Every finding on record at Saginaw Senior Care and Rehabilitation Center, LLC

Based on observation, interview and record review the facility failed to ensure 1. Medications were not left at bedside for Residents #24 and #28; 2. Medications was administered with physician order for Resident #28; and 3. Timely assessment, intervention and ongoing monitoring were completed for Resident #9's new skin alternation was completed. Findings Include:Resident #9On 12/2/2025 at approximately 1:15 PM, Resident #9 was observed resting in bed, his left eye appeared reddened with thick colored drainage. Cascading down the left side of his mouth, there were multiple clusters of tan colored circular appearing sores. The resident reported the physician assessed both areas the day prior. Nurse E shared the resident was evaluated by the physician yesterday and prescribed antibiotic eye drops for conjunctivitis and the skin area by his mouth was also assessed.On 12/2/2025 at approximately 4:00 PM, a review was conducted of Resident #9's medical record and it revealed the resident admitted to the facility on [DATE] with diagnoses that included, Hemiplegia & Hemiparesis, Chronic Kidney Disease, Hyperlipidemia, Hypertension and Heart Disease. Further review of the records revealed the following:Progress Notes:12/1/2025 at 14:56: (Physician) rounded, Resident has redness and drainage to left eye. Resident denies pain.12/2/2025 at 15:17: Resident continues antibiotics for conjunctiva no adverse reactions notes. There were no progress notes regarding Resident #9's skin alteration. Skin Assessment:12/1/2025: Nothing new noted December 2025 TAR (Treatment Administration Record):There were no treatment orders in the TAR related to Resident #9's skin alterations on his face.On 12/3/2025 at 1:40 PM, Infection Preventionist H shared Resident #9 is being administered an antibiotic for pink eye. Preventionist H was asked if the skin alteration by the left side of his mouth was assessed and she reported she was not aware of any issues. Resident #9 was observed in his wheelchair and the left corner of his mouth was reddened with herpes like lesions cascading down by his jaw line. The right mouth crease area had smaller but similar lesions. Preventionist H reported she was not aware of this, but their Clinical Care Coordinator did round with the physician, and she will gather additional information on if this area was assessed. Preventionist H was asked if documentation on this area would be an expectation and she responded, yes.On 12/3/2025 at 1:50 PM, CNA (Certified Nursing Assistant) M shared Resident #9 has had those circular skin lesions for approximately 3-4 days. She explained them as crusted appearing scabs, which she thought was connected to his eye infection, as its on the same side of face and could have drained down. On 12/3/2025 at 3:45 PM, Infection Preventionist H stated the skin alteration on Resident #9 is now being treated with A&D ointment twice daily for two weeks and a one-time order for today. After speaking with the physician, they think it is MASD (Moisture- Associated Skin Damage). After speaking with the Clinical Care Coordinator, it was stated the assessment on Monday it looked like chapped skin. Resident #24On 12/2/2025 at 11:45 AM, Resident #24 was observed resting with her eyes closed in bed. A small medicine cup with a thick, light brown substance was observed puddled beneath the end of the bed and wheelchair. On 12/2/2025 at approximately 12:00 PM, Nurse E was informed regarding the unknown substance and upon entering the room Nurse E identified the unknown substance as Pro-Stat (supplement to promote wound healing). Resident #24 then stated she accidentally knocked it over. It appeared the entire contents of cup had been spilled out.On 12/3/025 at approximately 8:30 AM, a review was conducted of Resident #24's medical records and it indicated she admitted to the facility on [DATE] with diagnoses the included, Idiopathic Hypotension, Parkinson's Disease, Abdominal Aortic Aneurysm, Major Depressive Disorder, Heart Disease and Intestinal Obstruction. Further review of Resident #24's records revealed the following:December MAR (Medication Administration Record):- Pro-Stat AWC- two times a day 30ml (milliliters) prostat [NAME] Marked off on the MAR as administered to Resident #24 on 12/2/2025 upon rising.Progress Notes:There are no progress notes that detailed the resident was not administered the Pro-stat as she spilled it nor that it was readministered to her. Medication Audit Report:The report indicated Resident #24 was administered Pro-stat 30ml on 12/2/2025 at 8:21 AM.It can be noted Resident #24 does not have a physician order or assessment for self-administration of medications. The Pro-stat was left at bedside for approximately three hours without nursing being aware it had not been ingested as the resident had spilled it. Furthermore, the documentation related to this occurrence was nonexistent. On 12/3/2025 at 12:05 PM, an interview was conducted with the DON (Director of Nursing) regarding the observation with Resident #24. The DON reported while the nurse would not have been able to change her initial documentation in the MAR, she could have completed a progress note after the fact to the occurrence. The DON stated Resident #24 is not assessed to administer her own medications nor should medications be left at bedside. On 12/4/2025 at 10:30 AM, the Administrator shared they have educated nursing staff about leaving medications at bedside at their staff meetings on 7/2/2025, 7/29/2025 and 9/16/2025. Resident #28 On 12/2/2025 at 1:40 PM, Resident #28 shared she is prescribed Jardiance and at times it causes flare ups in her perineal area. On Saturday she was uncomfortable, and a nurse provided her with peri cream for that area which was effective. On Sunday morning around 5:00 AM the resident began to feel uncomfortable again and requested the same peri cream from the CNA (Certified Nursing Assistant). The CNA informed Resident #28 she would alert the nurse to her needs. Resident #28 proceeded into the restroom and prepared herself to apply the cream, she heard someone come into the room and place what she believed to be the peri cream on her bedside table. The resident put on gloves, picked up the small cup and began to apply the cream generously to her vaginal area. Resident #28 soon realized she was applying muscle rub to her vaginal area not peri cream. Clinical Care Coordinator/Wound Nurse L was aware of the incident and reviewing the concern form with her for accuracy. Coordinator L shared once she was made aware she took the resident to shower and completed a skin assessment to which she did not find any alterations.On 12/2/2025 at approximately 3:30 PM, a review was conducted of Resident #28's medical records and it indicated the resident was admitted to the facility on [DATE] with the primary diagnosis of Congestive Heart Failure. Resident #28 was able to make her needs known to staff. Further review of Resident #28's medical record yielded the following:Physician Orders:There was no current order for the muscle cream that was left at bedside for Resident #28 to apply. Nor was there an order for self- administration of medications. Assessments:There was no self- administration of medications assessment completed for Resident #28.Progress Notes: There were no progress notes located regarding the resident applying the muscle cream to her vaginal area, steps taken after nursing was informed of the incident and continued assessment and monitoring of the area.On 12/3/2025 at 11:35 AM, an interview was conducted with the DON (Director of Nursing) regarding the incident. The DON stated the CNA assigned to Resident #28's care on night shift stated the resident asks for muscle rub around the same time every shift. When she pressed her call light she asked for muscle cream for her thigh. The nurse (assigned to Resident #28) stated the CNA informed him Resident #28 requested muscle cream for her thigh. The nurse took the muscle cream in the room and placed it down but did not hand it directly to the resident or further assess her need for the cream. Resident #28 called the nurse back to room to inform him that she applied the muscle cream to her vaginal area. The nurse provided her with towels and soap and filled the sink with water, so she was able to wash off the area. He also checked in on Resident #28, and she did not have any further complaints at that time.The DON was asked if the resident was able to self- administer medications to which she replied, No. She also asked if Resident #28 had an order for muscle rub, given it was being applied (per staff account) regularly and she again replied, No. The DON expressed understanding with the concern.Review was conducted of the concern form completed by Resident #28: .Patient stated n 11/29/25 at 0500 patient asked her CENA for some cream for her peri area. Patient was in the bathroom when the nurse set a med cup with a cream in it on pt (patient) bedside table. The patient thought this was cream for her peri area. So she took the cream in the bathroom and applied it to her labia and entire peri area. She soon realized it was the wrong cream. Patient reported this to her CENA and nurse on Saturday as well as Sunday and states no assessment was done. Situation brought to wound care nurse on Monday 12/1/2025 at 1430. Review was conducted of the facility policy entitled, Medication Administration-General Guidelines, dated September 1, 2023. The policy stated, .Medications are administered in accordance with written orders of the prescriber.Residents can self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications.The resident is always observed after administration to ensure the dose was completely ingested.topical medications used in treatments are listed on the treatment administration record. Review was conducted of the facility policy entitled, Self-Administration of Medications dated June 2019. The policy stated, Residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents in the facility, and there is a prescribers order to do so.

Based on observation, interview and record review, the facility failed to identify open dates on multi-dose medications in 3 of 3 medication carts for Resident's #38, #42, #57, #62, #83, and #84, resulting in opened and undated multi-dose medications.Findings include: Observation and interview on 12/03/2025 at 7:35 AM Review med storage of the 3rd drawer of the medication cart 100 hall revealed of Resident #83's ophthalmic drops noted: timolol 5%, and Latanoprost 0.005% both are open and used with no open dates on boxes or bottles. licensed Practical Nurse (LPN) Q stated that she is a float nurse and that she just started her shift and she did not open those medications or use them. Observation of multi-dose medications noted a white sticker with open date and expiration date that the nursing staff are to fill out upon opening the medication. Record review of Resident #83's December 2025 Medication Administration Record revealed Timolol 5% ophthalmic solution install 1 drop in both eyes two times a day for glaucoma was administered upon rising and at bedtime on 11/29/2025, 11/30/25, 12/1/25, and 12/2/25. Latanoprost 0.005% ophthalmic solution install 1 drop in both eyes at bedtime for glaucoma was administered at bedtime on 11/29/2025, 11/30/25, 12/1/25, and 12/2/25.Observation during medication administration pass on 12/03/2025 at 8:02 AM of the 400 hall Medication cart revealed that Resident #62 had two (2) Fluticasone-Salmeterol Inhalation Aerosol powder breath activated 250-50 mcg/act devices for the resident that were opened and the seals broken with no open/used date on the device or the box. There were two (2) Fluticasone-Salmeterol inhalations devices both opened/used and not dated. Inhaler Device #1 had 60 doses, with 17 doses left to use, and the #2 inhaler device had 60 doses with 59 doses left on the inhaler device to be used. Record review of Resident #62's Medication Administration Record for November 2025 revealed that the resident had Fluticasone-Salmeterol Inhalation Aerosol powder breath activated 250-50 mcg/act one inhalation inhaled orally two times a day for COPD (Chronic Obstructive Pulmonary Disease) 1 puff BID. Order start date: 8/4/2025. Record review of Resident #62's November 2025 and December Medication Administration Record revealed that the resident had Fluticasone-Salmeterol Inhalation Aerosol powder breath activated 250-50 mcg/act one inhalation inhale orally two times a day for COPD (Chronic Obstructive Pulmonary Disease) 1 puff BID.In an observation and interview on 12/04/2025 at 7:56 AM with the Director of Nursing (DON) in the 100/200 medication room refrigerator noted 2 insulin pens located on the bottom of the refrigerator on the lowest surface of the refrigerator. The DON stated that no those should not be on the bottom of the refrigerator, they should be on the shelf with the other insulins. She did not know why the 2 insulin pens were resting on the floor of the refrigerator. Observation and interview on 12/04/2025 at 8:10 AM of the 300/500 hall medication cart with Licensed Practical Nurse (LPN) R revealed R#84 had Albuterol sulfate 90mcg inhaler was opened and did not have an open date on device or box. R#57 had inhaler Anoro Ellipta inhaler 62.5/25 mcg device was opened and used and did not have an opened date on device or box. R#38 had a Symbicort160/4.5 mcg inhaler with 110 doses left out of a 120 dispensed left on the device. There was No open date on device or box. Record review of Resident #84's December 2025 'Medication Administration Record' revealed Albuterol sulfate 90mcg inhaler 1 puff inhaled orally four times a day related to chronic obstructive pulmonary disease was administered on 12/01/25, 12/02/25 and 12/03/25. Record review of Resident #57's December 2025 'Medication Administration Record' revealed Anoro Ellipta inhalation aerosol powder breath activated 62.5/25 mcg, one inhalation inhaled orally in the morning for chronic obstructive pulmonary disease was administered on 12/01/25, 12/02/25 and 12/03/25. Record review of Resident #38's December 2025 'Medication Administration Record' revealed Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5mcg (Symbicort), two puffs inhale orally tow times a day for chronic obstructive pulmonary disease was administered on 12/01/25, 12/02/25 and 12/03/25. Record review of the facility pharmacy 'Storage and Stability of Selected Medications' list undated, located within the medication carts ring binders noted that inhalers, nasal spray, & nebulizer treatments date when opened. Ophthalmic & Otics date when opened.

Based on observation, interview and record review, failed to ensure 1. maintain adequate biohazard receptacle (with lid) on the 300 and 500 halls in 2 of 2 soiled utility rooms reviewed for biohazard receptacles, and 2. proper infection control procedure during toileting and peri care for 1 resident (Resident #72) of 3 resident's reviewed for ADL care, resulting in the potential to affect the health and safety of the facility water for a census of 68, increase the risk of cross contamination of blood borne body fluids and contaminated soiled linen bags. Findings Include: Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing. Findings include: Biohazard Receptacle: Observation was made on 12/2/25 at approximately 9:45 a.m., on Hall 300 in the soiled utility room accompanied by Nurse, RN K revealed a cardboard box sitting on the floor with trash and a tied off red biohazard bag sitting inside without any top on it. During an interview done on 12/4/25 at 8:50 a.m., Infection Control Nurse, RN H said the procedure should be if body fluids, CNA's do initial clean up, housekeeping sanitizes. The red bag (containing blood and body fluids) should be put in the soiled utility rooms (on 300 and 500 hall) in a identified biohazard container with a top on it. When the biohazard container is full the facility contracts with a biohazard pick up company for removal. This surveyor repeatedly requested this policy/procedure for red bag (blood and body fluids) disposal throughout the survey. A booklet of operating procedure for an OnSite Waste disposal machine (used per booklet for sharps) was given to this surveyor. According to the operating booklet, another machine was available if requested by the facility for reg bag disposal. No policy/procedure was given to this surveyor during the survey regarding biohazard waste containment or disposal. On 12/4/25 at 9:00 a.m., the Director of Nursing and this surveyor went with CNA's C and D as they walked us through how to dispose of a red biohazard bag. Both CNA's walked to the 300-hall soiled utility room, opened the door and said there was supposed to be a biohazard container in the room for red bags. Both of the CNA's were surprised it was not there. Both halls, 500 and 300 biohazard containers, were missing. When this surveyor asked the CNA's what they would do if they had a red bag at that time, they both agreed they would put it in the regular trash bin in the soiled utility room. During an interview done on 12/4/25 at 8:50 a.m., Infection Control Nurse, RN H stated Central Supply/Stocker N took it (the biohazard container with the red bag and trash in it) to the trash, it's in the dumpster (outside regular trash dumpster). During an interview done on 12/4/25 at 10:30 a.m., Central Supply/Stocker N stated The Infection Control Nurse threw the biohazard container out in the dumpster. There should be a biohazard container with a lid on it in all soiled utility rooms (Halls 300 and 500). There should also be a trash can in the soiled utility rooms. I have never had this happen before; there has always been a biohazard container for them (staff) to use. During an interview done on 12/4/25 at 11:00 a.m., the DON stated There should be a biohazard container, I was not aware that the containers were removed from the soiled utility rooms. My plan is to educate staff about PPE (personal protective equipment) and biohazard containers. Resident # 72: Review of the Face Sheet, Minimum Data Set/MDS dated 9/25, nursing progress notes dated 10/25 through 12/4/25, and care plans dated 9/5/25, revealed Resident #72 was [AGE] years old, admitted to the facility on [DATE], had confusion with a responsible party in place, and required assistance with all Activities of Daily Living/ADL's. The residents diagnosis included, Dementia, behavioral disturbances, visual deficit, chronic kidney disease, malnutrition, psychosis, and adjustment disorder. Observation made on 12/3/25 at 9:01 a.m., revealed Nursing Assistant/CNA C toileting and dressing Resident #72 in her room's bathroom. CNA C toileted, did peri care and dressed the resident (wearing gloves), then put the soiled linens in a clear plastic bag sitting on the floor in the bathroom. She then picked up the bag of soiled lines with her gloves still on and set it by two other bags of soiled linens near the exit door of the room. CNA C then proceeded to remove her contaminated gloves, washed her hands and then directly picked up the three bags of soiled linens off the floor and walked out of the residents' room directly to the soiled utility room on hall 500, opened the door and put the bags in the room in the soiled linen plastic container. Review of the residents ADL and Urinary incontinence care plans dated 8/24/25 and 9/5/25, revealed total dependance on staff for toileting, dressing and hygiene care. During an interview done on 12/3/25 at 8:15 a.m., CNA C said she did not realize she did not remove her gloves and wash her hands before she touched the outside of the soiled linen bags. CNA C said she knew she made a mistake, and the facility did educate her on infection control measures, handwashing and gloving. During an interview done on 12/4/25 at 11:00 a.m., the Director of Nursing/DON stated, I think the CNA (CNA C) needed a little more training, and IC (Infection Control Nurse) should be doing a bit more auditing. The DON said CNA C should have removed her gloves and washed her hands prior to touching the outside of the soiled linen bags. Review of the facility staff education done on 9/16/25, revealed an in-service titled Nursing Basics 101 was done which included basic ADL care. On 12/03/2025 at approximately 1:00-1:30pm during the environmental tour with the Maintenance Director A, observed uncapped shut off valves and an unused atmospheric vacuum breaker in the shower room located in the 200 hallways. On 12/03/2025 at approximately 1:55-2:15pm, during the housekeeping and laundry tour with the Housekeeping and Laundry Manager B, observed a hopper with a spray nozzle off to the side that appears to be unused in the soiled utility room adjacent to the laundry room. When interviewed on whether the hopper is used, the Housekeeping and Laundry Manager B stated that they don't use the hopper. On 12/03/2025 at approximately 1:55-2:15pm, during the housekeeping and laundry tour with the Housekeeping and Laundry Manager B, observed an unused atmospheric vacuum breaker upstream capped plumbing lines and an unused spray nozzle with accumulated dust on the nozzle in the soiled utility room located in the 500 hallways. On 12/03/2025 at 2:15-2:30pm, interviewed the Maintenance Director A on flushing the spray nozzle to the hopper in the soiled utility room adjacent to the laundry room, and he stated that the spray nozzle is not flushed. When interviewed on whether the spray nozzle in the soiled utility room in the 500 hallways was flushed, he answered that it wasn't flushed. According to the facility's Dead End Water Pipe Policy, it states, The organization is committed to .identifying and assessing all dead end pipework in the building's water distribution system and removing or mitigating dead legs to ensure water safety. In addition, under the Corrective Actions section, it states Removal of Dead Legs .wherever possible, dead legs should be physically removed .capping off is discouraged because stagnant water can still accumulate. According to Controlling Legionella in Potable Water Systems by the Centers for Disease Control and Prevention dated January 3rd, 2025, Flushing: Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures regularly as needed to maintain water quality parameters within control limits and Eliminate dead legs, which are sections of no- or low-water flow.

Based on observation, interview and record review, failed to ensure 1. the water program was maintained properly, 2. maintain adequate biohazard receptacle (with lid) on the 300 and 500 halls in 2 of 2 soiled utility rooms reviewed for biohazard receptacles, and 3. proper infection control procedure during toileting and peri care for 1 resident (Resident #72) of 3 resident's reviewed for ADL care.Findings Include:Resident #18: Review of the Face Sheet, Minimum Data Set, dated 12/25, nursing progress notes dated 12/1/25 through 12/4/25, and orders dated 11/25, revealed Resident #18 was [AGE] years old, readmitted to the facility on [DATE] after a hospital transfer, required assistance with all Activities of Daily Living/ADL's, had a history of urinary tract infections/UTI's, was confused and unable to interview due to decreased cognition. The residents' diagnosis included, Dementia, Diabetes, Vascular Disease, Neuromuscular Dysfunction of Bladder, and had a feeding tube placed with and a suprapubic catheter. Review of physician orders and nursing progress notes dated 11/10/25, revealed Resident #18 was started on Doxycycline antibiotic for a UTI. Review of the residents Suprapubic Catheter care plan dated 11/25, revealed the catheter was to be checked every shift (including checked for tubing placement and having a privacy bag). Observation was made on 12/2/25 at 12:42 p.m., of Resident #18 wheeling herself slowing down hallway 500 toward the main dining room. The residents catheter tubing was noted to be dragging on the floor under her wheelchair. There was no privacy bag on the catheter bag connected to the tubing, and she was headed toward the dining room for lunch. During an interview done on 12/4/25 at 8:03 a.m., the Director of Nursing/DON stated We are supposed to change the catheter when they get back from the hospital, she was at the hospital. We don't have any privacy bags, we need them, I am going to order some. The DON agreed this was a dignity and protentional infection concern. Review of the facility Quality of Life Dignity policy dated 2009, stated Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Helping the resident's to keep urinary catheter bags covered.

Based on interview and record review, the facility failed to follow pharmacal procedure/policy regarding collection of discontinued narcotics, with a double/witness nurse signature when removed from medication carts, resulting in the potential for missing/misappropriation of narcotic medications. Findings include:Observation and interview on 12/2/2025 during the screening process of the annual survey of Resident #19, was observed to be lying in bed watching television. Resident #19 made good eye contact and revealed that the resident was admitted /transferred from another nursing home and that he was on pain medications when he first came to the facility. Record review of Resident #19's November 2025 Medication Administration Record (MAR) revealed that on 11/18/2025 the resident was started on Tramadol 50mg tablet narcotic/opioid by mouth for pain scheduled four times a day at 8:00am, 12:00pm, 4:00pm, 8:00pm. The 11/18/2025 Tramadol pain medication was discontinued on 11/26/2025. Then on 11/26/2025 Resident #19 was ordered Tramadol 50mg tablet oral four times a day scheduled at 00:00am (midnight), 06:00am, 12:00pm, 18:00pm. Record review on 12/5/2025 of the facility provided a large 4-inch white three ring binder, which held the 'Controlled Substance Proof-of-Use' forms dated from January 2025 through December 5, 2025 revealed that at the bottom of each proof of use form 'Disposition of Unused Drugs' required: Date discontinued, amount remaining, authorized signature, date disposed, disposal, and witness (second person). Record review of the large 4-inch ring binder noted a hundred or more 'Controlled Substance Proof-of-Use' form with the bottom disposition of unused drugs portion as blank. Within the large white ring binder, it was noted that Resident #19's Tramadol 50mg tablet 'Controlled Substance Proof-of-Use' form from April 12th, 2025, revealed Tramadol 50mg tablet narcotic/opioid by mouth every 8 hours. The 'Controlled Substance Proof-of-Use' form for Resident #19 noted that on 4/28/2025 the resident received one tablet that was signed out by the nurse with 12 (tablets) remaining. There were no signatures other signatures noted on the form. There were no witness signatures that the remaining narcotic/opioid medication was removed from the secure medication cart or by whoever had removed the narcotic medication. Record review of Resident #19's second 'Controlled Substance Proof-of-Use' form Tramadol 50mg tablet narcotic/opioid dated 4/12/2025 noted 60 tablets, again the disposition of unused drugs was left blank. Record review of Resident #19's third 'Controlled Substance Proof-of-Use' form Tramadol 50mg tablet narcotic/opioid dated 4/24/2025 noted 30 tablets, again the disposition of unused drugs was left blank. Record review of the facility provided 'Disposal of Medications and Medication-related supplies, Controlled Substance Disposal' dated 9/1/2023, revealed the facility complies with federal and state requirements for the disposal of medications included in the Drug Enforcement Administrations (DEA) classification of controlled substances . (C.) Controlled medications are disposed of in a manner which minimizes the risk of accidental exposure and/or diversion. (D.) All controlled substances remaining in the facility after a resident has been discharged or the order is discontinued are disposed of 1.) In the facility by two licensed nurses or a licensed pharmacist. (E.) Disposition of a resident's-controlled substances . is documented on the individual controlled substance count sheet. (G.) The nurse's and/or pharmacist witnessing controlled substance destruction ensures that the following information is entered on the controlled substance count sheet: Date of destruction, resident's name, Name and strength of medication, prescription number, quantity of medication destroyed, signatures of witnesses. (H.) Controlled substance count sheets are maintained with medication supply until they are destroyed and then they are stored for 5 years.In an interview and records review on 12/04/2025 at 9:20 AM with the Director of Nursing (DON) of Narcotic reconciliation and disposal process, the state surveyor observed discontinued narcotic/opioid medications were kept in a file cabinet in DON's office. Observation of the file cabinet drawer noted two (2) bottles of morphine sulfate liquid (Roxanol). Record review of the 'Controlled Substance Proof-of-use' forms for Morphine liquid (Roxanol) were noted to be blank under the heading of 'Disposition of Unused Drugs'. Record review of the Large white binder of 'Controlled Substance Proof-of-use' forms, noted a hundred or more forms in the binder. The Director of Nursing (DON) stated that 'we destroy the medications with drug buster chemical substance. We put three trash bags in a trash can, so there are three layers of trash bags, we scan the bar code on the pharmacy label, and then we punch out the medications into the trash bag and pour the drug buster stuff over the medications and throw the bag in the trash. The DON explained that the controlled substance proof of use forms (yellow forms) come from the pharmacy with each controlled medication, the sheet is used for counting the medication at each shift and the used medications are signed out on the sheets. Disposition of unused drugs: at the bottom of the pharmacy yellow sheet is blank, there are none with a two nurse witness signatures noted in the large white binder from January 2025 through today 12/4/2025 noted, there were few with single signature noted at the bottom of the forms. Process is that the narcotic medications are removed from carts by DON, stored in the file cabinet until disposal, the DON did not have the floor nurses witness the removal of the medications. The DON stated, I go to the cart to get the destruction meds, pick them up, put them in lock file cabinet, and my goal is to destroy meds very couple of weeks, so that my report to pharmacy is longer, instead of just one or two meds destroyed. I grab a manager, come into the office, match the medications with the matching sheets, I use the bar code scanner, the bar code on the med pack, we double check the med card, then punch the medications into the trash can, once we are done we pour the drug buster over the top of the medications and throw the bag away in the trash, It should go in the hazard bags, but we throw it in the trash. In an interview on 12/05/2025 10:01 AM with the Director of Nursing (DON) stated that I only have a second nurse sign at the time of the actual destruction on the pharmacy generated report that I print off sheet and have the second nurse sign at that time. Record review of the large white binder with the DON revealed that none of the controlled count substance count sheets (yellow forms) had two nurse signatures on the forms, there were hundreds of yellow forms to review with no signature, only a single signature noted on 'Controlled Substance Proof-of-use' forms.

Based on observation, interview and record review, the facility failed to ensure medication error rate was less than 5% when two medication errors were observed from a total of 25 opportunities for two sampled residents (#70 and #83). This deficient practice resulted in a medication error rate of 8% and the potential risk for decreased medication efficacy. Findings include: Resident #70:Observation on 12/3/2025 at 9:37AM of Resident #70's medication administration with Licensed Practical Nurse (LPN) Q of Ammonium Lactate External Cream 12%, was applied to the back area of the resident while seated up in chair at bedside. Voltaren 1% gel was applied to the bilateral knees and oral medications were given at the same time. Record review of Resident #70's 'Medication Admin Audit Report' dated printed 12/3/2025 at 12:52PM revealed that the medications Ammonium Lactate External Cream 12%, to the back was scheduled for 7:00AM and Voltaren arthritis pain external gel 1% was scheduled for 8:00AM administration. The 12/3/2025 administration time was documented as 9:30AM. Resident #83:Observation on 12/3/2025 at 9:03AM of Resident #83's medication administration with Licensed Practical Nurse (LPN) Q of Metformin oral 1000mg tablet for diabetes was administered at this time. The residents already had ingested their breakfast meal. Record review of Resident #83's 'Medication Admin Audit Report' dated printed 12/3/2025 at 12:52PM revealed that Metformin 1000mg by mouth two times day for diabetes take with food was scheduled for 8:00AM administration. The 12/3/2025 administration time was documented as 9:03AM. Record review of the facility 'Medication Administration- General Guidelines' policy dated 9/1/2023, revealed section B. Administration: Medications are administered within 60 minutes of scheduled time .In an interview and record review on 12/03/2025 at 12:04 PM with the Director of Nursing (DON) reviewed Resident's #70 and #83's 'Medication Admin Audit Report' revealed that Resident #70's Ammonium Lactate External Cream 12%, to the back was scheduled for 7:00AM and Voltaren arthritis pain external gel 1% was scheduled for 8:00AM administration. Resident #83's medication Metformin 1000mg tablet was scheduled to be administered at 7:00AM. Documented times of medication administered at 9:05. The DON stated that scheduled medications can be given 1 hour before and 1 hour after designated scheduled time. In an interview on 12/04/2025 at 1:16 PM with Resident #70 revealed that the staff do put mole cream on her back and a different kind arthritis cream on her knees and down my legs and on my toes too, all over. It helps and feels better. The mole cream, the one nurse will put it on before breakfast and then the next nurse will put it on later in the day after breakfast, and then they put it on again before bed. Observation and interview on 12/03/2025 at 8:21 AM with Registered Nurse O during the medication administration task revealed a resident list/report sheet with medications and vital signs left on top of the medication 400 cart open to all residents/staff/visitors that pass by. Registered Nurse O stated that she should have turned over the papers before leaving the cart to give medications to Resident.

This citation pertains to Intake Number MI00149908. Based on observation, interview and record review, the facility failed to 1) Ensure that staff were educated on the in-house procedure during a full code while CPR (Cardio Pulmonary Resuscitation) was being performed, (Resident #102 had no pulse or respirations), 2) Ensure proper use of Automated External Defibrillator (AED) equipment during a code, and 3) Ensure only designated and current CPR card holders participated in chest compressions during CPR for 1 resident (Resident #102), resulting in confusion during a code, no documentation taken, improper placement of the AED pads, and uncertified Nursing Assistant/CNA performing chest compressions during a full code while doing CPR. Findings Include: Every minute counts in CPR; the person doing chest compressions should switch out (hand over to another person if available) every 2 minutes or when they get tired. The compressor (person doing compressions) calls for a position change by saying switch and them switches positions. AHA American Heart Association. Resident 102: Review of the Face Sheet, physician orders, nurse's notes, and care plans, dated [DATE] through [DATE], revealed Resident #102 was [AGE] years old, alert and able to make her own healthcare decisions, dependent on staff for all Activities of Daily Living (ADL) and was admitted to the facility on [DATE]. The resident's diagnoses included, Acute and Chronic respiratory failure, pneumonia, heart failure, diabetes, fracture of the vertebra with healing, morbid obesity, alcohol abuse, mood disorder, anxiety disorder and depression. The the nursing notes, dated [DATE], stated This nurse walking by resident room at approximately 0019 (12:19 a.m.) and observed patient appeared to be sleeping and noticed patient didn't have CPAP in place. I entered into her dark room to tell her to let's get CPAP (noninvasive ventilation) on and noticed patient appeared to not be breathing. This nurse called out to patient and touched patient, and some coolness was felt, and resident also appeared to have had an nemesis, and I didn't feel a pulse. I walked out to nurses' station to retrieve crash cart and told my CENA (nursing assistant) that patient appeared deceased and made a overhead page to call a CODE BLUE (called a full code). Staff responded immediately and I started to call police as I hurried back to room and started CPR immediately. CPR continued continuously even after EMR (Emergency Medical Response) arrived. EMR called time of death (TOD) at 1240am (12:40 a.m.). Emergency contact (sister) was notified and the on-call NP (Nurse Practitioner) and manager notified. Police and medical examiner arrived per this being an unexpected passing. Patient was examined and picked up by Medical Examiner staff. During an interview done on [DATE] at 8:00 a.m., Nurse LPN B stated I found the resident. I was walking by and she did not have her Bi-Pap on. I could see a dark pinkish color (on the residents face), I assessed her pulse (the resident had no pulse). I grabbed the crash cart and announced code blue. I yelled out to call 911, a CNA called 911. I put one pad on the chest and (Nurse A) put the other one on. The machine told us to stop and EMS told us to disregard the machine and keep going. Nurse B continued doing chest compressions per EMS instructions when the facility AED machine said to stop. During an interview done on [DATE] at 1:10 PM, Nurse LPN A stated No one at the facility trained me on the AED (Facility Automated External Defibrillation machine). I was on the other side of building and heard the Code Blue. I put the pads on (the AED pads on the resident). In 1 to 2 minutes I asked if somebody would take over. Nurse A said there were 3 EMS (Emergency Medical Services) staff, and 2 nurses in the room along with a total of 4 CNA's. The nurse said she told CNA F to document what was going on during the code. The nurse said she did not tell the CNA F what to write down as it was happening. The nurse said there was no notes, and she did not document anything at all. The EMS staff asked CNA C to do CPR, and she did it; no facility nurse intervened or took over (CNA's had not been educated at all regarding a code or CPR procedure and their role during the code). Nurse A stated I believed CNA's do not do CPR, I was shocked. EMS told me to slow down; they gave me instructions on how to do CPR during the code. I feel we did an excellent job; I will be sure to document next time. During an observation done on [DATE] at approximately 1:30 p.m., Nurse A was requested to put the AED machine pads on the manikin that was in the room. She misplaced the chest pad per the picture that was on the pad. During an interview done on [DATE] at 2:20 p.m., Nursing Assistant/CNA C said she did chest compressions during the code on Resident #102. CNA C stated My CPR card expired in ,d+[DATE]. My nurse's were out of breath, neither nurse (Nurse B or Nurse C) told me I could not do it (CPR). During an interview done on [DATE] at 2:40 p.m., CNA D denied she did anything in the room. She was not able to recall who did what and she took no notes. CPR was done on Resident #102 on [DATE] (6 days before the interview was done). During an interview done on [DATE] at 7:00 a.m., CNA F stated The EMS told me to do CPR, so I did it, no one stopped me. They (EMS personnel) told me to move, your not doing it right. I was not educated on CPR at the facility. I was asked by (Nurse B) to take notes. She didn't tell what to write. I left the notes on the bedside table. No one asked me about the notes; I left the notes in the room, I don't remember what I wrote down. Any notes that CNA F said she had done were not found by staff. During an interview done on [DATE] at 10:04 a.m., Nurse, RN G (Nurse on-call/MDS Nurse on [DATE]) stated she (Nurse B) called me at 2:30 a.m., I missed the call and I called the facility back at 5:00 a.m. I told (Nurse B) to make a statement. Nurse G entered nursing notes dated [DATE]; the only documentation of the whole full code CPR that was done. During an interview done on [DATE] at approximately 11:01 a.m., the Director of Nursing said she was informed of the incident (could not recall date), and did not start an investigation because I was off. The DON did not call anyone at the facility to initiate an investigation. I should of told someone to investigate. During an interview done on [DATE] at 11:45 a.m., Nurse, RN H stated It would be the Administrator or the DON who initiates an investigation, and stated CNA's can't be doing CPR at the facility (unless done per policy or procedure and education has been given by facility).

