaust ventilation grills were observed heavily soiled with accumulated dust and dirt deposits. Large Television Lounge: 3 of 6 overhead light assemblies were observed non-functional. Housekeeping Closet (490): The mop sink basin was observed heavily soiled with accumulated dirt and grime deposits. 5th Floor (South) Soiled Utility Room: The wall/floor vinyl coving strip was observed loose-to-mount, directly beneath the hand sink basin. The damaged wall/floor vinyl coving strip measured approximately 12-18-inches-long. Small Television Lounge: The sofa loveseat cushion and arm rests were observed stained from previous bodily fluid exposure. One of four partition column wooden ledge plate Formica laminate surfaces were observed missing. The missing Formica laminate surface measured approximately 3-inches-wide by 12-inches-long. Spa and Shower Room (544): The shower stall overhead light assembly was observed non-functional. The shower stall drywall ceiling surface was also observed etched, scored, bubbled, and particulate. The damaged drywall ceiling surface measured approximately 4-feet-wide by 4-feet-long. Staff Restroom (547): The ceiling drywall surface adjacent to the shower stall was observed etched, scored, and particulate. The damaged drywall surface measured approximately 24-inches-wide by 24-inches-long. 5th Floor (North) Beauty Shop: The hair sink basin atmospheric vacuum breaker was observed non-functional. The bonnet was also observed missing from the atmospheric vacuum breaker assembly. Two 24-inch-wide by 24-inch-long acoustical ceiling tiles were also observed stained from a previous moisture leak. The return air exhaust ventilation grill was further observed heavily soiled with dust and dirt deposits. Occupational/Physical Therapy: 1 of 4 office chairs were observed etched, scored, and particulate, exposing the inner Styrofoam padding. On 03/01/23 at 10:55 A.M., An interview was conducted with Director of Maintenance B regarding the failed #5 elevator car. Director of Maintenance B stated: An emergency call to City Elevator Service from [NAME], OH has been placed. On 03/01/23 at 11:35 A.M., A common area environmental tour was continued with Director of Environmental Services C. The following items were noted: 6th Floor (South) Soiled Utility Room: Three 24-inch-wide by 24-inch-long acoustical ceiling tiles were observed stained and bubbled from a previous moisture leak. Storage Room (641): One 24-inch-wide by 24-inch-long acoustical ceiling tile was observed stained from a previous moisture leak. Large Dining Room: The single toggle light switch pole was observed non-functional. Spa & Shower Room: The return air exhaust ventilation grill was observed heavily soiled with accumulated dust and dirt deposits. The shower stall overhead light assembly was also observed non-functional. The corner ceramic tile and interior ceramic tile were further observed cracked, broken, and missing. Staff Restroom (650): The hand sink hot water valve assembly was observed out-of -adjustment. The hot water valve actuator handle was also observed touching the goose neck spout assembly. 6th Floor (North) Soiled Utility Room: 1 of 2 overhead light assemblies were observed non-functional. Nursing Station: The black oscillating desk fan was observed soiled with accumulated dust and dirt deposits. Staff Restroom (694): The hand sink cold water valve assembly was observed out-of-adjustment. The cold-water valve actuator handle was also observed resting at a 90-degree angle facing the drywall surface. Staff Restroom (693): The commode base seat was observed etched, scored, and particulate. Lounge (662): Five 24-inch-wide by 24-inch-long acoustical ceiling tiles were observed stained from previous moisture exposure. Spa & Shower Room (691): The return air exhaust ventilation grill was observed heavily soiled with accumulated dust and dirt deposits. On 03/01/23 at 12:20 P.M., An environmental tour of sampled resident rooms was conducted with Director of Environmental Services C. The following items were noted: 303: The Bed A overhead light assembly switch was observed broken and missing. The restroom shower stall overhead light assembly was also observed non-functional. Three 24-inch-wide by 24-inch-long acoustical ceiling tiles were additionally observed stained from a previous moisture leak. The restroom overhead light assembly protective cover was also observed missing. The entrance foyer wallpaper was further observed loose-to-mount. The damaged wallpaper surface measured approximately 3-feet-wide by 6-feet-long. The restroom metallic entrance door was also observed ajar, allowing the door to not completely close. 307: The Bed A window ledge was observed with a flat bed sheet placed to absorb leaking water during inclement events. The restroom shower stall overhead light assembly was also observed non-functional. 308: Two of three restroom overhead light assemblies were observed non-functional. 317: The Bed A box fan was observed soiled with accumulated dust and dirt deposits. The restroom commode water supply was also observed running continuously. The hand sink(s) were additionally observed draining slowly. Director of Environmental Services C stated: The [NAME] valve diaphragm is stuck open., referring to the restroom commode water supply running continuously. 320: The Bed A drywall corner and wall/floor vinyl coving base was observed etched, scored, and particulate. The damaged drywall surface measured approximately 3-feet-long. 322: The Bed A overbed light assembly switch was observed broken. The Bed A wallpaper and wall/floor vinyl coving base was also observed loose-to-mount. The damaged wallpaper surface measured approximately 2.5-feet-long. 323: The Bed A and Bed B overbed light assembly upper 48-inch-long fluorescent bulbs were observed non-functional. The restroom shower stall overhead light assembly was also observed non-functional. One small blanket and two bath towels were further observed resting on the window ledge to prevent cold air drafts. 326: The Bed 1 black clip fan was observed soiled with accumulated dust and dirt deposits. 351: The Bed B white desk fan was observed soiled with accumulated dust and dirt deposits. The restroom shower stall overhead light assembly was also observed non-functional. 352: The Bed A and Bed B overbed light assembly upper 48-inch-long fluorescent light bulbs were observed non-functional. The Bed A and Bed B overbed light assembly pull string extensions were also missing. The restroom shower stall overhead light assembly was further observed non-functional. 353: The restroom shower stall overhead light assembly was observed non-functional. The Bed A overbed light assembly pull string extension was also observed missing. The drywall and wall/floor vinyl cove base were further observed loose-to-mount, adjacent to the restroom entrance door. The damaged drywall surface measured approximately 1 foot-long. 354: The Bed A overbed light assembly pull string extension was observed missing. The Bed A overbed light assembly upper 48-inch-long fluorescent light bulb was also observed non-functional. The corner drywall surface adjacent to the windows was additionally observed etched, bubbled, raised, and moist. The damaged drywall surface measured approximately 3-feet-wide by 4-feet-long. The restroom hand sink was further observed draining very slow. 356: The Bed A overbed light assembly upper 48-inch-long fluorescent light bulb was observed non-functional. 364: The hand sink basin was observed draining very slow and leaking water onto the flooring surface. The Bed A window soffit was also observed etched, scored, and bubbled. The Bed A window soffit wallpaper was additionally observed loose-to-mount. The restroom shower stall overhead light assembly was additionally observed non-functional. The restroom hand sink overhead light assembly was further observed non-functional. The hand sink basin was observed draining slowly. Resident #17 stated: They mop the floor several times a day. Resident #17 also stated: I saw a mouse running across the window ledge about two to three weeks ago. Resident #17 further stated: The flooring edge was missing, and the mouse ran into the wall to escape. Eight cylindrical pest control sticky strips were also observed dangling from the wall surface, adjacent to the Bed A headboard. Resident #130's family members allegedly purchased and installed the sticky strips to alleviate flying insects (gnats). 365: The Bed A overbed light assembly pull string extension was observed missing. The Bed A overbed light assembly upper 48-inch-long fluorescent light bulb was also observed non-functional. The Bed B overbed light assembly front protective panel was additionally observed missing. 366: The restroom commode water supply was observed continuously running. 367: The drywall surface adjacent to the Bed A headboard was observed etched, scored, and particulate. The damaged drywall surface measured approximately 2-feet-wide by 3-feet-long. The Bed B overbed light assembly pull string extension was also observed missing. 403: One of three restroom overhead lights were observed non-functional. The Bed B overbed light assembly pull string extension was also observed missing. 411: The Bed A and Bed B overbed light assembly pull string extensions were observed missing. The restroom shower stall overhead light assembly was also observed non-functional. 412: The entrance foyer overhead light assembly was observed non-functional. 423: The Bed A overbed light assembly pull string extension was observed missing. The Bed B black desk fan was observed soiled with accumulated dust and dirt deposits. 460: One of three overhead restroom light assemblies were observed non-functional. The Bed A overbed light assembly pull string extension was also observed missing. 507: The Bed B overbed light assembly pull string extension was observed missing. The restroom return air exhaust ventilation grill was also observed soiled with dust and dirt deposits. 511: The Bed A overbed light assembly upper 48-inch-long fluorescent light bulb was observed non-functional. The Bed A black box fan was also observed soiled with dust and dirt deposits. Two of three restroom overhead lights were also observed non-functional. 512: The Bed A and Bed B overbed light assembly actuator switches were observed broken and missing. One of the three restroom overhead lights were also observed non-functional. The restroom return air exhaust ventilation grill was further observed heavily soiled with accumulated dust and dirt deposits. 518: The Bed A overbed light assembly upper 48-inch-long fluorescent light bulb was observed non-functional. The black oscillating desk fan was also observed soiled with accumulated dust and dirt deposits. One of two duplex outlets were additionally observed non-functional. One of two duplex outlets were also observed loose-to-mount. The restroom shower stall overhead light assembly was further observed non-functional. 519: The restroom shower stall overhead light assembly was observed non-functional. The hand sink overhead light assembly was also observed non-functional. The Bed A overbed light assembly pull string extension was additionally observed missing. The Bed A corner drywall surface was further observed etched, scored, and particulate. 524: The Bed A overbed light assembly pull string extension was observed missing. The Bed A drywall and vinyl wall/floor coving base was also observed missing. The damaged area measured approximately 6-feet-long. The Bed B overbed light assembly switch was additionally observed broken and missing. One blanket and one bath towel were further observed resting on the window ledge to prevent cold air drafts. 525: The Bed B overbed light assembly pull string extension was observed missing. The Bed A drywall surface was also observed dented and broken. The damaged drywall surface measured approximately 3-feet-wide by 4-feet-long. The entrance foyer overhead light assembly was further observed non-functional. One of three restroom overhead light assemblies were additionally observed non-functional. 617: The overbed light assembly pull string extension was observed missing. The overbed light assembly plastic light lens cover was also observed heavily soiled with dust and dirt deposits. The oscillating floor fan was further observed soiled with accumulated dust and dirt deposits. 656: 4 of 6 wooden wardrobe door hinges were observed broken, allowing the two doors to not close properly. 657: Three 24-inch-wide by 24-inch-long acoustical ceiling tiles were observed stained from a previous moisture leak. The restroom flooring tile grout was also observed stained, directly beneath and adjacent to the commode base. 658: Two 24-inch-wide by 24-inch-long acoustical ceiling tiles were observed stained from a previous moisture leak. The Bed A and Bed B overbed light assembly pull string extension(s) were also observed missing. The 4-leg metal frame restroom commode support was further observed corroded and particulate. 664: Lubricant oil residue from the pneumatic door closer assembly was observed protruding down the second room metallic entrance door. 667: The vinyl flooring tile was observed missing adjacent to the restroom entrance door (four 12-inch-wide by 12-inch-long vinyl tiles were observed damaged). The 4-leg restroom commode support metal frame was also observed etched, corroded, and particulate. 669: The restroom shower curtain was observed missing. 670: The Bed A headboard was observed etched, scored, and particulate. The Bed A drywall surface was also observed etched, scored, and particulate. The damaged drywall surface measured approximately 24-inches-wide by 72-inches-long. The restroom shower curtain was further observed missing. On 03/01/23 at 04:15 P.M., A telephone interview was conducted with Director of Maintenance B regarding the facility elevator system. Director of Maintenance B stated: Elevator cars #5 and #8 were working until this morning. Director of Maintenance B also stated: Elevator car #5 failed this morning and an emergency call was made for repairs with City Elevator Service from [NAME], OH. Director of Maintenance B additionally stated: Elevator cars #3, #4, #6, and #7 have not worked since I started. Director of Maintenance B further stated: We only had three cars out of seven working before today. On 03/01/23 at 04:20 P.M., A telephone interview was conducted with Director of Maintenance B regarding the facility maintenance work order system. Director of Maintenance B stated: We use the Issue Trak software system. On 03/02/23 at 02:15 P.M., Record review of the Issue Trak Work Orders for the last 60 days revealed no specific entries related to the aforementioned maintenance concerns. On 03/02/23 at 02:30 P.M., Record review of the Policy/Procedure entitled: Janitor Closets/Mop Fill Areas Cleaning dated 04/2012 revealed under Policy: Janitor closets and mop fill areas are cleaned daily to maintain these areas in a clean, neat, orderly, and secure manner. On 03/02/23 at 02:45 P.M., Record review of the Policy/Procedure entitled: General Cleaning of a Resident Room dated 11/08/19 revealed under Policy: Resident rooms will be maintained and kept clean to promote a homelike environment. On 03/02/23 at 03:00 P.M., Record review of the Policy/Procedure entitled: Common Public Areas Cleaning dated 04/2012 revealed under Policy: Day rooms and lounges are cleaned daily to provide clean, sanitary, odor free, and neat appearing public areas.

Based on observation, interview, and record review the facility failed to ensure proper indwelling urinary catheter (device used to empty the bladder) care for four (R35, R50, R79, and R127) of four residents reviewed for dependent urinary catheter care, resulting in the potential for accidental removal, trauma to urethra and bladder, and urinary tract infection. Findings include: R127 During an observation and interview on 2/27/23 at 9:53 AM in R127's room with Family Member (FM) N, when asked about the care for R127, FM N said, Well he has a catheter, and they never make sure it is connected to his leg. When they come in to take care of him it (catheter) gets pulled and tugged on. You know that must hurt. FM N then proceeded to pull back the sheets and revealed that R127's catheter was not secured to his leg. During an observation on 2/28/23 at 1:20 PM, R127 did not have a device to secure the indwelling catheter. During an interview on 2/28/23 at 1:25 PM with Unit Manager (UM) O, while observing the indwelling catheter, UM O was asked if there should be a device to secure the hose (tubing) of the catheter, UM O said, Yes, there should be an anchor to hold it down. When asked the reason for securing the catheter down, UM O said, To prevent it from getting pulled on when turning the resident. When asked is it possible that a resident would have discomfort when it gets pulled, UM O said, Yes. Record review of R127's face sheet revealed admission into the facility on [DATE] and readmission on 2/4/23 with a pertinent diagnoses of a stage four pressure ulcer (Bedsore with muscles and tendons exposed). According to the MDS dated [DATE], R127 had impaired cognition and was total dependence with ADL care. Further review of section H (bowel and bladder) marked R127 had an indwelling catheter. Record review of R127's electronic medical records revealed no indwelling catheter care plan had been implemented for the resident. Record review of physician's orders dated 1/14/23, documented, Ensure foley anchor is in place q (every) shift, check for any kinks, hematuria (blood in urine), and sediment, notify MD (Medical Doctor) with any concerns. Ensure urinary privacy bag is in place and always keep bag below level of bladder. During an observation on 3/1/23 at 10:15 AM, R127 was observe to have an anchor (securement device) adhered to catheter tubing. However, the tubing was not secured to R127's leg. During an interview on 3/1/23 at 2:11 PM with Assistant Director of Nursing (ADON), when asked the purpose of securing an indwelling catheter, ADON said, It keeps the catheter from pulling on the resident and prevent trauma. When asked if all residents with an indwelling catheter should be provided and anchor to secure the hose/tubing of the catheter, the ADON said, Yes. 22349 R35 On 2/27/23 at 3:05 PM R35 was observed seated in his wheelchair in his room. R35's urinary catheter was tucked down through his pant legs and into a drainage bag that had a privacy cover. R35 said his catheter gets in the way and he has had problems with his catheter being pulled and tugged on that causes him pain. On 3/01/23 at 9:51 AM R35 was observed laying in his bed with his urinary catheter tubing draining into a collection bag attached to the bed frame. The urinary catheter was not attached to an anchoring device. At this time CNA P was asked about the catheter being anchored to the resident's thigh. CNA P said, Yes, the catheter should be attached to his thigh with tape or something. I'll get one from the nurse. On 3/02/23 at 10:25 AM R35 was observed laying in his bed with his urinary catheter tubing draining into a collection bag attached to the bed frame. The urinary catheter was not attached to an anchoring device. An anchoring device was observed to be secured to the resident's right thigh, but the catheter tubing was not secured to the device. At this time Licensed Practical Nurse (LPN) Q was asked to observe the catheter tubing. LPN Q stated, The catheter tubing should be attached to the anchoring device. That is what it is there for. A review of R35's Electronic Health Record (EHR) revealed the resident had multiple diagnoses that included history of stroke and urinary retention that required a urinary catheter to drain urine. On 12/23/22 the physician ordered; Ensure foley catheter anchor is in place every shift, check for any kinks, hematuria, and sediment, notify MD with any concerns. A care plan for 'urinary catheter care' initiated on 8/4/21 included the following intervention; Use a catheter strap. Every Shift; Day, Night. R79 On 2/27/23 at 10:38 AM R79 was observed laying in his bed alert and awake. R79 had a suprapubic (s/p) urinary catheter (a tube that is surgically inserted through the abdominal wall into the bladder to drain urine) draining into a collection bag. The catheter tubing was pulled tight from the insertion site and hanging down from the bed and not attached to any anchoring device. The resident had an anchoring device attached to his right thigh that was not being utilized. On 2/28/23 at 8:47 AM R79 was observed laying in his bed. Upon inquiry he said that his s/p catheter was leaking a little bit around the insertion site but the nurse flushed it and it is draining into the tube and not leaking now. The catheter tubing was pulled tight from the insertion site and hanging down from the bed and not attached to any anchoring device. The resident did not have an anchoring device. On 3/02/23 at 9:57 AM R79 was observed laying in his bed. R79's s/p catheter was draining yellow urine into a collection bag. The s/p catheter was not secured to any anchoring device. On 3/02/23 at 10:15 AM Unit manager LPN M was asked about R79's s/p catheter. LPN M said that s/p catheters should be attached to anchoring devices to prevent pulling at the site and accidental dislodgement. LPN M said she would ensure R79 had an anchoring device. A review of R79's EHR indicated that the resident had several diagnoses that included neuromucular bladder that required a suprapubic urinary catheter to drain urine. On 4/20/22 the physician ordered the following; Ensure foley anchor is in place q shift, check for any kinks, hematuria, and sediment, notify MD with any concerns. Ensure urinary privacy bag is in place and keep bag below level of bladder at all times. A urinary care plan initiated on 6/18/21 included the following intervention; Ensure catheter anchor is in place. 39958 R50 In an observation on 2/27/23 at 10:36 a.m., Resident #50's (R50) catheter drainage bag hung from the right arm of the wheelchair and R50 foot was observed to rest on the drainage tubing. Review of a face sheet revealed, R50 admitted to the facility on [DATE] with pertinent diagnosis which included Dementia and Chronic Kidney Disease. Review of a Minimum Data Set (MDS) assessment, with a reference date of 2/16/23 revealed R50 had cognitive impairment with a Brief interview for Mental Status (BIMS) score of 7 out of 15 and required an indwelling catheter. Review of Physician orders revealed, R50 had orders which included, ensure foley anchor is in place q (every) shift, check for any kinks, hematuria, and sediment, notify MD (Doctor) with any concerns with a start date of 11/30/22. Maintain 16 Fr Suprapubic Catheter w/ (with) 10 cc (ml) balloon with a start date of 11/30/22. In an observation and interview on 3/01/23 at 9:25 a.m., Certified Nursing Assistant (CNA) R pulled R50's shirt up and anchor with brown matter was near the entrance of the Suprapubic catheter. In an interview on 3/1/23 at 9:29 a.m., LPN H reported the nurse provides care to R50's suprapubic catheter. In an interview on 3/1/23 at 9:40 a.m., LPN H reported R50 room had a large amount of drainage around the catheter site. In an observation on 3/1/23 at 9:42 a.m., CNA R assisted R50 to bed. A anchor heavily soiled with dark brown matter was around R50's catheter. The anchor was stuck together and not applied to R50's body and had no date. R50 had sticky residue on the left thigh. LPN H reported the residue was the tape where the anchor was positioned on R50's leg. In an interview on 3/1/23 at 9:54 a.m., LPN H reported the catheter anchor should be checked every couple days. LPN H then reported it should be removed when it is soiled. Review of the Catheter Care, Indwelling Catheter policy with a revised date of 8/2012 revealed, . Residents will have indwelling catheters cared for daily and as needed . Procedure . 9. Ensure that catheter tubing is secured to the resident's thigh.

Based on observation, interview and record review, the facility failed to post resident menus for 71 of 131 residents who received meals from the kitchen (specifically residents R70, R88, R38, and R52), resulting in resident complaints of not being informed of meal choices of the day and displeasure with meal service. Findings include: R70 On 3/1/23 at 12:35 P.M. during an observation and interview with R70 concerning selection of her meals, R70 stated, We never know what we are going to get for a meal, they serve us whatever they want to. The resident continued to explain you take what comes on the tray, I do not get to choose what I want. You get food, but it may not be what you want. Sometimes I ask staff especially when I get something I just do not like what I received for the meal. During the interview R70's tray was served the resident reviewed the tray and commented, Can I get some chocolate milk? I Prefer chocolate milk, but I never can get it, so maybe I can ask for Chocolate Boost (Supplement). R70 reported there was no posted menu on the unit and she was not aware of,or familiar with the channel on the television identified for providing the menu served to the residents. Review of the Minimum Data Set (MDS) dated [DATE], stated R70 was admitted to the facility on [DATE], with diagnoses that included: cerebral accident and hypertension. The resident was independent in cognitive skills for decision making (ability to think) and was independent in activities of daily Living (ADLs). On 3/1/23 at 12:05 P.M. Dietary Manager (DM) A was asked where was the menus posted for the residents and how did the residents know what was served for the day's meal? DM A said across from each nursing station a board should indicate the first and second choices on the resident's menu and that someone from the Dietary department should be calling each station letting the nursing staff know what's on the menu. When asked how that information was relayed to the residents DM A explained the televisions in each resident's room and in the common area of each floor the television should display the menu for the day. During the interview an observation was made with DM A of the television screens in the common areas and the nursing stations. The televisions in the common area were disconnected and no menu was posted on the third floor. DM A then stated the facility no longer had the capability to have access to the channel that displayed the resident's menu for the day. A request was made to review the policy for posting of resident's meals. At 2:30 P.M., in a subsequent observation of each dining room and bulletin boards across from the Nurses Unit, no menus were observed posted throughout the facility. In addition, resident menus were not observed to be posted on the third floor on 2/28/23 and 3/1/23. 46481 R88 During interview on 2/27/2023, at 11:25 AM, when ask about the food menu's, R88 said, I do not know what is being served. I do not get a menu and I do not get to make any choices. Record review revealed R88 was admitted on [DATE], with diagnosis that included heart failure and hypertension. R88 was alert and oriented and cognitively intact. R38 During an interview on 2/28/2023, at 10:12 AM, R38 said she did not like the food and did not know what was ever going to be served for her meals. When R38 was queried did she get a choice of selecting foods items from the menu, R38 shook her head indicating no. Record Review revealed R38 was admitted on [DATE], with diagnosis: seizures, hypertension, diabetes mellitus. R38 was, alert, oriented and able to make needs known. R52 During an interview on 2/27/2023, at approximately 12:00 PM R52 was queried how was the food? R52 stated, I don't like the food. I never know what I am going to eat or receive on my tray. During an interview and observation at lunch on 3/3/2023, at 12:30 PM, R52 stated They serve me ham on the other day. I do not eat pork. The facility provided the spring and summer menu, 2022 cycle menu. Review of the menu revealed residents were served ham for the dinner meal on Tuesday, 2/28/2023. R52 was queried did he know what was being served for today's lunch, R52 stated he did not. Record review revealed, R52 was admitted on [DATE], with diagnosis: acute neurological disorder. R52 was alert and oriented, and cognitively intact. On 3/1/2023 At 3:00 P.M. review of the facility's policy, titled: Menus, with a revision date of August 2022, documented in part under procedure (4). Menus for Regular and Therapeutic or Special diets for the current week shall be posted in the Dietary Department and resident Dining Area.

Based on observation, interview, and record review, the facility failed to effectively clean and maintain food service equipment effecting 88 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination. Findings include: On 02/27/23 at 09:41 A.M., An initial tour of the food service was conducted with Dietary Manager A. The following items were noted: Paper Storage Room: 2 of 3 overhead light assemblies were observed non-functional. Dish Room: 6 of 15 overhead light assemblies were observed non-functional. 4th Floor North Nourishment Room: The Traulsen one-door reach-in cooler interior light bulb was observed non-functional. 5th Floor South Nourishment Room: 1 of 2 overhead light assemblies were observed non-functional. The 2017 FDA Model Food Code section 6-303.11 states: The light intensity shall be: (A) At least 108 [NAME] (10 foot candles) at a distance of 75 cm (30 inches) above the floor, in walk-in refrigeration units and dry FOOD storage areas and in other areas and rooms during periods of cleaning; (B) At least 215 [NAME] (20 foot candles): (1) At a surface where FOOD is provided for CONSUMER self-service such as buffets and salad bars or where fresh produce or PACKAGED FOODS are sold or offered for consumption, (2) Inside EQUIPMENT such as reach-in and under-counter refrigerators; and (3) At a distance of 75 cm (30 inches) above the floor in areas used for handwashing, WAREWASHING, and EQUIPMENT and UTENSIL storage, and in toilet rooms; and (C) At least 540 [NAME] (50 foot candles) at a surface where a FOOD EMPLOYEE is working with FOOD or working with UTENSILS or EQUIPMENT such as knives, slicers, grinders, or saws where EMPLOYEE safety is a factor. Power Washroom: The ceiling drywall surface was observed (etched, scored, particulate), within one corner. The damaged drywall surface measured approximately 36-inches-wide by 36-inches-long. Dietary Manager A indicated she would contact maintenance for necessary repairs as soon as possible. The 2017 FDA Model Food Code section 6-501.11 states: PHYSICAL FACILITIES shall be maintained in good repair. The Traulsen 4-door reach-in cooler door gaskets were observed soiled with accumulated and encrusted dust/dirt deposits. Dietary Manager A indicated she would have staff thoroughly clean and sanitize the door gaskets as soon as possible. 4th Floor South Nourishment Room: The Magic Chef microwave oven interior was observed (etched, scored, particulate, corroded). 5th Floor South Nourishment Room: The Magic Chef microwave oven interior was observed (etched, scored, particulate, corroded). 6th Floor South Nourishment Room: The Magic Chef microwave oven interior was observed (etched, scored, particulate, corroded). 6th Floor North Nourishment Room: The Magic Chef microwave oven interior was observed (etched, scored, particulate, corroded). The 2017 FDA Model Food Code section 4-601.11 states: (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. On 02/28/23 at 01:45 P.M., Record review of the Policy/Procedure entitled: General Cleaning of the Nourishment Rooms dated 11/08/19 revealed under Policy: The nourishment rooms will be kept neat and clean. Record review of the Policy/Procedure entitled: General Cleaning of the Nourishment Rooms dated 11/08/19 further revealed under Procedure: (2) All hard surfaces will be wiped down daily. This includes cabinet doors, refrigerator door, the inside and outside of the microwave paying attention to the microwave door seal which must be wiped down daily. Floors will be swept and spot mopped as needed. Drains will be kept free of debris. (4) Report any items in the room that appear to be broken or out of service, worn or will not come clean. You can report these issues to your supervisor. On 02/28/23 at 02:00 P.M., Record review of the Policy/Procedure entitled: Cleaning Equipment and Utensils dated 03/2012 revealed under Policy: It is the policy of this facility that food service equipment and utensils will be properly cleaned and sanitized to prevent contamination. Record review of the Policy/Procedure entitled: Cleaning Equipment and Utensils dated 03/2012 further revealed under Procedure: (3) All Dietary Staff will be in-serviced on cleaning and sanitizing equipment.