Based on observation, interview and record review the facility failed to prevent the development of and worsening of pressure ulcers for 3 residents (Resident #15, Resident #25, Resident #33) of five residents reviewed for pressure ulcers resulting in the development of facility-acquired pressure ulcers, including a Stage 3 pressure ulcer, and the worsening of pressure ulcers. Findings include: Resident #25 (R25): R25 is [AGE] years old and admitted to the facility on [DATE] with diagnosis that include encephalopathy, cerebral infarction and pressure ulcer of unspecified buttock, unspecified stage. R25 has a Brief Interview for Mental Status (BIMS) score of 3 as of 09/10/24 indicating severe cognitive impairment. On 10/07/24 at 09:30AM, R25 was observed lying supine in bed, a wedge cushion was noted to be at the end of the bed but not currently in use. R25 had protective boots on both feet. On 10/07/24 at 12:00PM, R25 was observed lying supine in bed, there was a wedge cushion noted on the bed but still not in use. On 10/08/24 at 10:12AM, R25 was observed lying supine in bed. R25 was also observed to have protective boots on both feet. On 10/08/24 at 01:30PM, an interview was conducted with Certified Nursing Assistant (CNA) K. CNA K was asked why R25 was positioned on their back so often during the day. CNA K stated that R25 often refuses to be turned off of their back and even when they try to place pillows under their sides for positioning R25 will throw them on the floor. CNA K stated they try to reposition him often while they are working. On 10/08/24 at 02:44PM, an interview was conducted with the DON (Director of Nursing). The DON was asked if R25 had all of their wounds present on admission or if any developed in the facility. The DON stated that the wounds were present on admission. The DON was asked if they feel the wounds have improved, worsened or remained stable. The DON stated they feel that some of the wounds have remained the same and fairly stable. On 10/09/24, R25 was observed to be discharged from the facility. On 10/09/24, record review revealed that R25 had developed an in-house acquired pressure ulcer on their left ischial tuberosity(an area on the buttocks) on 10/02/24 measuring: length 2.31cm, width 0.61cm, depth 1.0cm and was categorized as MASD(Moisture Associated Skin Damage). On 10/09/24, record review revealed that on 10/08/24 the same pressure ulcer measured: length 2.13cm, width 2.11cm and depth 3.0cm and was categorized as a Stage 3 wound (indicating full thickness tissue loss). On 10/09/24, record review revealed that R25 was admitted with a wound on the peri-anal area, classified as unstageable. On 10/02/24 the wound measured length 1.59cm, width 1.04cm and depth 1.04cm. On 10/08/24 the wound measured length 9.74cm, width 7.03cm and depth 4.0cm and was classified as unstageable. On 10/09/24, record review of R25's care plan titled, Skin Management revealed an intervention, please help me get turned and repositioned every 2 hours as allowed. 22927 Resident #15: An interview on 10/07/24 at 02:36 PM with Resident #15 revealed that her right heel had a sore on it and that she did not recall/remember how it developed/started. Record review of Resident #15's Minimum Data Set (MDS) dated [DATE] section M: Skin conditions- had no unhealed pressure ulcers noted. Record review of Resident #15's electronic medical record (EMR) revealed an admission skin assessment dated [DATE] revealed no skin issues with bilateral feet/heels. Record review of Resident #15's 'Wound Evaluation' form dated 2/21/2024 at 7:50AM revealed a pressure ulcer unstageable (slough and/or eschar) located on the right heel, as new, and in-house (in facility) acquired. Dimensions/measurements: area 3.45cm, length 2.01cm x width 2.05cm. Observation of wound photo located in the medical record revealed a dark/blackened area of good size to Resident #15's right heel. Record review of Resident #15's Minimum Data Set (MDS) dated [DATE] section M: Skin conditions- noted one unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar. Record review of Resident #15s 'Skin & Wound- Total Body Skin Assessment' dated 2/20/2024 revealed skin assessment with good turgor, normal skin color, warn temperature, normal moisture, normal condition and no new wounds. Record review of Resident #15's nurse progress note dated 2/22/2024 noted blood-filled blister to right heel. 10/08/24 02:54 PM Record review of the skin care plan noted to observed skin daily and report to nurse any findings dated 2021. How did the right heel blood blister start if it would have been pink/red before it became blackened. Record review of the Point Click Care wound definitions: Suspected Deep Tissue Injury- Purple or Maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Unstageable- Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Observation and interview on 10/08/24 at 01:02 PM with Resident #15 and Licensed Practical Nurse (LPN) F revealed observation of Resident #15's right heel wound heeled with scar tissue noted. Resident #15 stated that it (right heel wound) would hurt and burn something awful and that it was a big old hole in my foot/heel. In an interview and record review on 10/09/24 at 09:56 AM with the Director of Nursing (DON) of Resident #15's admitted [DATE] skin assessment was good with no concerns of bilateral feet/heels. Record review of Resident #15's electronic medical record 'Wound Evaluation' tab on 2/21/24 revealed the right heel with eschar with dead necrotic skin The DON was asked what happens or when the blackened cap falls the wound? The DON stated that the wound becomes an open wound, and potential for infections. The state surveyor in quired about care plan intervention of Certified Nurse Assistance's are to review skin daily, was it done? DON stated that Both Resident #15 and Resident #33's right heel pressure ulcers were preventable, with floating heels, prafo boots, repositioning, and getting the resident out of bed for few hours. Venous wounds would have done a doppler at the time development of the wounds, not months later. Resident #33: In an interview on 10/07/24 at 11:31 AM with Resident #33 revealed that when she came into the facility, she did not have a right heel sore. Observation on 10/07/24 at 11:31 AM the state Surveyor observed right foot/heel dressing of gauze wrap that soaked through the dressing and onto the sheets with brown ring, dressing dated 10/6/2024. Record review of Resident #33's Admission Skin Assessment form dated 5/30/2024 revealed skin concerns to chest of implanted port, left hand blister, right neck old access site, coccyx redness, right arm bruising. There was no skin concern related to bilateral foot heels noted. Record review and Interview on 10/7/2024 with Resident #33 revealed that she does hemodialysis on Mondays/Wednesdays/Fridays and was waiting to go to dialysis. Observation and interview on 10/07/24 at 12:21 PM with the Director of Nursing (DON) was requested to observed Resident #33's right foot/heel dressing dated 10/6/2024. Observation of drainage tan to brown in color was noted onto sheets through the dressing. The DON stated that Resident #33's dressing is to be changed daily in the mornings by the night shift nurse before leaving their shift, yes, she would have gone to dialysis with that dressing if you hadn't brought me into see the dressing. The DON stated that the facility Wound Care nurse/Infection Preventionist had resigned Friday, she took photos every Wednesday, and on admission. We just ordered soft boots for the resident; we don't have them yet. The state surveyor observed no boots in the closet or in the room. In an interview on 10/07/24 at 12:25 PM with Resident #33 with the DON present stated that the right foot/heel dressing was not changed this morning. The DON stated that Licensed Practical Nurse (LPN) F will be in to dress the wound before she goes to dialysis. Observation on 10/07/24 at 12:32 PM with Licensed Practical Nurse (LPN) F and Director of Nursing (DON) applied spray derma cleanse with 4x4 gauze, wiped the surface of the wound. The state surveyor observed an open wound with puss drainage noted by the DON, treatment of Santyl (debride). Wound measurement with tape measurement revealed a 1cm X 0.5cm open wound with hole in the back of resident's heel measurement. Santyl ointment into the opening, covered with a telfa non-stick 3x2 dressing gauze and gauze wrap. In an interview on 10/08/24 at 10:08 AM with Licensed Practical Nurse (LPN) F Observation of Resident #33's right heel dressing was changed at 6:00AM the dressing was clean and intact; a smaller brown ring was noted again on the sheet under the heel. no drainage noted on dressing. Sheet was not changed after dressing. In an interview and records review on 10/09/24 at 09:42 AM with Director of Nursing (DON) of Resident #33's electronic medical record revealed the admission assessment on 5/30/24 did not have any foot heel skin concerns. Wound/skin tab revealed Right heel wound started on 7/17/24 as a blacked eschar unstageable before anyone found it? Director of Nursing (DON) stated that Resident #33 was originally in her room on the 100 hall and the Certified Nursing Assistant (CNA) did skin assessment and found the wound as eschar and reported it to the nurse. The CNAs are to check skin each day and report, they should have reported a reddened area before it became eschar. Eschar is a blackened skin, necrotic and dead. We could have placed an intervention prior to the eschar. In an interview and record review on 10/09/24 at 10:09 AM with the Registered Nurse (RN) Clinical Care Coordinator B performed a record review of the wound & skin tab in electronic medical record to review right heel wound progression. RN B stated that the heel would have start out getting boggy/soft, redden and turn white, then we gradually start to see the breakdown of the tissue until it starts to die, when it dies it becomes eschar blackened. Unstageable. cap falls off under then it broken down and open, seeping a smell. The Certified Nursing Assistant (CNA) are to review skin daily, and report to nurse skin changes. While reviewing a photo of Resident #33's right heel wound RN B stated depending on the resident and their circulation that wound would take 2-3 weeks to develop into eschar.

Based on interview and record review the facility failed to treat residents with dignity and respect for 10 of 10 residents in a confidential meeting and R317, resulting in long call light wait times, humiliation from incontinence and fear of reprisal. Findings include: Resident #317 (R317): R317 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include acute respiratory failure, hypertension, anemia and endocarditis. R317 has a BIMS (Brief Interview for Mental Status) score of 15, indicating R317 is cognitively intact. On 10/07/24 at 12:56 PM an interview was conducted with R317. R317 was asked how their stay has been so far at the facility. R317 stated over the previous weekend (10/5 and 10/6), there were only 4 CNA's (Certified Nursing Aides) for the entire building. R317 stated they had to wait an hour for their call light to be answered and said they had an accident(incontinent of urine). R317 stated they were very humiliated, and they had guests visiting that day. R317 became tearful when discussing the incident. R317 then went on to say they turned on the call light their first night in the facility and staff never arrived to help them to the bathroom, R317 was incontinent of urine at this time and had to sit in urine for 6 1/2 hrs. Record review of the care plan for R317 revealed they require one staff assistance with a two wheeled walker to transfer. 38471 During Resident Council held on 10/8/2024 at 2:00 PM, the ten residents in attendance agreed unanimously with their concerns voiced about third shift staff. The attendees at the council reported the following: - 3rd shift waters are not passed consistently and there are many times when they will go without water until 1st shift arrives. -They act as if they do not want to be bothered to meet the needs of the residents. - When answering their call lights they will state, What do you want? - The staff are curt and do not treat them like human beings. - They are on their phones most of shift and when a call light goes off they grumble. - Nurses are not directing the aides throughout the shift and allowing them to have poor performance. - They are not comfortable advocating for themselves in these situations due to fear of reprisal from staff and being labeled as trouble. They expressed they would take longer to meet their needs and their quality of care would be lowered. 22927 In an interview on 10/07/24 at 11:28 AM, Resident #33 revealed that the third shift make the resident feel like she's a burden, and they have attitude. Resident #33 stated that the nurse aides have no compassion for the residents, and They (the aides) don't want to work. If (the Resident) need her brief changed and puts the call light on and they come in and say, 'What do you need now', it's awful, or (the Resident) have to lay in a wet/dirty brief for hours. In an interview on 10/09/24 at 08:08 AM, Resident #317 stated that the third shift the first couple of nights resident was admitted she felt ignored. Resident #317 stated putting on the call light at 3:00 am to use the bathroom, and no one came. Resident #317 stated they had to wet their brief, and no one came to change or assist until 10:00 am. Resident #317 stated they asked during the morning breakfast pass for staff assistance with a wet brief and staff stated that they could not change the resident right then because they were passing breakfast trays and then they came back in half hour. In an interview on 10/09/24 at 08:13 AM, Resident #44 when asked about concerns with third shift staff revealed that she tries to sleep through it, if she uses the call light on it takes a long time to get anyone (staff). The nurses are good, but the aides I don't care for. In an interview on 10/09/24 at 10:58 AM with the Human Resource (HR) Staff D, when asked about third shift staff concerns, revealed that the facility did have complaints on the 3rd shift staff being disrespectful, not being nice and with the attitude. HR D revealed that the facility had two Certified Nurse Assistance (CNA's) of concern. Management team have been having to do pop up visits at off hours in the night and the facility's still getting complaints, but we have to go through the proper format of disciplines and write ups before we can terminate a staff. We are watching the 3rd shift and are aware of concerns.

Based on observation, interview, and record review, the facility failed to implement and distribute baseline care plans for three residents (Resident #38, Resident #63, Resident #65), resulting in Resident #38 hand contractures with no interventions, Resident #63 had falls, and Resident #65 required hospitalization with the potential for lack of care related to unmet care needs. Finding includes: Record review of the facility 'Baseline Care Plans' policy dated [DATE], revealed the facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered and care of the resident that will meet professional standards of quality care. The baseline care plan must- (i.) be developed within 48 hours of a resident's admission. (ii.) Include the minimum healthcare information necessary to properly care for a resident Resident #63: Record review of Resident #63's admission Minimum Data Set (MDS) dated [DATE] revealed an elderly male cognitively intact. The MDS assessment noted the Resident #63 had a fall within the last month prior to admission. The MDS assessment noted a fracture related to a fall in the six months prior to admission marked as yes. Record review of Resident #63's Activity of Daily Living (ADL) care plan was missing the facility general statement of: I have been provided a copy of my baseline care plan within 48 hours of admission. Record review of Resident #63's medical diagnosis list revealed the resident was a full cardiopulmonary resuscitation (CPR). Medical diagnosis included: wedge compression fracture of first lumbar, gastro-esophageal reflux disease, repeated falls, long term use of anticoagulants, hypertension, benign prostatic hyperplasia, atrial fibrillation, atherosclerotic heart disease, heart failure, insomnia, angina pectoris and obstructive uropathy. In an observation and interview on [DATE] at 01:22 PM with Resident #63 and spouse revealed the left-hand thumb was purple in color with swelling noted. Resident #63 stated that he fell in the hallway. Resident #63's spouse was visiting stated that she did not know until she came into visit, The spouse stated that she did not get a phone call or notification at the time of the fall. Resident #63 stated that the facility just took an x-ray to see if it was broken. In an interview on [DATE] at 01:11 PM with the Director of Nursing (DON) revealed that Resident #63 had a fall, and the state surveyor requested incident report and x-ray report. The DON stated that the facility did not have the spouse phone number, and we did not ask the resident either, so she was notified yesterday when she came into the building to visit Record review on [DATE] at 01:29 PM of Resident #63's fall care plan revealed there were no new interventions implemented and care plan was not updated. Resident #65: Record review of Resident #65's closed electronic medical record revealed the resident was admitted on [DATE]. Medical diagnosis included post concussional syndrome, unspecified head injury, fall, orthostatic hypotension, disease of pancreas, vascular implants, atrial fibrillation, chronic kidney disease stage 4, atherosclerotic heart disease, peripheral vascular disease, mastopathy of breast, osteoarthritis, anxiety, hypertension, personal history of pulmonary embolism and headaches. Record review of Resident #65's Activity of Daily Living (ADL) care plan was missing the facility general statement of: I have been provided a copy of my baseline care plan within 48 hours of admission. In an interview and record review on [DATE] at 03:33 PM with Licensed Practical Nurse/Social Service Designee E revealed that resident baseline care plans start upon admission with the MDS assessment nurse puts the initial baseline care plan into the electronic medical system. The baseline care plan general statement: ' I have been provided a copy of my baseline care plan within 48 hours of admission' statement is located in the Activity of Daily Living (ADL's) and develops the Mood, Discharge, Skin, Diet, Falls, the main care plans, she puts them in based on the referral and interview upon admission and those are printed out and given to the resident and/or family within 48 hours. Social services designee E revealed that staff check that interventions on the care plan as given to resident or family. Record review of Resident #65's care plans revealed that the Resident and/or family did not have a baseline care plan. 49944 Resident #38 (R38): R38 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include progressive supranuclear ophthalmoplegia (a disorder that affects the way the brain controls movement, including eye movement), dementia, depression and anemia. Resident #38 has a BIMS (Brief Interview for Mental Status) score of 0, indicating severe cognitive impairment. On [DATE] at 01:18 PM, R38 was observed sitting in a reclining chair, their right hand was noted to be contracted and a rolled towel was placed in that hand. There was a glove observed on left hand. On [DATE] at 03:00 PM, record review of the MDS (Minimum Data Set), section G dated [DATE] revealed that R38 admitted with impairment on both sides. On [DATE] at 03:03 PM, record review of the EMR (Electronic Medical Record) for R38 revealed there was no physician order present for the treatment of the right-hand contracture and no care plan present for the contracture or therapy services being provided. On [DATE] at 03:04 PM, an interview was conducted with Therapy Manager A. Manager A was asked what therapy services were being provided to R38. Manager A stated that R38 is currently on a maintenance (restorative) program for range of motion. Manager A stated that R38 receives OT (Occupational Therapy) two times a week and PT (Physical Therapy) once a week. Manager A was asked about the towel in the right hand and glove on the left hand for R38. Manager A stated the rolled towel is for the contracture and the glove on the left hand is a family request, but they were unsure why R38 needed it. Manager A stated the family is now requesting to not have a towel for the right hand. Manager A was asked if there should be an order and a care plan for the towel and therapy services being provided. Manager A stated yes there should be. Record review of the policy titled, Restorative Program, revised [DATE] revealed: Process: 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, ADL's, 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. Monthly, the Restorative Nurse or designee will document a summary of the resident's participation and progress and determine the need to continue, revise, or discontinue the program based on the resident's needs, choices, and goals.

Based on observation, interview and record review the facility failed to revise and update care plans for four residents (R15, R18, R33, R63) of 20 residents reviewed for care plan revision, resulting in an inaccurate oxygen flow rate, inaccurate wound documentation, the physician not being notified of weight changes in a dialysis resident and no new interventions after a fall. Findings include: Resident #18 (R18): R18 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include heart failure, dementia, peripheral vascular disease and chronic pain syndrome. R18 has a BIMS (Brief Interview for Mental Status) Score of 0, indicating severe cognitive impairment. On 10/07/24 at 12:32PM, R18 was observed sleeping in their bed, R18 had a nasal cannula in place and was receiving oxygen via a concentrator at a flow rate of 4 liters per minute. The oxygen tubing was dated 10/6/24. On 10/08/24 at 09:57AM, R18 was observed in bed, receiving oxygen via a nasal cannula and concentrator at a flow rate of 4 liters per minute, the oxygen tubing was dated 10/6/24. On 10/08/24 at 03:55PM, record review of R18's medical record revealed a care plan dated 06/27/24 that R18 was to receive oxygen via nasal cannula at a rate of 2 liters per minute On 10/08/24 at 04:02PM, R18 was observed sitting up in a geri chair, oxygen was being administered at 4 liters per minute via a nasal cannula. This surveyor informed CCC (Clinical Care Coordinator) B that R18's concentrator was set to 4 liters per minute instead of the physician's order and care plan for 2 liters per minute. CCC B verified the rate of 4 liters per minute and stated they would check R18's oxygen level and notify the physician to see if R18 needed the increase in oxygen. Record review revealed that R18's oxygen administration care plan was updated on 10/8/24, after being informed of the discrepancy. Review of the policy titled, Care Plan-Comprehensive revealed: 8. Assessments of resident are ongoing and care plans are revised as information about the resident and the resident's condition change. 9. The care planning/interdisciplinary team is responsible for the review and updating of care plans: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly. 22927 Resident #15: In an interview and record review on 10/09/24 at 09:56 AM with the Director of Nursing (DON) of Resident #15's admitted [DATE] skin assessment was good with no concerns of bilateral feet/heels. Record review of Resident #15's electronic medical record 'Wound Evaluation' tab on 2/21/24 revealed the right heel with eschar with dead necrotic skin The DON was asked what happens or when the blackened cap falls the wound? The DON stated that the wound becomes an open wound, and potential for infections. The state surveyor inquired about care plan intervention of Certified Nurse Assistance's are to review skin daily, was it done? DON stated that Both Resident #15 and Resident #33's right heel pressure ulcers were preventable, with floating heels, prafo boots, repositioning, and getting the resident out of bed for few hours. Venous wounds would have done a Doppler at the time development of the wounds, not months later. Record review of Resident #15's care plans pages 1-49 revealed that 'Skin Management related to atherosclerotic heart disease, Parkinson's, dementia, diabetes, anemia, idiopathic neuropathy, sigmoid volvulus post-surgery, limited mobility and fragile skin. initiated on 12/9/2021 revealed interventions of: Certified Nurse Assistants (CNA's) will check my skin daily with care and report anything unusual they notice to the nurse: Date initiated 12/9/2021. Resident #33: Record review of Resident #33's care plans pages 1-38 revealed that 'Skin Management related to obesity, chronic kidney disease right heel wound. initiated on 5/30/2024 revealed interventions of: Certified Nurse Assistants (CNA's) will check my skin daily with care and report anything unusual they notice to the nurse: Date initiated 5/30/2024. In an interview and records review on 10/09/24 at 09:42 AM with Director of Nursing (DON) of Resident #33's electronic medical record revealed the admission assessment on 5/30/24 did not have any foot heel skin concerns. Wound/skin tab revealed Right heel wound started on 7/17/24 as a blacked eschar unstageable before anyone found it? Director of Nursing (DON) stated that Resident #33 was originally in her room on the 100 hall and the Certified Nursing Assistant (CNA) did skin assessment and found the wound as eschar and reported it to the nurse. The CNA's are to check skin each day and report, they should have reported a reddened area before it became eschar. Eschar is a blackened skin, necrotic and dead. We could have placed an intervention prior to the eschar. Resident #63: Record review of Resident #63's Minimum Data Set (MDS) dated [DATE] revealed a male with a Brief Interview of Mental status (BIMS) score of 14 out of 15, cognitively intact. MDS section J revealed a fall history resulting in fracture in the last six months: Yes. In an interview on 10/07/24 at 01:22 PM with Resident #63 revealed that he took a spill (fell ) last night, I had something in front of me, and I fell and sprained left thumb, they took an x-ray today. The spouse of the resident was at the bedside visiting and was surprised to hear that the resident fell , and she stated that she was not notified. Record review of Resident #63's 'Risk for Fall' related to history of falls, medication use, and pain. Initiated on 9/17/2024. Interventions included: wear non-skid footwear for all transfers and walking 9/17/2024. Record review of Resident #63's Fall incident report dated 10/6/2024 at 10:00PM revealed that the resident stood up from his wheelchair at the exit door by his room and lost his balance and fell . The situation factors noted: Footwear not in place. In an interview and record review on 10/08/24 at 01:11 PM with the Director of Nursing (DON) the state surveyor requested incident report and x-ray report. The DON stated that we did not have the spouses phone number and we did not ask the resident either, so she was notified yesterday when she came into the building to visit Record review on 10/08/24 01:29 PM with the DON revealed review of fall care plan revealed there were no new interventions implemented and care plan was not updated until 10/8/2024 to have staff perform frequent rounds on resident throughout the day.

Based on observation, interview and record review, the facility failed to maintain supervision of one resident (Resident #63) when up in the wheelchair, and notify a spouse of a fall/accident, resulting in an injury to the left thumb, pain, and the potential for continuous falls and injuries. Findings include: Record review of the facility 'Fall Reduction Program' policy dated [DATE], revealed the purpose was to provide a safe environment for residents, modify risk factors, and reduce risk of fall-related injury. Procedure: (1.) Identify/analyze risk for fall . (2.) Implement and indicate individualized interventions on care plan/Kardex Record review of the facility 'Unusual Occurrence' policy dated [DATE], revealed an unusual occurrence is any situation that involves harm or potential harm to a resident that is outside of the usual and expected. These include, but are not limited to falls, injuries, bruises Procedure: (5.) The charge nurse notifies the responsible party immediately . Record review of the facility 'Baseline Care Plans' policy dated [DATE], revealed the facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered and care of the resident that will meet professional standards of quality care. The baseline care plan must- (i.) be developed within 48 hours of a resident's admission. (ii.) Include the minimum healthcare information necessary to properly care for a resident Resident #63: Record review of Resident #63's admission Minimum Data Set (MDS) dated [DATE] revealed an elderly male cognitively intact with a Brief Interview of Mental status (BIMS) of 14 out of 15 score. The MDS assessment noted the Resident #63 had a fall within the last month prior to admission. The MDS assessment noted a fracture related to a fall in the six months prior to admission marked as yes. Record review of Resident #63's Activity of Daily Living (ADL) care plan was missing the facility general statement of: I have been provided a copy of my baseline care plan within 48 hours of admission. Record review of Resident #63's medical diagnosis list revealed the resident was a full cardiopulmonary resuscitation (CPR). Medical diagnosis included: wedge compression fracture of first lumbar, gastro-esophageal reflux disease, repeated falls, long term use of anticoagulants, hypertension, benign prostatic hyperplasia, atrial fibrillation, atherosclerotic heart disease, heart failure, insomnia, angina pectoris and obstructive uropathy. In an observation and interview on [DATE] at 01:22 PM with Resident #63 and spouse revealed the left-hand thumb was purple in color with swelling noted. Resident #63 stated that he fell in the hallway. Resident #63's spouse was visiting and stated that she did not know about the fall or injury to the thumb until she came into visit, The spouse stated that she did not get a phone call or notification at the time of the fall. Resident #63 stated that the facility just took an x-ray to see if it was broken. In an interview on [DATE] at 01:11 PM with the Director of Nursing (DON) revealed that Resident #63 had a fall, and the state surveyor requested incident report and x-ray report. The DON stated that the facility did not have the spouse phone number, and we did not ask the resident either, so she was notified yesterday when she came into the building to visit Record review on [DATE] at 01:29 PM of Resident #63's fall care plan revealed there were no new interventions implemented and care plan was not updated.

Based on observation, interview and record review, the facility failed monitor and document the weight loss of a hemodialysis resident, and to ensure timely re-weighs for weight loss for one resident (Resident #33), resulting in Resident #33 to have weight loss monitoring completion, follow-up of abnormal weights, and the potential for unidentified nutritional deficiencies and decline in overall health. Findings include: Record review of the facility 'Policy: Obtaining Weights and Re-weight Policy' undated, revealed each individual's weight will be determined and documented upon admission to the facility. Procedure: 1.) Nursing will be responsible for the initial determination of each individual's weight. Subsequent measurements for weight will be documented on the appropriate designated form or tracker in the computer database. Weight will be documented on the individual assessment instrument (MDS for nursing facilities), and in the medical nutrition therapy (MNT) assessment. Weight will be obtained weekly for 4 weeks after admission. Subsequent weights will be obtained monthly. unless physician orders or individual condition warrants frequent determinations. Re-weights will be done for a weight change of +/- (gain/loss) of 3# (pounds) for anyone under 100# pounds and for +/- (gain/loss) of 5# (pounds) for anyone 100 pounds and over. (2.) The Registered Dietitian (RD) or designee will be responsible for determining the desirable weight range Resident #33: In an interview on 10/07/24 at 11:32 AM with Resident #33 revealed that she received hemodialysis on Monday/Wednesday/Fridays. Resident #33 stated that her Dialysis port was infected and that she gets Vancomycin antibiotic at dialysis while receiving her dialysis treatment in the chair. In an interview and record review on 10/09/24 at 09:00 AM with Corporate Registered Dietitian (RD) R of Resident #33's weight log inconsistencies revealed admission beginning weight (wt.) was 281.0 pounds wheelchair on 5/30/2024, then on 6/29/2024 wt. 240.3 pounds wheelchair, that's a 40-pound wt. loss, there was no dietary note or review. RD R was asked about the weight fluctuation and stated that dialysis and Lasix, we go off the dialysis weights and we do review the dialysis communication forms, but that there was no dietary note or no re-weight performed by the facility. Record review of Resident #33's weight on 8/3/24 was 230.0 pounds mechanical lift and on 8/27/24 Resident #33's weight dropped to 208.0 pounds. Record review of Resident #33's progress notes and dietary notes revealed there was no mention of a 22-pound weight loss in a 24-day period. Registered Dietitian (RD) R reviewed the medical record for an answer, and none was found. RD R stated that the resident goes to dialysis 3 times a week and gets weighted at each treatment. The facility only documented one weight per month in May, June, July and august 2024 had few weights then in September. Registered Dietitian (RD) R revealed that a new dietitian started, and the process should be with each dialysis treatment sheet (3 times a week) are monitored, and then she reviews weights once a week. Record review of the physician progress notes 8/12/2024 RD F stated notified the physician and wrote note dated 7/30/24, but then the weight loss on 8/27/24 there was no notification of the physician.

Based on observation, interview and record review the failed to administer tube feeding per professional standards for one resident (Resident #8) of three residents reviewed for enteral nutrition, resulting in Resident #8 readmission enteral nutrition order being inputted incorrectly and facility staff administering the enteral feed without a physician's order. Findings Include: Resident #8: On 10/8/2024 at 8:15 AM, Resident #8 was observed asleep in bed with his tube feed infusing. The infusion rate was observed at 60 ml (milliliters) per hour, with the Jevity 1.5 formula being hung at 3:40 AM. Review was completed of Resident #8's enteral feed order and it indicated Jevity 1.5@ 65ml/hr flush of 45ml/hr water continuous to begin on 10/8/2024 at 3:00 PM. On 10/8/2024 at 8:45 AM, a review was conducted of Resident #8's records which revealed the resident readmitted to the facility on [DATE] with diagnoses that included, Acute Cystitis, Sepsis, Dementia, Dysphagia, Atrial Fibrillation, Hypertension and Major Depressive Disorder. Further review yielded the following results: Progress Notes: 10/2/2024 at 15:38: Pt (patient) came back from the hospital . 10/5/2024 at 18:10: .Peg feeding is up and running as ordered . MAR (Medication Administration Record) September MAR: Enteral Feed Order PEG tube: Jevity 1.5 60cc x 24 hour- free water flushed 45cc x 24 hours. initiated on 9/14/2024 and discontinued on 10/2/2024. October MAR: Jevity 1.5@ 65 ml/hr flush of 45ml/hr water continuous- ordered to begin on 10/8/2024 at 3:00 PM. Physician Orders: Jevity 1.5 @65ml/hr flush of 45ml/hr. Initiated on 10/2/2024 at 3:28 PM but this order was not categorized correctly and did not propagate to the MAR for daily administration. It was unknow if Resident #8 received enteral nutrition over the past seven days as there was no physician order. On 10/8/2024 at 9:15 AM, Resident #8's enteral nutrition orders were reviewed in the presence of Corporate Registered Dietitian R. This morning, she directed nursing staff to stop the tube feed to provide his gut a rest, with the plan to restart at his new infusion rate of 80 ml per hour at 11 AM. It was explained when she was in the resident's room his tube feed was infusing at 60 ml per hour and she thought it was running at 65 ml per hour since his readmission. Upon review of Resident #8's MAR there were no enteral nutrition orders from 10/2/2024 (readmission) to 10/8/2024 ( with begin time of 3 PM). It was unknown how Resident #8's order was missed, if he received any enteral nutrition and why it was infusing this morning without a physician order. Dietitian R stated she would follow up with this writer. On 10/8/2024 at 9:43 AM, Corporate Registered Dietitian R, followed up with this writer and explained the readmission tube feed order was located and explained the order did not carry over to the MAR, as it was categorized under other. The order was for 65 ml per hour with 45ml/hr flush. Prior to Resident #8 being discharged to the hospital his infusing rate was 60 ml/hour. Dietitian R was alerted by a facility nurse this morning, that it appeared the resident did not have a tube feed order. The dietitian further provided 72-hour history from Resident #8's pump that indicated he received enteral nutrition over the last 72 hours. It can be noted facility nurses were administering his tube feeding without an order nor documentation. The pump 72-hour lookback indicated the following: 24-hour history: 915 mL feed 630 mL flush 48-hour history: 2072 mL feed 1642 mL flush 72-hour history: 3412 mL feed 2723 mL flush On 10/9/2024 at 9:40 AM, an interview was conducted with Clinical Care Coordinator B regarding Resident #8's tube feed orders. Coordinator C shared prior to his discharge he was being administered tube feed and an oral diet. Upon his return he was still being administered his tube feed and if there was no hospital discharge order for enteral nutrition the nurses would have contacted the physician for an order. Coordinator C reviewed Resident #8's chart and stated while the order was inputted incorrectly upon admission all nurses that provided care to him should also have caught that he did not have a tube feed order. Furthermore, they should not have administered the Jevity without and order. Review was completed of the facility policy entitled, Enteral Nutrition Feeding, revised 9/23/2019. The policy stated, .To provide liquid nourishment and adequate hydration through a tube, into the stomach .Administration of tube feeding, and water flushes will be documented in the medical record. Review was completed of the facility policy entitled, Medication Administration- General Guidelines, dated September 1, 2023. The policy stated, Medications are administered in accordance with written orders of the prescriber.

Based on observation, interview and record review the facility failed to revise and update a physician's order for one resident (Resident #18) of two residents reviewed for oxygen administration, resulting in the improper flow rate of oxygen being administered. Findings include: Resident #18 (R18): R18 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include heart failure, dementia, peripheral vascular disease and chronic pain syndrome. R18 has a BIMS (Brief Interview for Mental Status) Score of 0, indicating severe cognitive impairment. On 10/07/24 at 12:32PM, R18 was observed sleeping in their bed, R18 had a nasal cannula in place and was receiving oxygen via a concentrator at a flow rate of 4 liters per minute. The oxygen tubing was dated 10/6/24. On 10/08/24 at 09:57AM, R18 was observed in bed, receiving oxygen via a nasal cannula and concentrator at a flow rate of 4 liters per minute, the oxygen tubing was dated 10/6/24. On 10/08/24 at 03:55PM, record review of R18's medical record revealed a physician's order for oxygen at a flow rate of 2 liters per minute via nasal cannula created on 06/27/24. On 10/08/24 at 04:02PM, R18 was observed sitting up in a geri chair, oxygen was being administered at 4 liters per minute via a nasal cannula. This surveyor informed CCC (Clinical Care Coordinator) B that R18's concentrator was set to 4 liters per minute instead of the physician order for 2 liters per minute. CCC B verified the rate of 4 liters per minute and stated they would check R18's oxygen level and notify the physician to see if R18 needed the increase in oxygen. Record review revealed that R18's physician order for oxygen administration was updated on 10/8/24 after being informed of the discrepancy. Record review of the policy titled, Oxygen Administration and Safety, effective 6/7/17 revealed: PURPOSE: Safe administration of oxygen therapy to the resident POLICY: Oxygen administration will be provided per physician's order observing appropriate safety measures. PROCEDURE: 1. Check physician's order for liter flow and method of administration. 2. When using oxygen cylinders, secure oxygen cylinder in appropriate holder. 3. Explain safety precautions to resident, family and any visitors. 4. Oxygen tubing will be labeled with date, changed weekly and as needed. The tubing will be stored in a plastic bag or similar storage device when not in use. 5. Apply humidification if ordered- Label and date if using prefilled disposable containers. Utilize sterile or distilled water for refillable humidification bottles. 6. If using a concentrator, change or clean filters as needed. 7. Resident's respirations and oxygen saturation levels will be monitored as ordered and as needed based on resident assessment. 8. Oxygen will not be utilized in the beauty shop, while a resident is smoking, or in other areas/events that may pose a potential risk. 9. If a resident wishes to participate in activities where oxygen is prohibited, a physician order will be obtained for intermittent removal of oxygen therapy.

Based on observation, interview and record review the facility failed to respond timely to pharmacy recommendations and follow parameters and/or check blood pressure prior to administration of medication for one resident (Resident #6) of five residents reviewed for unnecessary medications, resulting in Resident 6's pharmacy recommendations not being acknowledged by the facility and ensuring their blood pressure was taken and constraints followed prior to administration of medication. Findings Include: Resident #6: During initial tour on 10/7/2024 Resident #6 was observed resting in bed watching television she did not report any pressing concerns. On 10/8/2024 at 1:30 PM, a review was completed of Resident #6's medical records and it revealed she admitted to the facility on [DATE] with diagnoses that included, Heart Failure, Anxiety, Schizoaffective, Hypertension, Gastro-Esophageal Reflux Disease, Major Depressive Disorder and Nonpsychotic Mental Disorder. Review was conducted of Resident #6's Medication Regime Review's (MRR) from January 2024 to September 2024. It was found there were three reviews the facility failed to respond too. 1-24-2024 at 21:15: Pharmacist Recommends: Pantoprazole 40 mg QD (every day) (12-8-2022) Long term PPI (Proton Pump Inhibitors) therapy changes the pH and flora of the GI (gastrointestinal) tract, increasing risk of Clostridium difficile infections, pneumonias, iron-deficiency anemia, hypomagnesemia and osteoporotic fractures. Please consider the risks vs benefits and if reducing to pantoprazole 20 mg QD is applicable. 2/14/2024 at 17:00: Pharmacist Recommends: Cozaar Tablet 25 MG (Losartan Potassium) Give 1 tablet by mouth one time a day Hold for sbp (systolic blood pressure) < 120. Please add BP under supplementary documentation on the order to document/compare BP against hold parameter prior to administration. 2/14/2024 at 17:00: Pharmacist Recommends: Obtain CBC (complete blood count) with Diff, CMP (comprehensive metabolic panel), Carbamazepine, magnesium/vit B12, and Vitamin D level, TSH (thyroid), A1c, and Lipid Panel on next scheduled day then q 6 months. Please obtain these labs or upload the recent results. 5/8/2024 at 15:20: Pharmacist Recommends: Cozaar 25 MG 1 tab QD Hold for sbp < 120. Please add BP under supplementary documentation on the order so it can be documented on MAR ((Medication Administration Record). This will help compare to hold parameter prior to administration and retroactive review of holding trends. 5/8/2024 at 15:26: Pharmacist Recommends: Standing lab order: Obtain CBC with Diff, CMP, Carbamazepine, magnesium/vit B12, and Vitamin D level, TSH, A1c, and Lipid Panel on next scheduled day then q 6 months. Found a lipid panel, sodium, and a pending A1c lab report from 2-13-24. However could not find the other labs above. Please upload recent results or obtain a CBC with Diff, CMP, Carbamazepine level, magnesium, vitamin B12, vitamin D level, TSH. The CBC with Diff, CMP, Carbamazepine level, magnesium, vitamin B12, vitamin D level, TSH were not completed until August 2024 when the initial request was in January 2024, with two follow- up requests in February and May 2024. Pantoprazole 40 mg QD order remined unchanged from order date of 12/8/2022. The recommendation for supplemental documentation in the MAR for Cozaar was not added. While facility staff were documenting Resident #6's blood pressures, the hold parameter was not being adhered too and/or the blood pressure was not documented prior to administration. There were 21 times (as listed below) when this occurred. 9/18/2024 09:02 118 / 62 mmHg 9/16/2024 14:04 118 / 62 mmHg 9/16/2024 09:03 117 / 63 mmHg 5/23/2024 11:39 118 / 60 mmHg 5/21/2024 11:22 116 / 60 mmHg 5/20/2024 01:05 114 / 60 mmHg 5/7/2024 13:49 118/72 mmHg 4/28/2024 13:12 119 / 69 mmHg 4/17/2024 12:44 118 / 70 mmHg 4/14/2024 13:08 106 / 50 mmHg 4/13/2024 14:22 106 / 50 mmHg 4/12/2024 05:37 106 / 50 mmHg 4/5/2024 13:17 118 / 72 mmHg 4/4/2024 13:10 118 / 72 mmHg 4/2/2024 13:31 117 / 70 mmHg 3/31/2024 11:06 117 / 70 mmHg 3/30/2024 14:29 118 / 69 mmHg 3/28/2024 13:17 118 / 69 mmHg 3/27/2024 13:56 118 / 69 mmHg 3/19/2024 14:11 118 / 72 mmHg 3/10/2024 13:13 118 / 77 mmHg Review was completed of the facility policy entitled, Consultant Pharmacist Reports, revised December 2022. The policy stated, .Recommendations are acted upon and documented by the facility staff and/or the prescriber. Prescriber accepts and acts upon suggestions or rejects and provides and explanation for disagreeing . The Director of Nursing or designated licensed nurse address and document recommendations that do not require a physician intervention .

Based on observation, interview and record review the facility failed to document the clinical rationale for triple drug therapy for one resident (Resident #6) of five residents reviewed for unnecessary medications, resulting in Resident #6 being prescribed three antidepressant medications related to her Major Depressive Disorder diagnosis. Findings Include: Resident #6: During initial tour on 10/7/2024 Resident #6 was observed resting in bed ,watching television she did not report any pressing concerns. On 10/8/2024 at 1:30 PM, a review was completed of Resident #6's medical records and it revealed she admitted to the facility on [DATE] with diagnoses that included, Heart Failure, Anxiety, Schizoaffective, Major Depressive Disorder and Nonpsychotic Mental Disorder. Further review yielded the following results: Physician Orders: Sertraline HCI Tablet 100 MG (milligrams) for Major Depressive Disorder Trazadone HCI Tablet 50 MG for Major Depressive Disorder Wellbutrin XL Oral Tablet Extended Release 300 MG for Major Depressive Disorder Resident #6 was prescribed three antidepressants for her diagnosis of Major Depressive Disorder. There was no documented clinical rationale that confirmed the benefits of multiple medications from the same class or with similar therapeutic effects. On 10/8/2024 at 3:55 PM, an interview was conducted with Social Worker E regarding Resident #6's three antidepressant medications. Social Worker E expressed the resident is currently stabilized on the medication regime as when reductions were completed, she began to isolate, needed extensive encouragement to get out the bed and was more tearful. The social worker was asked where the documentation from the provider to this fact was located. After searching the notes, the documented rationale was not able to be located. Review was completed of the facility policy entitled, Use of Psychotherapeutic Medications, revised 11/2/2016. The policy stated, .Duplicative drug therapy will be discouraged and closely monitored . The policy did not address the need for clinical rationale if multi drug therapy is utilized.

Based on observation the facility failed to dispose of expired supplies and supplements located in the medication storage rooms on the 100 Hall and 400 Hall, resulting in expired supplies and supplements being available for use and consumption. Findings include: On [DATE] at 12:28 PM, the 100 Hall medication storage room was reviewed and revealed the following expired items: -A case of purple top vacutainers (tubes used to collect blood for lab testing) had expired on [DATE]. -Eight Ensure Plus supplement drinks had expired on [DATE]. -Nine sterile gauze pads had expired on [DATE]. These findings were verified with RN (Registered Nurse) C. On [DATE] at 12:40 PM, the 400 Hall medication storage room was reviewed and revealed the following expired item: - A box of lubricating jelly had expired [DATE]. This finding was verified with the NHA (Nursing Home Administrator). The policy provided by the facility titled, Medication Storage in the Facility does not address expired supplies and supplements.

This Citation has two Deficient Practice Statements. Deficient Practice Statement 1: This Citation Pertains to Intake Numbers MI00137515 and MI00141236. Based on interview and record review, the facility failed to ensure that timely and appropriate care was provided, per professional standards of practice and Health Care Provider orders, for one resident (Resident #802) of three residents reviewed for assessment and monitoring, resulting in a lack of accurate infection control surveillance, Resident #802 not receiving medications as ordered for Covid-19, a lack of comprehensive assessment, documentation, and a timely response to an acute change in condition, and death. Findings include: Resident #802: Review of intake documentation dated received [DATE] revealed concerns that Resident #802 had contracted Covid-19 and that the facility did not notify the family, and did not implement appropriate infection control procedures related to Covid-19. The intake detailed, On Wednesday, (Resident #802) complained to the nurse about difficulties breathing, but (facility staff) didn't call 911. (Licensed Practical Nurse [LPN] D) gave (Resident #802) albuterol (inhaled medication used to prevent and treat bronchospasm in individuals with obstructive airway diseases), then left the room for an hour or so, when (LPN D) returned, (Resident #802) was unresponsive. Per the intake, Resident #802 died in the facility. Review of a separate intake for the facility revealed concerns that appropriate infection control precautions to prevent the spread of Covid-19 were not being implemented and/or followed. Facility Infection Control (IC) data was requested from the facility Administrator and Corporate Registered Nurse (RN) W on [DATE] at 11:03 AM. Upon request for infection control data from [DATE], RN W revealed the facility (IC) angrily quit employment with the facility the prior week and were unsure of the location of prior data. Record review revealed Resident #802 was originally admitted to the facility on [DATE] with diagnoses which included Multiple Sclerosis (MS), paraplegia (paralysis of the lower body), neuromuscular disfunction of the bladder, and depression. Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed the Resident was cognitively intact and required limited-to-total assistance to complete Activities of Daily Living (ADL). Per the Electronic Medical Record (EMR), Resident #802 died in the facility on [DATE]. Any Incident and Accidents (I and A) and/or concern forms pertaining to Resident #802 were requested from the facility Administrator on [DATE]. On [DATE] at 9:00, the Administrator stated there were no I and A and/or concern forms for Resident #802. A review of Resident #802's EMR revealed the Resident made their own medical decisions but preferred to have their family involved in their care. Witness F was listed as Resident #802's Emergency Contact # 1. A form dated [DATE], entitled, Authorization List for PHI (Personal Health Information) included Witness F and specified to Please release medical information to whomever asks for it. A Code Status Form dated [DATE] was present in the EMR. The form specified Resident #802 was full code and wanted to receive Cardiopulmonary Resuscitation (CPR). Further review revealed a Physician . Progress Note dated [DATE] which specified the Health Care Provider (HCP) discussed code status with Resident #802 and the Resident wants everything to be done. The note indicated the (HCP) explained in detail what everything being done entails, and that Resident #802 wanted all resuscitation efforts made in a medical emergency. Review of progress note documentation in Resident #802's EMR revealed the following: - [DATE] at 3:07 PM: Nurses Note . Nursing staff was having a conversation with this resident it was noticed that responses were delayed and had a dry cough. A rapid covid test was performed and the Resident tested positive for Covid-19 this am. (Physician E) and family notified. New orders were monitor and follow protocols. - [DATE] at 4:10 PM: Nurses Note . Resident isolated in room and PPE staged. - [DATE] 12:37 AM: eMar (Electronic Medication Administration Record) -Medication Administration Note . Ventolin (albuterol) HFA Inhalation Aerosol Solution . 2 puff inhale orally every 4 hours as needed for Shortness of Breath for 14 Days PRN (as needed) - [DATE] 12:37 AM: eMar-Medication Administration Note . Acetaminophen (Tylenol) Tablet 325 mg (milligram) Give 2 tablet by mouth every 4 hours as needed for Generalized discomfort. Resident c/o (complain of) of discomfort. - [DATE] at 2:23 AM: Nurses Note . Walked into resident room around 1:10 AM, (Resident #802) was unresponsive performed OPR (sic) (CPR- Cardiopulmonary Resuscitation). Called 911. EMS took over. DON (Director of Nursing) and family called. EMS pronounced resident (deceased ) at 1:59 AM. - [DATE] at 4:03 AM: eMar -Medication Administration Note . Ventolin HFA Inhalation Aerosol Solution . 2 puff inhale orally every 4 hours as needed for Shortness of Breath for 14 Days PRN (as needed) Administration was: Ineffective - [DATE] at 4:03 AM: eMar-Medication Administration Note .Give 2 tablet by mouth every 4 hours as needed for Generalized discomfort PRN Administration was: Unknown. - [DATE] at 4:21 AM: Nurses Note . family was here to visit around 3:30 AM . (Funeral Home) here to pick up body. A review of assessment documentation in Resident #802's EMR revealed no assessments had been completed related to the Resident testing positive for Covid-19, a change in condition, and/or to the Resident's death in the facility on [DATE]. A review of Resident #802's EMR revealed no HCP visit notes and/or documentation indicating the Resident was assessed by the Physician/HCP after testing positive for Covid-19 and before their death in the facility. Review of Census documentation revealed Resident #802 was moved from the 400 hall of the facility to a room on the 200 hall of the facility on [DATE] at 9:15 PM. Review of Resident #802's Health Care Provider Orders in the EMR revealed the following: - Covid Test PRN (as needed) (Ordered: [DATE]) - Normal Saline Flush Intravenous Solution 0.9 % (Sodium Chloride Flush). Use 75 milliliter (mL) intravenously (IV) one time only for COVID . 1 liter to infuse at 75mL/hr . (Ordered: [DATE]) - Resident was actively assessed for symptoms of COVID - 19 (fever, shortness of breath, cough, sore throat, chills/shaking, loss of tastes/smell, muscle aches, headaches confusion, nausea, vomiting and diarrhea) three times a day. The patient did not display any of these symptoms during my shift. Document in a nurse's note if the patient experienced any of these signs or symptoms of COVID every shift for Monitoring (Ordered: [DATE]) - Ventolin HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally every 4 hours as needed for Shortness of Breath for 14 Days (Ordered by Phone: [DATE]). The order was signed by Physician E on [DATE] at 8:53 PM. - Paxlovid (,d+[DATE] [mg]) Oral Tablet Therapy Pack (antiviral medication used to treat Covid-19 - treatment should be initiated as soon as possible after Covid diagnosis) . Give 3 tablet by mouth two times a day for COVID 19 for 5 Days . (Ordered by Phone: [DATE]; Start Date: [DATE]; Discontinued: [DATE]) - Paxlovid (,d+[DATE] [mg]) Oral Tablet Therapy Pack (antiviral medication used to treat Covid-19 - treatment should be initiated as soon as possible after Covid diagnosis) . Give 3 tablet by mouth two times a day for COVID 19 for 5 Days . (Ordered by Phone: [DATE]; Start Date: [DATE]). The order was signed by Physician E on [DATE] at 8:53 PM. - Monitor patient for side effect r/t Paxlovid: anaphylaxis type reaction, hives, rash, diarrhea, high blood pressure, muscle aches, changes in smell. Three times a day for Paxlovid Therapy for 7 Days (Ordered by Phone: [DATE]; Start Date: [DATE]) - CBC (Complete Blood Count- blood test), BMP (Basic Metabolic Panel - blood test), CRP (C-Reactive Protein- blood test to identify inflammation in body) to be drawn next lab draw (Ordered and Discontinued: [DATE]) - Chest X-Ray 2-view .: (Ordered and Discontinued: [DATE]) Review of Resident #802's HCP orders revealed no orders related any type of Transmission Based Precautions (TBP) pertaining to Covid-19 diagnosis on [DATE]. However, discontinued orders for specific type of TBP were noted in the orders for 2020, 2021, and 2022. Further review revealed the Resident had not previously had an order for an inhaler and did not have an order for supplemental oxygen. A review of Resident #802's EMR revealed no results for the laboratory testing ordered on [DATE]. A Chest X-Ray was completed on [DATE] at 8:39 PM. The report detailed, Results . The lungs demonstrate no consolidation, masses or effusions . no evidence of significant pneumothorax (collapsed lung) . No focal airspace disease (abnormalities) . The report was signed by the facility Physician on [DATE]. Results of Covid-19 testing, including a PCR (polymerase chain reaction - more reliable/accurate test often used to confirm positive Point of Care [POC]/rapid test) were not present in Resident #802's EMR. Review of Resident #802's Electronic Medication Administration Record (eMAR) for [DATE] revealed the following: - Acetaminophen (Tylenol) 650 mg was administered on [DATE] at 2:06 PM and on [DATE] at 12:37 AM. A pain level of four (out of 10) was documented for both administrations. - Ventolin Inhaler was administered one time on [DATE] at 12:37 AM. - The ordered Paxlovid was never administered to the Resident. An interview was completed with Family Member Confidential Witness F on [DATE] at 9:15 AM. When queried regarding Resident #802, Witness F stated, On Sunday, Mother's Day 2023 ([DATE]), (Resident #802) tested positive for Covid. Witness F revealed they, along with other family members, went to visit the Resident in the afternoon on Mother's Day ([DATE]) and were informed by the nurse that (Resident #802) tested positive for Covid and they were unable to see them. Witness F stated, We asked why they (facility) didn't tell us that. When asked what the staff said in response, Witness F replied, The one nurse said, well you can probably go in there (Resident #802's room). Witness F verbalized the staff weren't wearing no masks or nothing in the hallways even though there were multiple residents who were Covid positive. When asked if Resident #802 was in the same room they had been in, Witness F replied, Yeah. (Resident #802) was in the same room so we stuck our head in there and (a female staff member) was in there feeding (Resident #802). Witness F revealed the staff member in Resident #802's room told them they could not come in and expressed confusion related to why one nurse said they could visit, and another said they could not. When asked what they did, Witness F replied, So we left. With further inquiry, Witness F revealed Resident #802 was moved to the Covid hall of the facility finally on Tuesday [DATE]th, 2023. When asked if they were saying Resident #802 tested positive for Covid-19 on Sunday [DATE] but was not moved to the Covid hall of the facility until Tuesday ([DATE]), Witness F confirmed. When queried if they knew why the Resident was not moved to the Covid unit [DATE], Witness F revealed they were unsure. Witness F then stated they were contacted by Licensed Practical Nurse (LPN D) in the evening, I wanna say 10:00 or 11:00 (PM) O'clock at night on [DATE]. Witness F revealed LPN D called to inform them that Resident #802 was having difficulty breathing and they were going to give them albuterol. With further inquiry regarding the phone call, Witness F stated they asked LPN D to keep an eye on (Resident #802) and send them to the ER if needed. When asked if they knew what type of albuterol, Witness F replied, Inhaler, like for asthma. Witness F continued, (LPN D) gave (Resident #802) albuterol and I don't even know if they even called the Doctor to approve (albuterol administration) or to inform them that (Resident #802) was having difficulty breathing. Witness F then stated, (Resident #802) shouldn't have died . You don't leave a patient who is having difficulty breathing, give them albuterol, and not go back to check and see if they are okay. (LPN D) didn't go back until an hour later. When asked to clarify if LPN D told them Resident #802 was short of breath, Witness F replied, Yes. (LPN D) called and said that (Resident #802) was complaining of shortness of breath and they were going to give them albuterol. Witness F was asked if Resident #802 contacted them and replied, No (Resident #802) can't call, can't use their phone (without assistance). Witness F revealed the Resident had limited mobility and could not use their hands very good. Witness F continued, Then (LPN D) called me and told me (Resident #802) passed. Witness F divulged they were shocked and asked LPN D what they were talking about. LPN D responded, (Resident #802) complained about having breathing problems, I gave them albuterol and then about an hour or so later I went back and (Resident #802) was unresponsive. Witness F indicated they had worked in the medical field and immediately had concerns regarding the care Resident #802 received. Witness F stated, You don't leave a patient who is having respiratory failure or a respiratory problem for over an hour, you just don't do that. Witness F verbalized further concerns that LPN D did not check to see the effectiveness of the albuterol in a timely manner and did not do their job. Witness F stated, It should be an RN (Registered Nurse) doing that stuff. When asked what they meant, Witness F revealed they did not think LPN's were able to complete assessments. Witness F revealed they went to the facility after informing other family members. When asked what happened when they got to the facility, Witness F revealed they were able to see the Resident when they arrived. When queried if they spoke to the nursing staff at the facility, Witness F indicated they spoke to LPN D and asked them why they did not call 911 and get the Resident to the hospital right away when they couldn't treat Resident #802 there after they started having difficulty breathing. Witness F was asked if LPN D responded and replied, Just to say they were sorry and (LPN D) started crying. Witness F stated they asked LPN D why they did not call 911 and LPN D responded, Well I did. Witness F verbalized they replied, Yeah after the point that (Resident #802) was unresponsive and (LPN D) said yes. LPN D then told them that Resident #802 didn't meet criteria to be critical to send them to the hospital. When queried if they asked LPN D what the criteria for critical was, LPN D verbalized they did but did not answer them. Witness F then stated, I asked how long (Resident #802) was unresponsive for and (LPN D) said I don't know. When queried if they had any additional concerns, Witness F stated, At that time, we were in the Covid (hall) and (LPN D) was walking around and not even wearing a mask. Witness F indicated they were concerned that the facility staff's lack of appropriate use of Personal Protection Equipment (PPE) contributed to the spread of Covid-19 in the facility. Review of Resident #802's EMR revealed a care plan entitled, Actual Infection r/t Covid Positive . [DATE] (Initiated: [DATE]; Revised: [DATE]). The care plan included the interventions: - Precautions other than standard: Transmission Based Precautions (Initiated and Revised: [DATE]) - Labs/diagnostics as ordered (Initiated: [DATE]; Revised: [DATE]) - Monitor and document response to treatment (Initiated: [DATE]; Revised: [DATE]) - Monitor me for s/sx (signs/symptoms) of an Adverse drug reaction every shift (Initiated: [DATE]; Revised: [DATE]) A second care plan in Resident #802's EMR entitled, Resident is at risk for psychosocial wellbeing concern r/t medically imposed restrictions r/t COVID-19 precautions . (Initiated: [DATE]; Revised: [DATE]) included the interventions: - Educate staff, resident, family and visitors of COVID-19 signs and symptoms and precautions (Initiated: [DATE]) - Follow facility protocol for COVID-19 Screening/Precautions (Initiated: [DATE]) A review of Resident #802's documentation in the EMR revealed the Resident was on Room Air and not receiving supplemental oxygen. An interview was completed with Certified Nursing Assistant (CNA) A on [DATE] at 11:45 AM. When queried if they recalled Resident #802, CNA A verified they did. CNA A was asked if they recalled the Resident being diagnosed with Covid-19, CNA A stated, I didn't even know he had it the last time until when I came in and they said (Resident #802) had passed. When asked if Resident #802 had a history of breathing difficulties and if they wore oxygen, CNA A replied, No and stated they were a pleasant person. On [DATE] at 4:35 PM, LPN D was contacted via phone. When queried if they recalled Resident #802, LPN D verbalized they did. LPN D was then asked if they were working the night Resident #802 passed and replied, Yeah. When queried what happened, LPN D stated, I can't talk to you know. LPN D was asked if there would be a more convenient time for them to talk and replied, I don't know. A review of LPN D's Human Resource file was completed on [DATE] at 4:50 PM with Staff G. LPN D's last Annual check off competency was dated [DATE]. When queried if they had a more recent annual competency, Staff G reviewed the file and verbalized they did not. When queried if annual competency education is supposed to be completed, Staff G confirmed it should be and was unable to provide further explanation. The facility schedule/assignments for [DATE] and [DATE] were requested from LPN D at this time. Review of a facility-provided schedule for [DATE] revealed CNA H, CNA I, CNA V, LPN D and LPN J were working when Resident #802 passed. On [DATE] at 7:56 AM, RN W provided a Monthly Infection Control Analysis form for [DATE]. The form did not provide Resident specific information but detailed 10 residents developed facility acquired Covid-19 infection. The line listed data was requested again at this time. CNA H was attempted to be contacted via phone on [DATE] at 8:18 AM. A voicemail message was unable to be left and a text message requesting a return phone call was sent. At 8:23 AM on [DATE], CNA I was contacted via phone. A voicemail and text message requesting a return phone call was left. On [DATE] at 8:26 AM, CNA V was attempted to be contacted via phone and a voicemail message was left requesting a return phone call. LPN J was attempted to be contacted via phone on [DATE] at 9:20 AM. A voicemail message was left requesting a return phone call. Return phone calls were not received from CNA H, CNA I, and CNA V. On [DATE] at 9:41 AM, an interview was completed with LPN D. When queried if they recalled Resident #802, LPN D confirmed they did and were the Resident's assigned nurse the night they passed. When asked what happened, LPN D stated, I remember when I went in the room, (Resident #802) said they had a headache. When asked, LPN D revealed they gave (Resident #802) Tylenol for their headache. LPN D continued, When I went back to check on their headache, (Resident #802) appeared short of breath. When asked how the Resident appeared short of breath, LPN D indicated the Resident appeared to be having trouble breathing. When asked if Resident #802 verbalized they felt short of breath, LPN D replied they did. LPN D stated, I gave (Resident #802) their inhaler then. When asked if they gave the inhaler because the Resident was having difficulty breathing, LPN D confirmed they did. When queried if the contacted the Physician/HCP, LPN D indicated they did not contact them at that time. When queried if they assessed the Resident's vital signs, LPN D replied, SPO2 (oxygen saturation) was okay. When asked what they did then, LPN D indicated they left Resident #802's room after administering the inhaler. LPN D then stated, Went back to check on (Resident #802) and put the SPO2 and vital sign machine on and it read something, not sure what, then it went to zero. LPN D was asked if Resident #802 responded when they put the blood pressure cuff and SPO2 monitor on them and stated, I don't remember. When asked to clarify what they were referring to when they said the monitor read something, LPN D indicated the monitor lit up like it was working. When queried if it was just the machine turning on, LPN D revealed they were unsure. When queried regarding the length of time following the inhaler administration until they went back to check on Resident #802, LPN D revealed they were not completely sure but around and hour maybe. LPN D continued, I left and had the CNA go get the other nurse. When asked where the CNA was, LPN D verbalized they were at the nurses' station. LPN D was asked how far the nurses' station was from Resident #802's room and revealed Resident #802's room was midway down the hall. When queried if they were wearing Personal Protective Equipment (PPE) in Resident #802's room, LPN D indicated they were. LPN D was then asked if they removed the PPE prior to exiting the room and stated, Yes, of course. When queried what specific type of TBPs were in place, LPN D specified they did not recall. When asked if they checked Resident #802 for a pulse or respirations prior to exiting the room, LPN D replied, No, I went to get help. When asked why they did not use the call light in the room, LPN D replied, I don't know. When asked what happened when they left Resident #802's room, LPN D stated, I went to the CNA and told them that I need your nurse now and went back to (Resident #802). (LPN J) came in, tapped (Resident #802) and started compressions. When queried if Resident #802 was breathing or had a pulse at that time, LPN D stated, I don't know, I don't know. When queried if they or LPN J checked for a pulse or breathing, LPN D revealed they did not check for a pulse and were unaware of LPN J checking for a pulse. LPN D was asked about the Resident's color and temperature but was unable to provide a response. When queried what happened next LPN D stated, EMS came and took over. They kept doing compressions. LPN D stated, They were down there a long time. When asked if they stayed in the room with the Resident, LPN D revealed they did not as EMS had taken over. LPN D then stated, Once it was all said and done, they (EMS) pronounced them (deceased ). LPN D revealed the contacted the family to inform them that Resident #802 had passed. When queried regarding the conversation with Resident #802's family went, LPN D verbalized the family was very upset. LPN D asked if they document medication administration in the eMAR at the time they remove a medication from the medication cart or when they return to the cart after administering the medication to the Resident takes the medication and replied, I go give it and then document. When queried if that was what they did when they administered Resident #802's medications on [DATE], LPN D stated, I don't know if I immediately documented it and indicated they recalled being busy and may not have documented the medications immediately following administration. When queried regarding the times on Resident #802's eMAR specifying the Tylenol and Ventolin inhaler were administered at the same time, LPN D stated, Yeah and they wasn't given at the same time. When asked to clarify if they were saying they did not administer the Tylenol and Ventolin inhaler at the same time but documented the medications were administered at the same time, LPN D verbalized confirmation. When queried if they listened to Resident #802's lung and heart sounds and/or completed a physical assessment when the Resident complained of shortness of breath, LPN D stated, I don't know. LPN D articulated that assessment findings such as lung sounds would be in a (progress) note. When queried why they did not document that Resident #802 was experiencing difficulty breathing and why no assessment documentation was completed, Resident #802 did not provide an explanation. When queried if supplemental oxygen was initiated for Resident #802 due to their difficulty breathing, LPN D replied that Resident #802 already had supplement oxygen in place via nasal cannula. When queried why there was no order for supplemental oxygen and vital sign documentation specified the Resident was on room air, LPN D was unable to provide an explanation. On [DATE] at 12:28 PM, RN W provided the IC Line Listing for [DATE]. The line list detailed Resident #802's onset date for Covid-19 was [DATE]. The line listing indicated the Resident did not have any orders and/or receive any medications for Covid-19 infection and did not move to the Covid hall of the facility. The signs and symptoms on the line list included, Cough, Resp > 25, Hoarseness or loss of voice, Difficulty breathing / Shortness of breath, Sore throat, Fatigue / Malaise, s/s (signs/symptoms) of common cold. Note: There was no documentation of Resp > 25, Hoarseness or loss of voice, sore throat, and/or Difficulty breathing / Shortness of breath in Resident #802's EMR. An interview was conducted with the DON on [DATE] at 1:45 PM. When queried regarding assessment and intervention expectations for a resident who develops difficulty breathing, the DON stated, I would expect a lung assessment and oxygen saturation. The DON stated they would attempt to sit them up, positioning, and apply oxygen if needed to improve oxygenation. The DON was then asked to review Resident #802's documentation in the EMR. When queried why there was no documentation related to the Resident having trouble breathing, the DON confirmed the lack of assessment and documentation. When asked, the DON verbalized documentation should have been completed. The DON was informed of interview completed with LPN D. When queried regarding the appropriateness of the care provided for Resident #802, the DON stated, If (a resident is) very short of breath, should pull call light to get the other nurse and call the Doctor to get an order to send out (to hospital). When queried regarding Ventolin inhaler administrator, the DON stated, I probably wouldn't give it they were short of breath because it is past that (medication being effective) When queried regarding facility policy/procedure related to TBPs and if there should be an order in the EMR specifying the specific type of precautions, the DON replied, Yes. When queried if there was an order in Resident #802's EMR, the DON reviewed and stated there was no order. When asked why there was not an order, the DON communicated that they did not work at the facility during Resident #802's stay and were unable to provide an explanation. The DON was then asked when Paxlovid should be initiated for an individual diagnosed with Covid-19 and indicated as soon as possible. When queried why Paxlovid was not ordered for Resident #802 until [DATE] when they tested positive for Covid-19 on [DATE], the DON was unable to provide an explanation. The DON was then asked to review Resident #802's eMAR. When queried if Resident #802 received any doses of Paxlovid, the DON replied, Never administered. When queried why Resident did not receive the ordered medication, the DON stated, I can't answer that because there is no note. When queried if the Resident's Physician/HCP should come to see and assess them following a change in condition, such a being diagnosed with Covid-19, the DON replied, Yeah. The DON was then asked if Resident #802 was assessed by their Physician/HCP following their diagnosis. The DON reviewed Resident #802's EMR and confirmed they were not. When asked, the DON verified concerns related to Resident #802's assessment, monitoring, and treatment. Resident #802's Certificate of Death was obtained and reviewed. Per the Death Certificate, Resident #802 died on [DATE] AM at 1:59 AM due to a. Covid-19 . Approximate Interval Between Onset and Death > 3 day; b. Respiratory Failure Approximate Interval Between Onset and Death ,d+[DATE] minutes . The Manner of Death was listed as Natural and the Medical Examiner was not contacted. Facility Physician E is listed as the Certifying Physician on the Death Certificate. An interview was competed with the facility Administrator on [DATE] at 8:45 AM. Resident #802's change in condition, lack of medication administration as ordered, nursing assessment, timely response, and death in the facility were reviewed. When queried, the Administrator stated, I'm not sure what happened. On [DATE] at 12:00 PM, the Administrator provided an investigation folder pertaining to Resident #802. The folder contained the following: - Typed Statement specifying, (LPN D): After receiving vitals and report from the nursing assistant at 12:15 AM or a little later, I went to assess. Resident was short of breath and in some discomfort while talking to them. (SPO2) 92 % . I gave Tylenol, albuterol and made sure oxygen was in their nose about 12:30 or 12:40. About ,d+[DATE] minutes later I went into reassess, I couldn't get a pulse, so I asked the nursing assistant for the other nurse . The typed statement was dated [DATE] and signed but the signed by LPN D. - Typed Statement specifying, 2nd Nurse, (LPN J). When I came back from my break at 1:10 AM, I was notified by the CNA that the Resident nurse was looking for me and was in (room number), when I entered the room, (LPN D) was trying to get vital signs. I noticed (Resident #802 wasn't breathing. I started CPR, (LPN D) called 911 and got the crash cart . The typed statement was dated [DATE] and signed but the signature was illegible. - Typed Statement specifying, (CNA I): I got vitals on residents around 10:30 and 11:00 PM, (Resident #802) was alert and knew I was in the room, (Resident #802) sounded really congested so I told the nurse their breathing sounding like they were having and hard time breathing . The typed statement was dated [DATE] and signed by CNA I. On [DATE] at 10:27 AM, Physician E was contacted via phone and a message with return number was left. A return phone call was not received. Review of EMS Run documentation for Resident #802 revealed the following: - Prehospital Care Report . Incident Date: [DATE] . Complaint . Cardiac Arrest/Death . Call Date/Time: [DATE] 1:23:50 (AM) . Arrived at Patient . 1:29:00 (AM) . Cardiac Arrest: Yes, Prior to EMS Arrival . First Monitored Arrest Rhythm of the Patient: Asystole (no electrical activity in heart/no heartbeat) . Impressions: Apnea (lack of respirations) . cardiac arrest . General Assessment . 1:29 AM . Skin: Cyanotic (bluish or purplish discoloration of the skin caused by lack of oxygen), Cold . Narrative .Per the patient nurse, she gave the patient a breathing treatment of albuterol at 1230 . the patient complained of breathing discomfort. Per the patient nurse, she went to go check on (Resident #802) at 1:10 AM and found the patient pulseless and not breathing . On [DATE] at 11:13 AM, RN W provided the facility Covid-19 LTC Respiratory Surveillance Line List for [DATE]. This line list indicated there were 12 Residents who tested positive for Covid-19 during the month and two of the 12 Residents died . Review of Resident #802's infection surveillance information