Based on interview and record review the facility failed to offer immunizations and provide education for five residents (R29, R43, R104, R115, and R124) of five residents reviewed for immunizations, resulting in the potential for the spread of respiratory infection among respiratory compromised residents. Findings Include: R29 Record review revealed R29 was admitted into the facility on [DATE] and readmitted on [DATE] with a pertinent diagnosis of chronic (long term) respiratory failure. According to the Minimum Data Set (MDS) dated [DATE], R29 had Impaired cognition and was required total assistance with Activities of Daily Living (ADLS) Record review of R29's Preventative Health Care revealed no documentation that immunizations for influenza, pneumococcal were offered or education provided. There was no documentation of the refusal of immunizations. R43 Record review revealed R43 was admitted into the facility on [DATE] and readmitted on [DATE] with a pertinent diagnosis of acute (a recent episode) and chronic respiratory failure. According to the MDS dated [DATE], R43 had intact cognition and required total assistance with ADLS. Record review of R43's Preventative Health Care revealed no documentation that immunizations for influenza and pneumococcal were offered or education provided. There was no documentated evidence that R43 refused immunizations. R104 Record review revealed R104 was admitted into the facility on [DATE] and readmitted on [DATE] with a pertinent diagnosis of chronic respiratory failure. According to the MDS dated [DATE], R104 had impaired cognition and required total assistance with ADLS. Record review of R104's Preventative Health Care revealed no current documentation that immunizations for influenza and pneumococcal were offered, or education provided. No documentation that resident or resident representative refused immunizations. Further review revealed last influenza immunization was offered on 10/20/21. R115 Record review revealed R115 was admitted into the facility on [DATE] and readmitted on [DATE] with a pertinent diagnosis of acute and chronic respiratory failure. According to the MDS dated [DATE], R115 had impaired cognition and required total assistance with ADLS. Record review of R115's Preventative Health Care revealed no current documentation that immunizations for influenza and pneumococcal were offered or education provided. No documentation that resident or resident representative had refused immunizations. Further review revealed resident had received last influenza vaccine on 11/1/21 and last pneumococcal vaccine in 1/12/13. R124 Record review of R124's face sheet revealed admission into the facility on [DATE] and readmission on 2/22/23 with a pertinent diagnosis of dependence on ventilator (device used to maintain breathing). According to the MDS dated [DATE], R124 had impaired cognition and required total assistance with ADLS. Record review of R124's Preventative Health Care revealed no documentation that immunizations for influenza and pneumococcal were offered or education provided. No documentation that resident or resident representative had refused immunizations. During an interview on 3/2/23 at 3:00 PM with Infection Control Preventionist (ICP), when asked where immunizations were documented in the electronic medical record for residents, ICP said, In the Preventative Health Care section of each residents record. After reviewing the Preventative Health Care section for each of the five sampled residents it was confirmed that immunizations were not offered to those residents. When asked when immunizations should be offered, ICP stated, They should be offered on admission; pneumococcal if appropriate and flu should be offered during flu season. The ICP then explained that the facility failed to offer flu and pneumococcal immunizations and education to residents R29, R43, R104, R115 and R124. During an interview on 3/2/23 at 3:30 PM with the Assistant Director of Nursing (ADON), when asked should the residents or the resident representatives been offered immunizations and education for each resident, ADON stated, Yes. When asked the purpose of providing immunizations, ADON said, To prevent the spread of infection. Record review of policy Influenza/H1N1 (Swine Flu) revised in January 2022, documented the following: .3. Have residents and staff immunized before the beginning of the influenza season, (start in October each year) . 4. If a new resident enters the facility during flu season, offer the resident the vaccine if not already received. Record review of policy Pneumonia/Vaccination revised January 2022, documented the following: .1. Offer pneumococcal vaccine to residents on admission. 2. Offer annual influenza vaccine.

Based on interview and record review, the facility failed to provide care in a respectful and dignified manner for two (R17 and R79) of seven residents reviewed for resident rights resulting in R17 and R79 being embarrassed and having feeling of low self-esteem when nursing staff talked on their cell phones about after-work activities while delivering care to the residents. Findings include: R17 On 2/27/23 at approximately 1:45 PM R17 said she felt ignored and disrespected because most staff at the facility come into her room and talk on their cell phones while delivering care to her. R17 said she reported this to the Director of Nursing (DON) and the DON gave the resident her personal cell phone number to contact her when this happens. One day every single person that came into my room was on their phone. The respiratory therapist, the CNA (certified nursing assistant), even the nurse while she was giving me my meds. It was ridiculous! On 2/28/23 at approximately 9:30 AM R17 said, So, just last night on the afternoon shift the CNA came in with her cell phone on speaker. She put her cell phone on my table while she was helping me. I had to hear everything. She said she was tired from last night and how she didn't want to be here. You know how that makes me feel when the person cleaning me up says they don't want to be here? I don't want to be here either! According to the Minimum Data Set (MDS) dated [DATE] R17 had multiple diagnoses that included respiratory failure with tracheostomy and morbid obesity. R17 required total assistance from one staff member for personal hygiene. R17 was identified to have intact cognition with a Brief Interview for Mental Status (BIMS) Score of 15/15 with no memory deficits. R79 On 2/27/23 at approximately 10:30 AM R79 said, The staff always say they are too busy. Yeah, they are too busy on their phones all the time. I have to wait for them to get off the phone before they get me up. On 2/28/23 at approximately 8:50 AM R79 said, I felt stupid and embarrassed a couple days ago because a CNA came in my room talking out loud. I thought she was talking to me, so I started talking to her. She said I'm not talking to you. I'm on my phone. I told her she shouldn't be on the phone while she is in here with me. She put her phone on speaker and continued to talk to someone else about her plans for the weekend while she was in here (the resident's room). Makes me feel like they don't really want to be here. According to the MDS dated [DATE], R79 had multiple diagnoses that included Rheumatoid Arthritis with impairment to all four extremities that required total assistance from one staff member for all Activities of Daily Living. R79 was identified to have intact cognition with a BIMS Score of 15/15 with no memory deficits. On 3/1/23 at 11:36 AM the Assistant Director of Nursing (ADON) was asked if there were any concerns from residents about facility staff being on their personal cell phones while delivering care. The ADON said she was unaware of any incidents or concerns regarding cell phone use but would contact the Director of Nursing (DON) who was not in the facility during the time of the survey. On 3/1/23 at approximately 2:30 PM the Nursing Home Administrator (NHA) was asked about the use of cell phones by staff during delivery of care. The NHA said, I have had several complaints from residents abouts staff using their cell phones in care areas. It is not allowed. We have in-serviced staff about this. We don't have a specific policy about cell phone use, but it is in the employee handbook. Everyone gets an employee handbook upon hire. Review of the employee handbook last revised 8/31/2019 page 46; No electronic devices or the use of electronic personal cell phones in care areas. The use of electronic personal cells phone or other electronic device is only permitted in designated areas during (staff) meal periods.

Based on observation, interview, and record review the facility failed to implement care plan interventions effecting three residents (R127, R58, and R65) of 34 residents reviewed for comprehensive care plans, resulting in the potential for unmet needs. Findings Include: R127 During observation on 2/27/23 at 9:53 AM in R127's room, resident was seen to have an indwelling urinary catheter (device used to empty the bladder of urine). Record review of R127's face sheet revealed admission into the facility on [DATE] and readmission on 2/4/23 with a pertinent diagnoses of a stage four pressure ulcer (Bedsore with muscles and tendons exposed). According to the MDS dated [DATE], R127 had impaired cognition and was total dependence with ADL care. Further review of section H (bowel and bladder) marked R127 had an indwelling catheter. Record review of R127's electronic record revealed no care plan written or implemented related to the indwelling urinary catheter. During interview on 3/1/23 at 2:11 PM with Assistant Director of Nursing (ADON), after reviewing all the care plans for R58 and R127 it was confirmed that R58 had no care plan for the diagnosis of dementia and R127 had no care plan for an indwelling catheter. When asked related to the timeframe each resident had been at the facility, should those care plans have been implemented, ADON stated, Yes. When asked the purpose of implementing care plans for residents, ADON replied, To ensure each resident received individualized care for their needs. R58 Record review of R58's face sheet revealed admission into the facility on [DATE] with a pertinent diagnosis of dementia (condition related to memory loss and judgement). According to the Minimum Data Set (MDS) dated [DATE], R58 had intact cognition and was provided with extensive assist with most Activities of Daily Living (ADLs). Further review of MDS revealed in section I, it was marked that resident had a diagnosis of dementia. Record review of all physician orders and care plans documented no interventions for dementia care. 22349 R65 On 2/27/23 at 11:07 AM R65 was observed in bed with a tracheotomy and splints to both arms (bilaterally). R65's arms were contracted at the elbow and wrist area with the splints pushed out to the side and not completely attached to the resident's forearms. There were two Velcro straps on each arm splint to attach the splint to the resident's arm and wrist areas. The Velcro straps were not connected at the wrist areas which allowed the resident's right elbow and both wrists to remain contracted. On the resident's window ledge (not in use) there were two carrot splints (carrot shaped splints used to position the fingers always from the palm to protect the skin from moisture and nail puncture). R65 was unable to be interviewed due to severely impaired cognition. Observations on 2/28/23 at 8:58 AM, 3/1/23 at 9:30 AM, 3/2/23 at 10:30 AM and again on 12:22 PM revealed that R65 did not have splints or carrots in place. According to the Minimum Data Set (MDS) dated [DATE], R65 had multiple diagnoses that included anoxic brain damage, functional quadriplegia and contractures of upper extremities with severe contracture of left hand. A Physician's orders dated 2/28/20 included the following; Restorative: Apply bilateral hand/wrist splints, and right elbow splint daily. The Restorative Therapy assessment dated [DATE] included the following; Resident to wear a Left hand/wrist carrot and a Right elbow brace and carrot for up to 4 hours a day. A review of R65's Electronic Health Record (EHR) revealed no care plan for restorative care or splints. On 3/2/23 at 12:30 PM during a interview with Nurse Manager, Licensed Practical Nurse (LPN) K she reviewed R65's EHR and confirmed there was no care plan for the restorative care or splinting. LPN K said, There should be a care plan for us to refer to for the splints. I don't know why it isn't there. According to the facility's RAI and Care Planning policy with an effective date 8/20/2020; As required at 42 CFR 483.25, the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and physical well-being. The care plan must be reviewed and revised periodically and the services provided or arranged must be consistent with each resident's written plan of care.

Based on observation, interview, and record review, the facility failed to ensure orthotic devices (hand/arm splints) were provided for two (R65 and R110) of 10 residents reviewed for restorative services resulting in the potential for deconditioning and worsening of contractures. Findings include: R65 On 2/27/23 at 11:07 AM R65 was observed in bed with a tracheotomy and arm splints to both arms (bilaterally). R65's arms were contracted at the elbow and wrist area with the splints pushed out to the side and not completely attached to the resident's forearms. There were two Velcro straps on each arm splint to attach the splint to the resident's arm and wrist areas. The Velcro straps were not connected at the wrist areas which allowed the resident's right elbow and both wrists to remain contracted. On the resident's window ledge there were two carrot hand splints (carrot shaped splints used to position the fingers away from the palm to protect the skin from moisture and nail puncture). R65 was unable to be interviewed due to severely impaired cognition. Observations on 2/28/23 at 8:58 AM revealed R65 to be in bed without arm splints or carrot splints in her hands. The arm splints and hand carrots were observed on the resident's windowsill. On 3/1/23 at 9:30 AM R65 was observed in a recliner-chair in the common area without any arm splints on. R65 did have carrot splints in both hands. On 3/2/23 at 10:30 AM R65 was in bed without arm splints or hand carrots in use. On 3/2/23 at 12:22 PM R65 was in bed without arm splints or hand carrots in use. According to the Minimum Data Set (MDS) dated [DATE], R65 had multiple diagnoses that included anoxic brain damage, functional quadriplegia and contractures of upper extremities with severe contracture of left hand. A Physician's orders dated 2/28/20 included the following; Restorative: Apply bilateral hand/wrist splints, and right elbow splint daily. A review of R65's Electronic Health Record (EHR) revealed no care plan for restorative care or splints. On 2/28/23 at approximately 4:20 PM Occupational Therapist (OT) S said that R65 had orders from therapy on 11/23/22 to receive PROM (passive range of motion) to BUE (bilateral upper extremities) 3-5 times per week for 12 weeks and splinting to bilateral hands that included arm splints and carrots for 4 hours a day, 3 - 5 times per week for 12 weeks. OT S said that she had written her orders on a Restorative Assessment form and given them to the Therapy Director for 'Restorative Therapy' to implement. OT S said, Restorative Therapy is under Nursing. They write the orders in the resident's medical chart. According to the Restorative Assessment form dated 11/23/22 the recommendations were written as stated above. A typed document dated 11/23/22 was signed by both Restorative Certified Nursing Assistants (RCNA) L and U that indicated the following; We have received training on active/active assisted/passive Range of Motion training, Don and Doff (apply and remove) splints, address skin and splint hygiene. We will communicate back to the therapy department if there is a decline or any change in ROM/splinting. On 3/2/23 at 12:30 PM during a interview with Nurse Manager, Licensed Practical Nurse (LPN) K she reviewed R65's EHR and could not see where consistent documentation of splint application or PROM was documented. LPN K confirmed there was no care plan for the restorative care or splinting and said, There should be a care plan for us to refer to for the splint and PROM orders. I don't know why it isn't there. On 3/02/23 at approximately 12:35 PM RCNA L was asked about R65's arm splints and hand carrots not being in use. RCNA L said she had not gotten to R65 yet because the other restorative aide, RCNA U had been pulled from restorative therapy and was working on the floor as a direct care CNA (Certified Nursing Assistant) RCNA L said, This happens a lot and puts us behind. R110 On 2/27/23 at approximately 11:30 AM R110 was alert and oriented laying in bed with a tracheotomy. R110 was able to answer questions verbally. R110 said that he was getting therapy and wore a splint on his right hand a while back but was not getting therapy or the hand splint now. R110 said that his strength had improved but his right hand in a contracted position. R110 could not recall when he had last received therapy or had the splint applied to his right hand. On 2/28/23 at 3:00 PM R110 was observed laying in bed leaning slightly off to the left side of the bed. R110 said that he slides to the left side of the bed and needs repositioning. At this time CNA V came into the room to reposition the resident. CNA V didn't know if R110 received any restorative therapy or if he wore a splint. A hand splint in a blue mesh bag was observed in the resident's closet. CNA V said, Restorative does the splints, so I don't know if he wears that or not. On 3/01/23 at 9:37 AM R110 was observed laying in bed without a right hand splint in use. The hand splint was observed in the resident's closet. R110 said he used to wear a splint on his right hand a while back, but no one had put it on him recently. According to R110's EHR the resident had multiple diagnoses that included history of a stroke with right sided weakness and tracheotomy. The MDS dated [DATE] indicated that R110 had impaired cognition but could easily make his needs known. R110 required extensive assistance from one person for all Activities of Daily Living and had impairment on both upper and lower extremity of one side. On 1/25/23 the Physician orders were; Restorative Nursing: PROM exercises of RUE (Right Upper Extremity) for 10 repetitions x 3 sets 3-5 x weekly as tolerated. Once a day on Mon, Tues, Wed, Thurs, Fri; 7:00 AM- 7:00 PM. There is no order for right hand splint. According to R110's 'Restorative Assessment' form dated 12/23/22 R110 was prescribed PROM to the RUE 2-3 x per week along with a Right hand splint daily 4 hours at at time 2 times per day from 12/23/22 - 3/20/23. On 3/1/23 at 10:07 AM the Therapy Director, Physical Therapist (PT) T said when residents are discharged from Physical Therapy (PT) and/or Occupation Therapy (OT) and placed on Restorative Therapy the Therapist writes the resident's orders on a 'Restorative Assessment' form and gives it to nursing for them to transcribe and implement the orders. PT T reviewed R110's EHR and confirmed the orders from the 'Restorative Assessment' form did not match the orders transcribed into the resident's EHR. There were no orders for R110's Right hand splint. PT T said therapy orders are written and sent to the DON (Director of Nursing) for them to be transcribed in the resident's EHR. Nursing is over the 'Restorative Therapy' program. On 3/2/23 at 12:30 PM during a interview with Nurse Manager, Licensed Practical Nurse (LPN) K she confirmed that R110 did not have any orders for the right hand splint. LPN K said she would call the DON to review the resident's orders. At 3:48 PM LPN K said the DON could not recall any orders for R110's Right hand splint. The DON was not present in the facility during the time of the survey. On 3/02/23 at approximately 12:35 PM RCNA L was asked about R110's Right hand splint and could not recall if it that was part of his therapy at this time. According to the facility's undated 'Restorative Policy'; PURPOSE and POLICY STATEMENT: Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition or choices demonstrate that such diminution was unavoidable. PROCESS: Candidates for a restorative nursing program maybe identified in the following ways: *After discharged from a skilled therapy service or in conjunction with a therapy service. *Upon review during the admission process and/or RAI assessments identifying that the resident could benefit from restorative programming. 1. Following identification of need, the interdisciplinary team will put a plan in place that identifies the restorative approaches that will support the resident needs/choices. 2. The applicable restorative interventions will be assigned, which may include ROM, ambulation, transfer, ADLs, adaptive equipment, splinting, bed mobility, bathing, dressing, oral care, toileting, communication and/or dining. 3. The program(s) will be identified in the resident's medical record. 4. Periodically the Restorative Nurse or designee will review and discuss progress or lack of progress toward restorative goals with caregivers and the resident/ representative. The resident's plan of care and restorative program will be revised as indicated. 5. The restorative aides will document tolerance and time in resident care guide/CNA POC charting per orders/frequency.

This citation pertains to intake MI00130258. Based on observation, interview, and record review the facility failed to follow the standards of infection control for proper PPE use (mask, gloves, gown) and hand hygiene for one resident (R43) out of three residents reviewed for transmission based precautions, resulting in the increased potential for cross-contamination of diseases which places a vulnerable population at high risk for infections. Findings include: In an observation and interview on 2/27/23 at 11:12 a.m., a sign on R43'room door with directions to see the nurse before entering the room was present. Licensed Practical Nurse (LPN) E reported a gown and gloves must be put on before entering R43's room. LPN E reported R43 had contact precautions for an infection in the tracheostomy. Review of an Admission Record revealed, Resident #43 (R43) was readmitted to the facility on [DATE] with pertinent diagnosis which included Acute and chronic respiratory failure with hypoxia and Dependence on respirator. Review of a Minimum Data Set (MDS) assessment, with a reference date of 1/27/23 revealed R43 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 12 out of 15 and required a tracheostomy. In an observation and interview on 2/28/23 at 9:31 a.m., LPN G stood in R43's room with a vital signs machine and did not wear a gown, or gloves. LPN G reported R43 did not have a sign on the door to indicate contact isolation precautions. LPN G stated, They don't have a tag on the door. LPN G reported R43 did not have PPE in the room. LPN G was then directed to the sign on R43's door which stated, Please See Nurse Before Entering the Room. LPN G then stated, Oh. In an interview on 3/1/23 at 10:01 a.m., Infection Preventionist (IP) F reported R43 had CRE in the stool and required contact isolation precautions. IP F then reported staff should wear a mask, gloves, and gown when entering R43's room. Review of a document with the title THE FOLLOWING RESIDENTS ARE ON CONTACT ISOLATION PRECAUTIONS with no date revealed, R43 named on the list with a diagnosis of CRE (Cabapemem-resistant Enterobacteriaceae) (body secretion infection). Instructions included Gowns, Gloves, Meticulous Hand-Washing with each care instance. In an interview on 3/2/23 at 3:25 p.m., Assistant Director of Nursing (ADON) D reported if a resident is on contact precautions staff must wear proper PPE when touching the resident. ADON D reported touching included taking a resident's vital signs.

This citation pertains to intake MI00132632. Based on interview and record review, the facility failed to immediately report allegations of abuse for one resident (R601) of three residents reviewed for abuse, resulting in allegations of abuse that were not reported to the Nursing Home Administrator and the State Agency timely and the potential for further allegations of abuse to go unreported and not thoroughly investigated. Findings include: Review of an Face Sheet revealed, R601 readmitted to the facility on [DATE] pertinent diagnosis which included Dementia, Adjustment disorder, and Anxiety. Review of a Minimum Data Set (MDS) assessment, with a reference date of 10/25/22 revealed R601 had severe cognitive impairment with a Brief interview for Mental Status (BIMS) score of 6 out of 15. Review of an Incident document with a discovered report date of 11/3/22 revealed, it was reported to the State Agency (SA) that on 10/24/22 Certified Nursing Assistant (CNA) D reported during care CNA G spit on R601 and verbalized derogatory words toward R601. In an interview on 12/1/22 at 2:39 p.m., Licensed Practical Nurse (LPN) C reported on 11/3/22 CNA D told her CNA G spit on R601 and stated derogatory words. LPN C reported she asked CNA D if she reported the incident, the answer was no. LPN C then reported the incident to the Nursing Home Administrator (NHA). In a telephone interview on 12/1/22 at 2:57 p.m., CNA D reported she did report the alleged incident on the day it occurred. CNA D reported she was off work for 3 days and reported the incident when she returned to work. In an interview on 12/1/22 at 3:05 p.m., Director of Nursing (DON) B confirmed that the alleged incident occurred on 10/24/22 and CNA D did not report it until 11/3/22. DON B reported all allegations of abuse should be reported immediately. In an interview on 12/1/22 at 3:49 p.m., NHA A reported that abuse should be reported immediately. Review of an Abuse and Neglect Prohibition Policy with a reviewed date of 8/2012 revealed, Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property . 7. Reporting and Response A. The staff will report all allegations of abuse, neglect, and misappropriation of property to the Administrator immediately .

This citation pertains to intake: MI 776. Based on interviews and record reviews the facility failed to conduct weekly skin assessments, obtain a timely initial wound care consult, or administer pressure ulcers treatments as prescribed for one (R709) of four residents reviewed for pressure ulcers, resulting in R709 developing a stage four ( full loss of skin and muscle, exposing bone) on his sacral/coccyx area while at the facility. Findings include: On 6/22/21 at 4:30 PM, R709's family member said the resident developed a Stage 4 pressure ulcer while at the facility. According to R709' face sheet he admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The initial Minimum Data Set (MDS) dated [DATE] R709 had intact cognition with a BIMS (brief interview of mental status) score of 15/15 and require two staff persons for bed mobility and transfers from surface to surface. R709 was determined to be totally incontinent of both bowel and bladder. Section M of the MDS indicated that R709 was 'at risk' for pressure ulcers but had 'none' at the time of the assessment. A care plan for 'pressure ulcers' was initiated on 1/26/21 identified the following interventions: weekly skin assessment will be conducted on shower days and any alteration in skin will be reported. Apply skin barrier cream with brief changes every shift and as needed. There is no documentation, progress note, or note on the resident's electronic medical record (EMR) to indicate that 'skin barrier' cream was applied with brief changes or every shift as needed. A review of R709's EMR revealed on 2/2/21 a progress note written by Licensed Practical Nurse (LPN) Y documented, red excoriated buttocks and scrotal area, wound care referral. There is no additional documentation indicating measurements or skin treatments administered. On 2/6/21 a progress note written by LPN Z documented, fragile skin to coccyx areas, barrier cream applied. There are no additional documentation indicating descriptions, measurements, or skin treatments administered until 2/23/21 (17 days later). R709's initial 'Wound Care' note is on 2/23/21 at 5:41 PM, (21 days after the initial wound care referral). The facility's wound care nurse (LPN) AA documented, resident noted to have s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan for 'pressure ulcers' was revised to Stage 3 pressure ulcer to left buttock/coccyx interventions included: wound care doctor will assess sites weekly for progress, appearance and treatment. The following two skin treatments were ordered: 1) cleanse left buttock and coccyx with normal saline apply Med honey gel then cover with dry dressing daily. 2) cleanse left lateral thigh with normal saline apply xeroform [MEDICATION(S)] dressing and cover with dry dressing every other day. A review of R709's February 2021's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Zero of 3 skin treatments (100%) were left 'blank' and not documented as 'administered' for the left lateral thigh skin treatment. The follows dates are left blank on the February MAR, with no corresponding progress notes: 4/23/21, 4/25/21 and 4/27/21. R709's EMR revealed that on 2/25/21, the Wound Care Physician's initial assessment (24 days after ordered) documented the following assessment: Wound #1 Sacro coccyx/bilateral buttocks is a Stage 3 pressure ulcer measuring 9 cm length x 12 cm width x 0.3 cm depth, with an area of 108 sq cm (square centimeters) and volume of 32.4 cubic cm. There is moderate amount of sero-sanguineous drainage (blood tinged) noted which has no odor, Wound bed has necrotic base epithelialization (discolored dead cells with some partial regeneration). Wound orders; were as follows: med honey gel daily and PRN. On 3/11/21, the wound care notes document the following wound assessment: Wound #1 Sacro coccyx bilateral buttocks is a Stage 3 measuring 9.0 cm length x 13.0 cm width x 2.5 cm depth. Wound Orders: Dakin's solution ¼ strength BID (twice a day) and PRN (as needed) for 7 days - with triad paste to peri wound (around the wound). A review of R709's March 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was written as Dakin's solution ¼ strength for 7 days - with triad paste to peri wound, PRN (as needed, not scheduled). There was no documentation on R709's March MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/18/21 the wound care notes indicated that R709's Sacro coccyx wound had deteriorated and documented the following assessment: Wound #1 Sacro coccyx bilateral buttocks is a Stage 3 measuring 10.0 cm length x 13.0 cm width x 4.0 cm depth. R709's wound was debrided (surgical excision of the necrotic tissue) in the facility and the following orders were prescribed: cleanse Sacro coccyx/buttock with normal saline, apply crushed [MEDICATION(S)] to wound bed (an anti-fungal medication), then apply hydrogel impregnated gauze to site and cover with dry dressing twice daily. On 6/24/21 at approximately 9:45 AM the Wound Care Nurse Practitioner (NP) BB was interviewed regarding R709's wound. NP BB said that R709's wound did deteriorate while he was at the facility and his coccyx wound was debrided at the bedside. NP BB was unaware that R709 had missed some skin treatments between 3/11/21 - 3/18/21, and confirmed that missing treatments could have resulted in his wound worsening. NP BB said that R709 had discharged home with the wound at a Stage 4 (total loss of skin and soft tissue, exposing bone) and home care nurses were aware of the ordered treatments at the time of discharge. A review of R709's last wound care note on 4/16/21 revealed the following assessment: Stage 4 pressure ulcer to Sacro coccyx is stable with 30% scatter yellow necrosis (dead cells/tissue) and minimal slough. Bone remains exposed. Discharge planning includes wound care notes. On 6/28/21 at 2:00 PM during an interview with Director of Nursing (DON) B she confirmed that the wound care physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON B confirmed that there were no administrations of the treatments documented on the PRN orders of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . DON B said the Wound Care physician comes into the facility weekly, except during times of covid-1 when tele-visits were conducted. DON B did not provide an explanation as to why the wound care consultation took 24 days to assess R709 and prescribed skin treatments after they were consulted. The original wound care nurse, LPN AA is no longer employed at the facility. A review of R709's progress notes revealed that on 3/11/21 at 5:49 PM, 3/12/21 at 3:32 PM, 3/13/21 at 5:30 AM and 6:00 PM, 3/14/21 at 6:55 AM, 3/15/21 at 6:30 AM, 3/16/21 at 4:47 PM, 3/17/21 at 5:00 PM, and 3/18/21 at 6:55 AM and 4:30 PM various nurses had documented that pressure ulcer treatment had been done. According to the facility's 'Pressure Ulcer and Skin Care Management' policy effective 1/12/2020: A resident that enters the facility without pressure ulcers does not develop pressure ulcers unless the resident's clinical condition demonstrates that they were unavoidable and a resident having pressure ulcers receives necessary treatment and services to promote healing , prevent infection and reduce the risk of new pressure ulcers developing. Procedure 1. A licensed nurse checks the resident's body for the presence of pressure ulcers, wound sand other skin conditions: at admission .weekly on resident. 2. The licensed nurse documents that the body check was completed on the resident's 'head to toe' skin records. 3. The presence of any pressure ulcer, wound, or other skin condition is documented weekly on the pressure ulcer skin report forms.