This Citation pertains to Intake Number MI00142682. Based on interview and record review, the facility failed to prevent the development of pressure ulcers to the bilateral heels and prevent the worsening of a sacral pressure ulcer and monitor/assess wounds timely and accurately for one resident (Resident #500) of 3 residents reviewed for pressure ulcer care, resulting in the development of facility acquired pressure ulcers, infection, delayed wound healing, pain, and overall deterioration in health status. Findings include: Resident #500: A review of Resident #500's medical record revealed an admission into the facility on [DATE] and readmission on [DATE] with diagnoses that included sepsis, metabolic encephalopathy, acute embolism and thrombosis of left lower extremity, stroke, thrombocytopenia, chronic kidney disease, anxiety disorder, and pressure ulcer of sacral region. A review of the Minimum Data Set (MDS) assessment with a target date [DATE], revealed a Brief Interview of Mental Status (BIMS) score of ,d+[DATE] that indicated intact cognition and the Resident was dependent for self-care and mobility to roll left and right and lying to sitting on side of bed. A review of Resident #500's OBRA Admission MDS assessment with a target date on [DATE] revealed Section M Current Number of Unhealed Pressure Ulcers at Each Stage indicated the Resident had one unstageable-slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar that was present upon admission/reentry. A review of Resident #500's Discharge MDS assessment with a target date on [DATE] revealed Section M Current Number of Unhealed Pressure Ulcers at Each Stage indicated the Resident had one Stage 2 pressure ulcer with zero of these Stage 2 pressure ulcers that were present upon admission/reentry, one Stage 4 pressure ulcer that was present upon admission/reentry and one unstageable that was not present upon admission/reentry. The MDS indicated the Resident had 2 pressure ulcers, one Stage 2 and one unstageable facility acquired pressure ulcer. Right Heel Wound: A review of Resident #500's wound measurements/assessment from wound evaluation documentation in the medical record included the following for the Right heel wound: -Evaluated on [DATE], Pressure-Deep Tissue Injury, located on the right heel, new wound, acquired: In-House Acquired, Area 4.83 cm2 (centimeters squared), Length 2.78 cm (centimeters), Width 4.04 cm, Exudate: none, Pain: none, Goal of Care: Healable. -Evaluated on [DATE], Pressure-Deep Tissue Injury, right heel, 7 days old, Exudate: light, serous, Pain: 5 at dressing. The Wound Evaluation lacked measurements. The Resident was transferred to the hospital on [DATE]. Progress note dated [DATE] at 6:05 PM, Resident was lethargic, cool, clammy, pale .slow to respond, cognition seemed impaired. ,d+[DATE], 97.4, 64, 14, BS (blood sugar) 91. Per report, resident has not eaten, (Doctor's Name) notified, order obtained to send pt (patient) out for eval . The Resident Returned to the facility on [DATE]. Upon return from the hospital, Resident #500's Right Heel Wound Evaluation documentation revealed the following: -Dated [DATE], Pressure-medical device related pressure injury-Deep Tissue Injury, present on admission, Area 11.38 cm2, Length 4.7 cm, Width 3.56 cm, Pain: none, Exudate: none. -Dated [DATE], Pressure-medical device related pressure injury-deep tissue injury, Area 1.99 cm2, Length 2.04 cm, Width 1.43 cm, Exudate: light, seropurulent, Pain: 4 at dressing. The measurement did not encompass the blackened heel area as did the measurement on [DATE], but the smaller opened area. The measurement on [DATE] did not include the wound on the side of the heel area. -Dated [DATE], there was no wound evaluation or measurements taken seven days after [DATE]. The Resident was sent out to the hospital on [DATE]. A review of Resident #500's progress notes revealed: -Dated [DATE] at 7:59 AM, Writer observed during dressing change blood tinge sputum coming from mouth. Resident was alert to self and responding appropriately to self yelling out in pain. Resident was medicated to help relieve pain during wound dressing. Writer noted that resident was pocketing medication. Notified doctor of concerns, ordered Stat CBC (complete blood count) and BMP (basic metabolic panel). -Dated [DATE] at 8:02 AM, Upon further assessment unable to obtain BP, Resident looks more lethargic. Doctor notified and ordered resident to be sent out. Left Heel Wound: A review of Resident #500's wound measurements/assessment, from wound evaluation documentation in the medical record, included the following for the Left heel wound: -Dated [DATE], Left Heel, New-8 hours old, Acquired: In-House, Area 3.91 cm2, Length 2.45 cm, Width 2.19 cm, Type: Blister, Exudate: none, Pain: 5 at dressing. The Resident was transferred to the hospital on [DATE]. Upon return to the facility on [DATE], the Left Heel wound evaluation included the following: -Dated [DATE], Pressure-Medical Device Related Pressure Injury-Deep Tissue Injury, Acquired: present on admission, Area 2.57 cm2, Length 2.25 cm, Width 1.49 cm. There was no documentation of the wound bed, exudate, periwound, pain, treatment, orders or progress of the wound. The wound was open, but the measurements did not provide a depth to the wound. -Dated [DATE], Pressure-Deep Tissue Injury, Area 3.48 cm2, Length 1.9 cm, Width 2.43, Wound Bed: Epithelial: yes, % Epithelial: 100%, Pain: 0. -Dated [DATE], there was no wound evaluation or measurements taken seven days after [DATE]. The Resident was sent out to the hospital on [DATE]. Sacral Wound: A review of Resident #500's wound measurements/assessment from wound evaluation documentation in the medical record included the following for the sacrum wound: -Dated [DATE], Pressure-Unstageable [Slough and/or eschar], Body Location: Sacrum, Acquired: present on admission, Area 118.62 cm2, Length 10.14 cm, Width 14.52 cm, Deepest Point: 4 cm, Max Undermining: 0.5 cm, Undermining: 0.5 cm from 2 to 5 o'clock, 0.3 cm from 6 to 10 o'clock, Longest Tunnel: 4 cm, Tunneling 4.0 cm at 10 o'clock, Wound Bed: Slough-yes, % slough 80%, Eschar-yes, % of Eschar 50%, Exudate: heavy, seropurulent and strong odor, Pain: 10, continuous. -Dated [DATE], Pressure-Stage 4, Sacrum, Area 100.18 cm2, Length 10.67 cm, Width 13.37 cm, Deepest Point 10 cm. Undermining and Tunneling had no data documented. -Dated [DATE], Pressure-Stage 4, Sacrum, Area 92.88 cm2, Length 12.54 cm, Width 13.71 cm, deepest point 6 cm. Undermining and tunneling had no data documented. -Dated [DATE], Pressure-Stage 4 Sacrum, Area 95.7 cm2, Length 9.6 cm, Width 13.65 cm, Deepest point 5 cm. Undermining and tunneling had no data documented. -Dated [DATE], Pressure-Stage 4 Sacrum, Area 109.86 cm2, Length 14.27 cm, Width 10.4 cm, Deepest Point 7 cm, Max Undermining 4 cm, Undermining 4.0 cm from 11 to 3 o'clock. -Dated [DATE], Pressure-Stage 4 Sacrum, Area 22.15 cm2, Length 5.85 cm, Width 5.32 cm. The deepest Point and undermining were not documented. The full wound bed was not exposed in the picture. -Dated [DATE], there was no wound evaluation or measurements taken seven days after [DATE]. The Resident was sent out to the hospital on [DATE]. A review of Resident #500's hospital records titled Discharge Summary, with an admitted [DATE] included the following regarding the sacral decubitus pressure ulcer, .wound culture obtained grew enterococcus, proteus, diphtheroids and candida .; bilateral heel pressure wounds: full thickness/stage 3 left heel and stage 1 right heel .; .Nonocclusive thrombus left common femoral vein .; .Sepsis with bacteremia ,d+[DATE]: BC (blood culture) x2: staph .; and .Worsening anemia, hgb 6.4 therefore one unit PRBC (blood transfusion) ordered . A review of Resident #500's hospital records dated [DATE], included the following: -History of Present Illness: .She was brought to the ED (emergency department) on ,d+[DATE] after she was found unresponsive. Per report patient has become unresponsive the day before with no improvement. She was found to be hypothermic, hypoglycemic with glucose of 27, Hypotensive. She was given D50 and IV fluids and started on Norepinephrine due to persistent hypotension. Foley catheter was changed in ED. Lab work showed Hgb (hemoglobin) 6.4 (low), WBC (white blood cell count)12.8 (high), K (potassium) 4.8, CO2 (carbon dioxide) of 8 (low) and BUN (blood urea nitrogen) of 97 (high), Cr (creatinine) 3.0 (high), lactic acid of 10.8 (critical high) . Principal Problem: Septic shock . Patient continues to be critically ill and remains at risk for clinical deterioration or death . -Wound Care progress notes, dated [DATE] at 3:40 PM, revealed, .Patient admitted for : Septic shock . Assessment: Posterior aspect assessed, patient with large stage 4 sacral wound. Moderate-large amount necrotic tissue to wound. Bone exposed. Foul odor noted. Wound deteriorating compared to photos from recent admission. Erosion to peri-wound skin likely from incontinent bowel movements . Review of Resident #500's admission documentation on [DATE], revealed, an admission assessment with skin integrity comments of All bony prominence's assess, and no issues present other than slightly red blanchable right outer heel and large buttock wound. Large approximately [DATE] moist pink wound bed, no odor. On [DATE] at 10:45 AM, an interview was conducted with the Director of Nursing (DON) and Administrator (NHA) regarding Resident #500's wound care and development of pressure ulcers to the heels. The DON indicated the Resident had admitted into the facility with a large sacral wound and the right outer heel was reddened but blanchable. When asked about measurements of the right outer heel, the DON indicated if it was blanchable, it was not considered a pressure injury and it was not measured. When asked about the origination of the Rt heel pressure wound, the DON and NHA reviewed the medical record, and the DON indicated the first picture of the right heel was on [DATE]. The DON indicated the wound to the right heel had opened on ,d+[DATE]. When asked about changing the staging to a Stage 2, the DON stated, No we kept it as a DTI (deep tissue injury). When asked why it was not staged as a Stage 2 once it opened, the DON indicated that it had opened in a little area and it was still a deep tissue, and indicated it will all open. When asked about the left heel origination of the wound, the DON indicated the Resident had a pressure wound that was a blister on the left heel that was still intact prior to being transferred to the hospital on [DATE]. The DON indicated the first picture and assessment of the left heel wound was on [DATE]. On [DATE] at 12:58 PM, an interview was conducted with Confidential Person (CP) B regarding the care provided to Resident #500. The CP reported that the Resident had multiple strokes, was declining, could not stay home any longer and was admitted into the facility in Fall of 2023. The CP indicated the Resident's wounds were not taken care of, the sacral wound had worsened and stated, The Nurse at (hospital name for admission on [DATE]) said it was so big you could put a fist in it, and reported the bone was not exposed before and after hospital admission on ,d+[DATE], the wound had gotten infected and was bigger with exposed bone. The CP reported a failure of cleaning and changing the dressing with feces left in the wound, decline in health, and kidney failure. The CP reported the Resident went back to the hospital on February 8th with wound infection, kidney failure, dehydration, sepsis and died on [DATE]th with the death certificate indicating cardiac arrest, metabolic encephalopathy and septicemia. On [DATE] at 2:26 PM, an interview was conducted with the DON regarding assessment and pictures of wounds for Resident #500. A review of the pictures dated [DATE] of Resident #500's sacral wound compared to the picture dated [DATE] was conducted with the DON. An observation was made of the picture on ,d+[DATE] with more depth to the wound as the picture taken on ,d+[DATE] and the lack of measuring the entirety of the wound bed. When asked about this, the DON indicated the measurement should include the depth and stated, Yes, they should be doing the depth every time, for assessment of the wound and include the full wound bed in the measurements. One of the sacral wound pictures included a wound on the upper thigh/buttock area that was separated by intact skin and was included in the measurements of the sacral wound. When reviewed with the DON, the DON indicated that should have been addressed as a separate wound and not included in the sacral wound measurements. A review of Resident #500's right heel wound pictures revealed on [DATE] the picture where measurements were taken did not encompass the entirety of the wound and on [DATE] the area that was measured was the small open area and not the entirety of the blackened area that encompassed the heel. The DON was asked about the accuracy of the wound measurements with the measurements taken of the small open area. The measurements indicated the wound had gotten smaller, but the measurements were of a small portion of the wound covering the heel with failure to properly assess the wound for worsening. The DON stated, They should encompass the entire wound not just that part (opened area of the right heel). On [DATE] at 2:39 PM, an interview was conducted with Nurse C regarding the assessment/pictures of Resident #500's wounds. When asked about the accuracy of the measurements of the wounds with the camera designed to assess the measurements, the Nurse indicated that she had been in the process of learning with another Nurse who had been absent on [DATE] when doing the wound assessments/pictures. When asked about frequency of wound assessments, the Nurse stated, We do evaluate the wounds every 7 days. When asked why Resident #500's wounds were not assessed 7 days after the assessment completed on [DATE], the Nurse reported being sick and not in the facility to do the wound assessments. The Nurse reported that there will be two of us that will be doing the wounds now, we have hired some staff. On [DATE] at 2:50 PM, the DON was asked about coverage of Nurse C when not available for wound assessments. The Nurse had been out sick when the wound measurements were due on [DATE] and then the Resident had been transferred out to the hospital on [DATE]. The DON indicated that she went around the first day and took (wound) measurements and I was going to take the measurements the next day to do the rest on the list, and reported that Resident #500 did not have her wound assessed prior to transfer to the hospital. The DON indicated that now there was a plan in place for people to cover for each person off. A review of facility policy titled, Wound Management Program, revised [DATE], revealed, .Policy: To assure that residents who are admitted with, or acquire, wounds receive treatment and services to promote healing, prevent complications and prevent new skin conditions from developing . Process .: .4. Complete the following documentation weekly, as applicable to type of wound/skin condition: Weekly Pressure Ulcer Wound Documentation and picture in wound rounds. Weekly Non-Pressure Wound Documentation and picture in wound rounds. Print off weekly documentation from wound rounds and scan it into PCC . The facility was utilizing a camera for measurements and Wound Evaluation documentation that was not addressed in the facility policy to provide directive to staff in obtaining accurate measurements of wounds.

Based on interview, record review, the facility failed to ensure quality of care for nursing assessment for two residents (Resident #17, Resident #62), resulting in infections for Resident's #17 peritoneal catheter site and Resident #62 being sent to the hospital for septic shock requiring antibiotic therapy and prolonged illness. Findings include: Record review of the facility provided 'Assessment, Nursing, Policy Number: NRS-114 and dated 07/01/2008, revealed that the purpose of the policy was to ensure adequate assessment of resident care needs in order to develop and comprehensive plan of care. Assuring the goals are directed at attaining the highest practical level of wellness based on residents' choices. Record review of the facility-provided 'Dialysis: Peritoneal', Policy Number: NRS-148 and dated 07/01/2008 revealed safe and accurate therapy to osmotically remove fluids Procedure: (#19.) Inspect the catheter site. If dressing is reapplied, apply clear transparent occlusive dressing. (#22.) Documentation in the clinical record: (c.) Temperature and status of the catheter sire. (e.) Condition of catheter dressing or if new dressing applied. Record review of the facility-provided 'Activities of Daily Living (ADL)', Policy Number NRS-102 and dated 07/01/2008, revealed that the purpose was to assist residents as needed in achieving maximum functional ability with dignity and self-esteem to improve quality of life. Resident #17: Record review of Resident #17's quarterly Minimum Data Set (MDS), dated [DATE] revealed an elderly male with cognitive skills for daily decision-making skills as severely impaired. Record review of Resident #17's medical diagnosis list included dementia, schizophrenia, bipolar depression, end stage renal disease and anxiety. Record review of Resident #17's electronic profile noted admitted was 5/18/2023. An interview on 10/17/23 at 02:15 PM with Resident #17's family members at bedside identified that the resident had a peritoneal dialysis catheter/tube in his abdomen since admission and has not used the peritoneal dialysis catheter for the 7 months the resident has resided in the facility. Observation on 10/17/23 at 02:16 PM of Resident #17's peritoneal catheter/tube to the abdomen showed that it was red and appeared inflamed at the opening site. Resident #17 stated that it hurts, when his family member touched the area. the state surveyor observed no split gauze dressing to the area, the family member stated the site was warm to the touch who touched the area. In an observation and interview on 10/17/23 at 02:20 PM, Registered Nurse (RN)/Infection Control Preventionist (ICP) A stated that she was not aware that the resident had a peritoneal catheter in place to his abdomen. Observation by RN/ICP A of Resident #17's abdomen peritoneal catheter/tube site revealed redness and painful to touch noted by facial expression. RN/ICP stated that the site did look infected and would follow-up with the physician. Record review on 10/17/23 at 2:27 PM of Resident #17's Care Plans, pages 1 through 24, revealed on page 21 a care plan, dated 05/19/2023, for Renal insufficiency related to end-stage renal disease. Interventions included: 05/19/2023; Notify physician if signs and symptoms of fluid imbalance such as neck vein distention, difficulty in breathing, increased heart rate, edema, elevated blood pressure, or adventitious breath sounds. 5/19/2023; Observe for adverse medication effects to decreased renal clearance. There were no interventions or care plan related to skin for peritoneal catheter site monitoring. An interview on 10/18/23 at 11:35 AM with Registered Nurse (RN)/Infection Control Preventionist (ICP) A revealed that Resident #17 was placed on Keflex (antibiotic) for the perineal catheter site that was infected. RN/ICP A stated that Resident #17 has been at the facility for 6 months with no care to the area. The facility made an appointment for a nephrology consultation, as well as an antibiotic for 7 days. In an interview and record review on 10/19/23 at 08:21 AM, the Director of Nursing (DON) revealed that a record review of the skin care plan did not mention a peritoneal catheter or to monitor the site for infection, cleaning, or dislodgement. Resident #62: Record review of Resident #62's admission Minimum Data Set (MDS), dated [DATE], revealed an elderly male with Brief Interview of Mental Status (BINS) 8 out of 15, cognitive impairment. Record review of Resident #62's medical diagnosis list included dementia, renal insufficiency, obstructive uropathy, septicemia, urinary tract infection, diabetes. Record review of Resident #17's progress note revealed an admitted [DATE]. Interview and observation on 10/17/23 at 09:31 AM of Resident #62's showed bladder scan results of 1343 ml dated 10/17/2023 at 8:23 AM in room with no attendant present. Resident #62 stated that they just scanned his bladder. Resident #62 stated that his bladder felt full, he did not feel well, and also he could not eat his breakfast because his stomach felt different. In an interview on 10/17/23 at 09:52 AM, Licensed Practical Nurse (LPN) K revealed the resident was going out to hospital because he has a milky yellow discharge from the penis area. He is uncircumcised. LPN K revealed that she did a bladder scan of 1343 ml, he had a change of condition from yesterday by registered Nurse (RN) C, so LPN K stated that she was sending Resident #62 out. Mobile Medical Response went into the room to get the resident. LPN K gave a report of Resident #62 having tenting skin and appearing dehydrated. An interview on 10/17/23 at 09:55 AM with Licensed Practical Nurse (LPN) K about Resident #62 revealed going out to hospital he has not had any urine output in 12-24 hours. LPN K revealed that she did straight catheter of Resident #62 with no output this morning and needs to go out to hospital. In an interview on 10/19/23 at 09:46 AM with Physical Therapy Assistant (PTA) J revealed that Resident #62 had needed more assistance during therapy (two people) whereas he had been a one- person assist. PTA J revealed that she reported to the Director of Nursing (DON) a change with increased assistance with transfers/bed mobility. It was a significant decline from previous levels. The change was reported around 10:00 AM in the morning. PTA J brought the progress note from that day for the State Surveyor. In the therapy notes for Friday for the prior week, Resident #62 refused to ambulate because he was feeling weak. Record review of Resident #62's 'Physical Therapy Treatment Encounter Notes', dated 10/11/2023, at 2:33 PM revealed that Resident #62 required frequent voice cues to stay on complete treatment session. Resident #62 was noted to refuse gait training today with complaint of fell ing weak. Physical therapy notes on 10/16/2023 at 9:43 AM revealed that Resident #62 required lying to sitting at the edge of bed with maximum assist. Static sitting balance at edge of bed with moderate assist, stand/pivot transfer bed to wheelchair with maximum assist with voice cues needed for upright posture. An interview on 10/19/23 at 09:11 AM with the Director of Nursing (DON) revealed that for Resident #62 was admitted with Urinary Tract Infection, sepsis, and diabetes. Record review of the care plans addressed: Infection related to sepsis; urinary tract infection dated 9/22/2023. Interventions included: Antibiotic as ordered, Labs/diagnostics as ordered, monitor for sign & symptoms of adverse drug reaction each shift, Report to physician any adverse effects or non-resolving symptoms such as fever, nausea, vomiting, acute change of mental status, vital signs outside of normal parameter of resident. Renal Insufficiency related to Acute Kidney Injury care plan interventions included: Notify physician if signs and symptoms of fluid imbalance such as neck vein distention, difficulty breathing, increased heart rate, elevated blood pressure, or adventitious breath sounds. There were no interventions to monitor output of urine with insufficiency diagnosis. Surveyor requested peri-care staff education/in-servicing for the last 10 months. Quality of care policy requested, diabetic monitoring policy requested, nursing assessment policy and documentation policy. Record review on 10/18/2023 of Resident #62's 'Change of Condition' form, dated 10/16/2023 at 5:38 PM, noted a functional decline, that started in the morning, additional pertinent diagnosis included dementia and diabetes. Blood pressure 105/66, pulse 76, respirations 17, temperature 97.7 degrees, pulse oxygen level 97% on room air blood sugar was 122, was taken on 10/16/2023 at 10:10 AM, there were no other vital signs taken for the day. Record review of Resident #62's nursing progress notes revealed that there was no change of condition progress note found. An interview and record review on 10/18/23 at 12:49 PM with Registered Nurse (RN) C revealed that Resident #62 on Monday (10/16/2023) therapy came out and said that he was really weak, and not acting like himself. RN C revealed that he did a 'Change of Condition' form on 10/16/2023 and ordered a UA and gave report to night shift nurse. Record review of progress notes revealed there was no note for change of condition. RN C stated that he would put a late entry since the state surveyor did not find a progress note today (10/18/2023). A record review of Resident #62's Hospital record, dated 10/18/2023 at 10:38 AM, revealed that the resident was treated for: (1.) Urinary Tract Infection. (2.) Septic shock. (3.) Hyperglycemia. (4.) Metabolic Acidosis.

This Citation pertains to Intake Numbers MI 426 and MI 587. Based on interview and record review the facility is placed in Immediate Jeopardy for its 1) Failure to transfer one resident (Resident #1) to the hospital for emergency medical treatment after the resident called 911 twice asking for help and assistance and its 2) Failure to provide adequate assessment and monitoring for Resident #1, of four residents reviewed for abuse and neglect. On [DATE] Resident #1, who was cognitively intact and her own responsible party, returned to the facility from [CONDITION(S)] at approximately 4:30 PM and did not receive her medication in a timely manner. Resident #1 called 911 around 9:00 PM with complaints of not feeling well and not receiving her medication and care. The 911 Center called the facility and spoke to Resident #1's nurse, RN A, who told 911 that Resident #1 was not in distress and that she had taken vital signs. After the call Resident #1 told RN A that she thought she was dying and requested to be sent to the hospital, because she did not think that she would make it through the night. At approximately 10:00 PM, Resident #1 called 911 again for help and assistance and stated that she needed to go to the hospital. The 911 Center again talked to RN A and was told by RN A that she had given Resident #1 anti-nausea medication. At 10:10 PM, the resident was yelling out for assistance and was found by two Certified Nursing Assistants (CNA) to have vomited . Resident #1 was breathing but became unresponsive. RN A did not respond to the CNA's request for help. Two other nurses responded to the CNA's request for assistance. Resident #1 suffered [CONDITION(S)] and Cardio-Pulmonary Resuscitation (CPR) was initiated. CPR was unsuccessful and the resident died at the facility on [DATE] at 11:17 PM. This Immediate Jeopardy places 55 residents residing at the facility at risk for comprehensive monitoring and assessment to identify changes in condition and assist with residents' request to seek further hospitalization and/or treatment due to residents' perceived assessment of their health status which placed all residents at risk for serious harm, injury and/or death. Immediate Jeopardy: The Immediate Jeopardy began on [DATE]. The Immediate Jeopardy was identified on [DATE]. The Administrator was notified in writing of the Immediate Jeopardy on [DATE] at 3:58 PM and a plan to remove the immediacy was requested. The Immediate Jeopardy was abated or removed on [DATE]. Findings include: A review of facility policy titled, Abuse, Neglect and/or Misappropriation of Resident Funds or Property, revision on [DATE] revealed, (Facility Company Name) will not tolerate verbal, sexual, physical or mental abuse, involuntary seclusion and/or neglect of its residents or misappropriation of resident's funds or property by anyone . Definitions . vi Neglect means intentional or reckless failure to provide a resident with any treatment, care goods or service necessary to maintain the health or safety of the resident when the failure results in serious physical harm to the resident . Resident #1: A review of Resident #1's medical record revealed a [AGE] year-old female with an admission into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of ,d+[DATE] that indicated intact cognition and the Resident required limited assistance of one-person physical assist with bed mobility, transfer, walking in room, and dressing, independent with setup help with eating and extensive assistance of one-person physical assist with toilet use. A review of the Admission Record revealed the Resident was her own responsible party. An investigation report was provided by the facility regarding neglect of Resident #1 on [DATE]. The investigation included the following: -Resident Assistance Form that revealed: Information about person requesting assistance: (Resident #1's family member) . What is your complaint about? . Why (Resident #1's name) was not sent to the hospital when she requested to go? When did the problem or incident occur? Friday [DATE]th . Time: 9 PM . How can we address your issues? When Resident requests to go to the hospital honor their request . -Incident: On [DATE] the family of (Resident #1) requested a meeting with the Executive Director and Director of Nursing. They verbalized concern that the resident had called 911 and she was not sent out per her request. Based on staff response she was not transported and this resulted in a delay in treatment. -Assess the Resident: Resident was originally admitted to the facility on [DATE] following 2 acute care admissions. Per H&P (history and physical) resident had been discharged from the hospital on [DATE] following a PE (pulmonary embolism) and returned again on [DATE] stating she was extremely weak, short of breath had nausea and diarrhea and didn't feel well. She was admitted for [CONDITION(S)], treated and then admitted to (facility name) on [DATE] . On ,d+[DATE] prior to [CONDITION(S)] the resident was scheduled for a fistulagram and returned following [CONDITION(S)] to the facility without difficulty . Due to resident nausea and diarrhea a rapid Covid swab, flu swab and PCR were completed. Both the rapid and flu swab were negative and the PCR was sent out to the lab. The resident had been placed in a private room in TBP (transmission-based precautions) and she indicated to her family the room was too hot. AC was provided and resident is noted as resting comfortably. Per record review at approximately 9PM the resident called 911, the RN spoke with 911 dispatch and notified them of her vitals and her 9pm medication were provided. She had also contacted a family member regarding her medications. At approximately 10pm resident again called 911 related to her nausea and an antiemetic was provided. At approximately 10:,d+[DATE]:15 (PM) the staff noted resident hollering out as she had vomited. They arrived at bedside and then she was unresponsive. The nurse was contacting 911 and 2 other nurses arrived at bedside with crash cart. At the time of arrival, the resident was experiencing agonal breathing and still had an apical pulse but it was weak and faint. The nurse applied the AED and it advised CPR to be started. CPR was initiated and continued until EMS arrived approximately 22:,d+[DATE]:30 (10:,d+[DATE]:30 PM) . -Interview: Nurse, RN A, statement: (RN A) states that about 7pm resident reported not feeling well. (RN A) took vital signs and gave hs (nighttime) medications around 9pm, BP (blood pressure) ,d+[DATE]. Around 9pm (Resident #1's family member) called stating that she was upset because no one was doing anything and she was not feeling well. Around this same time 911 called the facility stating that (Resident #1) called 911 stating she was not feeling well. (RN A) states she told 911 that she took her VS (vital signs), gave them her nursing assessment and encouraged her to drink water to help bring up her diastolic blood pressure and that she was in no distress at that time. (RN A) states she went to room several times and (Resident #1) said she did not like her room, it felt hot and she felt nauseous so (RN A) turned up the AC (air-conditioning). (Resident #1) stated she thought she was dying and requested to be sent to hospital because she did not think she would make it through the night. (RN A) states she gave [MEDICATION(S)] (anti-emetic medication) and [MEDICATION(S)] (antihypertensive medication) and told (Resident #1) that she would check on her every hour and for her to rest to let medication work. Around 10pm 911 call the facility again stating that (Resident #1) was not feeling well requesting to be sent to the hospital. (RN A) informed them that she had given [MEDICATION(S)] and [MEDICATION(S)] and again there were no signs of distress. Approximately 10 minutes later CNA's reported to (RN A) that (Resident #1) had vomited and (RN A) says at that time she called 911 for transfer out as her symptoms had progressed. The other two nurses from the back went into (Resident #1's) room and started the code. The interview revealed the following: Verbal Interview with DON (Director of Nursing)/RCD (Regional Clinical Director) via telephone [DATE], and signed by the DON and RCD. -Interview: Nurse LPN B statement: About 930 (9:30 PM) received call from (Resident #1's family member), he said she has not gotten her medication and needs meds for bp. I transferred call to (RN A). At that time, I did go to room [ROOM NUMBER] (Resident #1's room). She was lying in her bed and stated nurse gave my meds and now bp is low. (Resident #1) did appear to be anxious/nervous about medication, however there were no signed of distress. I notified (RN A) she that she says bp is low and offered to take it manually, (RN A) said no I got it. At 945 (9:45 PM) 911 called says 204 is on phone and needs help, needs bp meds and water and she is thinks needs to go to ER. Call transferred to (RN A). At 1015 (10:15 PM) CNA's came to back nurse station and said 204 is unresponsive and we help up here. Me and (LPN C) went up room, (RN A) was sitting at the desk. I went to room [ROOM NUMBER] noted agonal breathes, with eyes open. Apical heart sound heard but were irregular and weak. I then yelled for someone to get crash cart, call 911 and for someone go to door front door and wait to let first responder in. Crash cart arrived, AED applied and back board put under resident. AED indicated to start CPR. I continued to follow AED directions/CPR until first responders arrived about 10:30pm and took over the code. The statement was not signed or dated. -Interview: Nurse, LPN C statement: 1010 PM was receiving report from (LPN B). Three CNA's from the front of the building came up stating they needed help in room [ROOM NUMBER] as she was in distress. They said they thought she was unresponsive. So, I ran up front with (LPN B). (LPN B) went to room [ROOM NUMBER]. I went to (RN A) and asked for her glucometer, she gave me her keys to get the glucometer from her medication cart. Two of the CAN's (CNAs) came and got crash cart. While this was happening, (RN A) was trying to dial 911 but was having problems getting the call to go through. I dialed 911 from my cell phone and handed it to her. Then I took glucometer with me and went to room [ROOM NUMBER] where (LPN B) had started CPR and I stared taking notes and obtained a blood sugar of 359. Continued with code until MMR (ambulance)/first responders arrived at 1027 PM and took over the code. The statement was not dated or signed. -Interview: CNA E statement: Around 1010 (10:10 PM) me and (CNA I) were sitting by sink and heard yelling out from hall 2. There were two lights going off (CNA I) went to room [ROOM NUMBER] and I went to 204. I noticed she had vomited. I stayed with her and then (CNA I) came in and obtained pulse of 72 and Spo2 98%. She was not responding to me calling her name or my touch. I could see she was breathing and her eyes were wide open. (CNA I) then went and told (RN A) her nurse she had vomited and something is not right. (RN A) told (CNA I) it was from [CONDITION(S)] and that she had just given her medications. (CNA I) then when to the back two nurses (LPN B and LPN C) who came up to room [ROOM NUMBER]. Crash cart was brought in by (CNA D) and (LPN B) started chest compressions. (CNA I) held facemask with oxygen hooked up to resident's face. (LPN B) was telling me to take notes with what to write and the times. I then went and opened the front door for first responders. First responders arrived about 1030 and (RN A) come into room at that time. The statement was not dated or signed. -Interview: CNA F statement: Around 9pm (9:00 PM) I answered the phone and it was 911 stating the (Resident #1) called 911 and was requesting assistance. I gave the phone to (Nurse B), who took the call but then transferred it up to (Nurse A) her nurse. As I was walking up front I heard (Nurse A) telling (Nurse B) that (Resident #1) is fine and that she had just given her medications. A little while later I over heard 2 CNA's in her room calling her name as I went into the room to see if I could help one of the CNA's grabbed me and we went to the back of the building and notified the two other nurses that (Resident #1) needed help. The statement was not dated or signed. A review of Resident #1's medical record revealed the following Progress notes: -Dated [DATE] at 8:15 AM, Nurses Note: Resident left for [CONDITION(S)] via (name) transportation, [CONDITION(S)] communication paper was sent along with the resident, resident requested not to have any medications nor breakfast due to it will make her nauseated. Author LPN J. -Dated [DATE] at 5:03 PM, Nurses Note: Rapid COVID test completed with negative results. PCR collected. Rapid influenza completed with negative results. [CONDITION(S)] center updated. Author DON. -Dated [DATE] at 7:30 PM, Nurses Note: . Spoke with residents brother regarding resident stating she does not like the new room. Instructed that the rapid test was negative. Resident has all belongings in her room. Resident states its hot and that her fan runs on batteries that are dead. Air conditioner in her room turned on fan at high. Resident resting in bed with eyes closed. Author RN A. -Dated [DATE] at 9:00 PM, Nurses Note: .Spoke with resident brother about resident stating she has not had her BP medications. Instructed I was going in her room to give them. Resident called 911 I instructed them her vital signs were normal at ,d+[DATE] 78 97% 16 at this time after she had [CONDITION(S)] this afternoon and was in no distress, breathing unlabored. Resident stated she wanted her meds. Instructed to drink some water to help bring diastolic bp up. Resident voiced okay. Instructed resident I would check on her every hour. She verbalized understanding. Author RN A. -Dated [DATE] at 10:00 PM, Nurses Note: .Resident called 911 and stated she was nauseous. I instructed she has not vomited and I was administering a Zoran and [MEDICATION(S)]. Resident took medication and drank some ice water. Cup of ice water put on night stand where resident wanted it. She was resting laying down. Resident and nurse had a conversation about how she was feeling. Nurse instructed resident to rest and let the medication work and nurse would be back to check on her hourly. Author RN A. -Dated [DATE] at 10:10 PM, Nurses Note: .When CNA walked past resident door noted resident had vomited. Nurse calling 911 trying to contact son (name) and the DON. Staff in residents room stated she was unresponsive and CPR started at 22:15. 2220 (10:20 PM) no shock advised continue CPR BS (blood sugar) 329 c 2227 (10:27 PM) no shock advised continue CPR. 2230 (10:30 PM) Police and EMTs arrive and continue CPR. Suction used 2235 (10:35 PM) IV (intravenous) started epi ([MEDICATION(S)]) given automatic compressions started 2240 endotracheal tube inserted with oxygen for bagging 2245 (10:45 PM) calcium and epi BS HI (high) no carotid pulse 2247 (10:47 PM) suction 2250 (10:50 PM) asystole 2310 (23:10 PM) IV DC (discontinued) 2318 (11:18 PM) CPR stopped. Author RN A. A review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -Accucheck BID (twice a day) for DM (diabetes), scheduled at 5:00 PM, documented as not completed, Leave of Absence. -[MEDICATION(S)] Tablet 5 mg (milligrams). Give 1 tablet by mouth two times a day for PE (pulmonary embolism) Hx (history) for 30 days, scheduled ,d+[DATE] AM, not documented as given and ,d+[DATE] PM, documented as not given, leave of absence. ([MEDICATION(S)]-an anticoagulant medication used to treat and prevent blood clots) -[MEDICATION(S)] Tablet 25 mg. Give 1 tablet by mouth two times a day for cardiac, scheduled ,d+[DATE] pm, documented as not given, leave of absence. ([MEDICATION(S)]-[MEDICATION(S)]-a beta blocker that affects the heart and circulation used to treat heart failure and hypertension) -[MEDICATION(S)] HCl Tablet 100 mg. Give 1 tablet by mouth two times a day for cardiac, scheduled ,d+[DATE] AM, not documented as given on [DATE]; documented as given on [DATE] at 9:03 PM. ([MEDICATION(S)]-a vasodilator used to treat hypertension) -[MEDICATION(S)] ER (extended release) tablet Extended Release 24 hour 30 mg. Give 2 tablet by mouth two times a day for cardiac for 30 days, scheduled ,d+[DATE] AM, documented as not given; scheduled at 7:00 pm to (unable to determine), given on [DATE] at 9:03 PM. ([MEDICATION(S)]- a calcium channel blocker, used to treat hypertension and [CONDITION(S)]) -[MEDICATION(S)] HCl Tablet 25 mg. Give 12.5 mg by mouth every 8 hours as needed for itching, documented as given on [DATE] at 9:55 PM. ([MEDICATION(S)]-antihistamine used to relieve itching caused by allergic skin reactions and can be used as a sedative) -[MEDICATION(S)] HCl tablet 25 mg. Give 1 tablet by mouth every 8 hours as needed for dizziness, documented as given on [DATE] at 9:55 PM. ([MEDICATION(S)]-antihistamine, antiemetic, used to treat symptoms of motion sickness and [CONDITION(S)]/dizziness, prevent/treat nausea) -[MEDICATION(S)] Tablet 4 mg. Give 1 tablet by mouth every 6 hours as needed for nausea, documented as given at 9:55 PM. Further review of [MEDICATION(S)] given revealed, given three doses on [DATE] at 11:18 AM, 5:08 PM, and 11:53 PM; given on [DATE] at 9:57 PM, [DATE] at 3:26 PM, [DATE] at 3:20 AM, [DATE] at 12:55 AM, and [DATE] at 2:00 AM. ([MEDICATION(S)]-antiemetic to prevent nausea and vomiting) -[MEDICATION(S)] Tablet 10 mg. Five 1 tablet by mouth at bedtime for [CONDITION(S)] (hypertension), scheduled at 9:00 PM. Documented as given on [DATE] at 9:03 PM. ([MEDICATION(S)]-[MEDICATION(S)] Calcium-statin, used to lower LDL cholesterol and triglycerides) -[MEDICATION(S)] Tablet 100 mg. Give 1 tablet by mouth at bedtime for [CONDITION(S)], scheduled at 9:00 PM. Documented as given on [DATE] at 9:03 PM. (Losartan-[MEDICATION(S)] receptor antagonist, used to treat hypertension) Further review of Blood Pressure Summary document for Resident #1 revealed a range of random blood pressures obtained for Resident #1 that included the following: -[DATE] at 7:01 PM, BP ,d+[DATE]. -[DATE] at 9:51 AM, BP ,d+[DATE]. -[DATE] at 9:20 PM, BP ,d+[DATE]. -[DATE] at 8:54 AM, BP ,d+[DATE]. -[DATE] at 4:12 PM, BP ,d+[DATE]. -[DATE] at 1:06 PM, BP ,d+[DATE]. -[DATE] at 9:30 AM, BP ,d+[DATE]. -[DATE] at 8:10 PM, BP ,d+[DATE]. -[DATE] at 4:37 PM, BP ,d+[DATE]. -[DATE] at 5:00 PM, BP ,d+[DATE]. -[DATE] at 9:02 PM, BP ,d+[DATE]. The review of the history of blood pressures for Resident #1 from the Blood Pressure Summary revealed one of the high Blood pressures documented on [DATE] at 4:46 PM of ,d+[DATE], and one of the lowest blood pressures documented on [DATE] at 9:02 PM of ,d+[DATE]. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The blood pressure was neglected to be retaken to monitor the Residents blood pressure after the administration of medication at 9:03 PM on [DATE], the Resident became unresponsive at 10:10 PM on [DATE] and CPR was initiated at approximately 10:15 PM. On [DATE] at 10:02 AM, Central Dispatch, (Name of Township) Township Police was contacted regarding the 911 calls made by Resident #1, the phone conversation with Central Dispatch and Nurse A, and the 911 call made by the facility when the Resident was unresponsive on [DATE]. Central Dispatch Supervisor M indicated a FOIA (Freedom of Information Act) form would need to be submitted. The Freedom of Information Request Form was emailed to Central Dispatch. On [DATE] at 12:58 PM, an interview was conducted with CNA F regarding Resident #1 on [DATE]. The CNA's statement was reviewed. When queried why they had to go to the back of the building when getting assistance for Resident #1, the CNA reported that when they went to get help for the Resident, they had gone to Nurse A who was sitting at the Nurses station, told the Nurse something was wrong and she needed to go in there and the CNA stated, But she didn't go in so I went to two Nurses that I knew would check on the Resident. The CNA reported Nurse A was closer, but she did not go in to assess the Resident and then the CNA went to the other Nurses station to get the other Nurses (Nurse B and Nurse C) who ran up there and called for the crash cart and started CPR. On [DATE] at 1:11 PM, an interview was conducted with CNA E regarding Resident #1 on [DATE]. The CNA reported hearing Resident #1 yelling out, when they got to the room the Resident had vomited and it was all on her clothes and bedding, yellow in color. The CNA indicated the Resident was lying in bed on her side and did not respond when they turned her onto her back and stated, She was not responding to my touch. I was rubbing her hand. No response to noise. She had her phone in her hand. No one was on there. The CNA indicated the Nurse was told she had thrown up and was not responding and stated, She (the Nurse) didn't come in. The CNA stated, She (Nurse A) was sitting at the desk when the Resident was yelling out. Her room was right there, and reported when they went to check on the Resident yelling out, the CNA stated, The Nurse said nothing is wrong, that she just gave her nausea medicine and that it's from [CONDITION(S)]. On [DATE] at 1:48 PM, an interview was conducted with LPN B regarding Resident #1 on [DATE]. The Nurse reported getting a phone call from Resident #1's family member regarding the resident not receiving her medication after [CONDITION(S)] and reported she put the call to (RN A). The Nurse reported she was concerned after the family had called and went to Resident #1's room and stated, She was facing the door, lying in bed. She had [CONDITION(S)] and another appointment that day. (Resident #1) told me, 'I been asking for blood pressure meds, now my blood pressure is too low,' I told (RN A) what her concerns were and offered to take a manual blood pressure. She (RN A) said 'I got it.' You can't always count on the blood pressure machines, and indicated if the Resident was complaining of low blood pressure, then the nurse should be checking the blood pressure manually. The Nurse indicated that RN A sounded irritated and didn't want her to take the Resident's blood pressure. The Nurse reported that at approximately 9:45 PM, a call came from 911 regarding Resident #1. The Nurse reported the 911 dispatcher said the Resident doesn't feel right, she said she received her blood pressure meds, and it was now too low, got no water, wanted to go to ER and they wanted to speak to the Resident's nurse. The Nurse reported that she saw RN A coming down the hall and she went back to the unit where she put the call through. The Nurse reported that CNAs came down to the nurses' station, approximately 10:15 (pm), where she was giving report to another Nurse (LPN C), requesting immediate help due to Resident #1 not responding. They ran to the Resident's room to find her lying on her back in bed with her eyes wide open, gasping, agonal breathing, performed a sternal rub and stated, not one bit of response, told the CNAs to get a crash cart, checked heart rate that was extremely slow and irregular and had gasping breaths, proceeded to attach the AED and started CPR. When queried regarding the response of RN A, the Nurse reported they had passed her at or around the nurses station when her and Nurse C responded to the CNA's request for help with Resident #1 and reported that when they passed her at the Nurses Station, RN A said 'I don't need you to go in there,' and indicated RN A had not come to the Residents room to assess her assigned Resident or had assisted with the code, not until MMR (ambulance) was already in the room. On [DATE] at 2:29 PM, an interview was conducted with Nurse K who had been assigned care of Resident #1 while she was at the facility. When queried regarding Resident #1, the Nurse indicated the Resident occasionally had complaints of feeling queasy, had a picky appetite on [CONDITION(S)] days, and refused cardiac meds on [CONDITION(S)] days and stated, She had a routine. She was alert and oriented and had a regimen with her medication particularly on [CONDITION(S)] days. She knew what meds she needed. When asked if the Resident had called 911 prior to [DATE], the Nurse reported the Resident did not have a history of calling 911. The Nurse was asked if the Resident had called 911 and/or wanted to go to the hospital, the Nurse stated, I would send her out immediately, she was alert and oriented, 100% with it. Knowledgeable about her body, and reported the Resident was able to make decisions about her health and care. The Nurse stated, I would make every effort to get her out to the hospital ASAP (as soon as possible) . She knows her body, if she were to tell me she wasn't right, I would send her out. On [DATE] at 3:18 PM, an interview was conducted with RN A, who indicated she was assigned Resident #1's care on [DATE]. The Nurse indicated she had received a call from Resident #1's brother regarding the Resident upset about the room change and that she had not received her medications. The Nurse reported getting the meds ready and gave them about 9:00 PM, and reported the Resident was concerned because she had no water. When queried why the Resident did not have any water, the Nurse was unsure why and indicated they had moved her room that day and must not have brought her water over and stated, She was concerned, no meds and no water. She wasn't in any distress, and I had her meds and told her we could treat her at the nursing home for her complaints. The Nurse indicated that the Resident was concerned about her blood pressure because the diastolic number (lower number of blood pressure) was low and reported the Resident wanted to take her medication and she had encouraged her to drink water to bring the diastolic number up. The Nurse indicated the Resident had called 911 and she had talked to the dispatcher who said the Resident wanted to go to the hospital and told them she had taken vital signs, gave her water and would check on her every hour. The Nurse reported the Resident had called 911 again, around 10:00 PM, and said she was nauseated, the nurse talked to the dispatcher and gave [MEDICATION(S)] and other medication. When asked if she had monitored the Resident's blood sugar, the Nurse reported she was unaware the Resident was diabetic. When asked if she had rechecked the Bp on the Resident, the Nurse indicated she had not rechecked the Bp. When asked if she had listened to the Resident's heart, lungs or abdomen, the Nurse reported she had not listened with a stethoscope and stated, she had no signs or symptoms of anything. When queried if the Resident had called 911 to go to the hospital? RN A stated, yes, and if the Resident had called a second time to 911, the Nurse stated, Yes. When queried why she had not gone to the Resident's room when the CNA reported the Resident had vomited and that something was wrong with the Resident, the Nurse stated, They were already in the room, and indicated she had called the DON when the CNA had said she had vomited and then the other nurses came down the hall and Nurse C was going to check the Resident's glucose level and had given RN A her phone to reach 911. Nurse RN A indicated she had problems calling 911 on the nurses' station phone, tried multiple times but the call would not go through, and had used Nurse C's phone to get through to call 911. The Nurse indicated she had printed off a face sheet and medication list and stated, by the time I finished all that, EMS was coming, and I had let them in. The Nurse reported EMS had worked on reviving the Resident for about an hour and was pronounced by the doctor who was with the EMS team that was in the room. When asked why Resident #1 did not get her medication when she came back from [CONDITION(S)], RN A stated, When I looked back, I seen she refused her meds (before [CONDITION(S)]). After [CONDITION(S)], she should have gotten them, I don't know why she didn't get them, and indicated she thought the Nurse had gotten an admission. When asked if the information was passed on in report, the Nurse reported she was not made aware during report from the off going shift that the Resident had not had her medication. When asked why she turned down Nurse B taking a manual bp or assessed the Resident with complaints of low blood pressure, the Nurse reported she had taken a blood pressure when she gave the pills and it had not had time to start to take effect and reported she had not been informed of any Resident complaints. RN A stated, I learned a valuable lesson, the Medical Examiner told me if a patient says they want to go to the hospital they need to go to the hospital or if they think they are dying, they are telling the truth and to send them to the hospital. RN A was asked if Resident #1 was alert, oriented and could make decisions about her care and the Nurse stated, Yes. When queried if the Resident had the right to seek further treatment and transfer to the hospital, the Nurse stated, Yes, especially when she is alert and oriented. Blood pressure medication given to Resident #1 was verified with RN A, on [DATE] at 11:16 AM. The Nurse reported she had taken the blood pressure, given the medication to the Resident and told her what the blood pressure reading was as she was taking the pills. The Nurse reported the Resident was concerned about low blood pressure and encouraged her to drink water to bring up the diastolic blood pressure. The Nurse reported the Resident did not have water at the bedside and had provided some to the Resident. The Nurse reported not rechecking the Resident's blood pressure after she had given the medication. On [DATE] at 4:35 PM, an interview was conducted with the Director of Nursing regarding Resident #1's events on [DATE]. The investigation report and the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON reported the Resident had gone to an appointment prior to [CONDITION(S)] and had been picked up at approximately 9 AM. The DON reported the Resident came back around 4 or 4:30 pm after going to the appointment for the fistulagram and [CONDITION(S)]. The DON was asked if the Res was not feeling well, nauseated, was the blood sugar monitored? The DON reported no assessment was documented of the blood sugar until the code. The DON indicated that the Resident would have eaten dinner and that the blood sugar should have been monitored prior to eating. The DON was queried if the Physician had been notified of the medications not given. With review of the medical record, the DON indicated there was no documentation that the Physician had been notified. The DON reported that the Resident was her own responsibly party, was alert and oriented and would refuse her medication before [CONDITION(S)] and that having nausea was her baseline. On [DATE] at 10:14 AM, an interview was conducted with Nurse LPN C regarding Resident #1 on [DATE]. The Nurse reported they were alerted about 10:10 PM of Resident #1 unresponsive by the CNA that came from the other unit, herself and Nurse Bran to the unit, Nurse B went into the room, and I ran to get supplies and get the crash cart with the CNA. The Nurse continued and stated, The CNA took the crash cart into the room, and I went to get the blood glucose monitor, (Nurse A) had stated to (Nurse C) that 'she (Resident #1) wasn't dying' and indicated the Nurse was irritated and stated, She didn't want us up there. Nurse A was not getting through to 911 on the desk phone and Nurse C stated, so I dialed my p [TRUNCATED]