This citation pertains to intake #MI 45. Based on interview and record review, the facility failed to provide timely, appropriate hospital care and services for one (#702) of four sampled residents reviewed for quality of care, resulting in prolonged fever, increasingly abnormal blood test results, infection and dehydration. Findings include: The complainant reported to the State agency that resident #702 (R702) had a fever and developed dehydration while receiving hydration and nutrition via gastric feeding tube, requiring hospitalization . During a phone interview on 1/15/19 at 10 AM, the complainant said that R702 was transported to the hospital emergency room from the facility and was told by hospital physicians that R702 had a bed sore that contained a lot of pus and infected tissue that needed to be removed (debrided) and that (R702) had dehydration. The complainant questioned how that could be, if R702 was receiving fluids by feeding tube as prescribed that was connected to an infusion pump regulated and adjusted by staff. Per the complainant, R702 was treated in the hospital for two weeks, improved and then discharged to another skilled nursing facility. R702's clinical record was reviewed and revealed the following: R702 was admitted on [DATE] with [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] noted R702 had severe cognitive impairment, a gastric feeding tube and required total assistance for all care. The tube feeding (TF) was prescribed at 75 cubic centimeters (cc) per hour. R702 was noted to have a small, fragile skin area to the coccyx from a healed scar (cicatrix) on admission. On 11/8/18, per notes by the contracted wound specialist, who began seeing R702 weekly, the area opened to a stage II (partial skin loss) pressure sore. On 11/15/18, the area was noted to be healed. On 11/25/18, nurses noted the area had re-opened measuring 1 centimeter (cm) by 1 cm. On 11/28/18, blood work was obtained. The white blood count (WBC) was high 13 (normal range 4.8-10.8), a sign of infection; Blood Urea Nitrogen (BUN) was high at 49 (normal range=10/24), the amount of waste product in the blood determining function of kidneys; Chloride level was 93 (normal range=96-108), a sign of dehydration. Water flushes through the TF were increased from 40 cc to 50 cc per hour. On 11/29/18, the wound specialist noted the wound had developed into a stage III (full thickness skin loss) pressure sore measuring 5.5 cm by 4.5 cm with a moderate amount of serous drainage and necrosis (black, dead tissue) at the base. On 12/5/18 at 2 PM, nurses noted drainage coming from (feeding tube insertion) site at the abdomen. The type of drainage was not noted. The TF was stopped, a new tube inserted, an X-ray done to confirm proper placement, blood work was ordered and the TF was restarted at 10:30 PM. At 11:45 PM, R702's temperature was 101 degrees. It was re-checked on 12/6/18 (no time noted) and was 98.9 degrees. On 12/6/18, the wound specialist noted the sore measured 13 cm by 14 cm with a large amount of drainage, necrosis, odor and was deteriorating. Crushed [MEDICATION NAME] (antibiotic) was prescribed topically (on the surface) to the wound. Per a 12/6/18 lab report, the WBC had increased to 15.9, the BUN increased to 50 and the chloride level dropped to 86. The next documented temperature was 100.8 on 12/7/18. A stat (immediate) chest x-ray and urine culture were ordered. The x-ray was negative for pneumonia. The urine culture showed large (greater than 100,000) colonies of E.coli (a bacteria found in feces) and that the bacteria would be susceptible (responsive) to a list of 16 different types of antibiotics, if prescribed. The water flushes were increased from 50cc to 60 cc per hour. The TF itself continued to run daily at 75 cc per hour starting at 6 PM until 1350 cc infused. On 12/9/18, the BUN increased further to 96, chloride level decreased to 82 and sodium level was low at 128 (normal range 133-148), a sign of dehydration. There were no documented nurse's notes between 12/7/18 and 12/10/18. Nurses documented in an SBAR (acute change in condition) Communication Form dated 12/10/18 at 2 PM: Abnormal labs, elevated blood sugar, fever this started on 12/7/18 temperature 100.3 BUN of 96 Blood sugars were 360-500-393-366 on 12/10/18 (normal range-=70 to 120). On 12/10/18, one (1,000 cc) bag of intravenous (IV) fluids was prescribed at 60 cc per hour for electrolyte imbalance/abnormality and recheck the electrolyte levels afterwards. The IV line had to be inserted by an outside nurse contractor and the IV started running at 4:25 PM per the contractor's note. On 12/11/18 at 5 AM, nurses noted, Resident has appeared to be in a hyperglycemic (high blood sugar) state .blood sugar was 500 and temperature was 100.8 degrees. The physician ordered blood and urine cultures. At 12 noon, nurses noted the physician was called. A bladder scan was ordered due to zero urine output. The urinalysis report dated 12/11/18, noted the urine was cloudy containing a marked amount (3+) of bacteria. The urine culture noted the presence of greater than 100,000 colonies of gram negative rods (a type of bacteria increasingly resistant to most antibiotics). A 12/11/18 lab report noted: sodium at 127, chloride at 81 and BUN at 116-result verified by repeat analysis. An SBAR form dated 12/11/18 noted: Diaphoretic (heavy sweating), increased temperature, [MEDICAL CONDITION], increased blood sugar and continues to remain in the 400-500 range. The resident has abnormal wheezing writer gave Tylenol because the temperature was increased and then temperature went down to 99.6 The blood sugar levels were high, despite receiving insulin. A handwritten note was observed on the back of a blank 12/11/18 lab report: Diagnosis: [REDACTED]. Per an order and a hospital transfer form dated 12/11/18: diagnosis-azotemia. There was no documented order for antibiotics between 11/28/18 thru 12/11/18, other than [MEDICATION NAME] topically to the pressure sore, nor an indication on medication records that R702 received had them. At 6 PM, when informed of the delay in proper care and treatment during acute change in condition in the resident already compromised by [MEDICAL CONDITIONS] and diabetes, the Administrator and acting Director of Nursing did not respond. Per review of the facility's Acute Change in Condition policy dated 1/2011: An Acute Change of Condition (AC[NAME]) is a sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains. 'Clinically important' means a deviation that, without intervention, may result in complications or death If a plausible cause was not found readily in someone with an AC[NAME], assess whether [MEDICAL CONDITION], fluid and electrolyte imbalance, infection, and medication related effects is the cause for the AC[NAME].

Based on observation, interview and record review, the facility failed to implement appropriate and timely care and services for one (#29) of 37 sampled residents reviewed for quality of care, resulting in consistently elevated, uncontrolled blood sugar levels and repeated emergency hospital transports and treatment for [REDACTED]. On 11/13/18 at 9:20 AM, resident #29 was observed lying in bed. The resident appeared very thin, lethargic, slow to respond to questions with some confusion and had a gastric feeding tube with a bag of tube feeding formula hanging by the bedside. At 2:30 PM, the resident's clinical record was reviewed. The resident was readmitted from the hospital on [DATE] with [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] noted that the resident had intact cognition and required total assistance for most care. The resident's Medication Administration Record (MAR) noted: From 10/17 thru 10/31/18, the resident was prescribed Humalog short-acting insulin, 6 units, three times a day with meals, scheduled at 7:30 AM-12 Noon-4:30 PM, but the 7:30 AM dose was missed on 10/18/18, the 12 Noon doses were missed on 10/25/18, 10/27/18 and 10/28/18, the 4:30 PM dose was missed on 10/28/18. At 7:30 AM on 10/26/18, the glucometer used to test the blood sugar level read Hi, meaning the level was too high for the device to measure, meaning above 500 (normal range=70 to 100). The MAR noted that the scheduled 6 units of insulin was given. There was no documented indication the physician was notified of the high reading or documented reasons why the doses were missed. The resident was prescribed [MEDICATION NAME] long-acting insulin, 8 units, every 12 hours at 9 AM-9 PM, but 9 AM doses were missed from 10/17 thru 10/21/18, on 10/25/18, 10/26/18, 10/29/18 and 9 PM doses on 10/20/18, 10/21/18, 10/25/18 and 10/28/18. At 9 AM on 10/26/18, the glucometer read Hi. The MAR noted that the scheduled 8 units of insulin was given. There was no documented indication the physician was notified or reasons why the doses were missed. The resident's blood sugars were tested each time insulin doses were given, although there was no documented order to do so and no documented order to give extra insulin doses based a sliding scale for elevated, abnormal blood sugars. The MAR indicated that the levels averaged 250-350 in October. On 10/30/18, nurses noted that the resident was hypoglycemic with a blood sugar of 50. The physician was called and ordered: decrease the [MEDICATION NAME] 8 units, down to 6 units every 12 hours and give an injection of [MEDICATION NAME] (to bring the blood sugar up) now (immediately). The MAR for 11/2018 reflected that starting 11/1/18, [MEDICATION NAME] 6 units was given every 12 hours, but no indication that Humalog was given. There was no documented order to discontinue it. Also, per the MAR and nursing notes, the blood sugar levels were not documented from 11/1 thru 11/4/18. The MAR was left blank in the spaces provided. On 11/5/18, a night shift nurse noted: The resident's blood sugar was elevated (no level noted)at 9 PM the previous night on 11/4/18 and attempts were made to notify the resident's primary care physician (PCP) three times without success. There was no documented indication the Director of Nursing (DON) or Administrator were notified of the situation. At 2:45 AM on 11/5/18, the night shift nurse had reached another physician and received an order: Give 10 units of [MEDICATION NAME] now and monitor blood sugar three times daily before meals. There was no documented re-check of the blood sugar until 7 AM. At 7 AM, the day shift nurse noted that the blood sugar still read Hi. She called the PCP's Nurse Practitioner (NP 'AA') and received a second order to give [MEDICATION NAME] 10 units now. The nurse noted on the MAR the following parameters (instructions) for sliding scale insulin: For a blood sugar of 151-200-give 2 units insulin, 201-250-give 4 units, 251-300-give 6 units, 301-350-give 8 units, 351-400-give 10 units, above 400-call physician. However, there was no written order for sliding scale insulin, the type of insulin to give and no corresponding parameters instructing how much insulin to give. There was no documented re-check of the 7 AM blood sugar until 11:30 AM. At 11:30 AM, the blood sugar remained elevated at 347. From 11/5/18 thru 11/13/18, the MAR noted that the blood sugar levels were higher than in October, averaging 350-400, including 14 times where 10 units of sliding scale insulin was given for levels above 351. On 11/7/18 at 7:30 AM, the blood sugar was 490. 10 units of sliding scale insulin was given with no documented indication the physician was notified. On 11/14/18 at 11:09 AM, the Registered Dietitian (RD 'S') was asked if she was aware of the resident's consistently elevated blood sugars since readmission on 10/16/18 and if there was any discussion with the physician. She said, I don't get involved with the blood sugars, that's the doctor. There were no documented progress notes in the chart from the PCP or NP 'AA' regarding the elevated blood sugars. At 11:20 AM, NP 'AA' was asked by phone about the high blood sugar levels and the whereabouts of progress notes discussing it. A few minutes later, he appeared on the nursing unit with a readmission History and Physical (H&P) dated 10/17/18 and said progress notes addressing the blood sugars were in the chart. The H&P, written by the PCP's associate physician, noted: significant past medical history of [REDACTED].continue insulin with sliding scale, continue [MEDICATION NAME] (insulin) monitor closely and will adjust treatment plans based on clinical course There was no documented prescription for [MEDICATION NAME] or an order for [REDACTED]. When asked how the blood sugars were being addressed, NP 'AA' was unable to respond and began looking through the chart. When he saw that blood sugars were not recorded on the MAR for 11/1 thru 11/4/18, he said, It's a nursing issue, indicating he was not responsible for that. He reviewed the orders and saw that there were no orders for sliding scale insulin and parameters. He then pointed to the sliding scale written on the MAR (without an order) and said, The doctor has the sliding scale here. This is what he wants her to get. When asked to see his or the PCP's notes addressing the resident's high blood sugars, the NP saw that there were no progress notes since readmission on 10/16/18 and that the latest note was dated 8/31/18. When asked if there were any adjustments in the insulin, NP 'AA' read the order to decrease [MEDICATION NAME] from 8 units to 6 units and said, It was decreased for [DIAGNOSES REDACTED]. She has a lot of hypoglycemic reactions, that's why it was decreased. She is very brittle. He did not respond when it was mentioned that there was only one documented hypoglycemic episode since 10/16/18 and shown the otherwise high levels on the MARs. He did not respond when asked if the intention was to maintain the resident on [MEDICATION NAME] 6 units based on the one hypoglycemic episode and the indication that Humalog was not being given. The NP pointed to the now orders for insulin 10 units and said, See, she had been getting insulin when it's elevated and indicated the plan was to keep giving the resident 10 units of now insulin each time. NP 'AA' said that the resident's hemoglobin AIC (HbAIC) level was 10.5 on 10/16/18 when asked, and then left to talk to nursing staff about the resident. (HbAIC is a blood test used to detect average concentrations of glucose in the blood over a three month period. The normal range is 5.6 or below.) On 11/14/18, nursing staff noted that the resident's blood sugar was 408 at 11:30 AM. Per nursing notes at 11:45 AM: (NP 'AA') notified with order to give [MEDICATION NAME] 16 units now. At 1:30 PM: (NP 'AA') gave new order to give [MEDICATION NAME] 2 units before meals and continue with current sliding scale. At 4 PM, the concerns with assessment, monitoring, documentation and management of the resident's blood sugar were discussed with the DON and a policy on diabetic management was requested. She deferred questions and concerns to nurse Unit Manager 'Z'. Nurse 'Z' and nurse 'U' proceeded to look in the resident's chart and said, There's no order for sliding scale insulin or the sliding scale (parameters) that were written on the MAR by the day shift nurse and said there were no progress notes, just the 10/17/18 H&P that was reviewed before. Nurse 'Z' was asked to provide any further information by survey end, but there was none provided. On 11/15/18 at 10:38 AM, the DON said there was no facility policy on diabetic management. She said, The physician should be monitoring and providing his own orders for that. The DON then said, She's (the resident) being transferred out to the hospital now. At 10:52 AM, a hospital transfer form noted: [DIAGNOSES REDACTED]. When asked about the hospital transfer, nurse 'U' said she could not get a reading on the glucometer because the level was too high, so the resident was being sent to the hospital. Further review of the clinical record revealed that after speaking with NP 'AA', nurses 'U' and 'Z' and the DON, there remained no written order for sliding scale insulin and parameters until one was obtained from NP 'AA' at 8 AM on 11/15/18, a few hours before the resident was sent back to the hospital emergency room for [MEDICAL CONDITION] for the second time in a month.

Based on observations, interviews, and record review the facility failed to provide necessary care and services for two of 13 sampled residents (#133, #29), reviewed for skin integrity, resulting in R#133 developing two pressure ulcers; one 'stage 3' pressure ulcer, (a small crater, with total loss of skin exposing soft tissue, not muscle) on her left heel and a 'deep tissue injury' (pressure related injury to the subcutaneous tissue under intact skin, appears as a deep bruise) on her right heel and the potential for contamination of existing wounds and development of further pressure ulcers for R#29. Findings include: Resident #133: During an interview on 11/13/18 at 11:39 AM, with R#133's daughter said that the resident developed pressure ulcers on both of her heels while at the facility. The resident's daughter said staff do not place the soft booties (soft foam booties, designed to off-load pressure on the heels) on the resident, and they have not been repositioning the resident every two hours. During an observation on 11/13/18 at 1:17 PM, the resident was observed to be up in the wheelchair with dressings wrapped around both of her feet. The resident had slippers on that were backless and did not fit correctly on her feet due to the dressings. The resident's soft foam boots were observed to be in her closet on the floor. The resident did not have a specialty 'low air-loss mattress' in place. On 11/13/18 at 3:30 PM, R#133 was laying in bed, her heels flat on bed mattress, with dressings in place, no soft foam boots on. On 11/14/18 at 9:01 AM, R#133 was seated in her wheelchair eating breakfast. Both of her feet were wrapped with dressings, without slipper or soft foam boots in use. On 11/14/18 at 3:02 PM, R#133 was laying in bed with her feet and heels flat on the mattress, dressings intact, but no soft foam boots on. On 11/15/18 at 11:29 AM. R#133 is seated in her wheelchair with her family at bedside. The resident's daughter observed that the resident did not have her soft foam boots on and opened the closet. The resident's soft foam boots were still on closet floor. During an interview with the wound care specialist, on 11/15/18 at 10:25 AM, she said that both of R#133's pressure ulcers on her heels developed while she was in the facility. According to the medical record, R#133 admitted with multiple [DIAGNOSES REDACTED]. The 'Admission Nursing Assessment', dated 9/28/18, indicated the resident's skin was intact and free from any breakdown. A 'Braden Scale' dated 9/28/18 (a tool used to predict the risk of developing a pressure ulcer) identified the resident as being 'at high risk' for developing a pressure ulcer. On 10/1/18, the 'Resident Skin Assessment & Management Tool' indicated the resident had bilateral intact heels, with the left heel being 'boggy and soft'. Revision of the resident's 'Braden Scale', dated 9/30/18, 10/7/18 and 10/14/18, identified the resident as at 'mild risk' for developing a pressure ulcer. The Minimum Data Set, ((MDS) dated [DATE] indicated the resident required extensive assistance from one staff person for bed mobility and repositioning. The resident was totally dependent on staff for transfers from surface to surface (bed to wheelchair). Section 'M' of the MDS identified the resident has not having any pressure ulcers, but had a pressure reducing mattress in place. The MDS dated [DATE], on section 'M', indicated that R#133 had one, 'stage 3' pressure ulcer. A care plan for pressure ulcers, initiated on 10/10/18 identified the following interventions; turn and reposition every hour. There is no update to include the wound care physician's orders [REDACTED].'. According to the wound care specialist notes: On 10/11/18, R#133 had a left heel 'fluid filled' blister that measured 6 centimeters (cm) x 10 cm. The wound care physician ordered; dry dressings every two days and prn ( as needed), to float the heels, and for soft heel lift boots while in bed. On 10/18/18, R#133 had eschar (dry blackened skin) on her left heel. The orders are the same as on 10/11/18. On 10/25/15, R#133 has a stage 3 pressure ulcer on her left heel that measures 5 cm x 9 cm with drainage. The orders are for santyl to the left heel every day with dressing, to float the heels, and for soft heel lift boots while in bed. On 11/1/18, R#133 has a stage 3 pressure ulcer on her left heel that measures 5 cm x 8 cm, and a right heel with a deep tissue injury measuring 4 x 4.5 cm with dark maroon base. The orders are for a dry dressing every 2 days and prn (as needed) to right heel, and santyl daily and prn to the left heel. To float the heels, and for soft heel lift boots while in bed. On 11/8/18, R#113 has a stage 3 pressure ulcer on her left heel that measures 5 cm x 7 cm, now with a depth of .02 cm. The orders are the same as 11/1/18. Resident #29- On 11/13/18 at 9:20 AM, resident #29 was observed lying in bed. The resident appeared very thin, weak and had an indwelling urinary catheter. At 2:30 PM, the resident's clinical record was reviewed. The resident was readmitted from the hospital on [DATE] with [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] noted that the resident had intact cognition, required total assistance for most care, including bed repositioning, was non-ambulatory and had limited range of motion to one side of the body. On 10/18/18, the resident was prescribed wound treatments daily with an anti microbial cream to pressure sores on the sacrococcyx area and lateral (outer) right knee. On 10/25/18, a bleach solution used to treat infected wounds, was prescribed to the sacrococcyx area twice a day and [MEDICATION NAME] (antibiotic) twice a day for 14 days. On 11/1/18, the wound specialist noted that the sacrococcyx sore measured 12 centimeters (cm) by 9.5 cm by 1 cm deep with large serous drainage. The right outer knee sore measured 3.5 cm by 4 cm with moderate serous drainage. On 11/8/18, the specialist noted that both sores were at stage 4 (full thickness skin loss) with bone and tendon exposed. On 11/15/18 at 9:10 AM, the resident was observed preparing to be weighed by nurse aide 'R'. When the covers were removed, the resident was lying on her back. The right leg was observed to be turned outward with the outer right knee pressing on the bed. The left leg was severely contracted (the knee was permanently flexed) with the knee lying on the inner aspect of the right knee. There was no cushioning in place to prevent pressure sores from developing to bilateral inner knees and no cushion or padding under the right outer knee to prevent the sore from worsening. A dressing to the outer right knee sore was detached on three of its' four sides and totally saturated with drainage. Serous drainage was on the bed underneath the uncovered sore. The resident was turned from side to side while obtaining the weight by mechanical lift and the urinary catheter tubing was repositioned. After weighing the resident, she was tucked back in bed on her back with the covers pulled up to her chin. At 9:25 AM, wound care nurses 'T and V' were asked to observe the knee wound. When the covers were pulled back, nurse 'V' observed that the dressing was completely off, had rolled up and was underneath the resident's right thigh. The uncovered sore was located directly on top of the catheter tubing, which was left running underneath the leg. When asked, nurse 'T' said that the right foot should have been elevated to bring the knee up off the bed and a pillow should have been between the knees. At 9:50 AM, the wounds were observed with the wound specialist. Both pressure sores were at stage 4 with bone exposure. The sacrococcyx sore measured 11.5 centimeters (cm) by 10.4 cm by 1 cm deep with a slight foul odor detected. The right lateral knee sore measured 4 cm by 3 cm. At 10:40 AM, when told about the contracted knee pressing against the other knee, the knee wound draining on the bed, the catheter tubing underneath the wound and the lack of pressure relief interventions specifically for the knees, the Director of Nursing did not respond. The resident's Alteration in Skin Integrity care plan dated 10/18/18 noted: Goal- Skin impairment will display signs of healing and free of infection. Interventions included: Provide pressure relieving devices and positioning devices such as pillows/cushions and keep positioned off affective areas. Per review of the facility's Pressure Ulcer Prevention and Treatment policy dated 2/2012: Avoid positioning resident on a pressure ulcer. Use positioning devices to raise a pressure ulcer off the support surface Protect pressure ulcer from exogenous sources of contamination Assess and identify complicating conditions that may contribute to pressure ulcer development. Develop care plan to eliminate or minimize risk factors Use pressure reducing or relieving devices as necessary Position to prevent pressure from medical devices such as tubes