This Citation pertains to Intake Number MI 426. Based on interview and record review, the facility 1) Failed to ensure assessment, monitoring and notification to the physician in a timely manner for a resident experiencing a change in condition, and 2) Failed to monitor orthostatic blood pressures as ordered by the Physician, for one resident (Resident #1) of three residents reviewed for care needs, resulting in Resident #1 calling family and 911 expressing she was going to die, expressing low blood pressure, frustration, fear and a the lack of staff response. The facility failed to perform continued assessment and monitoring for a change in condition and the resident experienced deterioration and subsequent death. Findings include: Resident #1: A review of Resident #1's medical record revealed a [AGE] year-old female with an admission into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of ,d+[DATE] that indicated intact cognition and the Resident required limited assistance of one-person physical assist with bed mobility, transfer, walking in room, and dressing, independent with setup help with eating and extensive assistance of one-person physical assist with toilet use. A review of the Admission Record revealed the Resident was her own responsible party. Further review revealed the Resident was dependent of renal [CONDITION(S)] and went out of the facility for hemodialysis treatments. An investigation report was provided by the facility regarding neglect of Resident #1 on [DATE]. The investigation included the following: -Resident Assistance Form that revealed: Information about person requesting assistance: (Resident #1's family member) . What is your complaint about? . Why (Resident #1's name) was not sent to the hospital when she requested to go? When did the problem or incident occur? Friday [DATE]th . Time: 9 PM . How can we address your issues? When Resident requests to go to the hospital honor their request . -Incident: On [DATE] the family of (Resident #1) requested a meeting with the Executive Director and Director of Nursing (DON). They verbalized concern that the resident had called 911 and she was not sent out per her request. Based on staff response she was not transported and this resulted in a delay in treatment. -Assess the Resident: Resident was originally admitted to the facility on [DATE] following 2 acute care admissions. Per H&P (history and physical) resident had been discharged from the hospital on [DATE] following a PE (pulmonary embolism) and returned again on [DATE] stating she was extremely weak, short of breath had nausea and diarrhea and didn't feel well. She was admitted for [CONDITION(S)], treated and then admitted to (facility name) on [DATE] . On ,d+[DATE] prior to [CONDITION(S)] the resident was scheduled for a fistulagram and returned following [CONDITION(S)] to the facility without difficulty . Due to resident nausea and diarrhea a rapid Covid swab, flu swab and PCR (polymerase chain reaction- test used to detect Covid-19) were completed. Both the rapid and flu swab were negative and the PCR was sent out to the lab. The resident had been placed in a private room in TBP (transmission-based precautions) and she indicated to her family the room was too hot. AC was provided and resident is noted as resting comfortably. Per record review at approximately 9 pm medication were provided. She had also contacted a family member regarding her medications. At approximately 10 pm resident again called 911 related to her nausea and an antiemetic was provided. At approximately 10:,d+[DATE]:15 the staff noted resident hollering out as she had vomited. They arrived at bedside and then she was unresponsive. The nurse was contacting 911 and 2 other nurses arrived at bedside with crash cart. At the time of arrival, the resident was experiencing agonal breathing and still had an apical pulse but it was weak and faint. The nurse applied the AED and it advised CPR to be started. CPR was initiated and continued until EMS arrived approximately 22:,d+[DATE]:30 (10:27 PM-10:30 PM) . A review of Resident #1's medical record revealed the following Progress notes: -Dated [DATE] at 8:15 AM, Nurses Note: Resident left for [CONDITION(S)] via (name) transportation, [CONDITION(S)] communication paper was sent along with the resident, resident requested not to have any medications nor breakfast due to it will make her nauseated. Author LPN J. -Dated [DATE] at 5:03 PM, Nurses Note: Rapid COVID test completed with negative results. PCR collected. Rapid influenza completed with negative results. [CONDITION(S)] center updated. Author DON. There was a lack of documentation regarding an assessment of a change in signs and symptoms to indicate Covid-19 illness. -Dated [DATE] at 7:30 PM, Nurses Note: . Spoke with residents brother regarding resident stating she does not like the new room. Instructed that the rapid test was negative. Resident has all belongings in her room. Resident states its hot and that her fan runs on batteries that are dead. Air conditioner in her room turned on fan at high. Resident resting in bed with eyes closed. Author RN A. -Dated [DATE] at 9:00 PM, Nurses Note: .Spoke with resident brother about resident stating she has not had her BP (blood pressure) medications. Instructed I was going in her room to give them. Resident called 911 I instructed them her vital signs were normal at ,d+[DATE] 78 97% 16 at this time after she had [CONDITION(S)] this afternoon and was in no distress, breathing unlabored. Resident stated she wanted her meds. Instructed to drink some water to help bring diastolic bp up. Resident voiced okay. Instructed resident I would check on her every hour. She verbalized understanding. Author RN A. -Dated [DATE] at 10:00 PM, Nurses Note: .Resident called 911 and stated she was nauseous. I instructed she has not vomited and I was administering a [MEDICATION(S)] and [MEDICATION(S)]. Resident took medication and drank some ice water. Cup of ice water put on night stand where resident wanted it. She was resting laying down. Resident and nurse had a conversation about how she was feeling. Nurse instructed resident to rest and let the medication work and nurse would be back to check on her hourly. Author RN A. -Dated [DATE] at 10:10 PM, Nurses Note: .When CNA walked past resident door noted resident had vomited. Nurse calling 911 trying to contact son (name) and the DON. Staff in residents room stated she was unresponsive and CPR started at 22:15. 2220 (10:20 PM) no shock advised continue CPR BS (blood sugar) 329 c 2227 (10:27 PM) no shock advised continue CPR. 2230 (10:30 PM) Police and EMTs arrive and continue CPR. Suction used 2235 (10:35 PM) IV (intravenous) started epi ([MEDICATION(S)]) given automatic compressions started 2240 endotracheal tube inserted with oxygen for bagging 2245 (10:45 PM) calcium and epi BS HI (high) no carotid pulse 2247 (10:47 PM) suction 2250 (10:50 PM) asystole 2310 (23:10 PM) IV DC (discontinued) 2318 (11:18 PM) CPR stopped. Author RN A. A review of Resident #1's medication administration record (MAR) and the Medication Admin Audit Report revealed the following: -Accucheck BID (twice a day) for DM (diabetes), scheduled at 5:00 PM, documented as not completed, Leave of Absence. -[MEDICATION(S)] Tablet 5 mg (milligrams). Give 1 tablet by mouth two times a day for PE (pulmonary embolism) Hx (history) for 30 days, scheduled ,d+[DATE] AM, not documented as given and ,d+[DATE] PM, documented as not given, leave of absence. ([MEDICATION(S)]-an anticoagulant medication used to treat and prevent blood clots) -[MEDICATION(S)] Tablet 25 mg. Give 1 tablet by mouth two times a day for cardiac, scheduled ,d+[DATE] pm, documented as not given, leave of absence. ([MEDICATION(S)]-[MEDICATION(S)]-a beta blocker that affects the heart and circulation used to treat heart failure and hypertension) -[MEDICATION(S)] Tablet 100 mg. Give 1 tablet by mouth two times a day for cardiac, scheduled ,d+[DATE] AM, not documented as given on [DATE]; documented as given on [DATE] at 9:03 PM. ([MEDICATION(S)]-a vasodilator used to treat hypertension) -[MEDICATION(S)] ER (extended release) tablet Extended Release 24 hour 30 mg. Give 2 tablet by mouth two times a day for cardiac for 30 days, scheduled ,d+[DATE] AM, documented as not given; scheduled at 7:00 pm to (unable to determine), given on [DATE] at 9:03 PM. ([MEDICATION(S)]- a calcium channel blocker, used to treat hypertension and [CONDITION(S)]) -[MEDICATION(S)] HCl Tablet 25 mg. Give 12.5 mg by mouth every 8 hours as needed for itching, documented as given on [DATE] at 9:55 PM. ([MEDICATION(S)]-antihistamine used to relieve itching caused by allergic skin reactions and can be used as a sedative) -[MEDICATION(S)] HCl tablet 25 mg. Give 1 tablet by mouth every 8 hours as needed for dizziness, documented as given on [DATE] at 9:55 PM. ([MEDICATION(S)]-antihistamine, antiemetic, used to treat symptoms of motion sickness and [CONDITION(S)]/dizziness, prevent/treat nausea) -[MEDICATION(S)] Tablet 4 mg. Give 1 tablet by mouth every 6 hours as needed for nausea, documented as given at 9:55 PM. Further review of [MEDICATION(S)] given revealed, given three doses on [DATE] at 11:18 AM, 5:08 PM, and 11:53 PM; given on [DATE] at 9:57 PM, [DATE] at 3:26 PM, [DATE] at 3:20 AM, [DATE] at 12:55 AM, and [DATE] at 2:00 AM. ([MEDICATION(S)]-antiemetic to prevent nausea and vomiting) -[MEDICATION(S)] Tablet 10 mg. Five 1 tablet by mouth at bedtime for [CONDITION(S)] (hypertension), scheduled at 9:00 PM. Documented as given on [DATE] at 9:03 PM. ([MEDICATION(S)]-[MEDICATION(S)] Calcium-statin, used to lower LDL cholesterol and triglycerides) -[MEDICATION(S)] Tablet 100 mg. Give 1 tablet by mouth at bedtime for [CONDITION(S)], scheduled at 9:00 PM. Documented as given on [DATE] at 9:03 PM. (Losartan-[MEDICATION(S)] receptor antagonist, used to treat hypertension) Review of the Progress Notes revealed a lack of documentation of assessment for itching and dizziness on [DATE] when the medication [MEDICATION(S)] and [MEDICATION(S)] had been administered at 9:55 PM and a lack of re-assessment of the Resident's vital signs after receiving the [MEDICATION(S)], [MEDICATION(S)] ER, and Losartan with the documented concern of a low diastolic blood pressure. A review of Resident #1's medical record revealed a documented fall on [DATE] at 7:43 PM, Resident was found lying on her side on the floor of her room. Resident is independent in all transfers and stated that she was walking to her closet and as she tried to take two steps back to her bed she blacked out and her legs gave out on her and she fell on the floor and ended up on her side . Review of the document Falls Assessment, dated [DATE], revealed, . Summarize the impact of this problem/need on the resident . Was standing without walker at dresser. States when to take two steps backward with legs became weak and she fell to the floor. No injuries noted or reported . Education to be provided to nurse to obtain BS (blood sugar) at time of fall and notify family. Blood sugars reviewed and are stable with lowest BS 98. Orders to obtain orthostatic blood pressure BID (twice a day) x (times) 3 days . A review of the orders revealed, date ordered [DATE] with a start date on [DATE] at 20:00 (8:00 PM) for Orthos bid x 3 days, two times a day for r/o (rule out) [CONDITION(S)] for 3 days . A review of the MAR and Blood Pressure Summary in the medical record for Resident #1 revealed the orthostatic blood pressures documented as follows: -Dated [DATE] at 1900 (7:00 PM), MAR, Bp ,d+[DATE], Pulse 82. BP Summary documented at 4:37 PM, position: sitting. -Dated [DATE] at ,d+[DATE] (7:00 AM to 10:00 AM), MAR, BP ,d+[DATE], Pulse 78. Bp Summary documented at 8:49 AM, position: sitting -Dated [DATE] at 1900, MAR, BP ,d+[DATE], Pulse 82. BP Summary documented at 4:46 PM, position: sitting. -Dated [DATE] at ,d+[DATE] BP, MAR, not documented, Pulse not documented. Bp Summary documented at 7:15 AM, ,d+[DATE], position: sitting. -Dated [DATE] 1900, MAR, BP not documented, Pulse not documented with reason given TO (transferred out/discharged ). BP Summary documented at 5:00 PM, BP ,d+[DATE] sitting. BP Summary documented at 9:02 PM, BP ,d+[DATE], position: lying. Review of the progress notes revealed a lack of orthostatic blood pressures and pulses documented in the lying, sitting and standing position. Further review of Blood Pressure Summary document for Resident #1 revealed a range of random blood pressures obtained for Resident #1 that included the following: -[DATE] at 7:01 PM, BP ,d+[DATE]. -[DATE] at 9:51 AM, BP ,d+[DATE]. -[DATE] at 9:20 PM, BP ,d+[DATE]. -[DATE] at 8:54 AM, BP ,d+[DATE]. -[DATE] at 4:12 PM, BP ,d+[DATE]. -[DATE] at 1:06 PM, BP ,d+[DATE]. -[DATE] at 9:30 AM, BP ,d+[DATE]. -[DATE] at 8:10 PM, BP ,d+[DATE]. -[DATE] at 4:37 PM, BP ,d+[DATE]. -[DATE] at 5:00 PM, BP ,d+[DATE]. -[DATE] at 9:02 PM, BP ,d+[DATE]. The review of the history of blood pressures for Resident #1 from the Blood Pressure Summary revealed the one of the high Blood pressures documented on [DATE] at 4:46 PM of ,d+[DATE], and one of the lowest blood pressures documented on [DATE] at 9:02 PM of ,d+[DATE]. On [DATE] at 1:48 PM, an interview was conducted with LPN B regarding Resident #1 on [DATE]. The Nurse reported getting a phone call from Resident #1's family member regarding the resident not receiving her medication after [CONDITION(S)] and reported she put the call to (RN A). The Nurse reported she went to Resident #1's room and stated, She was facing the door, lying in bed. She had [CONDITION(S)] and another appointment that day. (Resident #1) told me, 'I been asking for blood pressure meds', now she complained her blood pressure was too low. I told (RN A) what her concerns were and offered to take a manual blood pressure. She (RN A) said 'I got it.' You can't always count on the blood pressure machines, and indicated if the Resident was complaining of low blood pressure, then the nurse should be checking the blood pressure manually. The Nurse indicated that RN A sounded irritated and didn't want her to take the Resident's blood pressure. The Nurse reported the 911 dispatcher said the Resident doesn't feel right, she said she received her blood pressure meds, and it was now too low, got no water, wanted to go to ER and they wanted to speak to the Resident's nurse. The Nurse reported that she saw RN A coming down the hall and RN A went back to the unit where she put the call through. The Nurse reported that CNAs came down to the nurses' station, approximately 10:15 (pm), where she was giving report to another Nurse (LPN C), the CNAs requested immediate help due to Resident #1 not responding. They ran to the Resident's room to find her lying on her back in bed with her eyes wide open, gasping, agonal breathing, performed a sternal rub and stated, not one bit of response, told the CNAs to get a crash cart, checked heart rate that was extremely slow and irregular and had gasping breaths, and proceeded to attach the AED and started CPR. When queried regarding RN A, the Nurse reported they had passed her at or around the nurses station when her and Nurse C responded to the CNA's request for help with Resident #1 and reported that when they passed her at the Nurses Station, RN A said 'I don't need you to go in there,' and indicated RN A had not come to the Residents room to assess her assigned Resident or assisted with the code, not until MMR (ambulance) was already in the room. LPN B was queried regarding professional standards of practice with complaints that a Resident was having nausea/vomiting. The Nurse indicated that an assessment would be conducted immediately that would include vital signs, bowel sounds, make sure the head of the bed was elevated, question what was eaten, check bowel movement records, check for other discomfort-back pain, chest pain, pain in the abdomen. The Nurse stated, I would notify the doctor if I felt it was necessary, and reported she would give medication as ordered after doing the assessment. When asked when the assessment would be completed, the Nurse stated, immediately. On [DATE] at 2:29 PM, an interview was conducted with Nurse K regarding standard of practice for assessment for a Resident that complained of nausea. The Nurse indicated an assessment would include listening to bowel sounds, check when the last BM (bowel movement) was, assess for pain, pain in the abdomen, palpated the abdomen and reported anything the Resident complained of should be documented. When questioned how orthostatic blood pressures were obtained, the Nurse stated, Lying, sitting, standing, 30 seconds apart. The Resident reported he had checked the orthostatic blood pressures on Resident #1 and stated, no issues, there was not a drop (in blood pressure). A review of the documentation of the one set of blood pressures in the medical record, the Nurse indicated that all three sets should be documented. On [DATE] at 3:18 PM, an interview was conducted with RN A, who indicated she was assigned Resident #1's care on [DATE]. The Nurse reported administering Resident #1's medications about 9:00 PM. The Nurse indicated that the Resident was concerned about her blood pressure because the diastolic number (lower number of blood pressure) was low and reported the Resident wanted to take her medication and she had encouraged her to drink water to bring the diastolic number up. The Nurse indicated the Resident had called 911 and she had talked to the 911 dispatcher who said the Resident wanted to go to the hospital and told them she had taken vital signs, gave her water and would check on her every hour. The Nurse reported the Resident had called 911 again, around 10:00 PM, and said she was nauseated, the nurse talked to the dispatcher and gave [MEDICATION(S)] and other medication. When asked if she had monitored the Resident's blood sugar with complaints of nausea, the Nurse reported she was unaware the Resident was diabetic. When asked if she had rechecked the Bp on the Resident, the Nurse indicated she had not rechecked the Bp. When asked if she had listened to the Resident's heart, lungs or abdomen, the Nurse reported she had not listened with a stethoscope and stated, she had no signs or symptoms of anything. When queried if the Resident had called 911 to go to the hospital? RN A stated, yes, and if the Resident called a second time to 911, the Nurse stated, Yes. When queried why she had not gone to the Resident's room when the CNA reported the Resident had vomited and that something was wrong with the Resident, the Nurse stated, They were already in the room, When asked why she turned down Nurse B taking a manual bp or assessed the Resident with complaints of low blood pressure, the Nurse reported she had taken a blood pressure when she gave the pills and it had not had time to start to take effect and reported she had not been informed of any Resident complaints. Blood pressure medication given to Resident #1 was verified with RN A on [DATE] at 11:16 AM. The Nurse reported she had taken the blood pressure, given the medication to the Resident and told her what the blood pressure reading was as she was taking the pills. The Nurse reported the Resident was concerned about low blood pressure and encouraged her to drink water to bring up the diastolic blood pressure and to ring if she felt any different and reported the Resident didn't ring until after 10 (10:00 PM). The Nurse reported the Resident did not have water at the bedside and had provided some to the Resident. The Nurse reported not rechecking the Resident's blood pressure after she had given the medication. On [DATE] at 4:35 PM, an interview was conducted with the Director of Nursing (DON) regarding Resident #1's events on [DATE]. The investigation report and the medication administration record were reviewed with the DON. The DON reported the Resident had gone to an appointment prior to [CONDITION(S)] and had been picked up at approximately 9 AM. The DON reported the Resident came back around 4 or 4:30 pm after going to the appointment for the fistulagram and [CONDITION(S)]. The DON was asked, if the Res was not feeling well, nauseated, was the blood sugar monitored? The DON reported no assessment was documented of the blood sugar until the code. The DON indicated that the Resident would have eaten dinner and that the blood sugar should have been monitored prior to eating. The DON was queried if the Physician had been notified of the medications not given earlier in the day. With review of the medical record, the DON indicated there was no documentation that the Physician had been notified. The DON reported that the Resident was her own responsibly party, was alert and oriented and would refuse her medication before [CONDITION(S)] and that having nausea was her baseline. When asked why the Resident had changed rooms, tested for Covid-19 and influenza and put in isolation precautions, the DON indicated they were monitoring for Covid-19 due to increased nausea and the Resident not feeling well. A review of the MAR revealed an order Resident was actively assessed for symptoms of COVID-19 {fever, shortness of breath, cough, sore throat, chills/shaking, loss of tastes/smell, muscle aches, headaches confusion, nausea, vomiting and diarrhea] three times a day. The patient did not display any of these symptoms during my shift. Document in a nurse's note if the patient experienced any of these signs or symptoms of COVID. Review of the Progress notes lacked documentation for assessment of signs and symptoms of Covid-19. A review of the MAR and Progress notes revealed documentation that the Resident requested [MEDICATION(S)] on [DATE] at 2:00 AM, on [DATE] at 9:43 PM and [DATE] at 7:59 PM, the DON indicated there was not an assessment for the change in condition of the increased nausea and not feeling well. The DON was queried why the [MEDICATION(S)] that was prescribed for itching and [MEDICATION(S)] that was prescribed for dizziness was given on [DATE] at 9:55 PM when the Resident had complained of vomiting. The DON was unsure why the Nurse had given the medication and indicated there was not an assessment documented for the use of the [MEDICATION(S)] and [MEDICATION(S)] or an assessment for itching or dizziness. The DON was asked about the ordered orthostatic blood pressures and indicated Resident #1 had a fall and the orthostatic blood pressures were ordered to rule out issues. A review, of the MAR, progress notes and vital signs, was conducted with the DON. There was a lack of documentation of the orthostatic blood pressure monitoring of the blood pressure and pulse except for the one entry. The DON indicated the order was not put in correctly to document the lying, sitting and standing blood pressures and pulses. On [DATE] at 11:06 AM, a phone call was made to Resident #1's Family Member G regarding her care at the facility. The Family Member indicated the Resident had been admitted to the facility for rehab and to get stronger and that she was going to get a kidney transplant. The Family Member reported that the Resident's room was so hot that the Resident had passed out and fell and after having vomited, was put in a room for isolation. The Family Member reported being in contact with Resident #1 on [DATE] and stated, She got back from [CONDITION(S)], and she did not get her medication and the nurse was not attending to her. She didn't have any water. I called her at about 9:00 and she had just gotten her blood pressure medication, but they did it backwards, they gave her the pills then they took her blood pressure. She takes a high dose of blood pressure meds. If her blood pressure is too low, she would have refused them, did it the opposite way, gave the meds then took the blood pressure. The Family Member reported family found out she had called 911 two times and stated, the nurse called the ambulance off. She needed emergency service and they were told not to come. The Family Member reported Resident #1 was not feeling well and stated, She thought it was because she didn't get her meds. She was very distraught over her lack of care that day (at the facility). Very upset, thought she was going to die, said she didn't think she was going to make it out of there. We didn't know she called 911 for help until after she died . She wouldn't have called 911 if she didn't need to go to the emergency room . Family Member G called on [DATE] at 10:37 AM, with further information regarding Resident #1. The Family Member indicated he had talked to other family members and reported the Resident had contacted other family members the evening on [DATE]. The Family Member indicated the Resident had asked for medication from when she got back after [CONDITION(S)] and wanted her daily medication. The Family Member indicated on [CONDITION(S)] days she wouldn't take her meds before but when she got home and stated, She would take her daily meds, that was her normal routine, especially her blood pressure meds. What you take beforehand would be cleaned out when they clean the blood. The Family Member reported that Resident #1 had texted the family member: -Text at 5:48 pm I need my pills for today I just rang my bell. I missed two doses already. -Text at 5:46 PM, I'm feeling sick all over again. -Text at 5:48 pm I just rang the bell. I need my pills for today. I've missed 2 doses already. -Text at 7:15 PM, I have been back for the last 3 hours. I told them my blood pressure is up. I've missed my morning meds. Still no response. -Text at 8:29 PM, Just woke up. No meds no water. -Text at 8:40 pm, they told (Family Member) they gave me my pills-liar. Meaning they didn't give her her pills. -Text at 9:06 PM, Nurse just gave me my pills before taking my blood pressure. ,d+[DATE]. I took it (medication) without thinking. My blood pressure was going to drop. She said to drink all the water and I will check on you through the night. They are not going to check on me. I am going to die. The Family Member stated, That was the last text words to me. I called at 9:07 PM and talked to the nurse (RN A). She said she (Resident #1) was asking for meds. She gave her the meds and took her blood pressure after she gave the meds. She took the blood pressure and was surprised how normal it was and was concerned and told her to drink her water to bring her blood pressure up. On [DATE] at 6:57 PM, an interview was conducted with Nurse LPN N who was assigned care of Resident #1 on [DATE]. The Nurse indicated Resident #1 came back approximately 4:30 PM on [DATE] from [CONDITION(S)] and was put into her new room to monitor for Covid-19, was tested for Covid-19 and influenza. The Nurse indicated she took care of her from that time until the end of her shift when the nurses give and get report between 6:00 and 6:30 PM. The Nurse was asked if she had received report from the day shift Nurse. The Nurse stated, The only report was from [CONDITION(S)] communication form. I got notification from the DON because of possible Covid, and reported she had not received report from the Nurse assigned her care prior to leaving the facility for her appointment and [CONDITION(S)]. When asked why Resident #1 was being tested for Covid-19, the Nurse stated, She was symptomatic, runny nose, coughing. The room in the back was very hot. When asked if the Resident had nausea, the Nurse stated, I received no complaints of nausea. Previously I believe she had nausea a couple days before that. When asked if the Resident had asked for her medication to be taken, the Nurse reported the Resident didn't have any meds to be given and stated, none were showing up (on the MAR to be given). The Nurse was asked if she was aware the Resident had not taken her morning and daily medications and the Nurse stated, No. No report was given. When asked if a CNA had informed her that the Resident was requesting her medications, the Nurse reported she was not aware and that she had told the oncoming Nurse that she had not given any medication. The Nurse was questioned if the Resident had supper and indicated she had eaten. The Nurse was asked if she monitored the Resident's blood sugar and stated, If she was a diabetic I would have. With review of the medical record that the Resident was diabetic and blood glucose monitoring was ordered, the Nurse stated, I don't recall because nothing was triggering for to get one. The Nurse was asked about an assessment for a resident complaining of not feeling well and nausea, the Nurse reported an assessment would consist of monitoring vital signs, checking the blood sugar if diabetic, do a head to toe assessment that included lung sounds, bowel sounds. When asked what assessment would be done for complaints of low blood pressure, the Nurse reported an assessment would be completed, check blood pressure every 15 minutes and notify the physician, track the blood pressures and see where it was going. When asked if a CNA says she needs help that something is wrong with a Resident, the Nurse stated, I would go and check the Resident and speak to them to tell me how she is feeling. Get in there as soon as possible, if they need you in there right now, I would drop whatever I was doing and go. On [DATE] at 12:17 PM, an interview was conducted with Physician L regarding Resident #1 and the events on [DATE] was reviewed with the Physician. The Physician indicated they had seen Resident #1 once when at the facility. The Physician was asked if professional standards of practice were followed when the Nurse had administered the medication of Losartan 100 mg, [MEDICATION(S)] 100 mg and [MEDICATION(S)] ER 60 mg with a blood pressure of ,d+[DATE]. The Physician stated, The Nurse did not follow protocols. When asked what the protocols were, the Physician indicated if systolic blood pressure was less than 100, hold the medication, if diastolic less than 50 or 55 then hold and stated, Sometimes its ok to run it a little lower. If the blood pressure was low, she could have called to let me know. The Physician expressed that the Nurse could have called the Physician and we would have set up a plan, try interventions, re-evaluate, if it was not working, then send to the hospital. The Physician reported they had not been notified by the Nurse prior to the Resident's death. The Physician reported that once the Resident called 911, it was out of our hands, send her. When asked about blood pressure parameters for blood pressure medication, the Physician indicated that if they are not ordered with the medication, all they have to do is call me and we can set those up. The orthostatic blood pressures, for Resident #1, of one set of a blood pressure and heart rate documented that did not indicate the position of the Resident was reviewed. The Physician reported, well then, they were not done. I can't evaluate them if they are not documented. On [DATE] at 12:44 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked regarding facility policy and protocol for the administration of blood pressure medications and monitoring parameters. The DON reported the ordering for the parameters would come from the doctor and ordered individually for the Resident and indicated they did not have a protocol for blood pressures parameters for blood pressure medications. A review of Resident #1's medical record revealed parameters were not ordered with the blood pressure medication. The DON was asked if there was a concern when RN A had given the blood pressure medication to Resident #1 with a blood pressure of ,d+[DATE]. The DON stated, It's a nursing judgement, and indicated the Nurse should have asked the Resident, checked what her normal blood pressures were, notify the doctor to see what he orders from there, and monitor the blood pressure. A review of the

This Citation pertains to Intake Numbers MI 684, MI 446, and MI 976. Based on interview and record review, the facility failed to prevent falls with injuries for three residents (Resident #1, Resident #3, Resident #5) of five sampled residents, resulting in 1) Resident #1 being left on the toilet and sustaining a fall, 2) Resident #3 with severe cognitive issues falling out of bed and landing on the Hoyer lift legs resulting in a fracture of the leg, and 3) Resident #5 with severe cognitive issues being left on the toilet and sustaining a fall with a laceration to the head. Findings include: Record review of facility 'Fall Reduction Program', dated 9/25/2016, revealed the purpose is to provide a safe environment, modify risk factors, and reduce risk of fall related injuries. Identify/analyze resident risk for falls. Record review of facility 'Fall Prevention Teaching' Staff education, dated 3/26/2021 at 2:30 PM, educated the staff that the most successful fall prevention programs focus on the conditions of the individual, the conditions of the environment, and the interactions between the two. Prevention: there are several key steps that caregivers can put in place to help prevent falls during this time of social distancing: (#3.) Increase wellness checks for those higher risk . Resident #1: Record review of Resident #1's pre-admission hospital history and physical, dated 2/27/2021, revealed reason for hospitalization was [CONDITION(S)] and fall with back pain rated at 10 of 10. Record review Resident #1's facility medical record diagnosis included a history of falling, fracture lumbar vertebrae, [CONDITION(S)], [CONDITION(S)], heart failure, hypertension, diabetes mellitus and need for assistance with personal care. Record review of Resident #1's Admission assessment, dated 3/12/2021 at 5:26 PM, revealed that the resident was admitted from the hospital via stretcher with [CONDITION(S)]/fall, compression fracture of lumbar 1, CVA (stroke/Cardiovascular Accident). Record review of Resident #1's Progress note, dated 3/12/2021 at 9:52 PM, noted left facial droop (stroke), 1 person transfer and TLSO (Thoracic Lumbar Sacral Orthosis) brace on when up. Record review of Resident #1's Progress note, dated 3/13/2021 at 3:08 PM, noted resident was observed on floor in the bathroom laying on left side . Record review of Resident #1's Fall Incident Report, dated 3/13/2021, revealed that the nurse was called to the resident's room by a Certified Nurse Assistant (CNA) and observed the resident on the bathroom floor, laying on his left side with TLSO brace on. The resident had tried to get off of the toilet. Injuries included an abrasion to the coccyx. The resident had been admitted within last 72 hours. No witnesses were found. Resident #3: Record review of Resident #3's Fall Incident Reports revealed: -On 9/1/2020 Resident #3 found on floor in front of wheelchair, no witnesses found. Predisposing physiological factors included impaired memory, gait imbalance. -On 10/22/2020 Resident #3 observed laying on the floor parallel to bed, resident stated that he was trying to get up out of bed .poor safety awareness was noted, call light note used, no witnesses found. -On 11/16/2020 Resident #3 resident found lying on floor on right side . resident slide out of bed. Poor safety awareness noted, impaired memory, incontinent noted. No witnesses found. -On 11/17/2020 Resident #3 found lying on the floor with a U-shaped pillow next to him and mattress on top of resident, residents head was under the bed with feet perpendicular to bed. -On 11/20/2020 Resident #3 observed laying on the floor in his room, in front of bed. Predisposing physiological factors noted confusion. No witnesses found. -On 11/30/2020 Resident #3 laying on the floor. Predisposing physiological factors noted impaired memory and incontinent. No witnesses found. -On 12/11/2020 Resident #3 observed laying on floor next to bed, appears to have rolled out of bed. Predisposing physiological factors noted impaired memory. Poor safety awareness was noted. No witnesses found. -On 12/14/2020 Resident #3 laying on the floor on his stomach. Poor safety awareness noted. Predisposing physiological factors noted confused. No witnesses found. -On 12/30/2020 Resident #3 observed laying on the floor on his right side next to the bed facing the door. Poor safety awareness noted. Predisposing physiological factors noted confused. No witnesses found. -On 1/4/2021 Resident #3 observed laying on his left side next to bed with his head facing door and feet pointing towards window. Resident noted to have back pain. Predisposing physiological factors noted confused and impaired memory. No witnesses found. -On 3/4/2021 at 6:40 AM noted Resident #3 observed on the floor next to bed, legs over Hoyer lift. Certified Nurse Assistant left to get help to get resident up out of bed and when the staff were approaching room to him up, they noted him to be too close to the edge of bed and he rolled out of bed before staff could get to him. This was witnessed. Resident sent to emergency room (ER) for evaluation for injury of laceration to face. Poor safety awareness and confusion was noted. Record review of Facility Reported Incident (FRI) incident summary revealed that on 3/11/2021 at approximately 11:00 AM during routine care the resident started to complain of right knee pain. The resident had noted swelling to his right knee. Physician notified and the X-ray ordered was inconclusive. Resident #3 was sent to the hospital for further evaluation. Record review of Resident #3's Hospital record, dated 3/11/2021, identified that the chief complaint was knee pain. The resident was noted to have dementia and had presented to the emergency room department one week prior on 3/4/2021 after falling and sustained a laceration to his left eyebrow for which 5 stitches were placed. The family member stated that 2 days prior Resident #3 had moaned and yelled out in pain while staff were moving him. X-ray showed tibial plateau fracture. Record review of the nursing home's incident summary of an injury of unknown origin, identified on 3/12/2021, revealed that Resident #3 had sustained a fall on 3/4/2021 from rolling out of bed and hitting his head on the floor. His right hip and leg landed on a mechanical lift that was near his bed in preparation for transferring the resident from the bed to a wheelchair. Resident #5: Record review of Resident #5's Hospital history and physical, dated 4/2/2021, revealed a chief complaint of low back pain and fall. The hospital noted that over the last two weeks, the patient has been falling more frequently and had fallen the night prior. Record review of Resident #5's admission assessment pages 1-14, dated 4/8/2021, revealed an altered mental status. Admission assessment noted confusion at times per hospital and spouse. Admission mobility/safety noted the need for extensive assistance with walking in the room. Record review of Resident #5's Fall Incident Report, dated 4/12/2021 at 5:00 PM, revealed that a staff member placed the resident in the restroom and then went to answer the next call light. Staff returned to find Resident #5 on the floor . Resident #5 noted to have a red area to top of head. Poor safety awareness noted. Predisposing physiological factors included confused, impaired memory, gait imbalance and recent illness. No witness were found. Record review of Resident #5's Fall Incident Report, dated 4/23/2021 at 12:00 PM, revealed staff overheard resident hollering Help me. Resident observed laying on right side facing the door of his room. Injury of laceration to back of head . Poor safety awareness noted. Predisposing physiological factors included confused, impaired memory. No witness found. Resident sent to hospital for evaluation. Record review of Resident #5's Progress notes, dated 4/23/2021 at 12:00 PM, revealed Resident with laceration to back of head with large amount of blood 4/23/2021 at 12:10 PM noted resident attempted to self-transfer. Resident seemed more confused and agitated today. Resident is alert only to himself . 4/23/2021 at 12:30 PM Resident observed on floor with laceration to the scalp, transferred to the hospital . 4/23/2021 at 6:23 PM resident returned to facility from hospital with staples placed in back of head Record review of Resident #5's Care plans, initiated on 4/9/2021, revealed that the resident was known to need assistance with Activities of Daily Living ADL) and mobility related to difficulty walking, low back pain, weakness, one-person assists with transfers, bed mobility and dressing. In an interview on 6/2/2021 at 12:35 PM with the Interim Director of Nursing/Corporate Regional Clinical Director, Resident #5' s falls were discussed. Resident #5 sustained a fall on 4/12/2021 and again on 4/23/2021. Resident #5 had a Brief Interview of Mental Status (BIMS) of 4 out of 15, indicating severe cognitive impairment, yet Resident #5 was left alone in the bathroom, resulting in a fall with a laceration to the scalp requiring stitches.

This citation pertains to Intake Number MI 101 Based on interview and record review the facility failed to prevent a fall for one resident (Resident #903) of three residents reviewed for falls resulting in a fracture. Findings include: According to Admission Record, printed 10/30/2019, Resident #903 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Census List revealed that Resident #903 was hosptalized on [DATE] and re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #903's Minimum Data Set (MDS) Resident Assessment Tool, dated 10/11/2019, Resident #903 had one fall since admission with major injury. Resident #903 had no documented behaviors and required extensive assistance from staff for activities of daily living (ADLs). According to Resident #903's care plan, she had potential/actual ADL deficit . mobility deficit related to [MEDICAL CONDITION], muscle weakness, difficulty walking, lack of coordination and right ankle fracture (initiated 09/18/2019, revised 10/07/2019). The care plan included the following intervention for ADL deficit: Total lift with toileting sling- 2 assist for all lifts I may request to use a bedpan instead (initiated 09/18/2019, revised 09/30/2019) and I have right sided weakness due to recent [MEDICAL CONDITION]. Resident #903 also had a care plan for cognition that stated, risk for confusion (related to) [MEDICAL CONDITION](initiated 09/18/2019). Interventions for Resident #903's cognition plan of care included, provide consistent routines and caregivers (initiated 09/24/2019), anticipate needs (initiated 09/18/2019) and allow adequate time to respond (initiated 09/24/2019). Resident #903 also had a care plan for Safety: Risk for falls (related to) impaired balance/poor coordination. Right sided weakness, [MEDICAL CONDITION], fracture of right lower extremity with (non weight bearing status). Has cast on right leg (initiated 09/18/2019, revised on 10/23/2019). Upon review of Change of Condition Evaluation, dated 9/29/2019, it was noted that Resident #903 had a fall and experienced pain to the right outer ankle. The evaluation explained, Resident was lowered to the floor by staff during a transfer. The evaluation noted that Resident #903's primary care clinician was notified and ordered an x-ray. Upon review of Falls Assessment, dated 9/29/2019, it was noted that Resident #903 did not have a history of falls. The assessment indicated that the contributing factors to the fall included difficulty maintaining a standing position, unsteadiness, impaired balance during transfers, medications, [DIAGNOSES REDACTED]. The Falls Assessment summary explained, .Resident [MEDICAL CONDITION] limitation to right side. Resident was lowered to the floor by CNA during a transfer to the toilet. Resident stated the floor was slippery and her right foot slipped and she fell . P[NAME] (plan of care) was not followed during transfer .Resident c/o (complaint) of mild pain in her right ankle . Provider notified obtained an order for [REDACTED]. According to Consultation Report, for planned surgery dated 10/11/2019, Resident #903 presents for .open reduction internal fixation of the right ankle .on 10/10/2019, related to a recent fall at (facility), slipping on water in her bathroom. The report explained that Resident #903 was having a great deal of post-op right ankle pain. The report also included Radiology Results from 09/30/2019 that said, .views of the right tib/fib were ordered, obtained and interpreted .show distal fibula fracture. Results of ankle x-ray 09/30/2019 also showed distal fibula fracture. According to Outpatient Consultation Record, dated 10/24/2019, Resident #903 was ordered to be non-weight bearing (NWB) on her right lower extremity due to her [DIAGNOSES REDACTED]. During an interview on 10/30/2019 at 1:30 PM, the Director of Nursing (DON) explained that the Certified Nursing Assistant D went into Resident #903's room to take Resident #903 to the bathroom. The DON said Resident #903 told CNA D that she was a one assist. The DON explained that Resident #903 said she lost her balance during the transfer to the toilet and attempted to sit back down in the wheelchair, but she went down to the floor. Resident #903 told the DON that her bathroom floor was slippery. When asked how Resident #903 transferred, the DON stated, She is supposed to be a two assist. Therapy has been working with her with a one assist so there is a little bit of confusion. When asked whose responsibility is it to know how to safely transfer a resident the DON replied, It would be the staff's responsibility to know her transfer status not the resident's responsibility. During an interview on 10/30/2019 at 1:40 PM, the Nursing Home Administrator (NHA) explained why the floor was wet. The NHA stated, When we stepped on the tile some tiny bubbles came up between the tile and when we stepped off the bubbles receded. We found that there was drip from the seal bolt from the left-hand side of the sink and it would drip down and go under the tiles. When asked if CNA D followed Resident #903's plan of care the NHA stated, I'm sure the CNA had checked the Kardex (plan of care) but I cannot speak for her. The NHA stated, it was (Resident #903's) preference to transfer with the help of one person. She was driving her care. She had to go to the bathroom badly. During an interview on 10/30/2019 at 1:50 PM, the Therapy Program Manager C explained that Resident #903 came to the facility after having a stroke and upon admission Resident #903 required a Hoyer (mechanical) lift to transfer. Therapy Program Manager C stated, Through therapy she had been progressing to a two person with a sit to stand (mechanical) lift and then prior to the incident in therapy she had started to be able to be a one person with a stand pivot but it wasn't consistent. Therapy Program Manager C confirmed Resident #903's plan of care for transfers at the time of the fall on 09/29/2019 was to be stand lift with two people assistance. Therapy Program Manager C further explained, I wanted to see more transfers with the nursing staff before I recommended her to be a one assist. During an interview on 10/30/2019 at 3:20 PM, Resident #903 recalled, I had to really go to the bathroom. The first two times I tried to stand I told her it was slippery and sat back in my chair. She was trying to figure out how to get the water and I told her the water was there before and they used paper towels to clean it up. The third time we had the paper towel on the floor. I lifted to sit on the toilet and my right leg went back and she fell over trying to catch me. It was very painful. I had severe childbearing like pain in my leg and my lower back. I ended up wetting on myself anyways, so they put me back in my bed. When asked how many staff help her go to the bathroom Resident #903 stated, It was always two people at (previous facility), one person held the seat and one person helped me out of the chair. When I hurt my foot, it was just one girl. Resident #903 said it was the girls second time taking care of her. When asked if she told the girl that she needed two people to help her, Resident #903 stated, I assumed if you're going to treat a person you would know everything about that person, so you do a good job. I don't know why she didn't go get help, but I noticed the workers are always rushing and not taking their time. Resident #903 explained that she felt the facility could have prevented the incident by fixing the floor before I got hurt. Why wait until after? Resident #903 said she brought the water on the floor to staff's attention every day since her first day there. Resident #903 stated, I hate that it happened, and I try not to think about it. It gets very painful . I feel like I'm delayed in my progress. I want to go home. During a phone interview on 10/31/2019 at 08:20 AM, CNA D said that Resident #903 had to use the bathroom and told her that she no longer needed two assists. CNA D stated, We attempted to transfer twice. The first time she wasn't ready. The second time she tried but she was getting weak and she was on the edge of the chair. After she started to slip it crossed my mind that I might need another person. When asked what Resident #903's transfer status was at the time of the fall, CNA D responded, The last day I was there she was still using sit to stand. CNA D admitted she did not check Resident #903's Kardex the day of the fall. When asked if it was facility policy to review a residents plan of care on their Kardex every day, CNA D responded, Yes, we are supposed to check it every day. When asked why a Kardex should be checked before transferring a resident, CNA D responded, So, you won't have the problem that I had and have a fall. When asked if there was anything on the floor at the time of the fall, CNA D stated, I did notice water on the floor before the fall, so I put paper towel on it. I wiped it up and threw away the paper towel. CNA D explained that after the fall Resident #903 told her that she had noticed water seeping from the floor the day before. CNA D said, When you put pressure on the bathroom floor, water seeped from the floor. During a follow up interview on 10/31/2019 at 9:05 AM, with NHA stated they did not have a policy about checking a Kardex. It is just standard practice to check the Kardex and follow it every day. Review of facility policy titled, Transfer Techniques, dated (MONTH) 1, 2008, revealed that it was facility policy to obtain help when necessary, or as identified on care plan/care guide to transfer a resident safely.

This citation pertains to Intake Number MI 501. Based on observation, interview, and record review, the facility failed to assess, monitor, and treat an area of skin damage for one resident (Resident #1) out of two residents reviewed for pressure ulcers, resulting in the development of an unstagable, odorous pressure ulcer on the sacrum (the base of the spine) of Resident #1. Findings include: According to the Admission Record, printed on 9/27/2019, Resident #1 was a [AGE] year old male originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Progress Notes, dated 8/30/2019, Resident #1 was sent back to the hospital on [DATE] due to difficulty swallowing. The Admission Assessment, dated 8/29/2019, for Resident #1 identified a skin issue and described the area as Pressure on the sacrum with measurements of 7 centimeters (cm) long and 1.5 cm wide with a depth of 0.1 cm. A care plan was initiated on 8/29/2019 for the sacrum area wound that included interventions for a daily check of the skin by the certified nursing assistants, a pressure reducing device on the bed, and treatments as ordered. According to the Progress Notes, Resident #1 was readmitted on [DATE]. On 9/6/2019 a pink area was noted in the Progress Notes on the coccyx (tail bone), from a former wound. The Admission Skin Assessment, dated on 9/6/2019, noted a skin issue on Resident #1's sacrum, but did not identify the type of the skin issue, the measurements of the area, a description of the area, or the stage of the area. On 9/9/2019 a Skin & Wound Evaluation was performed. The wound on Resident #1's sacrum was measured as 4 cm long with a width of 2.5 cm. The wound was described as Moisture Associated Skin Damage (MASD) and was noted to be present on admission. The skin was noted as intact with no documented drainage or signs of infection. According to the Order Summary Report, a treatment was initiated on 9/9/2019 for the MASD area to the sacrum to be cleaned with wound cleanser, pat dry, apply a barrier cream and cover with an [MEDICATION NAME] foam dressing every three days and as needed with a start date of 9/12/2019. According to the 2014 Prevention and treatment of [REDACTED]. The assessment of skin and tissues is important to pressure ulcer prevention, classification, or staging, diagnosis, and treatment. A stage 1 pressure ulcer is defined as an intact, non-blanchable area of redness, usually over a bony area. A stage 2 pressure ulcer is described as a partial loss of the skin with a shallow open area with a pink wound bed and no slough (yellow tissue). A stage 3 pressure ulcer has full thickness loss of the skin, with no visible bone, muscle or tendon, although the fatty layer of the skin may be visible. A stage 4 pressure ulcer is full loss of tissue with bone, muscle, or tendon exposed. Some slough may be in the wound bed. An unstagable wound is a pressure ulcer where the wound bed is covered by slough, yellow, tan, gray, green, or brown or by eschar (dead) tissue that is tan, brown, or black. These wounds are unstagable because the wound bed is not visible. Upon readmission to the facility on [DATE], Resident #1 had a percutaneous endoscopic gastrostomy tube in his abdomen for feeding according to the Progress Notes. According to the nutrition care plan, initiated on 9/9/2019, this required the head of the bed to be elevated, not less than 30 hours during and for one hour after the tube feed was running. According to the Medication Administration Record [REDACTED]. This would increase the pressure on his sacrum. According to the 2014 Prevention and treatment of [REDACTED]. Resident #1's care plan for Skin management sacrum area MASD did not include a turning schedule. Turning was not listed on the CNA care guide, printed on 9/27/2019. On 9/27/2019 at 8:13 AM, Resident #1 was observed laying on his back in his bed with the head of the bed elevated. Resident #1's feet were observed to be on the mattress, and not floated, or bridged up off the mattress. The care plan instructed that Resident #1 was to be assisted with floating his heels. On 9/27/2019 at 10:32 AM, Resident #1 remained on his back in the bed with the head of the bed elevated and his heels still resting on the mattress. Licensed Practical Nurse (LPN) B was observed as she provided a dressing change and wound care to the wound on Resident #1's sacrum. The current foam dressing was scrunched up on the wound. The dressing was saturated with a large amount of greenish, yellowish, brownish, red drainage. There was no date on the dressing, but a stain of ink was on the dressing. The wound itself had a foul odor. In the center of the wound was a large cap of yellow and brown. The wound bed was not visible, around the edges of the cap was yellow slough. LPN B cleansed the area with a wound cleanser. Each time LPN B wiped the area with a gauze pad, Resident #1 flinched and groaned. LPN B stated she had given him Tylenol prior to the dressing change. LPN B stated that the wound looked worse than the last time she had seen it and that she thought he needed something stronger for the pain. LPN B agreed there was a noted odor. During an interview with the Registered Nurse (RN) Unit Manager, Staff A on 9/27/2019 at 11:32 AM, she stated she had last seen the wound on Resident #1's sacrum, which she still referred to as MASD, and had documented on 9/23/2019 that the area had deteriorated and the wound bed was not visible but covered with 100% slough. RN A stated that the facility had no certified wound nurse and no physician who specialized in wound care that came to the facility. RN A stated that she looked at all pressure wounds weekly, but that the MASD on Resident #1 was cleared out of the computerized system the facility used for wound documentation. RN A stated that the nurses were to monitor non-pressure areas, such as MASD, and notify her of changes. The physician had been notified of the change in Resident #1's wound on Monday, 9/23/2019 and had made a referral to the wound clinic. RN A stated that the wound clinic required a signed order or referral to schedule an appointment. She had notified the physician via phone so had no signed referral form. She stated the form had been signed today and she had asked the receptionist on Monday to call and schedule an appointment. During an interview with the receptionist, Staff G, on 9/27/2019 at 2:20 PM, she stated that she had not been asked until today to call and schedule an appointment at the wound clinic for Resident #1. Receptionist G said that the appointment had been scheduled for (MONTH) 11, 2019, two weeks away. The facility policy for Wound Management Program, dated as revised on 8/17/2017, instructed that documentation for wounds were Weekly Pressure Ulcer Wound Documentation and picture in wound rounds and Weekly Non-Pressure Wound Documentation and picture in wound rounds. Resident #1 had an assessment and picture of his wound done 9/9/2019 and not another assessment done until 9/23/2019. There was no picture with the assessment done 9/23/2019. The Skin & Wound Evaluation, dated 9/23/2019, identified the wound as MASD, with the type identified as Incontinence Associated [MEDICAL CONDITION] on his Sacrum. There were no measurements documented. There was no description of the wound bed or drainage from the wound. There was no goal of care listed, no boxes checked for treatment, dressings, or additional care boxes listed on the form such as a turning and repositioning program. The assessment form had no additional notes nor did it have any boxes checked for notifications. There had been no assessment of Resident #1's wound between 9/9/2019 and the incomplete assessment done on 9/23/2019. Resident #1's treatment orders for the area had started on 9/12/2019, six days after his readmission, to cleanse the area with wound cleanser, pat dry, apply barrier cream to the area and cover with an [MEDICATION NAME] foam dressing every three days The dressing change had been scheduled for 9/15/2019, but not initialed as done on that date. A new treatment protocol had been initiated on 9/25/2019. This protocol, according to the (MONTH) 2019 MAR, was to Cleanse MASD area to sacrum with wound cleanser, pat dry apply [MEDICATION NAME] extra (cut to fit) cover with [MEDICATION NAME] foam daily and as needed. According to the 2014 Prevention and treatment of [REDACTED]. On 9/27/2019, these signs were observed in Resident #1 during the observation of his wound care. The attending physician (Dr. I) had documented on Resident #1 on 9/27/2019 at 11:27 AM. In the note, she had documented Resident #1's vital signs from 9/26/2019, a list of his diagnoses, and notes. The notes were: Summary: subjective ; [MEDICAL CONDITION] objective, as above heent awake alert cvs s21 s2 git soft peg lungs ctab extremities o [MEDICAL CONDITION] skin ; stage 4 decubitus ulcer with foul smelling discharge painful all meds reviewed ct above peg tube feedings tolerating protein calorie malnutrition sacral wound secondary to above pain meds prescribed wound care v During an interview with the Director of Nursing on 9/27/2019 at 1:30 PM, she stated that she thought Resident #1's wound should have been called pressure from the start. MASD is a [MEDICAL CONDITION] or diaper rash, not usually found on a bony prominence according to the article Diagnosing and treating Moisture-Associated Skin Damage published in the (MONTH) 2012 issue of Advances in Skin and Wound Care. At 1:30 PM on 9/27/2019, the Director of Nurses texted Dr I to call the facility to talk with this surveyor. She received a text back from Dr I that she was in a meeting and couldn't talk. During a follow up interview with RN A on 9/27/2019 at 2:30 PM, she stated that Dr I had been in the facility earlier. When RN A was asked if Dr I had seen and assessed the wound on Resident #1's sacrum, she replied, she did not lay eyes on him. When RN A had called Dr I for further instruction regarding the wound she was told, I will look at it when I am there next Thursday. Follow the protocol. RN A stated that the current treatment was the protocol. According to the list of facility Wound Products, (MONTH) (YEAR), which was provided as the facility protocol, there was no protocol for a suspected infection in a wound. RN A was asked if she would be satisfied if Resident #1 was her father, she answered, no.

This Citation pertains to Intake Number MI 868. Based on observation, interview and record review the facility failed to ensure that residents were assessed and appropriate interventions were enacted for two residents (Resident #36 and Resident #67) of 5 residents reviewed for change of condition and hospitalization resulting in, Resident #36 developing an upper body rash with itching and discomfort and Resident #67 developed pneumonia without receiving the ordered medications and treatment, resulting in being admitted to the hospital. Findings Include: Resident #36 During the initial tour on 5/14/19 at 9:45 AM, Resident #36 was observed lying in bed, awake, with a bare chest and a sheet pulled up to his abdomen. An abrasion was observed below the right scapula; It was bright red and scabbed about 1 in x 1 in. The resident also had white, healed scars on the right arm. Resident #36 said he had lots of scabbed areas related to scratching. I itch all over. A record review of the Face Sheet and Minimum Data Set (MDS) assessment for Resident #36 indicated he was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment, dated 4/5/19, indicated the resident had full cognitive abilities and needed assistance with all care. On 5/14/19 at 10:00 AM, Nurse L was queried about Resident #36's rash and scratching and said she thought he had a treatment for [REDACTED]. A review of the physician orders revealed that a treatment of [REDACTED]. There was nothing ordered for the right shoulder/scapula reddened/scabbed area. A record review of the orders, progress notes and assessments indicated there was no further treatment or documentation of the rash or wounds on the upper body and chest. A review of the Care Plan Skin Management, date initiated 1/3/19 and revised 1/4/19, did not mention a rash or any skin conditions and there were no interventions addressing the itching and rash. There were 4 interventions and the last 2 were updated on 1/4/19, both related to positioning. On 5/16/19 at 9:47 AM, Nurse J was interviewed about the lack of Care Planning, assessment and documentation of the resident's rash and said, I see there isn't anything. Nurse J was asked about the assessment of Resident #36's rash and stated, They should be looking at it and documenting. We measure on admission and then weekly to show the healing. On 5/17/19 at 10:03 AM, the Director of Nursing was interviewed about the lack of wound assessments and monitoring of treatments and stated, We need to assess and monitor and find out what is going on and follow up on that. Resident #67: A record review of the Face Sheet and MDS assessment, dated 2/22/19, indicated Resident #67 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. The MDS assessment revealed the resident had full cognitive abilities and needed assistance with all care. A review of a progress note, written on 3/4/19 at 4:18 PM, indicated Resident #67's lung sounds were assessed by the nurse after a family member requested it, because the resident had a new cough and her throat was bothering her. The nurse contacted the doctor and a chest x-ray was ordered. A progress note for Resident #67, written on 3/5/19 at 1:04 PM, identified diminished breath sounds and a cough. The chest x-ray results noted (infiltrates in both lungs) and said [MEDICATION NAME] (an antibiotic) and [MEDICATION NAME] (for cough and thick mucus) were ordered by the physician. A progress note written on 3/6/19 at 5:05 AM, for the resident, said the antibiotic was not yet started, .resident to start antibiotic [MEDICATION NAME] this AM for pneumonia. Bilateral breath sounds with rhonchi (a course sound) with diminished bases (decreased sounds of air circulation in the lungs due to fluid build-up) . loose congested cough . unable to bring up sputum . On 3/6/19 at 9:56 AM, a progress note was written for Resident #67 .was told the resident had called 911 .resident stated she was having trouble breathing. Vitals were checked again, and oxygen was applied .Resident stated she wanted to go to the hospital .Resident left facility via (ambulance) at 7:30 AM. A review of the physician orders for Resident #67 identified the following order: [MEDICATION NAME] tablet 500 mg: Give 1 tablet by mouth one time a day for infection for 7 days. The order date was 3/5/19. The orders also indicated the medication was already available at the facility, Status: On hand. A review of the Medication Administration records for (MONTH) 2019 revealed: [MEDICATION NAME] tablet 500 mg, Give 1 tablet by mouth one time a day for infection for 7 days, start date 3/6/19 0800 (8:00 AM). The medication was not documented as given. During an interview at 8:45 AM on 5/16/19 related to Resident #67's change of condition, Physician [NAME] stated that the resident had a lung condition (ongoing) with expected complications. A chest x-ray was ordered on [DATE] and completed 3/5/19. The results were received at 1:00 PM on 3/5/19 with results-infiltrates/pneumonia. The physician said an antibiotic and [MEDICATION NAME] were ordered. Physician [NAME] was asked if he was aware that the resident never received the antibiotic and replied No, I was not. It should be given as prescribed by the physician. On 5/16/19 at 10:45 AM, an interview with Nurse J provided, We should have given the initial dose and initiated the routine dose. On 5/17/19 at 9:00 AM, the Director of Nursing (DON) was asked about Resident #67 not receiving an antibiotic ordered for a new [DIAGNOSES REDACTED]. The DON said the nurse was newer to the facility and possibly did not know the correct process. A review of the facility policy titled, Medication Administration, dated 9/18, revealed Medications are administered as prescribed in accordance with manufacturers specifications, good nursing principles and practices .

Based on observation, interview and record review, the facility failed to prevent facility-acquired pressure ulcers for 2 (#2, #6) of 6 sampled residents, resulting in Resident #2 sustaining a Stage II pressure ulcer that developed into a Stage IV of the left trochanter, and Resident #6 sustaining a Stage II pressure ulcer to the leg outer heel. Findings include: During an attempted record review of the facility policy for pressure ulcers, the state surveyor was notified by the Director of Nursing B that there was no policy and that the facility only went by manufacture's product recommendations. Resident #2: Record review of Resident #2's Minimum Data Set (MDS), dated [DATE], revealed [AGE] year-old male with a history of pressure ulcers. In an interview on 4/14/17 at 7:20 AM, Registered Nurse OO stated she was wound care certified, revealed that Resident #2 had developed a facility-acquired left ischial tuberosity (left hip) stage II (Partial thickness skin loss with exposed dermis)identified on 1/11/17. RN OO stated that the skin photos of the Resident #6's wounds are inconsistent and incorrectly labeled. After an observation by RN OO of the 1/11/17 skin/wound photo taken of Resident #6, RN OO stated that the photo is the left tuberosity and not the right hip. RN OO stated that the left hip facility-acquired wound developed into a stage IV (Full thickness skin and tissue loss) wound, which required a wound vac to promote healing. An observation on 4/12/17 at 2:10 PM with Registered Nurse OO of Resident #2's pressure ulcer dressing changes noted that there were new open areas with bloody drainage and when cleansed noted to the coccyx track area. Record review was conducted of a new physician's order, dated 4/12/17, to apply duoderm spots to the 2 open areas and change every 3 days. Observation on 4/13/17 at 3:20 PM of Resident #2's left ischial tuberosity (left hip) wound vac dressing change by unit manager Registered Nurse BB revealed a strong odor to the wound and measurements of 3 cm long X 4 cm wide X 4 cm depth. During the wound vac dressing change RN BB was noted to de-glove and re-glove a total of five times without washing her hands. Resident #6: Record review of Resident #6's Minimum Data Set (MDS), dated [DATE], revealed [AGE] year-old male with severely impaired cognitive abilities. The MDS was noted that the Resident was admitted with a fracture to the left hip and a history of falls prior to admission. The MDS noted that there were no pressure skin issues upon admission on 2/1/17. Record review of Resident #6's nursing progress note, dated 2/9/17 at 6:46 AM, revealed the nurse was called to the resident's room for an excoriated area to the left heel measuring 1.5 cm long X 2 cm wide. Observation on 4/12/17 at 1:20 PM with Registered Nurse (RN) Staff OO of Resident #6's left heel wound revealed that it was a facility-acquired stage II pressure ulcer and not a [MEDICAL CONDITION] due to the placement of the wound on the lateral side of the heel and was caused by the residents black dress shoes. Observation of the left foot wound dressing change revealed an estimated 2.25 cm X 1.5 cm wound with serosanguanoious drainage noted. RN OO stated that the pressure wound was avoidable and due to the resident's shoes. A record review of Resident #6's re-admission paperwork on 3/27/17, revealed that facility care plans for skin management did not address the new right [MEDICAL CONDITION] skin or staple monitoring for infection at the surgical site and there was no mention of left heel dressing changes or monitoring of the site.

Based on observation, interview and record review, the facility failed to ensure resident safety, provide supervision and prevent 2 residents with poor safety awareness from falls with injuries (sampled Residents #3 and #6) of 6 residents reviewed for falls of a total of 15 sampled residents, resulting in a head injury (for Resident #3), a fracture (for Resident #6), unnecessary pain, distress and hospitalization . Findings Include: Resident #3: Review of the Face Sheet, Minimum Data Set (MDS, resident assessment) dated 2/19/17, Electronic Medication Record, nurses, social service and physician note's dated 3/17 and 4/17, revealed Resident #3 was a [AGE] year old male, admitted to the facility on [DATE], alert and orientated with some confusion, non-ambulatory due to bi-lateral leg contractures and required staff assistant for all activities of daily living (ADL's). The residents [DIAGNOSES REDACTED]. The resident received Remeron 30 mg daily (an anti-depressant, given for major depression disorder) and Ultram 50 mg twice daily for pain (a narcotic-like pain medication) at the facility, both of these medications have side effects of possible drowsiness, dizziness, vision changes, loss of memory and fatigue, which would decrease safety awareness and increase fall risk. Observation of Resident #3 was made on 4/12/17 at 1:40 p.m., he was laying in his room in bed. The residents' bed was not in the lowest position, it was approximately waist height (3.5 feet high). When this surveyor asked the resident if he had a bed height preference, he said no. Review of Resident #3's Safety care plan dated 11/8/16, revealed documentation the resident was to have a hi/lo bed and stated it should be kept in the lowest position I (the resident) tolerate when I'm in it and raised as needed for care and transfers, Date initiated 11/8/16. Review of the residents Safety care plan dated 11/8/16, revealed on 4/12/17 (the day this surveyor observed the resident was not in a hi-lo bed) his care plan had been up-dated to not include that he was to be in a hi-lo bed, it was removed from the care plan on 4/12/17. Review of the nurses' note dated 3/19/17 at 10:03 a.m., stated this writer called to resident's room by CNA and observed resident laying on his right side, assisted resident back to bed. Observed a laceration above right eye that measures 4 x 2 x .5 cm. Cleaned area and applied pressure to slow bleeding. Resident left with (ambulance) at 0845 (8:45 a.m.). Review of the hospital records dated 3/19/17, revealed Resident #3 was transferred to the hospital after a fall (on 3/19/17) resulting in a laceration and he received sutures to his right forehead. The hospital records (dated 3/19/17) said a [AGE] year old male presented to the emergency roiagnom on [DATE] following a fall at the facility and stated he explains that he was waiting for breakfast in bed when he began to feel dizzy and rolled out of bed, hitting his head on the table (bedside table). Patient has Steven Johnso[DIAGNOSES REDACTED] (immune complex involving the skin and mucous membranes) and is unable to ambulate. Review of the incident report and nurses note's dated 3/19/17, revealed on 3/19/17 at approximately 8:20 a.m., the resident was found on the floor of his room lying on his right side with a bleeding laceration (4 cm x 20 cm x .5 cm) above his right eye. The resident said he was trying to roll over in bed and he rolled to far. The resident was orientated to person, situation, time and place and had poor safety awareness, confusion, impaired memory with a predisposing factor being improper bed height. During an interview done on 4/13/17 at 8:00 a.m., staff member J (Physical Therapist/PT) was asked by this surveyor to go see the resident and after looking at his bed and his contracted legs he stated he pushes his whole body, my suggestion is a wide bed. During an interview done on 4/12/17 at 1:20 p.m., staff member H (Charge Nurse, LPN) stated he (the resident) was laying on his side, face down in a puddle of blood. He had a laceration above his eye brow on the right side. His bed was in the highest position, it should of been in the lowest, he didn't have a hi-lo bed, his bed was approximately 4 feet up (measured by team sanitation member using an electronic tape measure per staff member H given distance from the floor to her given height). I have to ride the CNA's (assigned CNA on 3/19/17), I didn't tell anyone because it doesn't matter, if I wrote her up nothing would of happened. I think she should have been written-up, I have told her several times to not leave the bed up. I feel if his bed would of been in the low position, injuries would of been minimized. During an interview done on 4/12/17 at 2:12 p.m., staff member G (Nursing Assistant/CNA) stated I heard them say he (the resident) was on the floor. I didn't read his care plan (a guide to the residents care), we have never had his bed in the low position. When he was on the floor by his bed, his bed was in the regular position, not the low position. He doesn't have any positional devices, he moves the upper part of his body. His bed should of been in the low position, no one questioned me about his fall and the bed position (improper bed height was documented on the facility Incident Report dated 3/19/17), so I should have been written up. During an interview done on 4/12/17 at 2:43 p.m., staff member E (MDS Nurse, RN) stated our facility doesn't use mats. This survey accompanied by staff member went into supplemental Resident #19's room and on the floor was observed a floor mat. During an interview done on 4/13/17 at 7:00 a.m., staff member I (CNA) stated we were passing trays (on 3/19/17 at the time of the residents fall), he was on the floor at the time. He was on the side of his bed facing his bathroom. The bed was in the high position. There was a lot of blood and he said his head was hurting, he said he was in pain. I feel it could have been prevented and he does scoot down (in his bed), he can't push himself back up because he's contracted. You are supposed to put the bed low, that's the protocol. Review of the facility Falls Reduction Program dated 9/25/16, stated Purpose: To provide a safe environment for residents, modify risk factors, and reduce risk of fall related injury. If fall occurs Charge Nurse to complete the following: Immediate interventions as identified by physical assessment and environmental observation. On the Incident report dated 3/19/17, it was documented that the resident's bed was at a improper bed height. Upon observation made on 4/12/17 at 11:35 a.m. and on 4/14/17 at 11:35 a.m., the resident was observed to be in a regular bed, not a high-low bed and on both observations it was noted that his bed was not in the lowest position. Review of the facility Falls in service dated 7/15/16, revealed staff had been educated on fall preventive measures. Record review of facility 'Falls Reduction Program' policy, dated 7/1/2008, revealed the purpose is to provide a safe environment for residents, modify risk factors, and reduce risk of fall-related injury. If a fall occurs, do incident report and neurological assessment. Interdisciplinary team is to review each incident and complete a root cause analysis. Resident #6: Record review of Resident #6's Minimum Data Set (MDS), dated [DATE], revealed an [AGE] year-old male with severely impaired cognitive abilities. The MDS noted that the Resident was admitted with a fracture to the left hip and a history of falls prior to admission. Record review of Resident #6's 'Fall assessment' form, dated 3/22/17, revealed that the resident was observed on the floor with facial grimacing and guarding the right hip. The Resident received x-rays and was transported to hospital for fractured right hip. Record review of all witness statements related to the incident revealed that the resident was found on the floor. Record review of Resident #6's emergency room record, dated 3/23/17, revealed the resident was seen post fall 5 hours after the fall from a wheelchair that resulted in a right hip fracture, which required surgical repair. Record review of Resident #6's electronic and paper medical records revealed that there was no neurological monitoring of the resident who was found on the floor with a fractured hip and was sent to the hospital 5 hours post fall. In an interview on 4/12/17 at 3:35 PM with the Director of Nursing B, the state surveyor requested the facility investigation and root cause analysis of Resident #6's fall with fracture, which occured in the facility. The Director of Nursing stated that she gave the surveyor the unusual/incident report and nurse's note and that was all that the facility had and that she had nothing else to give the surveyor related to the fall with fracture incident.

Based on observation, interview and record review, the facility failed to provide goods and services necessary to provide and perform cardio-pulmonary resuscitation (CPR) for one of six residents (Resident #310) in a total survey sample of 15 residents and eight supplemental residents, whose code status indicated the necessity for CPR in the event of a [MEDICAL CONDITION], causing a delay in the resident not receiving life-sustaining interventions by the facility, resulting in Immediate Jeopardy. On Monday, [DATE] at 5:55 AM, Resident #310 went into respiratory arrest. When the facility crash cart was brought into Resident #310's room, the crash cart had a suction machine that did not work, lacked an oxygen mask, an oxygen tank, an Ambu bag (used to deliver oxygen to the lungs), a backboard, and a non-rebreather mask. As a result, with the exception of chest compressions, CPR was not performed, and the suctioning necessary to clear the resident's airway of vomitus could not be performed, until emergency responders arrived in the facility. Findings include: According to Resident #310's face sheet, dated [DATE], Resident #310 was a sixty-eight year old female, who was admitted to the facility with the following Diagnoses: [REDACTED]. In addition, Resident #310 had a pacemaker. On [DATE] at approximately 5:55 AM, a Code Blue (a code used to identify a resident in need of immediate life-saving resuscitation) was broadcast over the facility's public address system. An observation was made of a staff member running into Resident # 310's room carrying a back board used for cardio-pulmonary resuscitation (CPR). Multiple staff members were observed surrounding Resident #310, who was lying in bed in her room. A crash cart was in the room. Registered Nurse (RN) A was heard screaming for staff to turn Resident #310 so as to position the backboard beneath her so that chest compressions could be administered. Resident #310 began to vomit and RN A attempted to suction her. However, the suction machine was not working. RN A was heard yelling for someone to locate an oxygen mask, because there was no oxygen mask on the crash cart. There was no Ambu bag (bag used to assist respirations during a resuscitation attempt) on the crash cart. An oxygen tank was observed being wheeled into the room, because there was no oxygen tank on the crash cart. An AED (automated external defibrillator) was seen on the crash cart, but staff did not attach the AED to Resident #310 to determine if Resident #310 had any cardiac activity. Because RN A had not been able to clear the resident's airway of vomitus by suctioning her, the staff had to stop chest compressions, and roll Resident #310 on her side to clear her airway before emergency responders arrived. When the emergency responders entered Resident #310's room at 6:10 AM, they supplied a suction machine, an Ambu bag, and an AED. MedlinePlus, a service of the National Library of Medicine (as downloaded from their website on [DATE]) describes the effect of minutes lost during CPR: .permanent brain damage begins after only 4 minutes without oxygen and death can occur as soon as 4 - 6 minutes later. According to documentation entered onto the facility's Plan for the Removal of Immediate Jeopardy [DATE], Resident #310 expired at the hospital on [DATE] at 1:00 PM. In an interview on [DATE] at 7:15 AM, Registered Nurse (RN) A stated that there had been an earlier Code Blue at the facility on [DATE] at 9:00 PM and the crash cart had not been restocked. RN A noted there was no oxygen mask on the crash cart, no oxygen tank, no Ambu bag, and no non-rebreather mask. The backboard was not on the crash cart. In addition, the facility's suction machine was not working. RN A said Resident #310 had become diaphoretic (sweating), nauseated and then lost consciousness. In an interview on [DATE] at 8:30 AM, Licensed Practical Nurse (LPN) C stated there was only one crash cart in the facility. On [DATE] at 8:35 AM, a record review of a note posted over the crash cart, dated [DATE], reflected the following message: if any item is removed from this crash cart, you need to replace it as soon as possible or inform nursing management so that it can be replaced in a timely manner. A record review of the facility's ER Cart Checklist for [DATE] indicated the crash cart had not been checked on [DATE], [DATE], or from [DATE] to [DATE]. In addition, the checklist indicated the contents were inventoried on [DATE] by RN A with the following comments: * O2 tank with nasal cannula - none, * Backboard - no, * Ambu bag/mask - no mask, * Non-rebreather mask - no. On [DATE] at 9:00 AM, a record review of the facility's Emergency Cart Scope of Practice, dated [DATE], documented it is the responsibility of nursing to visually verify each Emergency Cart daily and document on the ER cart audit form that a check has been completed. When the lock/seal is broken and items are used, it is the nurses' responsibility to have the cart restocked and resealed. On [DATE] at 10:00 AM, record review of a hand-written note documented by RN A noted the following comments: back board was obtained from room where crash cart is stored .while in code situation, suction did not function properly .there was no mask for ambu bag .(and) .ambu bag was obtained from external emergency responders and then used. The Administrator was notified on [DATE] at 1:15 PM of the Immediate Jeopardy that began on [DATE] at 5:55 AM. On [DATE] at 11:15 AM, it was confirmed by surveyor observation, interview and record review that the facility had implemented the following to remove the immediate jeopardy (IJ): - All residents, who wished to have Do Not Resuscitate (DNR) status, had a pink DNR paper in the Medication Administration Record [REDACTED]. Nurse Managers and social workers reviewed the Advanced Directives of all residents on [DATE] at 7:00 AM. The MAR indicated [REDACTED] - The Director of Nursing reviewed the Emergency Cart Policy on [DATE] at 1:30 PM. The policy was revised to reflect it was the nurse's responsibility to restock the cart after a code before they leave the building. - The facility ordered and received additional suction machines, CPR boards, suction tubing, suction canisters, Ambu bags and CPR micro-shields on [DATE] and [DATE]. - The Assistant Director of Nursing/Staff Development Coordinator (ADON/SDC) re-educated the licensed nurses on [DATE] at 2:30 PM and at 3:30 PM, 4:00 PM, and 6:00 PM; and education continued on [DATE] at 6:14 AM, 1:59 PM, 2:40 PM, 2:54 PM, 3:10 PM, 4:25 PM, and 6:15 PM on the revised Emergency Cart Policy. The facility had 27 licensed nurses on staff. As of [DATE], twenty-two nurses had attended the education and demonstrated understanding. Any nurses excluded from the education, will have education provided by the DON or ADON prior reporting to duty for their first scheduled shift. - The Assistant Director of Nursing/Staff Development Coordinator (ADON/SDC) will report findings to the Quality Committee monthly. The DON is responsible for compliance with this concern. - There was additional documentation for education lesson plan, signature of licensed nurses, and signatures from the Emergency Quality Assurance Committee Meeting. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity of no actual harm, with the potential for more than minimal harm that is not immediate jeopardy, due to all nursing staff having not yet been in-serviced and the facility's ability to sustain compliance, pending verification by the State Agency.