Based on observation, interview, and record review, the facility failed to ensure appropriate insertion technique and care of indwelling urinary catheters (a tube inside of the bladder that drains urine) per professional standards of practice and failed to ensure adequate infection control procedures for insertion of an indwelling catheter for two (Resident #122 and #29) of seven sampled Residents reviewed for Urinary Tract Infections [MEDICAL CONDITION], resulting in a non-sterile catheter being inserted into a Resident's bladder with a UTI, the high likelihood for the introduction of infectious microorganisms to the bladder, worsening UTI's, deterioration in overall health status and the potential for trauma to the urinary tract. Findings include: Resident #122 Review of a Face Sheet revealed, Resident #122 was originally admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment, with a reference date of 10/15/18, revealed Resident #122 had minimal cognitive impairment with a Brief interview for Mental Status (BIMS) score of 12, out of a total possible score of 15. Resident #122 required total dependence of two staff with transfers, bed mobility, dressing and toilet use. Resident #122 required total dependence of one staff with personal hygiene and required an indwelling catheter. Review of a Care Plan for Resident #122 with a problem start date of 7/16/18, revealed I require a suprapubic catheter R/T (related to) dx (diagnosis) of [MEDICAL CONDITION] bladder . Goal included . I will not exhibit obstruction, signs of infection, dislodgement of catheter, bowel perforation, or trauma secondary to catheter manipulation over the next 90 days. Approach included . Keep catheter system a closed system as much as possible . In an interview on 11/13/18 at 10:33 a.m., Resident #122 reported taking antibiotics for a Urinary Tract Infection [MEDICAL CONDITION]. In an observation on 11/13/18 at 10:40 a.m., Certified Nursing Assistant (CNA) K removed Resident 122's brief soiled with urine. The Suprapubic (surgically created connection between the skin and bladder) catheter tube that was inserted in Resident #122's abdomen was observed coming out near Resident #122's vagina with the balloon and tip of catheter exposed. CNA K stated Is that supposed to be there . I think I better get the nurse. CNA K then removed gloves, performed hand hygiene and exited Resident #122's room. In an observation and interview on 11/13/18 at 11:00 a.m., Licensed Practical Nurse (LPN) G entered Resident #122's room and assessed suprapubic catheter position. LPN G reported the catheter should not be in that spot. LPN G stated It's not draining anything. In an observation and interview on 11/13/18 at 11:04 a.m., Unit Manager E entered Resident #122's room and assessed suprapubic catheter position. Unit Manager E reported the tip of the catheter is coming out of Resident #122's backside and it should be in the bladder. Unit Manager E then removed gloves and exited room without performing hand hygiene. In an observation on 11/13/18 at 11:15 a.m., Director of Nursing (DON) entered Resident #122's room with Unit Manager E. In an interview on 11/13/18 at 11:16 a.m., Resident #122 reported pain at the suprapubic catheter insertion site. Resident #122 stated Y'all not gone keep putting that tube in . It hurt .I'm not going to keep going through this. in regard to removing the suprapubic catheter and inserting a new catheter. In an interview on 11/13/18 at 11:17 a.m., Unit Manager E reported the protocol to change catheters is once every 30 days and PRN (as needed). Unit Manager E reported the protocol is to change catheter tubing and drainage bag when you change the catheter. In an observation on 11/13/18 at 11:24 a.m., CNA K and Unit Manager E applied gloves with no hand hygiene performed before application of gloves. Unit Manager E explained the suprapubic catheter insertion procedure to Resident #122. Resident #122 reported the procedure is uncomfortable and does not want to go through it. Resident #122 declined the procedure. Unit Manager E reported they would give resident some time to think about the procedure. Unit Manager E removed gloves and exited room with no hand hygiene. In an interview on 11/13/18 at 11:29 a.m., Unit Manager E reported Resident #122 had the suprapubic catheter changed only every month, in regard to how often suprapubic catheter was changed. Unit Manager E reported Resident #122 suprapubic catheter was changed on 11/12/18. Unit Manager E stated Per chart the catheter was changed at 2am due to leaking. Review of Nurse's Notes revealed, on 11/12/18 at 12:00 p.m. Resident #122's suprapubic catheter changed. On 11/13/18 at 6:10 a.m., Resident #122's suprapubic catheter leaking and replaced. Review of a Medication Record with a date of 11/01/18 revealed, suprapubic catheter changed on 11/12/18 and 11/13/18. In an interview on 11/13/18 at 11:53 a.m., CNA K reported Resident #122 was repositioned and catheter bag was emptied this morning about 8am. In an interview and observation on 11/13/18 at 11:59 a.m., LPN F reported they pulled the catheter back into the bladder. Urine flowed through drainage tube into catheter drainage bag. Unit Manager E removed the suprapubic catheter and placed it in the trash can. Unit Manager E removed gloves and applied new gloves with no hand hygiene before application of new gloves. Resident #122 refused to have suprapubic catheter inserted. In an observation on 11/13/18 at 12:06 a.m., Resident #122 agreed to have suprapubic catheter reinserted. Unit Manger E applied gloves with no hand hygiene performed before application of gloves. Unit Manager E opened the indwelling catheter kit and placed catheter kit on Resident #122's bedside table without cleaning table prior to placing items on bedside table. A cup of water and bag Cheetos observed on bedside table. Unit Manager E then handed a package of swabs to LPN F. LPN F opened swabs and cleaned Resident #122's catheter insertion site. Unit Manager E removed gloves and applied sterile gloves with no hand hygiene performed before application of sterile gloves. Unit Manager E then inserted the catheter tube onto the drainage bag, open lubricant and applied lubricant to catheter tubing. No sterile technique observed. Unit Manager E inserted the suprapubic catheter into Resident #122. Resident #122 yelled out Ouch. Observed urine flowing through catheter tubing. In an interview on 11/13/18 at 12:16 a.m., Unit Manager E reported indwelling catheter insertion is a sterile procedure. Unit Manager E reported they maintained sterile field. Unit Manager E then reported hand hygiene should be performed before applying sterile gloves. In an interview on 11/14/18 9:12 a.m., Resident # 122 reported pain at the catheter site. In an interview on 11/14/18 at 12:01 p.m., Physician N reported they are unsure of where or how the catheter could have been exposed on the outside of Resident #122. Physician N reported they would assess Resident #122. In an interview on 11/14/18 at 12:17 p.m., Physician N reported Resident #122 may have a fistula. Physician N reported Resident #122 should be checked by urology. LPN F reported the suprapubic catheter was coming out of Resident #122's vagina. In an interview on 11/15/18 at 8:28 a.m., LPN I and LPN J reported catheter insertion is a sterile procedure. LPN I stated Changing the catheter too much will cause trauma. LPN I reported they contacted Physician N in regard to suprapubic catheter change ordered for today. LPN I reported Physician N did not want catheter changed and order received for change in 30 days or PRN (as needed). In an interview on 11/15/18 at 8:39 a.m., DON reported catheter insertion is a sterile procedure. DON reported the bedside table should be cleaned, hands washed, remove dirty, wash hands, prepare sterile field and then perform sterile procedure. Review of the Physician order [REDACTED]. Order dated 11/14/18 revealed, urology consult due to suprapubic malfunction possible evaluate for UV (ureterovaginal) fistula (passage between two hollow or tubular organs). In an interview on 11/15/18 at 12:20 p.m., Resident reported pain in the catheter site, stated It feels like it is pulling. Resident #29- On 11/13/18 at 9:20 AM, resident #29 was observed lying in bed. The resident appeared lethargic, slow to respond to questions with some confusion and had an indwelling urinary catheter. At 2:30 PM, the resident's clinical record was reviewed. The resident was readmitted from the hospital on [DATE] with [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] noted that the resident had intact cognition, required total assistance for most care, was incontinent of bowel/bladder and had an indwelling urinary catheter. On 10/29/18, an order was written for STAT (immediate) blood testing due to a fever. A urine culture was ordered on [DATE] which showed large colonies (greater than 100,000) of proteus bacteria in the urine. On 11/2/18 an order was written [MEDICATION NAME](antibiotic) for 7 days for UTI (urinary tract infection). On 11/14/18 at 11:20 AM, a re-admission history and physical dated 10/17/18 was reviewed in the resident's chart, which also noted that the resident was diagnosed with [REDACTED]. On 11/15/18 at 9:25 AM, wound care nurse V' was asked to observe the resident's pressure sores. When the covers were pulled back, the urinary catheter tubing was underneath the resident's right leg at the lateral knee area causing a potential for compression of the tube blocking the free flow of urine in a direction away from the bladder and into the urine drainage bag. There was no anchor on the tubing for stabilization to help prevent pulling, tension and dislodgement of the catheter. This lead to a potential for bleeding and urinary trauma caused when the inflated balloon connected to the catheter to hold it in place is suddenly pulled through the urethra (the small opening for drainage of urine) while still inflated. When asked, nurse 'V' said that the catheter tubing should have been anchored. She repositioned the tubing from underneath the leg to the top of the leg and left the room to get an anchor. A re-admission baseline care plan dated 10/16/18 noted that the resident had a urinary catheter. There were no documented interventions for catheter maintenance on the care plan and no subsequent documented care plans related to the catheter. At 10:40 AM, when told about the catheter tubing being underneath the leg, the missing anchor and no documented interventions for the resident, with a known history of UTIs, the Director of Nursing did not respond. Per review of the facility's Catheter Care, Indwelling Catheter policy dated 8/2012: Ensure that catheter tubing is secured to the resident's thigh. There was no mention of ensuring that the tubing was not kinked, compressed or improperly positioned.

Based on observations, interviews, and record reviews, the facility failed to administer tube feeding in accordance to standard of practice with regard to the resident's positioning, for one of nine residents (R#608) reviewed for tube feeding, resulting in R#608 aspirating his tube feeding (a condition which food, liquids, saliva, or vomit is breathed into the lungs), when the resident was laying flat in bed for an extended period of time during tube feeding administration. Findings include: During an observation on 11/13/18 at 10:59 AM, R#608 was in his bed, with the head of his bed slightly elevated, and bilateral wrist restraints on. Tube feeding was infusing at 95 ml/hr (milliliters per hour)through a PEG tube (flexible tube that is surgically inserted through the skin of the abdomen into the stomach), with the use of an electric pump. Nurse 'W' was interviewed at this time. Nurse 'W' said the resident was admitted to the facility yesterday and has pulled his PICC line out, (Percutaneous Intravenous Central Catheter, used to administer medications intravenously), and was prescribed restraints temporarily to keep the resident from pulling out other medical devices. The resident had a PEG, a urinary catheter, and tracheotomy tube (surgical opening of a direct airway through the front of the neck). On 11/14/18 at 3:46 PM, the resident was observed to be in a different room, in contact isolation, with a one-to-one staff person at his bedside. The resident had no wrist restraints on, and appeared to be asleep, the head of the bed was slightly elevated, almost flat. The resident's tube feeding was infusing at 95 ml/hr, by means of an electric pump. On 11/15/18 at 9:30 AM the resident was observed alone in his room, with the head of his bed slightly elevated, almost flat. Approximately a 15 degree angle. The resident's tube feeding was infusing by means of an electric pump at 95 ml/hr. The resident had a significant amount of yellowy beige drainage coming out of his tracheotomy and collecting in his trachea collar (a plastic cover over the tracheotomy that delivers humidified oxygen), running down his neck and pooling in his clavicle area and spilling onto the bed between his neck and left shoulder. The drainage was the same color and consistency of tube feeding. The pool of drainage in the resident left neck and shoulder area had started to curdle. The nurse manager was immediately notified. On 11/15/18 at 9:40 AM, nurse 'X' and Respiratory Therapist 'DD ', entered the room and immediately shut off the tube feeding pump and attempted to elevate the head of the resident's bed with the electric bed controller. The bed malfunctioned and could not elevate the head of the bed. The resident remained in an almost flat position. Nurse 'X' called maintenance to determine the cause of the bed malfunction. RT 'DD ' began suctioning into and down the resident's tracheotomy with a catheter and pulled up moderate amounts of yellowy beige secretions. The resident coughed profusely and expelled fair amounts of yellowy beige secretions. At 9:52 AM, RT 'DD ' said the the resident's secretions looked and smelled like tube feeding, and it was likely that the resident had aspirated tube feeding. The resident was still laying in an almost flat position. The bed is still unable to be positioned with the head elevated. At 9:54 AM the maintenance person, staff 'EE' assessed that the bed had two electrical cords that needed to be connected in order for the bed controller to function. The controller was unable to elevate the head of the bed, because it was not connected to electrical power. Staff 'EE ' could not say how long the resident's bed had been unable to elevate the head of the bed. According to the medical record, R#608 re- admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. admission orders [REDACTED]. A care plan for nutritional status: tube feeding, last revised on 7/9/18 had goals that included the following; resident will not exhibit any signs of complications from feeding tube or enteral feeding solution. The interventions included; elevate the head of the bed 30 - 45 degrees while tube feeding is running and 30 minutes following administration. On 11/15/18 at 10:10 AM, the physician ordered a STAT (immediate) chest X-ray to rule out aspiration. According to 'Managedhealthcareconnect.com'. Volume 16 - Issue 4 - (MONTH) 2008: The goal in the long-term care setting is to use preventive measure to decrease the incidence of aspiration and its development of pneumonia. To minimize the risk of aspiration, patients should be fed sitting up or at a 30-45 degree semi recumbent (positioning the head and torso at an angle of 45 degrees) body position, and remain in that position for at least one hour after feeding is complete. According to 'MyShepardConnection.org', to prevent the complication of aspiration in resident receiving tube feeding, elevate the head of the bed at least 30 degrees, or use an upright sitting position when administering tube feeding, water boluses or medications through the tube.

This citation pertains to intake #s MI 536, MI 569 and MI 951. Based on interview and record review, the facility failed to properly assess, monitor, document and provide appropriate, coordinated, timely interventions for two (#101, #104) of two sampled residents reviewed for quality of care, resulting in increasing respiratory distress, mental status changes, bleeding in the skull, [MEDICAL CONDITION] activity and delay in emergency hospital treatment following acute changes in condition. Findings include: The complainants reported to the State Agency that the facility did not properly assess, monitor and provide prompt hospital treatment for [REDACTED].#104 when the resident's medical condition began to decline. Resident #101- On [DATE] at 1 PM, the resident's clinical record and an Unusual Occurrence (incident) report were reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS completed [DATE] noted that the resident had severe cognitive impairment and required limited to extensive assistance for care. The resident had a legal guardian for oversight of care due to impaired cognition. The Unusual Occurrence report dated [DATE] at 4 PM, noted the resident was observed at that time by nurse aide 'B' sitting on the floor in the bathroom. The fall was not witnessed. The report noted there was no injury, the physician was called and instructed monitor resident. Interventions included, neuro (neurological) check. The nurse wrote in notes at that time, Upon entering room writer observed resident in chair. Range of motion performed. The nurse noted the following information on a Neurological Record sheet: one neuro check was performed by the nurse at 5:20 PM, almost 90 minutes after the fall occurred; The resident was alert with confused conversation; vital signs were not documented; both pupils were equal, reactive to light and measured 6 millimeters in size (normal range=2 to 6, abnormal range=7 to 9). There were no further documented neuro checks. (The nurse was unavailable for comment.) The Neurological Record sheet did not indicate the frequency in which to perform the checks. (Typically neuro checks are preformed every 15 minutes x 1 hour, then every 30 minutes x 1 hour, then every hour x 4 hours, then every 4 hours x 24 hours.) On [DATE] at 9 PM, the nurse noted: Patient found in room sitting on the side of the bed staring at the TV. I asked the patient was she ok and how was her day and she replied she doesn't know The patient asked me to call her daughter. When I returned to the room she seemed a little dazed the patient started to shake her hands and legs (while on the phone talking to daughter) I notified the doctor and the DON (Director of Nursing), whom instructed me to send the patient out (to the hospital). The daughter reported that she came to the facility after the resident did not sound right during the phone conversation and that the resident told her that she hit her head when she fell the day before. There was an order to Transport to ER. Diagnosis- mental status change and [MEDICAL CONDITION]. The Resident Transfer Form noted that the resident was transferred to the hospital on [DATE] at 8:25 PM with a pulse of 126 and a blood pressure of ,[DATE]. On [DATE] at 3:35 PM, aide 'B' was asked about the resident's fall and said that she saw the resident on the floor in the bathroom and got her up from the floor and put her in the chair. I can't remember who helped me. Then the nurse came in and checked her. When asked if the resident was supposed to be moved before being assessed by the nurse, the aide said, No, she was supposed to be assessed first. On [DATE] at 1 PM, the resident's hospital records were reviewed. Per the hospital notes: patient stated that she did not feel very well and daughter stated patient may have been slurring her words. Daughter then went to the nursing home to check on patient around 8 PM. Patient was found to be aphasic (unable to speak) with deviated gaze. Patient was taken to the emergency department Patient was admitted to the Neuro ICU On exam, patient was found to have right eye deviation 20 minutes later, patient had a fixed dilated right pupil. Per notes dated [DATE]: On further questioning, patient had fallen 2 days prior CAT scan reports of the head/brain dated [DATE] and [DATE] noted the following: History: .patient with head trauma after a fall yesterday, presenting with stroke findings. large [MEDICAL CONDITION] in the right parietal lobe (ruptured blood vessel between skull and brain; The collection of blood (hematoma) compresses brain tissue). subarachnoid hemorrhage in the right frontal lobe (blood between the brain and skull). extra axial fluid collection over the right frontal convexity (blood within the skull, but outside of brain tissue). complete compression of the right ventricle with structural midline shift and subfalcine herniation to the left (displacement of the brain due to high pressure that squeezed the brain within the skull). The hospital noted: Due to large bleed and herniation, palliative care was consulted will not recover Patient was discharged to in-patient Hospice. The resident died on [DATE]. The Death Certificate, signed [DATE] noted: Manner Of Death- Accident; Date Of Injury- [DATE]; Describe How Injury Occurred- Fall At Nursing Home. At 3:35 PM, when asked if aide 'B' was supposed to get the resident up from the floor before an assessment was done, the DON said no. The DON was asked if more than one neuro check should have been done, considering the pupils being just within normal range on the neuro check, the resident's confusion, cognitive impairment and possible inability to reliably state or tell whether she had hit her head during the fall or not. The DON said, It depends on individual circumstances. She then said, It depends if the doctor orders it or not. When asked if there had to be an order for [REDACTED]. Resident #104- On [DATE] at 2 PM, the clinical record for the resident was reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The minimum data set (MDS) was in progress. According to the resident's Advance Directive Care document signed [DATE], the resident was to receive intravenous fluids, a feeding tube and hospitalization if necessary, but was not to receive CPR-cardiopulmonary resuscitation, in other words, No Code. Per nurses notes dated [DATE] thru [DATE] at 4 PM, the resident had a [MEDICAL CONDITION] in the throat connected to a ventilator for breathing, had no signs of respiratory distress and was alert, responsive and able to communicate using non-verbal/verbal cues at times. Nurses noted on Vital Signs Flow Sheets from [DATE] thru [DATE] that the resident's blood pressure ranged from ,[DATE] to ,[DATE] with an oxygen saturation level (amount of oxygen in the blood) of 99 to 100% (normal range=,[DATE]%). Ventilator Flow Sheets dated [DATE] thru [DATE] documented by respiratory therapists (RTs), noted that the ventilator was set to deliver the resident 14 breaths per minute, but the resident was regularly able to breathe above the set rate; The ventilator was set to deliver 40% oxygen (room air is at 21%); The resident's cognition and physical appearance was normal throughout each of the days. The RTs were documenting the resident's status on average each day at 9 AM-3 PM-8:30 PM-2 AM. On [DATE] at 8:45 AM and again at 10:50 AM, RT 'D' noted that the resident was lethargic and [MEDICAL CONDITION] withheld today, meaning a plan to try to transition the resident from the ventilator to the use of [MEDICAL CONDITION], which allowed the resident to breathe on his own, was canceled. The next RT note at 2:45 PM by RT 'D', on the ventilator flow sheet, documented no distress or change in condition. There were no RT notes between 10:50 AM and 2:45 PM or any indication of communication with nursing staff about the resident. Per a note dated [DATE] from 7 PM-2 AM written by nurse 'F': The resident's blood pressure was low at ,[DATE], pulse was 110 and respirations were 32, physicians were notified, no new orders and continue to monitor the resident. These notes were crossed out as being an error. On [DATE] at 5 PM, when asked by phone why she had crossed out the notes, nurse 'F' said she was told to cross them out by a nurse manager and to re-write them to clarify that she had not reached the physicians, she had left them messages and did not hear back from them. However, there was no other documented nursing note on [DATE]. When asked what was going on with the resident the evening of [DATE], nurse 'F' indicated she had no recall of events prior to a note she had written on [DATE] at 2:30 AM: Physician called with new order for a bolus of fluid to reduce blood pressure, will continue to monitor. When asked about the note, nurse 'F' said, Let me see, I'm trying to remember. EMS was called and they came quick. No CPR was done by us or EMS. I don't know what EMS did after they left with him (the resident). A review of the physician order [REDACTED]., to give the bolus of fluid due to low blood pressure. On [DATE] at 10:30 AM, RT 'D' was asked about her notes indicating the resident was lethargic the morning of [DATE]. She said that the resident was usually alert and frequently attempting to talk and that the lethargy was a change from his usual behavior, so he was kept on the ventilator instead of attempting [MEDICAL CONDITION]. When asked if she had communicated this to nursing staff, RT 'D' said, yes, but could not state why there was no documented indication that she had done so or what the nursing staff's response was. At 11 AM, RT 'E's notes the evening of [DATE], were reviewed with her by phone. At 8:30 PM, RT 'E' noted that the resident's respiratory rate was 28, the oxygen level was increased from the setting of 40% on the ventilator, up to 50%; The resident's heart rate was 120, was restless; respiratory rate up, heart rate up. At 9:30 PM, RT 'E' noted that the oxygen level was increased further from 50% up to 60% on the ventilator. The resident had labored breathing, heart rate 140, respiratory rate 36. RT 'E' said, I had to suction him frequently and had to increase his oxygen. I always communicate with nursing staff. My job is to keep up the oxygen level. There is nothing else I can do. I gave (RT director-staff 'A') a note about it. She called me and asked what happened. At 11:40 AM, the resident's clinical record was reviewed with staff 'A' in the presence of the DON. She presented the note written by RT 'E' and said that she had RT 'E' come in (after getting off duty) and write the note because I was told that she had difficulty and was having to suction (the resident) frequently. Per the note, dated [DATE] at 7:30 PM: The resident was suctioned for a large amount of frothy thin secretions that looked like tube feeding formula and nursing staff was notified. There was no further documented indication that nursing staff and RT staff had communicated about the resident's condition. There were no further documented RT notes from [DATE] at 9:30 PM until [DATE] at 3:50 AM when an RT noted that the resident was in distress, was exhibiting Kussmaul breathing (deep, labored breathing, a form of hyperventilation) and was going to the hospital. When asked what happened with the resident from a respiratory stand point between 9:30 PM on [DATE] until 3:50 AM on ,[DATE]/AM, staff 'A' said, We were in and out of the room all night. There were other things going on with him. Read the nursing notes. Ask them (RT staff) what happened. Staff 'A' could not explain why there was no documented indication that RT staff was at the bedside and monitoring the resident more frequently or communicating with nursing staff as his condition was declining. When asked if the resident had coded, staff 'A' said, He was being bagged when transferred out, meaning taken off the ventilator and given breaths by a hand held device used when a respiratory arrest occurs or is eminent. Per a change in condition note (SBAR Communication Form) written by nurse 'F' on [DATE] at 4 AM and a hospital Transfer Form: Writer taking care of patient in room. Writer noticed (oxygen level) low on monitor, requested RT assistance Writer called 911 EMT transferred resident to (hospital). The transfer form noted the resident's blood pressure was ,[DATE] and he was unresponsive. When asked, the DON did not respond why there was a delay in hospital treatment for [REDACTED]. The DON was asked for a policy regarding communication and collaboration between nursing and RT staff for care of ventilator dependent residents. At 5 PM, she said there was no policy. On [DATE] at 10 AM, per review of the EMS transport sheets, EMS arrived to the facility on [DATE] at 3:49 AM; at 3:59 AM- blood pressure ,[DATE], respiratory rate 16, on a ventilator; Incident type- breathing problem; Narrative- Patient found unresponsive on a ventilator. Patient found to be a no code per advanced directives; Situation-Primary impression- Altered mental status. Initial acuity- critical; Departed the facility at 4:14 AM; Arrived at the hospital at 4:21 AM. Per emergency room notes at 4:24 AM: unresponsive, being bagged by RT staff; patient pronounced dead on arrival at 4:32 AM. At 6 PM, per review of the facility's policies on Condition Change of the Resident dated ,[DATE], Neuro Check dated (YEAR) and Fall Management Guidelines dated ,[DATE]: -Resident will be assessed for change of condition throughout shift and as needed. Purpose-To observe, record and report any condition change to the attending physician so proper treatment will be implemented After all resident falls, possible injuries or changes in physical or mental function can occur. Assess the resident's need for immediate care. Do not leave the resident alone. Assess the resident and notify the attending physician of the resident's condition. Compare the resident's current condition to his or her prior level of function. Assessment and monitoring include, but are not limited to, the following: personality changes Alterations in consciousness Unequal pupils Take vital signs including temperature -Purpose of neuro checks-To provide guidelines for neurological assessment that establishes a baseline, recognizes neurological trends and changes in the residents condition and that provides an elevation tool for references when evaluating the residents neurological status Neuro checks will be completed when a suspected head injury has occurred. (The policy did not address the timeliness and frequency of the checks.) -When a fall occurs, the nurse should assess the resident for injury If there is a suspected head injury, neuro checks should be completed per policy.

This citation pertains to Intakes MI 22 and MI 625. Based on observation, interview, and record review the facility failed to adequately assess, effectively monitor interventions, and manage complaints of pain for one (Resident #814) of 15 residents reviewed for pain from a total of 24 sampled residents resulting in ongoing complaints of intolerable pain to achieve optimal improvement for pain management. Findings include: On 8/22/17 at 9:50 am, Resident #814 was observed in bed. Resident #814 was observed to intermittently moan and grimace. Resident #814 was observed to attempt to lift up the right side of her body while grabbing and holding on tightly to the incontinence pad and fitted sheet. As Resident #814 was observed to grasp tightly onto the incontinence pad and fitted sheet and pulled downward, a slight raise/lift of her buttocks could be observed. Resident #814 was asked if she was in pain and responded, Yes! When asked if she could rate the pain on a scale of one to zero, Resident #814 stated, It's bad, 10. Then let out several more moans and physical attempts to reposition the lower half of her body. Resident #814 was then asked where was she having pain and stated, I'm sitting on it! Certified Nurse Assistant (CNA) J was in the room assisting the room mate. When CNA J became available she was asked about the pain Resident #814 was experiencing. CNA J explained that she recognized that Resident #814 was in pain, that she informed the nurse, and stated, I think she gave her something for pain. Resident #814 was asked if she received anything for pain, said that the nurse had given her something for the pain, and stated, She just gave me my medicines. CNA J stated, I had her repositioned off her bottom. She had to eat so I had to put her back on her bottom. At that time, Resident #814 was observed to grimace and push herself slightly onto her right side and asked to get up in the chair to get more comfortable. CNA J explained to Resident #814 that she had to be seen by wound care. Resident #814 replied, I wonder if anyone here is in as much pain as I am in. Resident #814 was observed to grimace, moan, and grasp onto the incontinence pad and fitted sheet. CNA J stated, I'm going to let the nurse know that you are still in pain. CNA J then left the room. CNA J informed Nurse I that Resident #814 was in pain. At 10:00 am, an interview with Nurse I revealed that Nurse I was aware that Resident #814 was in pain and added that Resident #814 was on scheduled pain medication. When asked when did she get her last dose of pain medication Nurse 'I stated At six a.m. When asked if she was aware that Resident #814 was in pain four hours after receiving her pain medication, Nurse I stated, (Resident #814) did say she was in pain. When asked if Resident #814 rated the pain or described the pain Nurse I did not provide a verbal explanation. However, Nurse I said that she was waiting for Physician K to become available so that she could ask what he wanted to do. At that time, Nurse I was observed to approach Physician K who was seated at the nurses station, explained that Resident #814 was experiencing pain. Physician K, without any physical assessment or inquiry of Resident #814 regarding her pain stated, I just saw her this weekend! Let's have pain management look at her. Nurse I queried if there was anything she could administer to Resident #814 at that time and Physician K stated, I don't want her to have any PRN (as necessary) medication. I just bumped her up from [MEDICATION NAME] (pain medication) to [MEDICATION NAME] (pain medication). Nurse I was then queried how she planned to help alleviate the pain Resident #814 was experiencing and stated, I'm going to see if we can reposition her. At 10:15 am, CNA J and Nurse I entered the room where Resident #814 was observed to wince, moan, grimace intermittently. Nurse I stated, We have to reposition you. Resident #814 explained that she did not want to move because It will hurt. Nurse I then asked, Where is your pain? Resident #814 replied, It's in my rear end. Nurse I and CNA J repositioned Resident #814 into a right side-lying position. During repositioning, Resident #814 was observed to wince, groan, grimace, whimper, and brace herself during repositioning. When staff touched her arms and legs Resident #814 stated, Don't touch me. When staff positioned the legs, Resident #814 began to whimper. At this time Physician K entered the room, asked Resident #814, Where is your pain? Resident #814 stated, In my bottom. Physician K then asked Resident #814 to rate her pain on a scale of 1 to 10. Resident #814 repeated, One to ten, one to ten. Physician K then stated, I asked you to rate your pain on a scale of one to ten. Resident #814 did not respond. Physician K exited the room, spoke with Nurse I and ordered a [MEDICATION NAME] to be applied to Resident #814's bottom. On 8/22/17 at 1:00 pm, a wound care observation was made. Treatment Nurse E explained that Resident #814 was on scheduled pain medication, that she received her pain medication at noon and that the medication should be effective for the wound care. Resident #814 was positioned onto the left side. During the observation a moderate amount of serosanguinous drainage was observed on a dressing dated 8/21/17. Treatment Nurse E stated, It was a Stage II and then it healed. (Resident #814) had been refusing to get up, shower, eat, and be repositioned because she was in so much pain. She would not let them (staff) touch her. During this time Resident #814 began to whimper. Treatment Nurse E added, I couldn't figure out what was happening to make the pressure ulcer increase in size and get worse when we put everything in place to help her heal. After I read the nurses notes I could see that she was experiencing pain which made it difficult for the staff to turn and reposition her. Review of the clinical record with Treatment Nurse E revealed the wound measured 1.5 centimeters (cm) x 2.0 cm x 0.01 cm with an area of 3 square cm and labeled as a Stage II pressure ulcer on 8/10/17. However, upon assessment on 8/17/17, Resident #814's pressure ulcer measured 5 cm x 14 cm x 0.2 cm with an area of 70 square cm and labeled as a Stage III pressure ulcer. On 8/23/17 at 8:40 am, Resident #814 was observed in bed, slightly positioned onto her right side, with facial grimacing and moaning with periodic grunting. Also, observed in the room was an IV pole with normal saline infusing into Resident #814's skin (Hypodermoclysis). When queried, Resident #814 stated, I'm having pain underneath. CNA G who was present in the room and preparing to assist Resident #814 with her meal explained that she was unfamiliar with Resident #814 and that she recognized that Resident #814 looks like she is in pain. During the meal observation Resident #814 was observed to moan, grimace, take deep breaths, and press her left hand into the mattress in between taking bites of oatmeal and eggs. CNA G was observed to encourage Resident #814 to take in bites of food. Resident #814 moaned when encouraged to open her mouth. Unit Manager D was queried regarding Resident #814's IV and explained that Resident #814 was getting the IV because she was dehydrated. Nurse I was queried if Resident #814 received the [MEDICATION NAME] Patch (pain) for Resident #814's complaints of bottom pain and explained that the pain patch was just delivered and that she had not applied it to Resident #814's area of pain (Resident #814 complained of pain in the area of her wound. When asked if she had received anything else to help control her pain since yesterday Nurse I was unable to provide a verbal explanation. CNA G was asked if Resident #814 complained of pain and stated, Earlier she didn't say anything. But, right now looking at her face, I would say she was in discomfort. At 9:45 am, Resident #814 was observed to be in the same position as she was in during the morning meal observation. Resident #814 was also observed to wince and grimace when speaking with occasional jerking motions when she would apply any pressure to her bottom area. At 12:00 pm Resident #814 was observed seated in a more upright position in a geri-chair with continual facial grimacing and occasional moans and whimpers. CNA G was observed to comb Resident #814's hair and explained that she would reposition Resident #814 off of her bottom. Resident #814 was observed to whimper and moan as CNA G attempted to reposition Resident #814. At 12:15 pm, CNA G and CNA H entered the room to help reposition Resident #814 for comfort. During repositioning Resident #814 could be heard stating, Don't move me, don't touch me as she whimpered and cried out loud. Upon re-entering the room CNA H stated, Wait. Let's get another chair. I think this chair is too small to reposition her onto her side. We won't be able to get her off her bottom. At 12:30 pm, Unit Manager Nurse D was asked, How are staff addressing (Resident #814's) complaints of pain. Nurse D stated, When you ask her if she is in pain she doesn't always respond or tell you where her pain is. At this time, Nurse D was asked to query Resident #814. Nurse D entered Resident #814's room. CNA G stated, (Resident #814) is complaining about her bottom. Nurse D queried Resident #814 and Resident #814 explained to her that she was having pain where I sit. Nurse D exited the room. Nurse D was asked if she assessed Resident #814 where she complained of pain and stated, No. I did not. At 12:55 pm, further query and review of Resident's clinical record with Unit Manager Nurse D revealed that nursing either did not perform pain assessments or noted or the Medication Administration Record (MAR) that Resident #814 was experiencing pain but did not consistently document what was done to address the pain or if the interventions used were effective. Review of the Pain Assessment noted that Resident #814's pain was only relieved by medication and there was little information regarding which pain medication was effective at which time to effectively manage Resident #814's pain. Nurse D then explained that documenting interventions and their effectiveness was necessary to address any residents complaints of pain. During the interview with Nurse D was queried regarding Pain Management. Nurse D explained that Pain Management had arrived and completed the form titled Physical Medicine and Rehabilitation dated 8/22/17. However, the only recommendations were to draw labs for [MEDICAL CONDITION] Factor, Uric Acid, and a Psychology Consult. There were no interventions that addressed Resident #814's unresolved complaints of pain. On 8/23/17 at 3:45 pm, the Director of Nursing (DON) was informed of Resident #814's complaints of pain and acknowledged that she was aware of Resident #814's complaints of pain and because of the pain, She does not want to be touched. When asked how was staff to address her complaints of pain she explained that she was aware that nursing staff had approached Physician K and, He did not want to go any further with addressing Resident #814's complaints of pain. When queried regarding Resident #814's pain assessments, the DON explained that pain assessments are to be done by nursing staff on each shift and documented in the MAR and the interventions whether effective or ineffective should documented in order to provide pain management. On 8/22/17 at 4:00 pm, clinical record review revealed that Resident #814 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The initial Minimum Data Set ((MDS) dated [DATE], noted Resident #814 had intact cognition, had no behavior or mood problems, required extensive to total one person assistance with all activities of daily living with the exception of eating. Resident #814 had no range of motion limitations, no pressure ulcers upon admission, and experienced no pain at admission. In addition, the MDS pain assessment noted that in the last 5 days resident received scheduled pain medications and received PRN (as necessary/unscheduled) pain medication. However, review of the MAR revealed Resident #814 was only on one scheduled pain medication ([MEDICATION NAME]). Per Nurse's Notes: 8/10/17 Wound Care, Coccyx reopened. 8/11/17, Family Member .stated (Resident #814) declined since admission she is concerned .endorsed to assigned nurse to contact physician (K) of Resident's pain unrelieved causing her to refuse to get out of bed. 8/11/17, Resident complained of pain throughout entire body. Writer contact (Physician K) to inform him of pain medication ([MEDICATION NAME]) not effective. Resident states pain medication doesn't work they only pain medication that was effective was [MEDICATION NAME]. Writer informed (Physician K) of what is going on and was requesting for an increase in pain medication. (Physician K) stated, have a pain management doctor see her first and I will be in to see her. 8/14/17, Resident informed to Detroit Police Officers, Stated she be in pain and just want to be handled more gently, because she be in pain. DON and Social Worker notified. 8/17/17 per wound care coccyx had increased to a Stage III. 8/19/17 Resident refused to be undressed and gown put on for bed on 8/18/17. CENA's made several attempts starting at 10 pm. Last attempt was at 10:45 pm. 8/22/17 at 11:00 am, Resident alert and responsive with complaints of pain to buttocks and all over body. Doctor notified of current pain medication schedule and that patient is still in pain. Doctor instructed to have pain management assess patient to have pain management adjust if needed. Patient was repositioned to relieve pain from buttocks. Will administer scheduled pain medication when due. Will continue to monitor patient pain level. Review of the Admission Nursing assessment dated [DATE], revealed that Resident #814 experienced no pain on admission. Review of a Pain Evaluation signed on 7/5/17 and 8/10/17 revealed Resident #814 noted the following diagnoses; Lupus, Chronic Right Shoulder Pain, Arthritis. Pain is increased by movement. The Wong-Baker Faces Pain Rating Scale indicated that Resident #814's pain ranged from a two (hurts little bit) to an eight (hurts whole lot). The type of pain, location, and frequency was not included on the pain evaluation. The evaluation also included an area to rate the pain experienced and an area to rate the pain one hour after medication, three hours after medication, worst it gets, and best it gets which was also incomplete. The Pain Evaluation also indicated in the Conclusion area, No pain, intervention is not necessary. Re-assess quarterly or with onset of pain. A Physician order dated 8/14/17 indicated that Pain Management be consulted regarding uncontrolled pain. However, there was no Pain Evaluation initiated at the onset of Resident #814's new complaints of uncontrolled pain. In addition, there was no evidence at the time of record review that Pain Management addressed Resident #814's complaints of pain. A Pain care plan dated 7/24/17 noted the following interventions, Administer pain medications. Return to assess effectiveness, Monitor and record any complaints of pain, location, duration, quantity, quality, alleviating factors, aggravating factors, Nurses continue to monitor my pain daily, Position me for comfort with physical support as necessary. A Care Plan dated 8/22/17 documented, Resident is mildly to moderately dehydrated and requires short term hydration. Per the Medication Administration Record (MAR) noted to Assess Resident (#814) each shift for pain. Resident #814 was not assessed for pain on the following afternoon shifts: 8/7, 8/13, 8/16, 8/21. Resident #814 was not assessed for pain on the following midnight shifts: 8/3, 8/4, 8/5, 8/7, 8/8, 8/10, 8/13, 8/17, 8/18, 8/21, 8/22. According to the MAR, Ask if having pain. Place N' if not experiencing pain. Place Y if resident is experiencing pain. Document assessment of pain, interventions provided and effectiveness of interventions. If resident unable to verbalize; use the non-verbal signs of pain located in the back of the pain evaluation. Document signs of non-verbal pain, interventions provided and effectiveness of interventions. Review of the MAR revealed that on the following dates nursing staff documented that Resident #814 had experienced pain, however there was no corresponding documentation that indicated that Resident #814's pain was assessed, that interventions were implemented, or the effectiveness of the interventions; Day Shift 8/15, 8/16, 8/17, 8/18, 8/19, and on 8/21. Afternoon shift 8/15, 8/17, 8/18, and 8/21. On 8/23/17 at 5:10 pm review of the facility policy titled, Pain Management effective 6/2012 documented, The facility will assess and identify residents experiencing pain, determine the type and severity of the pain and develop a plan for pain management. The staff monitors and documents the resident's response to pain management interventions. Pain may be localized to one area, or may be more generalized. It may be acute or chronic, continuous or intermittent (comes and goes) or occur at rest or with movement. The pain experience is very subjective; pain is whatever the resident says it is and occurs whenever the resident says it does. A full assessment of pain includes: Origin, location, severity, alleviating factors, exacerbating factors, current treatment, and response to treatment.

This citation pertains to MI 615. Based on interview and closed record review, facility staff failed to provide the necessary care and services in monitoring a resident's condition and reporting changes in a timely manner for 1 (#107) of 4 residents sampled for assessment and monitoring after a fall in a total of 16 residents resulting in delayed hospitalization for an extensive subarachnoid hemorrhage (bleeding into the area between the brain and the thin tissues that cover it). Findings include: Resident #107 was admitted to the facility on [DATE], per the Admission Record. Per a Physician's History & Physical (H&P) Report, Resident #107 had several medical [DIAGNOSES REDACTED]. According to a Minimum Data Set, dated dated [DATE], Resident #107 was non-verbal with a history of dementia. The resident had a [MEDICAL CONDITION] (surgically created opening into the windpipe to provide an airway and to remove secretions) and was on a ventilator (machine to assist or control a person's [MEDICAL CONDITION] ventilation). She required total assistance by nursing staff for all ADL's (activities of daily living). A Fall Risk Assessment, dated [DATE], indicated the resident was at high risk for falls. An incident report, dated [DATE], documented that Resident #107 was found with ". . .upper body, (L) shoulder, head out of bed on safety mat" at 2 a.m.. R.N. (Registered Nurse) "NN" documented in a nurses note that no change was noted at the time of the fall compared to her condition before the fall. The resident looked at staff and tracked their movements, moved all extremities, had a blink, gag, and cough reflex, and no evidence of pain. According to the nurses note, the resident "followed simple commands". There was no visual head injury; redness, bruising, lacerations, or other [MEDICAL CONDITION]. At 7:45 a.m., R.N. "NN" documented in a nurses note that the resident remained at baseline. R.N. "NN" was interviewed by telephone on [DATE] at 3 p.m. She said she reported off to R.N. "CC" when the shift ended, giving her information about the resident's fall and the assessments she made during her shift. Respiratory Therapist (R.T.) "FF" was interviewed on [DATE] at 2:15 p.m. She said she cared for Resident #107 on [DATE] during the day shift, starting at 7 a.m. R.T. "FF" said she would do ventilator checks and give respiratory medications when she began her shift. She said she would suction a resident if necessary, otherwise she would suction the resident at 11:00 a.m. The R.T. said 11 a.m. might be the first time during her shift that she would assess for a gag reflex when she suctioned the resident. R.T. "FF" documented that she checked Resident #107's ventilator function and gave medications to her at 9:00 a.m. At 9:00 a.m. the resident was asleep. At 11:00 a.m. R.T. "FF" said she suctioned the resident and found that the resident did not have a gag reflex. It was documented that she reported this to the nurse on duty (R.N. "CC"). At 2:45 p.m. R.T. "FF" documented that Resident #107 was "not responding", and this also was reported to R.N. "CC". R.N. "CC" was interviewed by telephone on [DATE] at 11:10 a.m. R.N. "CC" documented on a Neurological Record for Resident #107 at 8:30 a.m., 12:30 p.m., and 4:30 p.m. on [DATE]. Vital signs were very consistent in the three readings. There was no change in pupil response from the previous shift. R.N. "CC" documented that Resident #107 opened her eyes spontaneously and opened her eyes when spoken to at 8:30 a.m., 12:30 p.m., and 4:30 p.m., even though Respiratory Therapist "FF" documented that the resident was "not responding" at 2:45 p.m. The nurse also documented on the Neurological Record that the resident was alert , uttered speech, and moved all four extremities at each assessment, even though the R.T. documented that the resident was nonresponsive at 2:45 p.m. R.N. "CC" wrote a nurses note, dated [DATE]. There was no time documented on the nursing entry. In the note, the nurse documented that the resident's gag reflex was "weak", the resident was "unresponsive" with no response to deep pain. The note did not indicated that the physician was notified. The note stated that the resident was transferred to the hospital, but there was no time of the transfer documented. R.N. "CC" was interviewed by telephone on [DATE] at 12 p.m. R.N. "CC" said she cared for Resident #107 on [DATE]. The nurse said she always documented the time when writing a nurses note and questioned how her nurses note could now be without a time. R.N. "CC" denied that R.T. "FF" told her about Resident #107's absent gag reflex at 11 a.m. and her unresponsiveness at 2:45 p.m. The nurse said she would never let a resident go without a gag reflex for 5 hours without doing something about it. R.N. "CC" could not recall what time the resident was transferred to the hospital. Hospital records for Resident #107 were reviewed on [DATE] at 2 p.m. According to Emergency Department notes, Resident #107 entered the hospital on [DATE] at 5:45 p.m. A Physician's H&P documented that the resident was unresponsive to verbal stimuli, will not open eyes, only withdraws to pain in her lower extremities. A CT (medical imaging used for diagnosis) of the brain was ordered. An acute subarachnoid hemorrhage was found. The resident was admitted to the neurological ICU for aggressive treatment per wishes of the family, according to the physician H&P report. The resident expired on [DATE], per the discharge summary, dated [DATE]. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO MAINTAIN NOTHING BY MOUTH (NPO) STATUS FOR ONE (#701) OF TWO RESIDENTS OBSERVED RECEIVING MEDICATION, FROM A TOTAL OF 10 RESIDENTS OBSERVED WHO RECEIVED MEDICATION, WHEN THE NURSE ADMINISTERED LIQUID MEDICATION ORALLY TO A RESIDENT IN SEVERE RESPIRATORY DISTRESS, WHO DISPLAYED LABORED BREATHING; JUGULAR VEIN DISTENTION; USE OF ACCESSORY MUSCLES; AND EXPULSION OF COPIOUS AMOUNTS OF MUCOUS FROM THE MOUTH. THIS RESULTED IN AN IMMEDIATE JEOPARDY (IJ) TO THE HEALTH AND SAFETY OF THE RESIDENTS, WITH THE POTENTIAL WITH THE POTENTIAL TO FURTHER EXACERBATE THE CONDITION OF ASPIRATION PNEUMONIA, [MEDICAL CONDITION], HARM, SERIOUS INJURY OR DEATH. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 07/16/13 AT 3:30 P.M. THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 7/16/13 AT 6:00 P.M. AND A PLAN OF CORRECTION WAS REQUESTED AT THIS TIME TO REMOVE THE IJ. THE IMMEDIATE JEOPARDY WAS REMOVED ON 7/16/13 AT 8:00 PM BASED ON THE PROVIDER'S IMPLEMENTATION OF CORRECTIVE ACTIONS ON 7/16/13, AS VERIFIED ONSITE ON 7/17/13. ALTHOUGH THE IJ WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE REMAINED AT ISOLATED. NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT WAS NOT IMMEDIATE JEOPARDY. FINDINGS INCLUDE: DURING A TOUR OF THE FACILITY ON 7/16/13 AT 10:12 AM, RESIDENT #701 WAS OBSERVED IN BED HAVING DIFFICULTY BREATHING AND WAS EXPERIENCING SHORTNESS OF BREATH (SOB). RESIDENT #701 WAS EXPELLING THICK, STICKY, CREAMY GRAYISH MUCOUS MIXED WITH SALIVA FROM HIS MOUTH. THE RESIDENT'S LEFT JUGULAR VEIN WAS DISTENDED (SWOLLEN, PROTRUDING FROM THE NECK). RESIDENT #701 WAS EMACIATED (THIN) AND NO OXYGEN WAS INFUSING VIA AT 2 LITERS PER NASAL CANNULA AS ORDERED BY THE PHYSICIAN. ON 7/16/13 AT 12:30 PM, DURING THE MEDICATION PASS OBSERVATION, MEDICATION NURSE "A" WAS OBSERVED IN THE HALLWAY IN FRONT OF RESIDENT #701'S ROOM AS SHE PREPARED RESIDENT #701'S MEDICATIONS. AFTER ENTERING RESIDENT #701'S ROOM, MEDICATION NURSE "A" INSTRUCTED RESIDENT #701 TO OPEN HIS MOUTH AND THE NURSE ADMINISTERED ONE MILLILITER (ML) OF [MEDICATION NAME] 0.125 MILLIGRAMS (MG) SUB-LINGUAL (SL) (A MEDICATION USED TO REDUCE THE AMOUNT OF FLUID OF MANY ORGANS AND GLANDS IN THE BODY). THE RESIDENT WAS OBSERVED HAVING DIFFICULTY BREATHING AND WAS EXPELLING SECRETIONS, APPROXIMATELY FIVE SECONDS AFTER ADMINISTERING THE [MEDICATION NAME], NURSE "A" ASKED RESIDENT #701 TO OPEN HIS MOUTH SO A SECOND MEDICATION, [MEDICATION NAME] 10 ML ([MEDICAL CONDITION] REFLUX--HEARTBURN), COULD BE ADMINISTERED. NURSE "A" WAS STOPPED JUST BEFORE ADMINISTRATING THE THE [MEDICATION NAME] . MEDICATION NURSE "A" FAILED TO ASSESS RESIDENT #701'S RESPIRATORY STATUS, ASSESS AND EVALUATE PHYSICAL EVIDENCE OF RESPIRATORY DISTRESS AS EVIDENCED BY THE RESIDENT COUGHING, CHOKING ON HIS SECRETIONS, AND STRUGGLING TO EXPECTORATE. MEDICATION NURSE "A" FAILED TO FOLLOW THE PHYSICIAN'S ORDERS AND ADMINISTER MEDICATION VIA PERCUTANEOUS ENDOSCOPY TUBE (PEG) AS ORDERED BY THE PHYSICIAN. MEDICATION NURSE "A" WAS INTERVIEWED ON 7/16/13 AT 12:45 PM, AND ASKED "WHY" SHE FAILED TO ASSESS RESIDENT # 701'S BREATHING STATUS, MAINTAIN NOTHING BY MOUTH STATUS (NPO) AND FOLLOW PHYSICIAN'S ORDERS TO ADMINISTER MEDICATION VIA PEG TUBE. THE NURSE STATED, "(RESIDENT #701) HAS AN ORDER FROM THE PHYSICIAN TO RECEIVE ALL MEDICATIONS THROUGH THE TUBE--NOTHING BY MOUTH (NPO) DUE TO DYSPHAGIA, [MEDICAL CONDITION] OF THE NECK. YOU SEE HE IS HOSPICE, ALERT AND CAN TELL YOU WHAT HE WANTS. WE HAVE BEEN GIVING HIM ALL HIS MED'S BY MOUTH AND PATIENT HAS BEEN TOLERATING IT VERY WELL. " A REVIEW OF RESIDENT #701'S PHYSICIAN'S INTERIM ORDERS ON 7/16/13 AT 1:28 PM, REVEALED THAT ON 07/12/13 AT 1:50 P.M., THE FACILITY PHYSICIAN WROTE an order for [REDACTED]. ON 7/14/13 AT 1:15 P.M., THE PHYSICIAN WROTE an order for [REDACTED]. DURING AN INTERVIEW WITH THE DIRECTOR OF NURSE'S (DON) ON 7/16/13 AT 2:55 P.M., SHE REPORTED THE PHYSICIAN ORDERED RESIDENT #701 TO RECEIVE ALL MEDICATIONS VIA PEG TUBE. ON 7/17/13, AT 9:08 AM, DURING AN INTERVIEW WITH RESIDENT #701 REGARDING THE ADMINISTRATION OF HIS MEDICATIONS THE PREVIOUS DAY, HE STATED, "I AM AWARE THAT I AM SUPPOSE TO RECEIVE ALL MY MEDICATION'S VIA PEG TUBE, YET THE NURSES KEEP ON GIVING ME MY MEDICATION BY MOUTH CAUSING ME SO MUCH DISCOMFORT, SHORTNESS OF BREATH, AND PAIN." RESIDENT #701 POINTED AT HIS RIGHT UPPER QUADRANT AND STOMACH AND STATED, "IT HURTS SO MUCH HERE...I RECEIVE MY TUBE FEEDINGS MEDICATIONS AT ODD TIMES AND I HAVE INTENSE PAIN MOST OF THE TIME BECAUSE THEY RUSH MY FEEDINGS AND GIVE IT AT WRONG TIMES." REVIEW OF RESIDENT #701'S ADMISSION NURSING assessment dated [DATE], REVEALED RESIDENT #701 WAS RECEIVING HOSPICE SERVICES AND AN ORDER FROM HOSPICE INSTRUCTED RESIDENT #701 WAS TO RECEIVE "OXYGEN AT 2 LITERS PER NASAL CANULA" DUE TO PAST MEDICAL HISTORY, [MEDICAL CONDITION] (CA), [MEDICAL CONDITION] SECONDARY TO A PERFORATED COLON, SHINGLES, DEEP VEIN [MEDICAL CONDITION] [MEDICAL CONDITION] REFLUX DISEASE (GERD), AND PEG TUBE PLACEMENT. RESIDENT #701 WAS ASSESSED TO HAVE IMPAIRED VISION, PRODUCTIVE MODERATE AMOUNT OF SPUTUM WITH COARSE RESPIRATORY SOUNDS, POOR APPETITE, AND MODERATE PAIN SCALE OF 3 OUT OF TEN WITH 10 AS THE HIGHEST. INFORMATION OBTAINED FROM THE HOSPICE CLINICAL SUMMARY DATED 7/11/2013, REVEALED RESIDENT #701 WAS diagnosed with [REDACTED]. THE RESIDENT WAS DESCRIBED AS "CACHECTIC (PHYSICAL WASTING OF MUSCLE MASS AND LOSS OF WEIGHT), LETHARGIC (LOW ENERGY) AND HAD DYSPHAGIA (DIFFICULTY SWALLOWING)". A REVIEW ON 7/16/13 AT 4:15 PM, OF THE NUTRITIONAL EVALUATION DATED 7/11/13, INDICATED RESIDENT #701 WITH [DIAGNOSES REDACTED]. INCREASED RESIDUALS, LIKELY RELATED TO METASTASIS, ORDER TO HOLD IF RESIDUALS GREATER THAN 50 ML TO STOMACH. RESIDENT WAS NPO STATUS. THE PHYSICIAN'S "HISTORY AND PHYSICAL" DATED 07/12/13, REVEALED RESIDENT #701 WAS "COUGHING UP SPUTUM, UNDER HOSPICE SERVICES FOR OBSTRUCTIVE [MEDICAL CONDITION] CA, AND PEG TUBE." THE HOSPICE ASSESSMENT AND CARE PLAN DATED 7/11/2013, REVEALED RESIDENT #701 REQUIRED MODERATE PHYSICAL ASSISTANCE WITH ACTIVITIES OF DAILY LIVING (ADLS). RESIDENT #701 JUDGMENT WAS INTACT, AND HIS SPEECH AND LANGUAGE WAS EASILY UNDERSTOOD. THE ADMISSION CARE PLAN DATED, 7/11/13, REVEALED THAT RESIDENT #701 WAS TOTAL CARE, NPO, ENTERAL FEEDING, AND UNDER HOSPICE CARE DUE TO TERMINAL ILLNESS. AN INTERVIEW WITH THE PHYSICIAN AND HOSPICE AGENCY WAS REQUESTED ON 7/17/13 AT 9:10 A.M.; HOWEVER, THE HOSPICE NURSE AND PHYSICIAN WERE NOT AVAILABLE. ON 7/17/13 AT 5:50 PM, THE DIRECTOR OF NURSING (DON) WAS ASKED HOW NURSES WERE TRAINED TO ASSESS RESIDENTS PRIOR TO ADMINISTRATION OF MEDICATION. THE DON WAS UNABLE TO ANSWER WHY THE NURSE DID NOT ASSESS RESIDENT #701'S BREATHING AND STATED, NURSE "A" DID NOT FOLLOW THE PHYSICIAN'S ORDER FOR THE CORRECT ROUTE TO ADMINISTER MEDICATION. ON 7/17/13 AT 5:15 PM, A REVIEW OF THE FACILITY POLICY TITLED, "MEDICATION PASS GUIDELINES", EFFECTIVE DATE 12/2012, REVEALED MEDICATIONS ARE ADMINISTERED IN ACCORDANCE WITH WRITTEN ORDERS OF THE ATTENDING PHYSICIAN. CONTACT PHYSICIAN FOR CLARIFICATION PRIOR TO ADMINISTRATION BASED ON RESIDENT'S CURRENT CONDITION OR DIAGNOSIS. ON 07/16/13 AT 8:00 P.M., THE IMMEDIATE JEOPARDY WAS REMOVED AFTER THE VERIFICATION OF THE FOLLOWING: ELEMENT #1 RESIDENT #701 WAS ASSESSED AND SHOWS NO SIGNS OF ADVERSE REACTION FROM RECEIVING MEDICATION ORALLY. THE RESIDENT'S PHYSICAL STATUS AND WELL-BEING WAS ASSESSED. RESIDENT #701'S ASSESSMENT REVEALED AN ALERT AND ORIENT CACHETIC MALE WITH O2 AT 2 LITERS PER NASAL CANNULA. PULSE OX WAS 99% WITH APICAL RATE EQUAL WITH RADIAL AT 94, FULL AND BOUNDING, SLIGHTLY IRREGULAR. RESPIRATIONS WERE 12 TO 16 PER MINUTE WITH SHORT RESPIRATORY EXCURSIONS, DEEP EXCURSIONS RESULT IN COUGHING PRODUCING TAN, CREAMY IN CONSISTENCY [MEDICATION NAME]. RESIDENT ADMITS HE TALKS AND MOVES QUIETLY TO PREVENT COUGHING EPISODES. LUNG SOUNDS/AIR EXCHANGE AUDIBLE ALL LOBES WITH INSPIRATORY RALES TO UPPER LOBES ARTERIALLY. RESIDENT WHEN ASKED COMFORT LEVEL COMPLAINED OF PRESSURE TYPE PAIN TO ANTERIOR CHEST. RESIDENT AGREED THAT MUSCLES "HURT FROM COUGHING". CHARGE NURSE ADMINISTERED PAIN MEDICATION AS ORDERED THROUGH THE PEG TUBE, NOT RESISTANCE NOTED WITH EASY INSTALLATION. ABDOMEN FLAT WITH MILD BOWEL SOUNDS ALL QUADRANTS. GENTLE PALPITATION PRODUCED NO DISCOMFORT. PEDAL PULSES STRONG AND EQUAL. RESIDENT ABLE TO REPOSITION SELF MOVING ALL EXTREMITIES EASILY WITH NO SHORTNESS OF BREATH NOTED. RESIDENT APPEARS TO MODERATE SPEECH AND ACTIVITY TO REDUCE COUGHING RESIDENT diagnosed with [REDACTED]., AFEBRILE. THE PHYSICIAN HAS BEEN NOTIFIED AND INFORMED OF MEDICATION ERROR. VERBAL ORDER RECEIVED TO MAINTAIN NPO AND ADMINISTER MEDICATION VIA PEG TUBE EXCEPT HOSPICE ORDERED [MEDICATION NAME]. ALL MEDICATION ORDERS HAVE BEEN REVIEWED AND REVISED AS NEEDED. RESPONSIBLE PARTY HAS BEEN NOTIFIED. CARE PLANS AND CARE GUIDES HAVE BEEN UPDATED. ELEMENT 2 RESIDENTS IDENTIFIED AT RISK WHO ARE NPO OR ON THICKENED LIQUID MEDICATION ORDER HAVE BEEN REVIEWED. PHYSICIANS HAVE BEEN NOTIFIED FOR ANY ORDER CLARIFICATIONS. ANDY PHYSICIAN ORDER CLARIFICATION HAS BEEN IMPLEMENTED ON THE MAR AND PHARMACY NOTIFIED OF ANY CHANGES. RESIDENTS WHO NPO HAVE BEEN IDENTIFIED THEIR MED ORDER HAS BEEN REVIEWED TO ENSURE MEDICATIONS ORDERS AND ADMINISTRATION RECORDS IDENTIFY CORRECT ROUTE OF MEDICATION ADMINISTRATION. RESIDENT IDENTIFIED HAVE BEEN ASSESSED AND CARE PLANS UPDATED. ELEMENT #3 FACILITY HAD REVIEWED THE GENERAL DOSE PREPARATION AND MEDICATION ADMINISTRATION POLICY AND DEEMED IT APPROPRIATE. ALL LICENSED NURSES WILL BE IN-SERVICES ON GENERAL DOSE PREPARATION AND MEDICATION ADMINISTRATION POLICY. ALL LICENSED NURSE WILL BE IN-SERVICES ON MEDICATION ADMINISTRATION--THE 12 MINUTE TRAINER WHICH INCLUDES ORAL LIQUID AND SOLIDS, EYE DROPS/INHALERS/PATCHES, MEDICATION VIA [DEVICE], AND F-TAGS. THE NURSES ROLE. ALL LICENSED NURSES WILL BE IN-SERVICED ON RESIDENT ASSESSMENT AND APPROPRIATE INTERVENTION. IN-SERVICES WILL SPECIFICALLY FOCUS ON CORRECT ROUTE; MEDS SHOULD BE ADMINISTERED TO RESIDENTS. THIS IN-SERVICE WILL ALSO INCLUDE REVIEW OF POLICY AND PROCEDURE FOR CLARIFICATION OF ROUTES. A MEDICATION REVIEW WILL BE CONDUCTED BY A PHARMACIST. IN-SERVICE FOR INTERACT SBAR DOCUMENTATION FOR ASSESSING RESIDENT FOR NEW SYMPTOMS, SIGNS, AND OTHER CHANGES IN CONDITION WILL BEGIN ON 7/18/13 AND CONTINUE THROUGH 7/22/13. IN-SERVICE ON GENERAL DOSE PREPARATION AND MEDICATION ADMINISTRATION POLICY. ALL LICENSED NURSE WILL BE IN-SERVICES ON MEDICATION ADMINISTRATION--THE 12 MINUTE TRAINER WHICH INCLUDES ORAL LIQUID SOLIDS, EYE DROPS/INHALERS/ PATCHES, BEGAN ON 7/16/13 AT 8:00 P.M. TO 12:30 A.M. THESE IN-SERVICES CONTINUE TO BE ONGOING FROM 6:00 AM TO 7:00 AM DAILY AND WILL CONTINUE UNTIL ALL LICENSED NURSES ARE INSERVICES. ALL INSERVICES WILL BE GIVEN BY THE DON/DESIGNEE. ELEMENT #4 THE DON/DESIGNEE WILL CONDUCT MEDICATION PASS COMPETENCY REVIEW ON ALL LICENSED NURSES. THE DON OR DESIGNEE WILL CONDUCT RANDOM MEDICATION PASS REVIEW AUDITS ON LICENSED NURSES A MINIMUM OF THREE TIMES PER WEEK. RANDOM MEDICATION PASS REVIEWS WILL BEGIN ON 7/18/13. FINDINGS WILL BE REPORTED TO THE ADMINISTRATOR WEEKLY. THE FINDINGS WILL ALSO BE REPORTED TO THE QA COMMITTEE MONTHLY. THE DON IS RESPONSIBLE FOR MAINTAINING COMPLIANCE WITH THIS CITATION."

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO IMPLEMENT INTERVENTIONS TO PREVENT THE DEVELOPMENT OF A PRESSURE SORE FOR ONE (#706) RESIDENT AND FAILED TO PREVENT THE WORSENING OF AN EXISTING PRESSURE ULCER FOR ONE (#711) RESIDENT FROM A TOTAL OF SEVEN RESIDENTS REVIEWED FOR PRESSURE ULCERS FROM A TOTAL SAMPLE OF 24 RESIDENTS RESULTING IN THE DEVELOPMENT OF A STAGE III PRESSURE ULCER AND A IMPAIRED PRESSURE ULCER HEALING. FINDINGS INCLUDE: ON 7/16/13 AT 9:40 AM AND AT 4:30 PM, RESIDENT #706 WAS OBSERVED IN BED WITH THE HEAD OF THE BED (HOB) IN THE UP POSITION. THE RESIDENT WAS OBSERVED IN A POSITION WHERE SHE WAS CRADLED IN THE MATTRESS WHICH POSITIONED THE RESIDENT'S CHIN TOWARD THE CHEST. [MEDICAL CONDITION], A SURGICAL OPENING IN THE RESIDENT'S NECK TO ALLOW THE EXCHANGE OF OXYGEN), WAS INTACT AND ATTACHED TO OXYGEN TUBING AND THE VENTILATOR EQUIPMENT. THE VENTILATOR WAS OBSERVED ON THE RESIDENT'S RIGHT SIDE CORNER BEHIND THE RESIDENT'S BED. ON 7/17/13 AT 9:00 AM, 11:00 AM AND 2:00 PM, RESIDENT #706 WAS OBSERVED IN BED WITH THE HOB ELEVATED, CRADLED IN THE MATTRESS. THE VENTILATION EQUIPMENT WAS INTACT AND POSITIONED ON THE RESIDENT'S LEFT SIDE, NEXT TO THE HEAD OF THE BED. ON 7/18/13 AT 9:00 AM, THE RESIDENT WAS OBSERVED WITH THE HOB ELEVATED, IN A CRADLED POSITION WITH THE VENTILATION EQUIPMENT INTACT AND POSITIONED ON THE RESIDENT'S LEFT SIDE NEXT TO THE HEAD OF THE BED. ON 7/18/13 AT 12:25 PM, RESIDENT #706 WAS OBSERVED IN BED WITH THE HOB UP, IN A CRADLED POSITION WITH THE VENTILATION EQUIPMENT INTACT. TREATMENT NURSE 'D' QUERIED RESIDENT #706, WHO COMPLAINED OF PAIN ON THE RIGHT SIDE OF THE NECK AND JAW AREA. A WOUND DRESSING WAS OBSERVED ON THE RIGHT SIDE OF THE RESIDENT'S TRACH, BELOW THE STOMA, ON THE COLLAR BONE. NURSE 'B' AND 'D' WERE THEN OBSERVED TO PERFORM WOUND CARE. TREATMENT NURSE 'B' ANNOUNCED THAT SHE WOULD START WITH THE STAGE III PRESSURE ULCER AT THE PERI-TRACH AREA (COLLAR BONE). NURSE 'B' REMOVED THE DRESSING FROM THE RIGHT SIDE OF RESIDENT #706'S [MEDICAL CONDITION] TO REVEAL A WOUND WITH BLACK AND GREEN COLORED EDGES WITH A PINK AND WHITE WOUND BASE WHICH SHE IDENTIFIED WAS LOCATED IN THE PERI-TRACH AREA (CLAVICLE--COLLAR BONE). NURSE 'B' AND 'D' WERE QUERIED REGARDING THE ONSET OF THE PRESSURE ULCER AND REPORTED RESIDENT #706 WAS NOT admitted INTO THE FACILITY WITH THE PRESSURE ULCER. NURSE 'B' DESCRIBED THE ULCER AS A STAGE III PRESSURE ULCER BECAUSE IT HAD SLOUGH, (DEAD TISSUE THAT SEPARATES FROM SKIN AS A RESULT OF INJURY. A STAGE THREE PRESSURE ULCER IS DESCRIBED AS FULL THICKNESS TISSUE LOSS WHEREBY SLOUGH MAY BE PRESENT BUT DOES NOT OBSCURE THE DEPTH OF TISSUE LOSS). WHEN QUERIED HOW THE PRESSURE ULCER OCCURRED, NURSE 'B' STATED THAT IT WAS THE RESULT OF, "HOW THE TUBING (VENTILATOR) WAS PRESSED INTO THE SKIN." REVIEW OF THE RESIDENT ADMISSION RECORD REVEALED RESIDENT #706 WAS admitted on TO THE FACILITY'S VDCU (VENTILATOR DEPENDENT CARE UNIT) ON 6/4/13 WITH [DIAGNOSES REDACTED]. PER THE ADMISSION MINIMUM DATA SET ((MDS) dated [DATE], RESIDENT #706 WAS NON-VERBAL, SOMETIMES ABLE TO MAKE SELF UNDERSTOOD AND WAS SOMETIMES ABLE TO RESPOND APPROPRIATELY TO SIMPLE, DIRECT COMMUNICATION ONLY AND WAS DETERMINED TO BE "SEVERELY COGNITIVELY IMPAIRED". RESIDENT #706 WAS ASSESSED TO REQUIRE EXTENSIVE ONE PERSON PHYSICAL ASSISTANCE WITH BED MOBILITY AND REQUIRED TOTAL 2 TO 3 PERSON PHYSICAL ASSISTANCE WITH ALL OTHER ACTIVITIES OF DAILY LIVING "AT RISK" DEVELOPMENT AND WAS admitted WITH UNHEALED PRESSURE ULCERS AT A STAGE III AND STAGE IV. THERE WERE FIVE ADDITIONAL "UNSTAGEABLE" (SUSPECTED DEEP TISSUE INJURY IN EVOLUTION) PRESSURE ULCERS ON OTHER LOCATIONS OF THE RESIDENT'S BODY. SKIN AND ULCER TREATMENTS WERE DOCUMENTED AS PRESSURE REDUCING DEVICE FOR BED, TURNING/REPOSITIONING, NUTRITION PROGRAMS TO MANAGE SKIN PROBLEMS AND PRESSURE ULCER CARE. THERE WERE NO INTERVENTIONS THAT ADDRESSED PRESSURE ULCER PREVENTION RELATED TO VENTILATOR EQUIPMENT. THE MDS DOCUMENTED THAT RESIDENT #706 WAS TO RECEIVE THE FOLLOWING TREATMENTS: OXYGEN THERAPY, SUCTIONING, [MEDICAL CONDITION] CARE AND A VENTILATOR. REVIEW OF THE CARE AREA ASSESSMENT REVEALED THAT A PRESSURE ULCER CARE PLAN WAS TO BE DEVELOPED TO, "PROMOTE HEALING AND PREVENT FURTHER SKIN BREAKDOWN." THE BRADEN SCALE (AN ASSESSMENT TOOL USED TO DETERMINE THE RISK FOR DEVELOPING PRESSURE ULCERS) DATED 6/5/13, REVEALED A SCORE OF "16" (MILD RISK). THE "ADMISSION NURSING ASSESSMENT" DATED 6/4/13 AND THE "ADMISSION SKIN ASSESSMENT AND MANAGEMENT TOOL" DATED 6/5/13 DID NOT DOCUMENT ANY PRESSURE ULCERS TO THE PERI-TRACH AREA OR COLLAR BONE FOR RESIDENT #706. IDENTIFICATION OF A NEW PRESSURE SORE AREA WAS DOCUMENTED IN THE WOUND CARE NOTES DATED 7/09/13 AS FOLLOWS: "PERI-TRACH 1.3 CM (CENTIMETERS) X 1.0 CM, PINK BASE WITH MINIMAL YELLOW SLOUGH WITH MINIMAL SEROSANGUINOUS (WATERY FLUID THAT CONTAINS BLOOD) DRAINAGE...DIAGNOSIS...PRESSURE ULCER STAGE II [MEDICAL CONDITION]....RECOMMENDATIONS...FREQUENTLY REPOSITION, SANTYL (A MEDICATION THAT CONTAINS ENZYMES TO FACILITATE IN BREAKING DOWN SLOUGH) AND ALLEVYN (A PROTECTIVE WOUND COVERING) EVERY TWO DAYS AND PRN (AS NECESSARY) TO PERI TRACH)." WOUND CARE NOTES RELATED TO THE PERI-TRACH AREA, DATED 7/16/13, DOCUMENTED THE FOLLOWING: "1.2 X 1.2 CM PINK BASE, MINIMAL SEROUS (WATERY FLUID) DRAINAGE." REVIEW OF THE PHYSICIAN'S NOTES, DATED 7/17/13, REVEALED NO ASSESSMENT DOCUMENTED RELATED TO THE DEVELOPMENT OF A PRESSURE ULCER NEAR THE PERI-TRACH AREA. REVIEW OF NURSES NOTES DATED 7/6/13 REVEALED WOUND CARE DOCUMENTATION AS FOLLOWS: "NOTED WITH DRESSING TO RIGHT PERI-TRACH AREA 1.0 X .5 YELLOW BASE WITH MODERATE SEROUS DRAINAGE. AREA CLEANSED AND WITH TREATMENT WITH ALLEVYN. CARE PLAN CURRENT. WILL CONTINUE TO MONITOR." REVIEW OF THE CARE PLAN ENTITLED, "I HAVE AN ALTERATION IN SKIN INTEGRITY AS EVIDENCED BY", DATED 6/5/13, REVEALED THE FOLLOWING GOAL: "NO FURTHER BREAKDOWN WILL BE NOTED WITH THE FOLLOWING APPROACHES: "ASSESS SKIN DURING CARE AND REPORT ANY CHANGES IMMEDIATELY." THE CARE PLAN WAS UPDATED ON 7/6/13 AND REVEALED "RIGHT PERI-TRACH STAGE II." THERE WERE NO DOCUMENTED INTERVENTIONS TO PREVENT PRESSURE ULCERS PRIOR TO THE ONSET OF THE PRESSURE ULCER AT THE PERI-TRACH AREA FOR RESIDENT #706. REVIEW OF THE "RESPIRATORY CARE PLAN FOR VENTILATOR AND [MEDICAL CONDITION] RESIDENTS DATED 6/4/13, REVEALED THE FOLLOWING PLAN OF CARE FOR RESIDENT #706: "FUNCTIONAL IMPAIRMENT: PLAN... PROVIDE MECHANICAL VENTILATION...PLAN...POTENTIAL FOR INFECTION: [MEDICAL CONDITION] EACH SHIFT...EXPECTED OUTCOME...FREE FROM STOMA REDNESS, FREE FROM STOMA DRAINAGE, FREE FROM EXCORIATION." THE RESPIRATORY CARE PLAN DID NOT ADDRESS THE POTENTIAL OR ACTUAL CAUSE OF SKIN CONDITIONS RELATED TO THE VENTILATOR EQUIPMENT NOR DID IT ADDRESS RESIDENT POSITIONING TO PREVENT SKIN CONDITIONS. REVIEW OF RESIDENT #706'S CLINICAL RECORD DID NOT REVEAL ANY OTHER DOCUMENTATION RELATED TO RESPIRATORY THERAPY OR RESIDENT SKIN CONDITION/ASSESSMENT. PER FACILITY POLICY, THE "WEEKLY HEAD TO TOE SKIN CHECK" FORMS WERE REQUIRED TO BE COMPLETED EACH WEEK BY STAFF NURSES. THESE FORMS WERE REQUESTED FROM THE FACILITY AND THERE WERE NO "WEEKLY HEAD TO TOE SKIN CHECK" FORMS PROVIDED FOR REVIEW. ON 7/19/13 AT 9:45 AM THE VENT UNIT NURSE MANAGER 'H' WAS QUERIED REGARDING THE FACILITY ACQUIRED PRESSURE ULCER TO RESIDENT #706'S PERI-TRACH AREA. UNIT MANAGER 'H' WAS ASKED IF THERE WERE ANY INTERVENTIONS IN PLACE TO PREVENT A PRESSURE ULCER TO RESIDENT #706'S PERI-TRACH AREA AND STATED, "WHENEVER (RESIDENT #706) WAS TURNED THE VENT TUBING SHOULD HAVE BEEN ADJUSTED. THAT IS JUST COMMON SENSE." WHEN ASKED WHO WAS RESPONSIBLE TO POSITION RESIDENT #706 TO PREVENT PRESSURE ULCERS RELATED TO THE VENTILATION TUBING/DEVICES SITE, UNIT MANAGER 'H' STATED, "IT IS NOT JUST ONE DISCIPLINE THAT POSITIONS THE RESIDENT FOR COMFORT OR TO PREVENT PRESSURE ULCERS." UNIT MANAGER 'H' EXPLAINED THAT RESPIRATORY AND NURSING CONSTANTLY ASSESS RESIDENTS BUT WAS UNABLE TO EXPLAIN HOW RESIDENT #706 DEVELOPED A STAGE III PRESSURE ULCER IN THE PERI-TRACH AREA. ON 7/19/13 AT 11:15 AM, THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED REGARDING THE ONSET OF RESIDENT #706'S PRESSURE ULCER TO THE PERI-TRACH AREA. THE DON REPORTED THAT SHE WAS MADE AWARE OF RESIDENT #706'S ACQUIRED PRESSURE ULCER ON 7/18/13. THE DON WAS ASKED WHAT INTERVENTIONS WERE IN PLACE TO PREVENT THE ONSET OF A PRESSURE ULCER ON THE PERI-TRACH AREA. THE DON SAID THAT SHE WAS UNABLE TO EXPLAIN WHY THE AREA WAS NOT IDENTIFIED BECAUSE, "FLOOR NURSES DO WEEKLY SKIN ASSESSMENTS AND RESPIRATORY THERAPY [MEDICAL CONDITION] TWICE A SHIFT." THE DON EXPLAINED THAT PRESSURE ULCER PREVENTION WAS A MULTI-DISCIPLINARY EFFORT. WHEN ASKED HOW THE RESPIRATORY THERAPY DEPARTMENT WAS INVOLVED IN RESIDENT CARE, THE DON STATED, "THE RESPIRATORY DEPARTMENT DOES NOT REPORT TO ME." THE DON WAS UNABLE TO EXPLAIN THE LACK OF SKIN ASSESSMENTS OR BATH SHEETS (TOOLS USED TO MONITOR AND ASSESS RESIDENT SKIN CONCERNS) FOR RESIDENT #706. THE FACILITY POLICY "SKIN MANAGEMENT FACILITY GUIDELINES" REVISED ON 1/2011 DOCUMENTED THE FOLLOWING: THE FACILITY IS COMMITTED TO PROVIDING CARE AND SERVICES TO RESIDENTS TO PREVENT THE DEVELOPMENT OF SKIN BREAKDOWN. THE FOLLOWING GUIDELINES ARE IN PLACE TO REACH THIS GOAL:... A CARE PLAN IS DEVELOPED UPON ADMISSION AND MAY ADDRESS; IDENTIFYING THE CONTRIBUTING RISKS FOR BREAKDOWN...PREVENTIVE DEVICES,...POSITIONING REQUIREMENTS, PROPER BODY ALIGNMENT...PLACE EACH RESIDENT ON A WEEKLY HEAD TO TOE SKIN ASSESSMENT. ..THE ASSESSMENTS WILL BE PLACED IN BINDERS ON EACH UNIT AND FILED IN THE MEDICAL RECORD MONTHLY." THE SKIN MANAGEMENT GUIDELINES DID NOT DOCUMENT CLEAR OR SPECIFIC INSTRUCTIONS FOR THE PREVENTION OF FACILITY ACQUIRED PRESSURE ULCERS. ( ) ON 7/17/13 AT 2:10 PM, A REVIEW OF THE CLINICAL RECORD REVEALED THAT RESIDENT #711 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE ADMISSION MINIMUM DATA SET (MDS), dated [DATE], INDICATED THAT RESIDENT #711 HAD MODERATELY IMPAIRED COGNITION AND REQUIRED EXTENSIVE PHYSICAL ASSISTANCE WITH MOST ACTIVITIES OF DAILY LIVING. THE ADMISSION SKIN ASSESSMENT SHEET AND MANAGEMENT TOOL, DATED 6/5/13, REVEALED THAT RESIDENT #711 HAD A UNSTAGEABLE PRESSURE SORE ON THE LEFT HEAL THAT MEASURED 5.5 CENTIMETERS (CM) LONG X 6.8 CM WIDE. THE NURSING CARE PLAN, DATED 6/5/13, REVEALED THAT RESIDENT #711 WAS SUPPOSED TO HAVE HIS HEELS FLOATED, HEEL LIFT BOOTS, AND PILLOWS FOR POSTIONING. ON 7/18/13 AT 1:00 PM, RESIDENT #711 WAS OBSERVED LYING IN BED. RESIDENT #711 HAD ON NO HEEL PROTECTORS AND HIS FEET WERE NOT SUSPENDED ON PILLOWS. AT 3:45 PM, DURING THE DRESSING CHANGE OBSERVATION WITH TREATMENT NURSE "B", RESIDENT #711 WAS OBSERVED LYING IN BED. RESIDENT #711 HAD ON NO HEEL PROTECTOR AND HIS HEELS WERE NOT FLOATED ON PILLOWS. RESIDENT #711 WAS OBSERVED TO HAVE AN UNSTAGEABLE PRESSURE SORE ON THE LEFT HEAL THAT MEASURED 5.6 CM LONG X 5.5 CM WIDE. THE PRESSURE SORE WAS COVERED WITH ESCHAR (DEAD TISSUE). THE EDGES OF THE WOUND HAD STARTED TO LIFT. FOLLOWING THE DRESSING CHANGE, TREATMENT NURSE "B" STATED, "I HAVE TO GET YOU SOME HEAL PROTECTORS." HOWEVER, ON 7/19/13 AT 9:25 AM AND 10:00 AM, RESIDENT #711 WAS OBSERVED LYING IN BED. RESIDENT #711 HAD ON NO HEEL PROTECTORS AND HIS HEEL WERE NOT FLOATED ON PILLOWS. ON 7/19/13 AT 10:40 AM, TREATMENT NURSE "B" WAS ASKED WHAT INTERVENTION WERE PUT IN PLACE TO PREVENT THE WORSENING OF RESIDENT #711'S LEFT HEEL PRESSURE SORE. TREATMENT NURSE "B" REVEALED THAT RESIDENT #711 WAS SUPPOSED TO HAVE PILLOWS UNDER HIS FEET TO FLOAT HIS HEELS AND HEEL PROTECTORS ON WHEN HE WAS IN BED. TREATMENT "B" REVEALED THAT DURING THE DRESSING CHANGE YESTERDAY SHE HAD NOTICED THAT RESIDENT #711'S HEELS WERE NOT FLOATED AND THAT HE WAS NOT WEARING HEEL PROTECTORS. TREATMENT NURSE "B" REVEALED THAT SHE HAD GOTTEN A PAIR AND PUT THEM ON. TREATMENT NURSE "B" REVEALED THE CNA (CERTIFIED NURSE AIDES) SHOULD HAVE PUT THEM ON. THE TREATMENT NURSE REVEALED THE "RESIDENT CARE GUIDE" WAS HOW INTERVENTIONS WERE COMMUNICATED TO THE CNAS. THE RESIDENT CARE GUIDE, DATED 6/4/13, WAS SHOWN TO TREATMENT NURSE "B". TREATMENT NURSE "B" REVIEWED THE CNA "RESIDENT CARE GUIDE" AND STATED, "I DON'T SEE IT" (THE INTERVENTIONS FOR HEEL PROTECTORS AND PILLOWS TO FLOAT THE HEELS). THE SKIN SECTION ON THE RESIDENT CARE GUIDE HAD NOT INTERVENTIONS CHECKED. ON 7/19/13 AT 2:10 PM, DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) AND TREATMENT NURSE "B", THE DON REVEALED THE UNIT MANAGERS WERE SUPPOSED TO ENSURE THAT INTERVENTIONS WERE PUT IN PLACE ALONG WITH THE TREATMENT NURSES. ON 7/19/13, A REVIEW OF THE FACILITY POLICY TITLED "SKIN MANAGEMENT FACILITY GUIDELINES, DATED JANUARY 2011, STATED, "RESIDENTS admitted WITH SKIN IMPAIRMENTS WILL HAVE: APPROPRIATE INTERVENTIONS IMPLEMENTED TO PROMOTE HEALING". THE UNDATED FACILITY POLICY TITLED "RESIDENT CARE GUIDE", STATED, "EACH RESIDENT WILL HAVE RESIDENT CARE GUIDE DEVELOPED...THAT ADDRESSES IDENTIFIED RISK AREAS AND RESIDENT'S INITIAL NEEDS...UPDATE THE RESIDENT CARE GUIDE ON AN ONGOING BASIS AS NECESSARY...ANY MEMBER OF THE INTERDISCIPLINARY TEAM RESPONSIBLE FOR THE RESIDENT'S CARE CAN UPDATE THE RESIDENT CARE GUIDE." ( )

THIS CITATION PERTAINS TO INTAKE #MI 000. BASED ON INTERVIEW AND RECORDS REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SAFETY DEVICES AND/OR SUPERVISION TO MAINTAIN PATENT AIRWAYS, PROVIDE ADEQUATE BREATHING, AND THE NECESSARY OXYGENATION TO SUSTAIN LIFE FOR 3 OF 5 SAMPLED MECHANICALLY-VENTILATED RESIDENTS (RESIDENT #101, RESIDENT #103 AND RESIDENT #105) WITH TRACHEOSTOMIES, FROM A TOTAL SAMPLE OF 8 RESIDENTS, RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #101, RESIDENT #103 AND RESIDENT #105. RESIDENT #101 PULLED OUT HIS OWN CUFFED TRACHEOSTOMY TUBE, CAUSING ARTERIAL TRAUMA, EXSANGUINATION, AND DEATH. RESIDENT #103 PULLED OFF HIS OXYGEN SEVEN TIMES IN TWO HOURS BEFORE EXPERIENCING CARDIOPULMONARY ARREST. RESIDENT #105 DECANNULATED HERSELF TWICE IN TEN MINUTES. THESE DEFICIENT PRACTICES PLACE 28 ADDITIONAL MECHANICALLY-VENTILATED RESIDENTS WITH TRACHEOSTOMIES AT HIGH RISK FOR SERIOUS HARM, INJURY AND/OR DEATH. FINDINGS INCLUDE: RESIDENT #101: REVIEW OF THE UNDATED FACE SHEET REVEALED THAT RESIDENT #101 WAS AN [AGE] year-OLD MALE, admitted to the facility on [DATE] AND REadmitted on [DATE], WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET (MDS) ASSESSMENT, DATED [DATE], REVEALED THAT THE COGNITIVE STATUS OF RESIDENT #101 WAS NEVER ASSESSED, BUT HE REQUIRED SPECIALIZED OXYGEN THERAPY, SUCTION, TRACHEOSTOMY CARE AND VENTILATOR SERVICES. REVIEW OF THE "RESPIRATORY EVALUATION/ASSESSMENT", DATED [DATE], REVEALED THAT RESIDENT #101 REQUIRED A CUFFED TRACHEOSTOMY TUBE TO MAINTAIN A PATENT AIRWAY AND MECHANICAL VENTILATION, FOR ADEQUATE BREATHING/OXYGENATION. REVIEW OF CARE PLANS, DATED [DATE], REVEALED THAT RESIDENT #101 REQUIRED: 1) SPECIALIZED RESPIRATORY SERVICES TO DELIVER TRACHEOSTOMY CARE AND ENSURE ADEQUATE MECHANICAL VENTILATION; 2) STAFF MONITORING (FOR) ANXIETY WITH MEDICATION ADMINISTRATION FOR SYMPTOMS THEREOF; AND 3) THE APPLICATION OF A LEFT HAND MITTED RESTRAINT AFTER STAFF WITNESSED HIM "PULL ON (THE) TRACH (TRACHEAL TUBE)." REVIEW OF PHYSICIAN ORDERS, DATED [DATE], REVEALED RESIDENT #101 WAS TO BE MAINTAINED ON A VENTILATOR THAT ASSISTED HIM TO TAKE 14 BREATHS EVERY MINUTE, WITH EACH BREATH PROVIDING HIS LUNGS WITH 500 MILLILITERS OF FORCED AIR, AND AN OXYGEN SETTING AT 50 PERCENT, TITRATED BY STAFF TO MEET HIS OXYGENATION NEEDS. REVIEW OF BOTH SOCIAL WORK NOTES, DATED [DATE], AND TWO HISTORY AND PHYSICALS, DATED [DATE] AND [DATE] RESPECTIVELY, REVEALED RESIDENT #101 WAS UNABLE TO FOLLOW SIMPLE COMMANDS DUE TO IMPAIRED COGNITION. DURING A TELEPHONE INTERVIEW ON [DATE] AT 3:10 P.M., RESPIRATORY THERAPIST (RT) #3 SAID THAT DESPITE THE APPLICATION OF THE MITTED HAND RESTRAINT, RESIDENT #101 FREQUENTLY PULLED AT HIS VENTILATOR TUBES AND TRACHEAL TUBE. ONCE AWARE THAT RESIDENT #101 DEMONSTRATED THESE UNSAFE BEHAVIORS, RT #3 SAID STAFF FAILED TO IMPLEMENT ANY ADDITIONAL SAFETY DEVICES AND/OR SUPERVISION TO ENSURE RESIDENT #101 RETAINED A PATENT AIRWAY, ADEQUATE MECHANICAL VENTILATION, AND/OR OXYGENATION. DURING AN INTERVIEW ON [DATE] AT 12:00 P.M., LICENSED PRACTICAL NURSE (LPN) #1 SAID THAT RESIDENT #101 WORE A LEFT HAND MITTED RESTRAINT BECAUSE HIS WIFE REPORTED THAT RESIDENT #101 HAD PRIOR SUCCESS REMOVING HIS TRACHEOSTOMY TUBE. LPN #1 SAID RESIDENT #101 HAD "A BUSY HAND" THAT HE FREQUENTLY USED TO STRIKE HIS VENTILATOR LINES AND/OR TRACHEOSTOMY TUBE. ONCE AWARE THAT THE RESIDENT DEMONSTRATED THESE UNSAFE BEHAVIORS, LPN #1 SAID STAFF FAILED TO IMPLEMENT ANY ADDITIONAL SAFETY DEVICES AND/OR SUPERVISION TO ENSURE RESIDENT #101 RETAINED A PATENT AIRWAY, ADEQUATE MECHANICAL VENTILATION, AND/OR OXYGENATION. DURING A TELEPHONE INTERVIEW ON [DATE] AT 3:30 P.M., CERTIFIED NURSING ASSISTANT (CNA) #1 SAID SHE ROUTINELY NOTIFIED THE LICENSED NURSE ON DUTY WHENEVER RESIDENT #101 ATTEMPTED TO STRIKE HIS VENTILATOR LINES AND/OR TRACHEAL TUBE WITH HIS MITTED HAND. DESPITE THESE NOTIFICATIONS, CNA #1 WAS UNABLE TO IDENTIFY ANY ADDITIONAL SAFETY DEVICES AND/OR SUPERVISION TO ENSURE RESIDENT #101 RETAINED A PATENT AIRWAY, ADEQUATE MECHANICAL VENTILATION, AND/OR OXYGENATION. DURING A TELEPHONE INTERVIEW ON [DATE] AT 3:20 P.M., RT #4 SAID THAT WHILE ASSIGNED TO RESIDENT #101, SHE FOUND THE MITTED RESTRAINT HAD NOT DETERRED HIM FROM PULLING AT "...HIS TUBE (TRACHEAL TUBE) ALL THE TIME." RT #4 SAID THE UNSAFE BEHAVIORS EXHIBITED BY RESIDENT #101 PLACED HIM AT RISK FOR NEGATIVE OUTCOMES ASSOCIATED WITH AN UNQUALIFIED REMOVAL OF THE TRACHEAL TUBE, UP TO AND INCLUDING DEATH. SHE THEN SAID, WHEN NURSING STAFF MEMBERS WERE INFORMED ABOUT RESIDENT #101 PULLING AT HIS TRACHEAL TUBE, THEY ROUTINELY FAILED TO INTERVENE OR ADMINISTER THE RESIDENT'S ORDERED ANTIANXIETY MEDICATIONS. ONCE AWARE THAT RESIDENT #101 DEMONSTRATED THESE UNSAFE BEHAVIORS, RT #4 SAID STAFF FAILED TO IMPLEMENT ANY ADDITIONAL SAFETY DEVICES AND/OR SUPERVISION TO ENSURE RESIDENT #101 RETAINED A PATENT AIRWAY, ADEQUATE MECHANICAL VENTILATION, AND/OR OXYGENATION. REVIEW OF THE admission orders [REDACTED]. REVIEW OF THE MEDICATION ADMINISTRATION RECORDS (MAR) FOR DATES BETWEEN [DATE] AND [DATE] REVEALED RESIDENT #101 NEVER RECEIVED THE ATIVAN ORDERED FOR ANXIETY WHILE RESIDING AT THE FACILITY. REVIEW OF NURSING NOTES, DATED [DATE], REVEALED RESIDENT #101 STILL REQUIRED A LEFT HAND MITTED RESTRAINT "...FOR SAFETY..." ON [DATE] AT 7:10 A.M., LPN #1 DOCUMENTED SHE FOUND RESIDENT #101'S LEFT MITTED RESTRAINT OFF AND HIS ORDERED HUBER (INTRAVENOUS ACCESS NEEDLE) DISLODGED FROM HIS CHEST'S MED-PORT AND LYING ON THE BEDROOM FLOOR. LPN #1 DOCUMENTED THAT SHE REAPPLIED THE MITTED RESTRAINT, AND LEFT THE RESIDENT UNSUPERVISED, WITHOUT ANY ADDITIONAL SAFETY INTERVENTIONS NECESSARY TO ENSURE THAT RESIDENT #101'S UNSAFE BEHAVIOR WAS MODIFIED AND/OR SUPERVISED TO RETAIN HIS REQUIRED INDWELLING LINES, A PATENT AIRWAY, ADEQUATE VENTILATION, AND/OR OXYGENATION. DURING A TELEPHONE INTERVIEW ON [DATE], RT #1 SAID DURING HER MORNING ASSESSMENT ON [DATE], RESIDENT #101 WAS FOUND UNSUPERVISED IN BED AT APPROXIMATELY 8:35 A.M., WITH HIS LEFT HAND MITTED RESTRAINT OFF AND HIS TRACHEA TIES UNDONE. AS RESIDENT #101 WAS ACTIVELY PULLED HIS TRACHEOSTOMY TUBE OUT WITH THE CUFF INFLATED. RT #1 SAID SHE IMMEDIATELY STOPPED HIM FROM FURTHER DISLODGING THE TRACHEAL TUBE, SECURED HIS TRACHEAL TIES FOR STABILITY, REAPPLIED THE MITTED HAND RESTRAINT SHE FOUND LYING ON HIS LAP, AND QUICKLY OBTAINED THE HELP OF A SECOND RESPIRATORY THERAPIST (RT #2), CONCERNED THE RESIDENT'S AIRWAY WAS UNSTABLE. DURING A TELEPHONE INTERVIEW ON [DATE] AT 12:45 P.M., RT #2 SAID THAT ON [DATE], WITHIN A MINUTE AFTER BEING SUMMONED BY RT #1, SHE (RT #2) EVALUATED RESIDENT #101. SHE REMOVED THE GAUZE FROM AROUND THE SURGICAL OPENING, HEARD A SIGNIFICANT AIR LEAK AND WITNESSED ALMOST COMPLETE DISLODGEMENT OF THE TRACHEAL TUBE WITH THE INFLATED CUFF BEING SEEN AT THE SURGICAL OPENING. RT #2 SAID THAT THE REINSERTION OF THE TRACHEAL TUBE FAILED ONCE THE CUFF WAS DEFLATED, BECAUSE LARGE VOLUMES OF BRIGHT RED BLOOD BEGAN TO PULSATE FROM RESIDENT #101'S TRACHEA, THROUGH AND AROUND THE TUBE. RT #2 SAID THERE WAS NOTHING ANYONE COULD DO WHILE RESIDENT #101 "BLED OUT" BECAUSE VAST VOLUMES OF BLOOD PREVENTED A PATENT AIRWAY, VENTILATION, OXYGENATION, AND CHEST COMPRESSIONS. RT #2 SAID RESIDENT #101 died WITHIN THREE MINUTES, LYING IN POOLS OF BLOOD THAT HAD COME FROM HIS NOSE, MOUTH, AND TRACHEA, FILLING THE VENTILATOR TUBING, SUCTION CANISTER AND COVERING HIS BODY, BED, FLOOR, AND WALLS. DURING AN INTERVIEW [DATE] AT 12:30 P.M., DIRECTOR OF RESPIRATORY CARE (DRC) #1 SAID THAT THE TRACHEAL ARTERY SAT NEXT TO THE CUFF TRACHEAL TUBES AND IT WAS POSSIBLE RESIDENT #101 INJURED THAT ARTERY WHEN HE PULLED OUT THE INFLATED CUFFED TRACHEAL TUBE. REVIEW OF THE MEDICAL RECORD REVEALED THE UNSAFE BEHAVIORS EXHIBITED BY RESIDENT #101, AND ASSESSED BY LICENSED NURSES, REGISTERED RESPIRATORY THERAPISTS AND CERTIFIED AIDES, WERE NOT ROUTINELY DOCUMENTED, WERE NOT EVALUATED FOR CAUSE, WERE NOT PLANNED FOR INDIVIDUALIZED INTERVENTIONS AND WERE NOT REASSESSED FOR MODIFICATION TO ENSURE RESIDENT #101 RETAINED ADEQUATE VENTILATION AND/OR OXYGENATION. ADDITIONALLY, STAFF FAILED TO DOCUMENT A DECANNULATION RISK ASSESSMENT FOR RESIDENT #101. RESIDENT #103: REVIEW OF THE UNDATED FACE SHEET REVEALED THAT RESIDENT #103 WAS AN [AGE] year-OLD MALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET (MDS) ASSESSMENT, DATED [DATE], REVEALED THAT RESIDENT #103 WAS "SEVERELY IMPAIRED," AND REQUIRED SPECIALIZED OXYGEN THERAPY, SUCTION, TRACHEOSTOMY CARE AND VENTILATOR SERVICES. REVIEW OF PHYSICIAN ORDERS, DATED ,[DATE], REVEALED RESIDENT #103 REQUIRED A TRACHEOSTOMY TUBE TO MAINTAIN A PATENT AIRWAY AND MECHANICAL VENTILATION TO ENSURE ADEQUATE VENTILATION AND OXYGENATION. REVIEW OF CARE PLANS, DATED [DATE], REVEALED RESIDENT #103 REQUIRED: 1) SPECIALIZED RESPIRATORY SERVICES TO DELIVER TRACHEOSTOMY CARE AND ENSURE ADEQUATE MECHANICAL VENTILATION; 2) STAFF MONITORING OF ANXIETY WITH ORDERS TO MEDICATE FOR SYMPTOMS THEREOF; AND 3) THE APPLICATION OF MITTED HAND RESTRAINTS TO ENSURE THE MAINTENANCE OF VENTILATOR TUBES AND A TRACHEAL TUBE PLACEMENT. REVIEW OF NURSING NOTES, DATED [DATE] AT 7:00 P.M., REVEALED THAT RESIDENT #103 WORE MITTED HAND RESTRAINTS BECAUSE HE WAS EXTREMELY STRONG, CONFUSED, UNABLE TO FOLLOW SIMPLE INSTRUCTIONS, AND PULLED AT HIS "LINES - TRACH (TRACHEAL TUBE) - ETC." BETWEEN THE DATES OF [DATE] THROUGH [DATE], NURSING STAFF CONSISTENTLY DOCUMENTED THAT RESIDENT #103 ONLY STOPPED THESE UNSAFE BEHAVIORS WHEN SLEEPING AND/OR AFTER THE ADMINISTRATION OF ORDERED ATIVAN. REVIEW OF RESPIRATORY THERAPY NOTES, DATED [DATE], REVEALED THAT ON THAT DAY, RESIDENT #103 HAD TAKEN HIMSELF OFF OF THE VENTILATOR AT 2:30 A.M., 2:50 A.M., 3:15 A.M., 3:25 A.M., 4:00 A.M., 4:15 A.M., AND 4:25 A.M. THE RESPIRATORY THERAPIST DOCUMENTED THAT RESIDENT #103 WAS RETURNED TO THE VENTILATOR ON EACH OF THE FIRST SIX TIMES HE DISCONNECTED HIMSELF, BUT FAILED TO DOCUMENT ANY ASSESSMENTS TO SUGGEST RESIDENT #103'S CONDITION REMAINED UNSTABLE. ON [DATE] AT 3:35 A.M., LPN #2 DOCUMENTED IN THE NURSE'S NOTES THAT THE RESPIRATORY THERAPIST TOLD HER "...RESIDENT (#103) HAD TAKEN HIMSELF OFF VENT (THE VENTILATOR) SEVERAL TIMES DESPITE THE REQUIRED HAND MITTS BEING IN PLACE." REVIEW OF THE MEDICAL RECORD FAILED TO IDENTIFY ANY ADDITIONAL SAFETY DEVICES AND/OR SUPERVISION IMPLEMENTED ON [DATE], TO ENSURE RESIDENT #103 MAINTAINED ADEQUATE BREATHING AND OXYGENATION, AFTER STAFF WITNESSED THAT HE DISCONNECTED HIS VENTILATOR SEVEN TIMES IN TWO HOURS. REVIEW OF THE MEDICATION ADMINISTRATION RECORD FAILED TO DOCUMENT THE ADMINISTRATION OF ATIVAN FOR THE ANXIETY EXHIBITED BY RESIDENT #103 ON [DATE]. REVIEW OF NURSING NOTES, DATED [DATE] AT 4:30 A.M., REVEALED THAT STAFF FOUND RESIDENT #103 OFF HIS MECHANICAL VENTILATOR, WITHOUT OXYGEN, UNRESPONSIVE, HAVING NO PULSE, NO BLOOD PRESSURE, AND NO RESPIRATIONS. NURSING NOTES DOCUMENTED THAT "CPR (CARDIOPULMONARY RESUSCITATION)" WAS INITIATED. DURING AN INTERVIEW [DATE] AT 11:30 A.M., RT #6 SAID HE TOLD NURSING STAFF THAT RESIDENT #103 WAS EXTREMELY AGITATED DURING THE MIDNIGHT SHIFT ON [DATE], AS EVIDENCED BY THE SEVEN TIMES HE REMOVED THE VENTILATOR TUBING, WITHIN TWO HOURS. RT #6 SAID THAT DESPITE THE NOTIFICATION TO NURSING, NO ADDITIONAL SAFETY DEVICES AND/OR SUPERVISIONS WERE IMPLEMENTED TO MODIFY THE RESIDENT'S UNSAFE BEHAVIORS, OR MAINTAIN HIS OXYGENATION. RT #6 SAID EACH TIME HE REAPPLIED THE OXYGEN SUPPLY, HE EDUCATED RESIDENT #103, BUT KNEW RESIDENT #103 COULD NOT UNDERSTAND WHAT WAS BEING SAID. DURING AN INTERVIEW [DATE] AT 11:00 A.M., LPN #2 SAID THAT EVEN THOUGH RESIDENT #103 REMOVED HIS VENTILATOR/OXYGEN SUPPLY SIX (6) TIMES BEFORE HE WAS FOUND UNRESPONSIVE, SHE (LPN #2) NEVER REASSESSED HIS CONDITION OR DOCUMENTED UNSAFE BEHAVIORS, NEVER PLANNED/OR IMPLEMENTED ANY NEW SAFETY INTERVENTIONS, AND MADE HER ONLY REASSESSMENT AT 4:25 A.M., WHEN A CERTIFIED NURSING ASSISTANT CALLED HER BECAUSE RESIDENT #103 WAS UNRESPONSIVE AND REQUIRED CHEST COMPRESSIONS WITH MANUAL VENTILATION/OXYGENATION, TO REGAIN A PULSE. REVIEW OF THE MEDICAL RECORD REVEALED THE UNSAFE BEHAVIORS EXHIBITED BY RESIDENT #103, AND ASSESSED BY LICENSED NURSES, REGISTERED RESPIRATORY THERAPISTS AND CERTIFIED AIDES, WERE NOT ROUTINELY DOCUMENTED, WERE NOT EVALUATED FOR CAUSE, WERE NOT PLANNED FOR INDIVIDUALIZED INTERVENTION, AND WERE NOT REASSESSED FOR MODIFICATION TO ENSURE THAT RESIDENT #103 RETAINED ADEQUATE VENTILATION AND OXYGENATION. ADDITIONALLY, STAFF FAILED TO DOCUMENT A DECANNULATION RISK ASSESSMENT FOR RESIDENT #103. DURING AN INTERVIEW [DATE] AT 3:30 P.M., DRC #1 SAID DESPITE THE SEVERE OUTCOMES ASSOCIATED WITH THE UNSAFE BEHAVIORS OF RESIDENT #101, AND RESIDENT #103, SHE WAS NOT INTERESTED IN THE APPLICATION OF ANY ADDITIONAL PHYSICAL RESTRAINTS AND FAILED TO IDENTIFY ANY ADDITIONAL SAFETY INTERVENTIONS TO PREVENT FUTURE INCIDENTS. RESIDENT #105: REVIEW OF THE UNDATED FACE SHEET REVEALED RESIDENT #105 WAS A [AGE] year-OLD FEMALE admitted TO THE FACILITY [DATE], AND REadmitted [DATE], WITH [DIAGNOSES REDACTED]. REVIEW OF THE Minimum Data Set, dated dated [DATE], REVEALED RESIDENT #105 HAD NO COGNITIVE ASSESSMENT. REVIEW OF PHYSICIAN ORDERS, DATED ,[DATE], REVEALED THAT RESIDENT #105 REQUIRED A TRACHEOSTOMY TUBE TO MAINTAIN A PATENT AIRWAY AND MECHANICAL VENTILATION TO ENSURE ADEQUATE VENTILATION AND OXYGENATION. REVIEW OF THE LAST "VENTILATOR FLOW SHEET," DATED [DATE], REVEALED THAT RESIDENT #105 WAS MAINTAINED ON A VENTILATOR THAT DELIVERED 10 BREATHS PER MINUTE. EACH BREATH PROVIDED HER LUNGS WITH 500 MILLILITERS OF FORCED AIR WITH THE OXYGEN SET AT 40 PERCENT. REVIEW OF THE FIRST UNUSUAL OCCURRENCE REPORT, DATED [DATE] AT 3:15 A.M., REVEALED THAT ON THAT DATE, RT #6 RESPONDED TO A VENTILATOR ALARM AND FOUND RESIDENT #105 STANDING AT HER CLOSET. RT #6 DOCUMENTED RESIDENT #105 HAD REMOVED HER OWN TRACHEAL TUBE WITH THE CUFF STILL INFLATED AND PLACED IT ON HER BED. RESIDENT #105 WAS NO LONGER CONNECTED TO HER VENTILATOR AND BLOODY SECRETIONS WERE FOUND AT THE TRACHEAL INSERTION SITE. RT #6 SUCCESSFULLY REINSERTED THE TRACHEAL TUBE ON THE THIRD ATTEMPT. REVIEW OF A SECOND UNUSUAL OCCURRENCE REPORT, DATED [DATE] AT 3:25 A.M., REVEALED THAT A SECOND VENTILATOR ALARM SOUNDED FOR RESIDENT #105 TEN MINUTES AFTER HER INITIAL DECANNULATION. STAFF RESPONDED TO THE ALARM AND FOUND RESIDENT #105 HAD REMOVED HER OWN TRACHEAL TUBE FOR A SECOND TIME WITH THE CUFF STILL INFLATED AND PLACED IT ON HER BED. RESIDENT #106 WAS NO LONGER CONNECTED TO HER VENTILATOR AND BLOODY SECRETIONS WERE SUCTIONED FROM HER AIRWAY, AFTER STAFF "REINSERTED" HER TRACHEAL TUBE. REVIEW OF THE MEDICAL RECORD FAILED TO DOCUMENT ANY ASSESSMENTS COMPLETED AFTER THESE TWO INCIDENTS TO ENSURE THAT RESIDENT #105 REMAINED STABLE. RESIDENT #105'S BEHAVIORS WERE NEVER DOCUMENTED IN THE MEDICAL RECORD. THE MEDICAL RECORD CONTAINED NO DOCUMENTED EVIDENCE TO SUGGEST STAFF IMPLEMENTED ANY ADDITIONAL SAFETY DEVICES AND/OR SUPERVISION TO MODIFY RESIDENT #105'S UNSAFE BEHAVIORS, TO KEEP HER TRACHEAL TUBE IN PLACE AND PROVIDE ADEQUATE VENTILATION. ADDITIONALLY, STAFF FAILED TO DOCUMENT A DECANNULATION RISK ASSESSMENT FOR RESIDENT #105. DURING AN INTERVIEW [DATE] AT 4:00 P.M., THE DIRECTOR OF NURSING (DON) #1 SAID STAFF ARE REQUIRED TO IMMEDIATELY IMPLEMENT NEW SAFETY INTERVENTIONS, WHEN RESIDENTS DEMONSTRATE BEHAVIORS THAT THREATENS THEIR WELL-BEING, BUT SHE COULD SEE THAT HAD NOT HAPPENED. ON [DATE] AT 1:30 P.M., THE ADMINISTRATOR WAS INFORMED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON [DATE] AS A RESULT OF THE FACILITY'S FAILURE TO PROVIDE ADEQUATE SAFETY DEVICES AND/OR SUPERVISION TO MAINTAIN PATENT AIRWAYS, ADEQUATE BREATHING, AND THE NECESSARY OXYGENATION TO SUSTAIN LIFE FOR RESIDENTS #101, #103 AND #105. THESE DEFICIENT PRACTICES PLACED 28 ADDITIONAL MECHANICALLY-VENTILATED RESIDENTS AT RISK FOR SERIOUS HARM, INJURY AND/OR DEATH. ON [DATE], THE SURVEYOR DETERMINED THAT THE FOLLOWING MEASURES HAD BEEN IMPLEMENTED BY THE FACILITY TO REMOVE THE IMMEDIATE JEOPARDY: 1. AS OF [DATE], RESIDENT #101 AND RESIDENT #103 NO LONGER RESIDED AT THE FACILITY PER RECORD REVIEW AND OBSERVATIONS. 2. AS OF [DATE], 28 RESIDENTS WITH TRACHEOSTOMY TUBES AND/OR MECHANICAL VENTILATORS WERE IDENTIFIED AS BEING AT RISK FOR POTENTIALLY UNSTABLE AIRWAYS AND INADEQUATE OXYGENATION, AS EVIDENCED BY RESIDENTS OBSERVED AND diagnosed with [REDACTED]. 3. AS OF [DATE], THE ADMINISTRATOR AND DIRECTOR OF NURSING REVIEWED AND DEEMED THE "ROUTINE VENTILATOR CHECK" POLICY AND THE "RESTRAINT DEVICE" POLICY APPROPRIATE, AS EVIDENCED BY RECORD REVIEW OF THE SAME. 4. AS OF [DATE], STAFF REASSESSED ALL 28 TRACHEAL TUBE RESIDENTS AND FOUND THAT THEIR AIRWAYS WERE PATENT AND THEIR VENTILATION/OXYGENATION WAS ADEQUATE, AS EVIDENCED BY OBSERVATIONS AND RECORDS REVIEW - NINE OF THESE RESIDENTS RESIDED ON THE THIRD FLOOR, 16 ON THE FOURTH FLOOR, AND 3 ON THE FIFTH FLOOR. 5. AS OF [DATE], ALL 28 TRACHEAL TUBE RESIDENTS HAD THEIR MEDICAL RECORDS REVIEWED AND UPDATED. AN ACCIDENTAL DECANNULATION RISK ASSESSMENT, A RESPIRATORY CARE PLAN FOR TRACHEOSTOMY/VENTILATOR CARE, AND APPROPRIATE CARE RESTRAINTS/SAFETY DEVICE/SUPERVISION CARE PLANS WERE FORMULATED AS NEEDED, EVIDENCED THROUGH RECORD REVIEW. 6. AS OF [DATE], 20 OF THE 28 RESIDENTS WITH TRACHEAL TUBES WERE IDENTIFIED AS BEING AT RISK FOR ANXIETY AND/OR UNSAFE BEHAVIORS WITH DOCUMENTED ORDERS, CARE PLANS, MONITORING, MEDICATION ADMINISTRATION, BEHAVIORAL FLOW SHEETS, SAFETY DEVICES AND/OR NECESSARY SUPERVISION IMPLEMENTED, EVIDENCED BY RECORDS REVIEW AND OBSERVATIONS. 7. AS OF [DATE], 4 TRACHEAL TUBE RESIDENTS WERE DEEMED APPROPRIATE FOR THE USE OF MITTED RESTRAINTS, WITH THE APPLICATION OF THE SAME, EVIDENCED BY OBSERVATIONS. 8. AS OF [DATE], QUALITY DAILY ROUNDS WERE INITIATED ON ALL TRACHEOSTOMY RESIDENTS. THESE ROUNDS DOCUMENTED THAT EACH TRACHEOSTOMY RESIDENT HAD A PATENT, SECURED AIRWAY, ADEQUATE VENTILATION/OXYGENATION, THEIR ANXIETY WAS MONITORED/MODIFIED, APPROPRIATE SAFETY DEVICES WERE IN PLACE, AND THE LEVEL OF SUPERVISION NECESSARY FOR THEIR SAFETY WAS IN PLACE, AS EVIDENCED BY RECORD REVIEW. 9. AS OF [DATE], THE QUALITY ASSURANCE COMMITTEE MET, REVIEWED, AND APPROVED CHANGES, TO THE "ACCIDENTAL DECANNULATION RISK ASSESSMENT" POLICY, AND INCORPORATED RESIDENT ANXIETY INTO THE ASSESSMENT TOOL, EVIDENCED BY RECORD REVIEW OF THE SAME. 10. AS OF [DATE], RESPIRATORY THERAPY CONTINUED TO DOCUMENT ROUTINE VENTILATOR CHECKS EVERY SIX HOURS TO MEET POLICY REQUIREMENTS, EVIDENCED BY RECORD REVIEW OF THE MEDICAL RECORD. 11. AS OF [DATE], THE FACILITY INITIATED EDUCATION FOR ALL LICENSED/REGISTERED NURSES, RESPIRATORY THERAPISTS, AND CERTIFIED NURSING ASSISTANTS, EMPLOYED AT THE FACILITY. THE EDUCATION CONSISTED OF THE FACILITY ' S POLICY/TOOL FOR ROUTINE VENTILATOR CHECKS, THE FACILITY'S POLICY/ TOOL FOR ACCIDENTAL DECANNULATION RISK ASSESSMENTS, ANXIETY SIGNS/SYMPTOMS/TREATMENTS WITH BEHAVIOR LOGS, COMPLIANCE AND REPORTING FAILURE TO ASSESS/TREATMENT/SUPERVISE RESIDENT ANXIETY, AND THE FACILITY'S POLICY/APPLICATION OF RESTRAINTS/SAFETY DEVICES, EVIDENCED BY THE SIGN-IN OF 52 OF 58 LICENSED/REGISTERED NURSES, 19 OF 22 RESPIRATORY THERAPISTS, AND 65 OF 69 CERTIFIED NURSING ASSISTANTS AND ONE CERTIFIED LETTER SENT TO A STAFF MEMBER ON MEDICAL LEAVE. THE ADMINISTRATOR DOCUMENTED ALL STAFF WILL BE INSERVED BEFORE THEY RETURN TO RESIDENT CARE. 12. AS OF [DATE], BEHAVIORAL LOGS ARE AVAILABLE FOR STAFF TO DOCUMENT RESIDENTS' UNSAFE BEHAVIORS FOR CONTINUITY AND FOLLOW-UP, PROVIDED BY SOCIAL SERVICES, AS EVIDENCED BY RECORDS REVIEW. 13. AS OF [DATE], RANDOM AUDITS WERE INITIATED AND REMAIN ONGOING. THE IMMEDIATE JEOPARDY (IJ) WHICH BEGAN ON [DATE] WAS REMOVED ON [DATE]. THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF "PATTERN" AND SEVERITY OF "NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY" UNTIL ALL APPLICABLE FACILITY STAFF COMPLETE EDUCATION AND SUSTAINED COMPLIANCE CAN BE VERIFIED BY THE STATE AGENCY.

THIS CITATION PERTAINS TO INTAKE #MI 495. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO IDENTIFY POTENTIAL HAZARDS AND PROMOTE A SAFE ENVIRONMENT FOR ONE (#501) OF THREE RESIDENTS REVIEWED FOR SAFETY FROM A TOTAL SAMPLE OF FIVE RESIDENTS, RESULTING IN INJURY WHEN A TELEVISION SET fell on TO RESIDENT #501'S HEAD. FINDINGS INCLUDE: ACCORDING TO THE UNUSUAL OCCURRENCE REPORT DATED 03/11/2013 AT 4:00 P.M., "RESIDENT (#501) STATED THAT SHE WAS COMING OUT OF BATHROOM IN WHEELCHAIR. SHE THEN WENT TO CLOSET TO PUT AWAY SOME ITEMS WHEN SHE WAS BENDING DOWN. STATED SHE FELT SOMETHING HIT HER HEAD." ON 04/04/2013 AT 11:00 A.M. AN INTERVIEW WAS CONDUCTED WITH ALERT AND ORIENTED RESIDENT #501. RESIDENT #501 EXPLAINED THAT ON THE DAY OF THE INCIDENT, "I WAS JUST FINISHED WASHING UP, WHEN I WAS BENDING DOWN AT MY CLOSET AND I FELT SOMETHING HIT ME REAL HARD ON MY HEAD. IT TRAUMATIZED ME. I BECAME REAL DIZZY AND COULDN'T MOVE. I SAW THE TELEVISION ON THE FLOOR NEXT TO ME. I CAN'T REMEMBER WHAT HAPPENED AFTER THAT. I FELT THAT I WAS GOING IN AND OUT OF CONSCIOUSNESS; I WAS LIGHTHEADED AND IN A LOT OF PAIN. I WAS TOLD THAT THE UNIT CLERK CAME IN THE ROOM AND THAT A RESIDENT ACROSS THE HALL WITNESSED THE INCIDENT. MY BOYFRIEND WAS THERE AFTER IT (THE INCIDENT) HAPPENED. THEY (FACILITY STAFF) HAD AN X-RAY DONE OF MY HEAD. A MIDNIGHT SHIFT NURSE NOTICED A DIFFERENCE IN ME SO SHE SENT ME OUT TO THE HOSPITAL WHERE THEY DID AN MRI (MAGNETIC RESONANCE IMAGING) OF MY HEAD. THE DOCTOR SAID THAT I HAD A CONCUSSION. I WAS HAVING REAL SHARP, EXCRUCIATING HEADACHES. THEY DIDN'T NOTIFY MY FAMILY ABOUT THE INCIDENT UNTIL 3:00 A.M. (ON 03/12/2013)." ON 04/04/2013 AT 11:10 A.M., RESIDENT WITNESS #21 WAS QUERIED ABOUT THE INCIDENT WITH RESIDENT #501. RESIDENT WITNESS #21 EXPLAINED THAT HE DID NOT WITNESS THE ACTUAL INCIDENT, BUT HE SAW RESIDENT #501 SHORTLY AFTER AND "SHE (#501) WAS DISCOMBOBULATED! SHE WAS CONFUSED AND WAS JUST NOT HERSELF." ON 04/04/2013 AT 11:30 A.M. OBSERVATIONS WERE MADE IN THE ROOM IN WHICH RESIDENT #501 RESIDED AT THE TIME OF THE INCIDENT. A SHALLOW SHELF APPROXIMATELY 8 INCHES DEEP WAS NOTED ABOVE THE CLOSET AND A SMALL FLAT SCREEN TELEVISION WAS BOLTED SECURELY ON THE SHELF. ON 04/04/2013 AT 1:46 P.M., FACILITY MAINTENANCE SUPERVISOR #9 WAS QUERIED ABOUT THE TELEVISION THAT fell OFF THE SHELF AND LANDED ON THE HEAD OF RESIDENT #501. MAINTENANCE SUPERVISOR #9 EXPLAINED THAT THE TELEVISION THAT HAD BEEN IN THE ROOM WHERE RESIDENT #501 RESIDED WAS NOT SECURELY SCREWED DOWN ONTO THE SHELF BECAUSE "IT (THE TELEVISION SET) HAD A GLASS BASE AND WE COULDN'T SCREW THROUGH THE GLASS BASE. THE ONLY TELEVISIONS THAT WERE SCREWED DOWN BEFORE THE INCIDENT WAS IN ROOMS 303 THROUGH 308, BUT SINCE THE INCIDENT OCCURRED ALL OF THE TELEVISION IN THE FACILITY HAVE BEEN SECURELY MOUNTED. WE CHANGED THE TV OUT IN THAT ROOM TO ONE WITH A PLASTIC BASE." WHEN QUERIED ABOUT RESIDENT #501'S CONDITION AFTER SHE WAS HIT WITH THE TELEVISION, MAINTENANCE SUPERVISOR #9 SAID "SHE (#501) SEEMED OKAY, (BUT) SHE WAS STUNNED." WHEN UNIT CLERK #22 WAS INTERVIEWED ON 04/04/2013 AT 2:20 P.M., SHE EXPLAINED THAT SHE DID NOT WITNESS THE ACTUAL INCIDENT BUT HAD BEEN AT THE NURSING STATION WHEN SHE (UNIT CLERK #22) "HEARD A LOUD BANG, THEN I HEARD HER (RESIDENT #501) SAY 'OW.' I WONDERED WHERE IT (THE SOUND) CAME FROM SO I LOOKED AND SAW THE RESIDENT (#501) WITH HER HEAD DOWN. THEN I NOTICED THE TV ON THE FLOOR NEXT TO HER. I WENT IN TO HER ROOM AND SHE REALLY WASN'T RESPONDING. I WAS TALKING TO HER AND IT WASN'T REGISTERING. I GOT THE NURSE AND I PICKED UP THE TV. SHE DIDN'T EVEN REALIZE THAT I WAS IN THE ROOM WITH HER BECAUSE THE NEXT DAY AFTER SHE RETURNED FROM THE HOSPITAL SHE SAID ME 'SOMEBODY TOLD ME THAT YOU CAME IN MY ROOM AFTER I WAS HIT WITH THE TELEVISION.' " ON 04/04/2013 AT 3:20 P.M., REGISTERED NURSE (RN) #13 WAS INTERVIEWED ABOUT THE INCIDENT. RN #13 REPORTED THAT SHE ALSO DID NOT WITNESS THE INCIDENT. "AT THE TIME, I (RN #13) WAS DOING MY BLOOD SUGARS AND SOMEBODY WAS POINTING AT THE ROOM. I SAW (UNIT CLERK # 22) CARRYING THE TELEVISION. WHEN I WENT IN HER ROOM SHE (RESIDENT #501) COMPLAINED OF A HEADACHE AND DIZZINESS. NEURO-CHECKS AND AN X-RAY OF SKULL WAS ORDERED. SHE DIDN'T SEEM CONFUSED, BUT SHE HAD A LOW TONE OF VOICE. SHE SPOKE A LOT SOFTER THAN USUAL." RN #13 REPORTED THAT SHE PERFORMED NEURO-CHECKS ON RESIDENT #501. ON 04/04/2013 AT APPROXIMATELY 3:30 P.M., WHEN THE FACILITY ADMINISTRATOR (FA) #1 WAS QUERIED ABOUT THE INCIDENT, SHE (FA #1) EXPLAINED THAT THE TELEVISION WAS NOT SECURED TO THE SHELF BECAUSE THE BASE OF THE TELEVISION WAS MADE OF GLASS. FA #1 FURTHER EXPLAINED THAT SOME OF THE SHELVES IN THE RESIDENT ROOMS WERE SHALLOW AND SOME WERE DEEPER; HOWEVER, ALL OF THE TELEVISIONS IN THE ENTIRE FACILITY HAD BEEN SECURED. WHEN QUERIED ABOUT RESIDENT #501'S CONDITION, FA #1 REPORTED THAT RESIDENT #501 HAD SUFFERED A CONCUSSION. REVIEW OF THE CLINICAL RECORD REVEALED THAT RESIDENT #501 WAS A [AGE] year OLD FEMALE WHO WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ASSESSMENT REVEALED A BIMS SCORE OF 15 WHICH INDICATED INTACT COGNITION. REVIEW OF RESIDENT #101'S NEUROLOGICAL RECORD DATED 03/11/2013 THROUGH 03/12/2013 REVEALED THAT NEURO-CHECKS BEGAN AT 11 P.M. IT WAS UNCLEAR IF RESIDENT #501 WAS ACTUALLY ASSESSED FOR LEVEL OF CONSCIOUSNESS AND ORIENTATION AT THE TIME JUST AFTER THE INCIDENT SINCE THE NEURO CHECKS BEGAN ON THE MIDNIGHT SHIFT. THE RESIDENT TRANSFER FORM DATED 03/12/2013 NOTED THAT RESIDENT #501 HAD "COMPLAINS OF DIZZINESS, HEADACHE, PAIN LEVEL 7, UNSTEADY GAIT...MENTAL STATUS FORGETFUL, CONFUSED..." ACCORDING TO HOSPITAL DISCHARGE INSTRUCTIONS DATED 03/12/2013, "...YOU'VE HAD A HEAD INJURY. YOUR SKULL AND OR BRAIN WERE AFFECTED..." ON 04/05/2013 AT 10:30 A.M., WHEN CERTIFIED NURSING ASSISTANT (CNA) #16 WAS INTERVIEWED, SHE (CNA #16) EXPLAINED THAT SHE WAS ASSIGNED TO CARE FOR RESIDENT #501 ON THE AFTERNOON OF 3/11/2013. "IT (THE INCIDENT) HAPPENED SHORTLY AFTER THE START OF SHIFT. SHE (RESIDENT #501) EXPLAINED TO ME WHAT HAPPENED. SHE WAS ON NEURO-CHECKS. I (CNA #16) TOOK HER VITALS. SHE COMPLAINED THAT THE BACK OF HER HEAD WAS HURTING. SHE WOULD GO IN AND OUT OF CONSCIOUSNESS. SHE DIDN'T SEEM RIGHT." ON 04/08/2013 AT 8:55 A.M. A TELEPHONE INTERVIEW WAS CONDUCTED WITH LICENSED PRACTICAL NURSE (LPN) #23 WHO WORKED THE MIDNIGHT SHIFT ON 03/11/2013 AND WAS ASSIGNED TO CARE FOR RESIDENT #501. "WHEN I (LPN #23) CAME IN (TO THE FACILITY), I WENT IN TO CHECK ON THE RESIDENT (#501) AND SHE INFORMED ME ABOUT THE INCIDENT. WHILE SHE WAS EXPLAINING TO ME WHAT HAPPENED TO HER, I NOTICED THAT SHE WAS NOT QUITE HERSELF. SHE WAS ROCKING WHILE SHE WAS TALKING TO ME, HER GAIT WAS SLOWER THAN USUAL AND HER SPEECH WAS DRAGGING ALONG. SHE COMPLAINED THAT SHE FELT REALLY DIZZY AND THAT SHE WAS IN PAIN. AT THAT TIME, THE X-RAY HAD NOT COME BACK YET. I COULDN'T FIND ANYTHING REGARDING THE INCIDENT WHEN I WENT TO LOOK FOR IT. I DIDN'T SEE ANY NEURO-CHECKS SO THAT'S WHY I STARTED THEM WHEN I GOT IN. I DECIDED TO SEND HER OUT TO THE HOSPITAL SO I TELEPHONED THE DOCTOR AND THE FAMILY WHO WERE NOT INFORMED THAT A TELEVISION HAD FALLEN ON THE RESIDENT'S HEAD. THE DOCTOR AGREED THAT SHE SHOULD BE SENT OUT. THE FAMILY TOLD ME, 'THANK GOODNESS YOU CALLED BECAUSE NOBODY INFORMED US ABOUT THIS.' THE RESIDENT (#501) RETURNED TO THE FACILITY A FEW HOURS LATER AND WAS TOLD THAT SHE HAD A CONCUSSION." ( )

REFER TO INTAKE # MI 848 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE AND APPROPRIATE CARE FOR DECUBITUS ULCER TO 1 RESIDENT (#103) OF 5 SAMPLED RESIDENTS RESULTING IN DELAYED HEALING OF CURRENT PRESSURE SORE, DEVELOPING NEW PRESSURE SORE AND POTENTIAL FOR COMPLICATION (I.E.[MEDICAL CONDITION] OR INFECTION). FINDINGS INCLUDE: RESIDENT # 103 WAS readmitted FROM THE hospital on [DATE]. HISTORY AND PHYSICAL (UNDATED) REVEALED [MEDICAL CONDITION] WITH [MEDICAL CONDITION], HAS A PATENT PEG (PERCUTANEOUS ENDOSCOPIC GASTROSTOMY)TUBE , URINARY CATHETER AND [MEDICAL CONDITION] (IN PLACE), ESSENTIAL HYPERTENSION, DIABETES MELLITUS AND STAGE 4 SACRAL DECUBITUS ULCER IN ADDITION TO OTHER DIAGNOSIS. THE MOST RECENT MINIMUM DATA SET WAS DATED 11/22/13, SHOWED THAT RESIDENT #103 REQUIRED TOTAL DEPENDENCE IN PERFORMING ADL (ACTIVITIES OF DAILY LIVING) WITH 1 TO 2 PERSON ASSISTANCE. TAR (TREATMENT ADMINISTRATION RECORD) DATED 2/21/13, HAD AN ORDER OF: SACRAL COCCYX: CLEANSE, APPLY CALCIUM ALGINATE QD (DAILY) AND BILATERAL HEELS: CLEANSE APPLY SANTYL WITH CALCIUM ALGINATE WITH ABD DRESSING QD. TAR RECORD DATED 2/21/13 TO 2/27/13 SHOWED TREATMENT WAS SIGNED AS ADMINISTERED ON 2/21/13 AND ON 2/26/13 ONLY. EVIDENCE SHOWED THAT RESIDENT #103 RECEIVED ONLY 2 TREATMENTS IN 7 DAYS. THE treatment for [REDACTED]. IT WAS DOCUMENTED THAT RESIDENT #103 RECEIVED ONLY ONE TIME TREATMENT TO BOTH HEELS OUT OF THE 7 DAYS DAILY TREATMENT ORDER. THERE WAS NO DESCRIPTION OR ANY EXPLANATION OR DOCUMENTATION FOUND IN THE BACK OF THE TAR. NO DOCUMENTATION WAS FOUND. UPON REVIEW OF THE NURSE ' S NOTES REGARDING TREATMENTS TO THE SACROCOCCYX AND TO BILATERAL HEELS. THERE WAS NO DOCUMENTATION FOUND IN THE NURSING ADMISSION ASSESSMENT RECORD FOR RESIDENT #103 DATED 2/21/13. NO INITIAL WEEKLY WOUND/SKIN HEALING RECORD OR THE WEEKLY NON PRESSURE SKIN CONDITION REPORT WAS FOUND IN RESIDENT #103 WOUND ASSESSMENT RECORD. UPON WOUND OBSERVATION CONDUCTED ON 2/27/13 AT 2:28 PM, RESIDENT #103 ' S SACROCOCCYX WOUND DRESSING WAS SATURATED WITH HEAVY SEROSANGUINOUS DRAINAGE WITH SLIGHT BLEEDING AND ODOR. IT WAS UNDATED. THE SACROCOCCYX WOUND MEASURED 11.0 CM X 7.5 CM X 2.7 CM (LXWXD). LEFT HEEL WOUND MEASURED 2.9 CM X 1.6 CM X O AND RIGHT HEEL 6.0 CM X 8.0 CM X 0. THERE WAS ANOTHER WOUND COVERED WITH A DRESSING BUT DID NOT HAVE A DOCTOR ' S /TREATMENT ORDER NOR ASSESSMENT OF A NEW WOUND FOUND. RIGHT LATERAL ANKLE (NEW AREA FOUND) MEASURED 1.0 CM X 1.0 CM X 0. WOUND NURSE #3 WAS INTERVIEWED ON 2/27/13 AT 2:09 PM, STATED THAT SHE WAS UNAWARE OF THE NEW OPEN AREA FOUND AT THE RIGHT LATERAL ANKLE AREA. SHE DENIED ASSESSING THE WOUND UPON ADMISSION ON 2/20/13. SHE STATED THAT RESIDENT #103 WAS NOT SEEN BY THE WOUND SPECIALIST SINCE HE WAS readmitted UP TO THE PRESENT (2/20/13 TO 2/27/13). WOUND NURSE #3 COULD NOT RECALL WHY RESIDENT #103 WAS NOT SEEN BY THE WOUND SPECIALIST ON 2/25/13. WOUND NURSE #3 COULD NOT GIVE A REASON WHY THE TREATMENTS WERE NOT GIVEN DAILY AS ORDERED AND WHY THERE WERE NO INITIAL WOUND ASSESSMENT AND WOUND MEASUREMENTS SINCE ADMISSION ON 2/20/13. ACCORDING TO THE DON (DIRECTOR OF NURSING) ON 2/28/13 AT 9:45 AM, THERE SHOULD BE AN INITIAL WOUND ASSESSMENT UPON ADMISSION BY THE ADMITTING NURSE, AND THEN THE WOUND NURSE WILL BE NOTIFIED FOR FOLLOW UP AND APPROPRIATE WOUND INTERVENTIONS IS INITIATED UNTIL THE WOUND DOCTOR EVALUATES THE RESIDENT ' S WOUND. THE WOUND SPECIALIST COME EVERY MONDAY BUT IF RESIDENT IN THE WOUND LIST IS NOT SEEN DUE TO SOME REASON, THE WOUND SHOULD STILL BE ASSESSED AND WOUND MEASUREMENTS SHOULD BE RECORDED IN THE WEEKLY WOUND/SKIN HEALING RECORD OR THE WEEKLY NON PRESSURE SKIN CONDITION REPORT. THE DON DID NOT FIND DOCUMENTATION IN THE NURSING ADMISSION ASSESSMENT RECORD FOR RESIDENT #104 ON 2/21/13 ADMISSION. THE DON AGREED THAT RESIDENT #103 DID NOT HAVE WEEKLY WOUND/SKIN HEALING RECORD OR THE WEEKLY NON PRESSURE SKIN CONDITION REPORT .THERE WAS NO WOUND SKIN ASSESSMENT /STATUS DOCUMENTED AFTER HOSPITAL DISCHARGE ON 2/20/13. ACCORDING TO RESIDENT #103 ' S WOUND CONSULTATION RECORD DATED 2/11/13, RE-EVALUATION/CONSULT SHOWED THE FOLLOWING WOUND MEASUREMENTS: SACROCOCCYX: 8.5 CM X 5.2 CM X 1.2 CM, PINK BASE, HEAVY SEROSANGUINOUS DRAINAGE, IRREGULAR EDGES. RIGHT HEEL 5.2 CM X 5.5 CM, LEFT HEEL 1.5 CM X 0.7 CM. RESIDENT #104 WAS TRANSFERRED TO THE hospital on [DATE], FOR SEVERE [MEDICAL CONDITION] AND RETURNED to the facility on [DATE]. THERE WAS NO INITIAL WOUND ASSESSMENT DOCUMENTED FOR RESIDENT #103 UNTIL 2/27/13, WHEN THE SURVEYOR AND WOUND NURSE #3 OBSERVED THE WOUND. THERE WAS A SIGNIFICANT MEASUREMENT INCREASE IN SIZE WITH THE CURRENT SACROCOCCYX, AND BILATERAL HEEL WOUND MEASURED BY WOUND NURSE #3 ON 2/27/13. ( )