This citation pertains to intake #MI 871. Based on observation, interview and record review, the facility 1) failed to ensure a resident's leaning-forward behavior was assessed and the appropriate safety interventions were in place for 1 of 5 residents (#501) reviewed for falls from a total sample of 5 residents and 2), and failed to ensure 20 of 41 supplemental sample residents (#506, #507, #508, #509, #510, #511, #512, #513, #514, #515, #516, #517, #518, #519, #520, #521, #522, #523, #524 and #525) with wheelchair alarms had alarms that were properly functioning, resulting in head and facial trauma with lacerations, severe bruising and hospitalization for resident #501, and an increased potential for more than minimal harm to the 20 residents (in a total facility census of 63 residents) who had a delayed alarming or non-functioning wheelchair alarms noted. Findings Include: Due to the requirements of the Health Insurance Portability and Accountability Act, the findings in this report are limited. Review of the Face Sheet, Nurses and physician progress notes [REDACTED].#501 was an [AGE] year old male, admitted to the facility on [DATE], was aphasiac (unable to speak) following a stroke, and dependent on staff for all activities of daily living, transfers, positioning and required assistance for feeding. The resident's [DIAGNOSES REDACTED]. The resident had a fall at the facility on 12/8/13, was transferred to the hospital and admitted with facial injuries. Review of the facility admission Data Collection dated 12/3/13, revealed the resident was "A & O x 0 (i.e., was not alert and orientated), did not speak, non-interviewable, slow to understand, a 2 person transfer and was not able to move all his extremities. Review of the facility Physical Therapy Evaluation and Treatment dated 12/4/13 (prior to Resident #501's fall on 12/8/13) stated, "decreased judgment and reduced static and dynamic balance, LE (lower extremities) muscle tone=spastic, coordination=impaired, visual=impaired, cognition follows direction=one step, safety awareness=impaired. Patient exhibit deficits with all functional activities at this time and pt. (patient) unable to stand and decreased trunk control for sitting balance." Review of the facility nurses notes dated 12/4/13 (no time documented, prior to the residents fall on 12/8/13) stated, "appears to not understand, appears frightened, tremors to both hands." Review of the admission cognition care plan dated 12/3/13, revealed staff were to anticipate the residents needs and observe for non-verbal cues. Review of the admission fall risk care plan dated 12/3/13 and Care Guide (un-dated), revealed the resident was to have a bed and chair (wheelchair) alarm due to his increased risk for falls. Review of the facility incident report dated 12/8/13, revealed at 5:15 p.m., resident #501 was found on the floor by staff with facial bruising and laceration. The incident report stated, "Res (Resident #501) was sitting in hallway in W/C (wheelchair), looked and res was lying on floor. Hematoma (extensive bruising) above R (right) eye, abrasion to R side of face, eye and nose. Resident was seated in wheelchair in hall; this writer heard a thud and looked in the direction of the noise and observed (Resident #501) on floor in front of his wheelchair. Brief description of plan to avoid this situation in the future, offer diversional activities, toilet when resident appears agitated, PT/OT (physical and occupational therapy) referral for half lap tray for positioning and seated balance." Review of the facility Patient Transfer Form dated 12/8/13, revealed Resident #501 was transferred to the hospital due to "not responding as usual." Review of the nurses notes dated 12/8/13 (no time documented), stated "Res (Resident #501) noted on floor in hallway, Res has large hematoma above R (right) eye with laceration, abrasion to R side of face, eye and nose, pupils unequal (a sign that the residents neurological status had changed due to his fall). Noted res to have increased tremors today." Review of the hospital records dated 12/8/13, revealed resident #501 was admitted to the hospital in critical condition with a primary [DIAGNOSES REDACTED]. The hospital was unable to accurately assess the resident's state of consciousness due to his aphasia following a prior stroke and documented this as "unspecified state of consciousness." Review of the hospital History of Present Illness dated 12/8/13 at 6:39 p.m., stated "[AGE] year old male, brought in by EMS (emergency medical services), after staff reported him to not be at his normal baseline in terms of interaction. He is normally borderline minimally communicative, and upon presentation not talking. He does respond to some commands, and acknowledges that he has pain in both his head and right arm. The patient has a large right supraorbital hematoma with significant swelling, anisocoria (pupils not equal in size, a sign of a neurological problem), left eye dilated to 4 mm, sluggishly and incompletely reactive, right eye 3 mm and reactive. ED (emergency department) Course: The patient also demonstrated weakness of the right upper extremity as compared to the left. When the patient returned from CT (having a cat scan of his brain), his mental status did appear reduced from prior presentation, did appear less interactive. Condition: Guarded, he is admitted to the neuro step down unit (neurological unit) for close observation and family understands that his condition is critical." Review of the CT of the head dated 12/9/13 performed at 6:49 p.m., stated "A small subdural hematoma at the posterior aspect of the left temporal and parietoccipital area remains unchanged in the interval examination, soft tissue swelling at the anterior aspect of the right eye." Review of the hospital Trauma Evaluation dated 12/8/13 at 9:23 p.m., stated "questionable subdural hematoma, right periorbital hematoma, admit to trauma service." Review of trauma service progress note dated 12/9/13 at 10:55 p.m. stated, "Continues to have swelling of right-orbital area and eye-lid making it hard to open his right eye." Review of the neurosurgery inpatient progress note dated 12/10/13 at 7:42 p.m., stated "He (the resident) now has pain in both his head and right arm." Review of the facility's Charge Nurse (RN), staff member "E's" written statement dated 12/8/13 (date of the resident's fall), stated, "Resident observed on floor in 200 hall, no alarms sounding." An interview was done on 12/17/13 at 1:35 p.m. in the facility conference room, with Nursing Assistant staff member "G". Staff member "G" (assigned on 12/8/13 to the hall the resident had resided on) stated, "he (resident #501) was in bed about 4:00 p.m.; I got him up before 4:30 p.m. I put him in his wheelchair by the shower room. My nurse (staff member "E") was down the hall passing pills. I got an alarm, a bed alarm; I folded the bed alarm in half and put it under his wheelchair cushion (staff member "G" said she was unable to find a wheelchair alarm pad so she used a bed alarm pad). When the alarm (the folded bed alarm) went off, it was a real low hum only; you had to go up close to hear the alarm. I did see him (the resident) lean to the side before he fell that night, his family member had told me (prior to 12/8/13) he had fallen before, we knew it. We don't have lap buddies (soft cushions that can be placed between wheelchair arms to assist in positioning and remind residents not to get up), we have tray tables, I never suggested it (a tray table to put in front of the resident while in his wheelchair to decrease his leaning forward)." An interview was done on 12/17/13 at 2:28 p.m., with staff member "E" in the conference room. Staff member "E" (assigned on 12/8/13 to the hall the resident was on) stated "I gave him (resident #501) a glass of juice, earlier I noted he was a little more shaky than usual, his cup was shaking (the resident had Parkinson's disease which can cause shakiness, unsteadiness and balance problems). I was standing at my med cart (medication cart) with my left side to him, the post and computer was blocking my view, I would have had to stand up and lean my head back to see him. (Charge nurse LPN, staff member "F") was at her med cart then (staff member "F") said "we are all going", I didn't know what she meant; Iooked and he (the resident) was on the floor. The alarm (the folded bed alarm in his wheelchair) was not sounding. (Staff member "F") said she heard a thug, she heard him (Resident #501) hit the floor. His face was planted on the floor. He has a history of leaning forward in his wheelchair, I did see him leaning about every time I saw him in his wheelchair, people (other staff) knew he leans forward." When this surveyor asked staff member "E" why the resident did not have safety interventions in place specific to his frequent behavior of leaning forward, she stated "they (nursing staff and management) did not get that far in the process. He had a large hematoma (bruise) above his right eye, an abrasion to the right side of his face, he was not responding like he normally does. His right pupil was smaller than the left (a clinical sign of a neurological problem, the resident had fallen and hit his head on the floor), so we sent him to ER (the emergency room )." Staff "E" was asked if she was aware that staff had taken a bed alarm and folded it in half (and used that instead of an alarm specifically designed for use in a wheelchair), and put it under the residents wheelchair cushion, and she said, "no". Further review of Resident #501's clinical record failed to reflect any safety interventions that specifically addressed the resident's behavior of leaning forward in his wheelchair. Review of Charge Nurse (LPN), staff member "F's" written statement dated 12/8/13, revealed the following: "I heard a single loud sound, I turned to see what the noise was and I observed (Resident #501) on the floor, laying on his R (right) side, his wheelchair was within two feet of where he was laying." An interview was done on 12/18/13 at 9:00 a.m. and at 9:27 a.m., in the conference room, with staff member "F". Staff member "F" (assigned on 12/8/13 to the unit the resident had resided on) stated "I heard a thump; I can't say the alarm was going off, I did not hear it." When this surveyor asked staff member "F" if she had heard the residents alarm sounding when he fell , face first out of his wheelchair on 12/8/13, she replied, "no". Staff member "F" stated "I heard a thug, he was on his right side (on the floor), he was looking up a little bit. He did not say anything; he just made eye contact and shrugged his shoulders. He had a hematoma about 4 cm above his right eye. He was sent out (to the hospital) due to a head injury." An interview was done on 12/17/13 at 4:00 p.m., with the Director of Nursing (DON). The DON stated "no, I was not aware they (CNA's) were folding a bed alarms and putting them in resident's wheelchairs." A phone interview was done on 12/18/13 at 1:41 p.m., with staff representative #1 from the bed and wheelchair alarm company that the facility used to purchase resident alarms. When asked by this surveyor if it was appropriate to fold the bed alarm (that their company sells) in half, and use it in a wheelchair as a wheelchair alarm device, representative #1 stated, "I wouldn't recommend that, use the chair (wheelchair) alarms." Review of the facility Alarm Devices policy dated 7/08, read: "The purpose of alarm devices is to alert staff to aid in the prevention and/or reduction of resident accidents and falls, to ensure the proper functioning alarm systems and devices." Observations made on 12/17/13 at 3:24 p.m. to 4:55 p.m., of the functionality of all facility residents with wheelchair alarms, done by the Director of Nursing, Nurse Manager (RN) staff member "C", staff member "D" and surveyors were as follows: At 3:24 p.m., in the resident's room, supplemental resident #506's wheelchair alarm had a 2 second delay in response time when the resident was assisted up from their wheelchair. During interview at the time of observation, the DON agreed the alarm should have sounded immediately upon activation (when the resident stood up) in order to alert staff to a potential impending fall. At 3:25 p.m. in the 200 hall shower room, supplemental resident #507's wheelchair alarm had a 3 second delay in response time when the resident was assisted up from their wheelchair. At 3:30 p.m. in the 200 hall shower room, supplemental resident #508's wheelchair alarm had a 2 second delay in response time when the resident was assisted up from their wheelchair. At 3:37 p.m. in the resident's room, supplemental resident #509's wheelchair alarm had a 5 second delay in response time when the resident was assisted up from their wheelchair. At 3:44 p.m. in the resident's room, supplemental resident #510's wheelchair alarm had a 1 second delay in response time when the resident was assisted up from their wheelchair. At 3:46 p.m. in the resident's room, supplemental resident #511's wheelchair alarm had a 2 second delay in response time when the resident was assisted up from their wheelchair. At 3:50 p.m. in the resident's room, supplemental resident #512's wheelchair alarm had a 2 second delay in response time when the resident was assisted up from their wheelchair. At 4:03 p.m. in the resident's room, supplemental resident #513's wheelchair alarm had a 1 second delay in response time when the resident was assisted up from their wheelchair. At 4:10 p.m. in the resident's room, supplemental resident #514's wheelchair alarm had a 1 second delay in response time when the resident was assisted up from their wheelchair. At 4:22 p.m. in the resident's room, supplemental resident #515's wheelchair alarm had a 3 second delay in response time when the resident was assisted up from their wheelchair. At 4:25 p.m. in the resident's room, supplemental resident #516's wheelchair alarm had a 1 second delay in response time when the resident was assisted up from their wheelchair. At 4:26 p.m. in the resident's room, supplemental resident #517's wheelchair alarm had a 3 second delay in response time when the resident was assisted up from their wheelchair. This was a folded bed alarm pad. At 4:31 p.m. in the multi-purpose room, supplemental resident #518's wheelchair alarm had a 4 second delay in response time when the resident was assisted up from their wheelchair. At 4:33 p.m. in the resident's room, supplemental resident #519's wheelchair alarm had a 2 second delay in response time when the resident was assisted up from their wheelchair. This was a folded bed alarm pad. At 4:37 p.m. in the multi-purpose room, supplemental resident #520's wheelchair alarm had a 6 second delay in response time when the resident was assisted up from their wheelchair. At 4:40 p.m. in the resident's room, supplemental resident #521's wheelchair alarm had a 6 second delay in response time when the resident was assisted up from their wheelchair. Observations made on 12/17/13 at 3:24 p.m. to 4:55 p.m., of residents with wheelchair alarms that did not alarm when tested by the Director of Nursing, Nurse Manager (RN) staff member "C", staff member "D" and surveyor were as follows: -At 4:14 p.m. in the resident's room, supplemental resident room #522's wheelchair alarm did not alarm, at all, when the resident was assisted up from their wheelchair. -At 4:15 p.m. in the resident's room, supplemental resident #523's wheelchair alarm did not alarm, at all, when the resident was assisted up from their wheelchair. -At 4:12 p.m. in the resident's room, supplemental resident #524's wheelchair alarm did not alarm, at all, when the resident was assisted up from their wheelchair. -At 4:55 p.m. in the resident's room, supplemental resident #525's wheelchair alarm did not alarm, at all, when the resident was assisted up from their wheelchair. An interview was done on 12/17/13 at 4:00 p.m. in the hallway, in private, while checking residents wheelchair alarms with the DON. The DON stated, "we did have a problem with alarms and staff are supposed to check them every shift." Review of the Nurse and CNA (Certified Nurse Aide) meeting documentation dated 12/11/13, revealed staff had been educated on the importance of checking resident alarms. The documentation stated, "alarms must be checked each and everytime (every time) you place a resident in the bed or chair. If an alarm does not work, you must see that it is replaced." Review of the Nurse Meeting documentation, dated 4/16/13, revealed that facility staff had been educated that, upon admission, all residents are at risk for falls. Review of the facility Falls Reduction Program, dated 3/16/12, revealed upon residents' admission to the facility, staff were to determine if they were at risk for falls; if identified as being at risk for falls, then staff were expected to initiate safety procedures and individualize interventions on the admission care plan. ( ) On 12-17-13 at 1:40 p.m. Nurse Aide Staff "G" was interviewed. Staff "G" was asked if she remembered resident #501, and if she was working the day he fell . Staff "G" said yes, she remembered him and was working the day he fell . When asked to tell what she knew about the resident and his fall, Staff "G" explained resident #501 had been in bed and she had needed to get him up. Staff "G" said she gathered all supplies prior to getting the resident out of bed. Part of the process was checking the alarm, and she saw Resident #501 did not have a wheelchair alarm. Staff "G" said she had to go and get one, but she couldn't find a chair sensor alarm pad, so she took a bed sensor alarm pad, instead, folder it in half and placed it in the resident's wheel chair. She then placed the resident's chair pad on top of it. Staff "G" said she then got the resident (#501) up and put him in the wheel chair. Staff "G" said she then was leaving for break. As she walked past the resident (#501), he was sitting in his wheel chair in the hallway by the shower room. When Staff "G" was asked during the interview where the nurses were, Staff "G" said the nurses were passing pills. Staff "G" said she had just passed the resident (#501) in the hallway and turned the corner when the nurse (staff "E") told her to come back, the resident (#501) had fallen. Staff "G" was asked if the alarm was sounding. Staff "G" said she had to lean close to the alarm box to hear it; it was a "low sounding hum." Staff "G" was asked if she ever had any alarms that didn't work. Staff "G" said she had another resident with an alarm that didn't work. The alarm didn't sound until the resident was in the bathroom. Staff "G" was asked what she did when the alarm didn't work. Staff "G" said she told the nurse. However, when specifically asked if she had told the nurse that she had to use a bed sensor pad, because she couldn't find a wheel chair sensor pad, Staff "G" said, no. Staff "G" was asked if she ever saw resident #501 lean forward in his chair. Staff "G" said she never saw him lean forward, if he had (leaned forward), she would have repositioned him. Staff "G" said the resident's family had told her he had fallen at home before. When asked if she thought the resident could have benefited by having a lap buddy, seat belt or tray table, staff "G" said she had thought about it, but didn't suggest it to therapy. During observation on 12-17-13 at 1:55 p.m., in the supply room, Staff "G" pointed to a large wire bin and said the alarms and sensor pads were kept here. All of the alarm sensor pads were removed from the wire bin. When asked if there were any chair alarm sensor pads, Staff "G" said she could not find any alarms for chairs, just the bed alarm sensor pads. Immediately following that observation, an unused facility wheel chair was obtained from the facility lobby. Staff "G" demonstrated how she had folded the bed alarm sensor pad for resident #501 in half and placed it in the resident's wheel chair. A chair cushion pad was then placed on top of the bed alarm sensor pad. During the demonstration, the second time the bed alarm sensor pad was sat on and released, the alarm did not sound. On 12-17-13 at 2:25 p.m., Staff Nurse "E" was interviewed. Staff "E" was asked what she knew about resident #501's fall on 12-8-13. Staff "E" said the resident was propelling himself in his wheelchair down the hall. The resident (#501) was in the hall beside the supply room when she gave him a glass of juice. Staff "E" said she noticed his hands were shaking more than the day before. Staff "E" continued to say, she had been by the resident (#501) in the hallway a couple of times, and he was sipping his juice. She went to the medication cart in front of the nurses' station, with her left side to the resident. Staff "E" said she was then unable to see the resident (#501) because of a post and a computer were blocking her view. Another staff nurse "F" was at her medication cart. The aide (staff "G") had just walked past him (resident #501), went around the hallway corner, and said she was going to go to break. Staff "E" said she heard him (the resident) and looked and he was on the floor. His face was down on the floor. Staff "E" was asked if the alarm was sounding. Staff "E" said the alarm was not sounding. Staff "E" said she checked the resident over and rolled him on his back. He had a large, large hematoma (an accumulation of blood with in the tissue that clots to form a solid swelling) on his forehead with an abrasion to his cheek. Staff "E" said they put him (resident #501) to bed, and he just wasn't responding like he normally did, his pupils were not right. The right pupil was not reacting and his right eye was swollen, so she sent him out (to the hospital). When asked if she knew that facility aide staff were taking bed sensor pads and using them in the residents' wheelchairs, Staff "E" said she did not know the aides were taking bed sensor pads and using them in the wheelchairs. Staff "E" was then asked if the facility had any problems with alarms not working. Staff "E" said, not until yesterday, when she found a resident's alarm that was hesitant in working. Staff "E" said she had told the aide to change the batteries in the alarm box. When asked if the aide did change the batteries, Staff "E" said she did not know.

This citation pertains to intake number MI 137. Based on interviews and record review, the facility failed to: 1) follow physician orders [REDACTED].#101), from a total sample of 6 residents reviewed for Physician orders [REDACTED]. Findings include: The professional standard of quality for physician orders [REDACTED]. The Professional Standard of Quality for documentation of the residents health care in a medical record is the information must be true and complete. (Fundamentals of Nursing, Concepts, and Practice. Mosby. Potter, P.A., Perry, A.G., 1985) The face sheet revealed Resident #101 was a [AGE] year old woman who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician orders [REDACTED]. During an unannounced, on site investigation conducted 7/24/2013, Resident #101's medical file was reviewed; according to the Nurses' Notes, there were no direct visual inspections/assessments of the wound (examinations performed with dressings removed) documented as performed on Resident #101's right residual limb, by facility staff, for the dates 6/4/2013, 6/5/2013, 6/6/2013, 6/7/2013, and 6/8/2013. During interviews on 7/11/2013 at 3:05 PM with Licensed Practical Nurse (LPN) #15, on 7/11/2013 at 3:25 PM with Registered Nurse (RN) #16, on 7/11/2013 at 3:40 PM with LPN #17, on 7/11/2013 at 3:50 PM with LPN # 18, on 7/12/2013 at 8:00 AM with LPN #22, and on 7/15/2013 at 8:00 AM with RN #19, nurses said they had not provided wound dressing changes to Resident #101's right residual limb, as ordered. During an interview on 7/11/2013 at 11:40 AM, Wound Care Nurse (WCN) #4 said the facility had been notified on 6/8/2013 (untimed), by an off-campus [MEDICAL TREATMENT] nurse, that Resident #101 had been sent to a local hospital for evaluation of her complaint of right residual limb pain and presence of a "large amount of purulent drainage and wound dehiscence" (Patient Assessment Documentation, dated 6/8/2013; untimed). Wound Care Nurse #4 said the [MEDICAL TREATMENT] nurse (#13) reported on 6/8/2013, the presence of a dressing on Resident #101's right residual limb that was dated 6/3/2013. "The only dressing changes that were done during her stay (6/3/2013 through 6/8/2013) were done by me on 6/3/2013. I asked the nurses why they initialed the TAR (Treatment Administration Record) as if the daily wound dressings were changed; I got a lot of 'I don't knows.' Seven or eight nurses were disciplined." According to the Operative Report dated 6/10/2013 at 8:27 PM, Resident #101 was diagnosed by Vascular Surgeon #24, preoperatively, with "failed right BKA (below knee amputation) flap with gangrene and soft tissue infection." The post-operative [DIAGNOSES REDACTED]." The operation performed was documented as "Right above knee amputation." During an interview on 7/11/2013 at 2:35 PM, Resident #101's attending physician (Witness #3) said he had provided wound care orders on 6/3/2013 at 6:00 PM to the facility wound care nurse (witness #4). He said, "I wasn't notified my orders weren't followed. I expect my orders to be followed." During an interview on 7/15/2013 at 9:25 AM, DON #2 said, "some of my nurses didn't do the wound care as ordered; that's what they claim. I expect doctor's orders followed, unless it's substandard care; then I want to be notified, and I'll talk with the Medical Director for advice."

This citation pertains to intake number MI 137. Based on interviews and record review, the facility failed to provide post-amputation wound care/assessments, as ordered by an attending physician, for 1 of 6 sampled residents (#101), from a total sample of 6 residents reviewed for wound care, resulting in deterioration of medical condition (infection of the Resident #101's right residual limb, a below knee amputation, with [MEDICATION NAME] Resistant [MEDICATION NAME]/VRE and [MEDICAL CONDITION] Resistant Staph/MRSA infections), transfer to a local hospital for evaluation in the emergency department, subsequent admission to the intensive care unit, and surgical intervention which included additional amputation of her right residual limb (right above knee amputation). Findings include: Resident #101 was no longer residing at the facility during the complaint investigation. The face sheet revealed that Resident #101 was a [AGE] year old woman who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Admission Data Collection form dated 6/3/2013 at 6:00 PM, Resident #101 was admitted to the facility with "bilateral below-knee amputations with history of gangrene." The Physician orders [REDACTED]. physician, 6/3/2013 to be administered, orally, to Resident #101, but was determined by culture/sensitivity performed of her right residual limb on 6/8/2013, that identified organisms - [MEDICATION NAME] Resistant [MEDICATION NAME]/VRE and [MEDICAL CONDITION] Resistant Staph/MRSA - were resistant to the use of the [MEDICATION NAME]. The manufacturer of [MEDICATION NAME] Ag wound dressings states the dressings provide "protection [MEDICAL CONDITION] and VRE."). According to the Nurses Notes dated 6/8/2013 at 9:00 AM, "Resident (#101) alert and oriented, yelling out in pain. Scheduled Oxy. ([MEDICATION NAME]; narcotic pain medication) given along with scheduled [MEDICATION NAME] (narcotic pain medication)." The Nurses Note dated 6/8/2013 at 9:45 AM documented Resident #101 refused to go to [MEDICAL TREATMENT], and a family member was notified, by phone, to "come to the facility to talk to her mother (Resident #101)." An addendum was added to the Nurses Notes, dated 6/8/2013 at 3:20 PM, that "Clarification of charting: wound care being provided as ordered to bilateral stumps; dressings not checked or changed on my shift (6 a - 6 p) due to resident not returning to facility after [MEDICAL TREATMENT]." According to the Patient Assessment Documentation dated 6/8/2013 (untimed), Registered Nurse (RN) #13, a [MEDICAL TREATMENT] nurse performing Resident #101's [MEDICAL TREATMENT], received a complaint of right residual limb pain from the Resident "who was moaning and praying." The Resident's daughter (witness #26) was documented as present "at chair side." RN #13 was documented as removing the dressing, finding presence of a "large amount of purulent drainage and wound dehiscence." RN #13 documented that the wound dressing of the Resident #101's right residual limb was dated 6/3/2013. Documentation by RN #13 included that e Resident #101's [MEDICAL TREATMENT] was interrupted to provide emergent transfer of Resident #101 to a local hospital for evaluation. During a phone interview on 7/24/2013 at 9:30 AM, RN #13 said, "She (Resident #101) was here on 6/8/2013 for [MEDICAL TREATMENT]. She was in a lot of pain. I looked at the wound of her right stump; she was in so much pain. The wound was draining a lot. I sent her to the hospital. Her right lower extremity dressing was dated 6/3/2013. The right lower extremity stump had bloody, purulent drainage, and the wound had dehisced." During a phone interview on 6/27/2013 at 3:50 PM, Resident #101's daughter (witness #26) said a [MEDICAL TREATMENT] nurse (#13) was performing [MEDICAL TREATMENT] on her mother on 6/8/2013, when her mother screamed out in pain, indicating the pain was of her right residual limb. Witness #26 said the [MEDICAL TREATMENT] nurse removed the dressing of the right residual limb, pointing out that the dressing was dated 6/3/2013. Witness #26 said, "I complained to the DON (director of nursing) and the facility's wound care nurse (identified as witness #4); they apologized to me for the dressing not being changed since 6/3/2013, and said that those responsible would be punished." During an unannounced, on site investigation conducted 7/24/2013, Resident #101's medical file was reviewed; according to the Nurses' Notes, there were no direct visual inspections/assessments of the wound (examinations performed with dressings removed) documented as performed on Resident #101's right residual limb, by facility staff, for the dates 6/4/2013, 6/5/2013, 6/6/2013, 6/7/2013, and 6/8/2013. According to " LEGAL AND ETHICAL ISSUES IN NURSING" BY G. GUIDO (2001), IT STATES THAT "DOCUMENTATION MUST SHOW CONTINUITY OF CARE, INTERVENTIONS THAT WERE USED, AND PATIENT RESPONSES TO THE THERAPIES IMPLEMENTED. NURSE ' S NOTES ARE TO BE CONCISE, CLEAR, TIMELY, AND COMPLETE. " (P. 171) IT STATES THAT A JURY CAN INFER THAT NO OBSERVATION OF THE PATIENT WAS CONDUCTED IF THERE IS NO MENTION OF A CHANGE IN THE CONDITION OF THE PATIENT. (P. 171)." Nursing Management of Chronic Wounds, 2nd edition by Moya Morison, Christine Moffatt, Jane Bridel-Nixon, & Sue Bale (1997), p. 76, " ACCURATE AND ONGOING WOUND ASSESSMENT IS ESSENTIAL TO PLANNING THE MOST APPROPRIATE LOCAL WOUND MANAGEMENT (SEE CHAPTERS 5 AND 6) AND TO EVALUATING ITS EFFECTIVENESS. IF FREQUENT AND THOROUGH WOUND ASSESSMENT IS BEING UNDERTAKEN, ANY ABNORMAL CHANGES IN A PREVIOUSLY HEALTHY HEALING WOUND CAN BE PICKED UP QUICKLY AND APPROPRIATE THERAPEUTIC ACTION TAKEN . . . IT IS A LEGAL REQUIREMENT TO HAVE THIS INFORMATION CLEARLY DOCUMENTED FOR PURPOSES OF ACCOUNTABILITY. " During an interview on 7/11/2013 at 11:40 AM, Wound Care Nurse (WCN) #4 said the facility had been notified on 6/8/2013 (untimed), by an off-campus [MEDICAL TREATMENT] nurse, that Resident #101 had been sent to a local hospital for evaluation of her complaint of right residual limb pain and presence of a large amount of purulent drainage and wound dehiscence. Wound Care Nurse #4 said the [MEDICAL TREATMENT] nurse (#13) reported on 6/8/2013, the presence of a dressing on Resident 3101's right residual limb that was dated 6/3/2013. WCN #4 said she began an investigation, approved by DON #2, to determine if facility staff had changed Resident #101's dressing of the right residual limb, daily as ordered. WCN #4 said it was determined through interviews with all eight nurses who had been assigned to Resident #101's care that the dressing of the right residual limb had not been changed as ordered, and no direct assessment of the wound made, for the dates 6/4/2013, 6/5/2013, 6/6/2013, 6/7/2013, and 6/8/2013. WCN #4 said she had been the sole person at the facility who had provided both wound care and direct assessment of the Resident's right residual limb; care was identified as provided by her on 6/3/2013. WCN #4 said, "I did the initial wound assessments, of both residual limbs, on 6/3/2013. I also took pictures of both limbs on 6/3/2013. I gave treatment to both limbs, as ordered, on 6/3/2013. I didn't do any further wound care for her during her stay. She was hosptalized on [DATE]. I'd have seen her again on 6/10/2013, but she was hospitalized . Daily dressing changes are done at this facility on third shift. I reviewed the Treatment Administration Record (TAR), and saw that wound care was initialed by facility staff as given. I interviewed all eight nurses assigned to the Resident and they said they looked at the dressings of both limbs to see that they were present, but they did not do any dressing changes. The only dressing changes that were done during her stay (identified as 6/3/2013 through 6/8/2013) were done by me on 6/3/2013. I asked the nurses why they initialed the TAR as if the daily wound dressings were changed; I got a lot of 'I don't knows.' Seven or eight nurses were disciplined." During interviews on 7/11/2013 at 3:05 PM with Licensed Practical Nurse (LPN) #15, on 7/11/2013 at 3:25 PM with RN #16, on 7/11/2013 at 3:40 PM with LPN #17, on 7/11/2013 at 3:50 PM with LPN # 18, on 7/12/2013 at 8:00 AM with LPN #22, on 7/15/2013 at 8:00 AM with RN #19, and on 7/18/2013 at 8:00 AM with RN #20, nurses (7 of 8 nurses assigned to the care of Resident #101 from 6/3/2013, the date of her admission to the facility, through 6/8/2013, the date of Resident #101's transfer to a local hospital for evaluation) said they had not performed wound dressing changes, and had not provided direct visual inspections/assessments of the wound (examinations performed with dressings removed) to Resident #101's right residual limb, as ordered. Those interviewed said they had only checked to see that a dressing was present on the right residual limb. Multiple, unsuccessful attempts were made to interview RN #21. During an interview on 7/11/2013 at 2:35 PM, Resident #101's attending physician (Witness #3) said he had provided wound care orders on 6/3/2013 at 6:00 PM to the facility wound care nurse (witness #4). He said, "I wasn't notified my orders weren't followed. I expect my orders to be followed." According to the Operative Report dated 6/10/2013 at 8:27 PM, Resident #101 was diagnosed by Vascular Surgeon #24, preoperatively, with "failed right BKA (below knee amputation) flap with gangrene and soft tissue infection." The post-operative [DIAGNOSES REDACTED]." The operation performed was documented as "Right above knee amputation." During an interview on 7/23/2013 at 10:00 AM, Vascular Surgeon #24 said, "Daily dressing changes can prevent infections which can cause patients to require another surgery and even increase the risk for mortality and complications. If daily dressing changes weren't done, that's inadequate care and it's wrong. This is a basic level of medical care, and she didn't get it." During an interview on 7/15/2013 at 9:25 AM, DON #2 said, "some of my nurses didn't do the wound care as ordered; that's what they claim. I expect doctor's orders followed, unless it's substandard care; then I want to be notified, and I'll talk with the Medical Director for advice." During an interview on 7/15/2013 at 10:50 AM, Nursing Home Administrator #1 said he expected facility staff to follow orders, "unless they disagree with them and address them to the necessary provider; doctor, Physician's assistant, or Nurse Practitioner."

This citation pertains to intake MI 106 and MI 183. Based on observation, interview and record review the facility fail to provide adequate supervision and assistance in 1 of 5 sampled Residents (Resident #101), from a total of 5 sampled Residents, resulting in Resident #101 falling 7 times in the facility between 3-20-12 and 5-8-12 and sustaining abrasions to her forehead and infraorbital region (eye area). Findings include: Resident #101 Review of the face sheet revealed Resident #101 was and [AGE] year old female, admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 had a Brief Interview of Mental Status (BIMS) score of 5/15 (severe cognitive impairment). The MDS revealed Resident #101 required extensive assistance of one person to walk in her room/transfer and limited assistance of one person to walk on the unit. Review of the Fall Risk Indication, dated 3-26-12 revealed that Resident #101 had a history of [REDACTED]. Resident #101 was unsteady walking even when using a walker. Review of the Risk for falls related to unaware of safety care plan, dated revisited on 4-16-12 and 4-29-12 documented Resident #101 had the following interventions: "Self releasing alarmed seat belt, low bed with alarm and mats on floor, I need activities that minimize the potential for falls while providing diversion and distraction, I do not understand that I am not to stand without help. I also did not know my limitations." Review of the Unusual Occurrence Form dated 3-24-12 at 5:10 AM documented, Resident #101 fell while walking alone in her room and was sent to the emergency room due to complaints of pain in the hip, femur and knee. Review of the Supervisor/Manager's investigation for the Unusual Occurrence for Resident #101, dated 3-24-12 at 5:10 AM documented the corrective action taken was frequent checks and send Resident #101 to the emergency room . Under quality improvement review was documented, "admitted [DATE] recent move to room 505-2. Resides in room with spouse. [DIAGNOSES REDACTED]. Inactive therapy" Review of the Unusual Occurrence dated 4-13-12 at 8:00 PM, revealed Resident #101 fell while attempting to go to the bathroom alone. Under immediate interventions was documented, "monitor of any post fall injuries times 72 hours." Review of the Evidence of investigation of unusual occurrence for Resident #101 dated 4-13-12 at 8 PM revealed the plan to avoid falls in the future was to have Resident #101 "up and sit at the nurses station and explained to the resident the need for the resident to call for assistance". Under action plan was documented, "Reinstruct to ask for assistance." Review of the Unusual Occurrence form dated 4-14-12 at 2:05 AM revealed that Resident #101 was observed on the floor next to her bed. Under immediate interventions was documented, "Resident placed on 15 minute checks." Review of the Evidence of investigation of unusual occurrence for Resident #101, dated 4-14-12 at 2:05 AM. revealed the Resident was found on the floor with the bed alarm sounding. Under brief description to avoid this situation was documented, "Resident placed on 15 minute checks, bed and chair alarms need to be checked frequently to assure proper function. She needs to be reminded frequently not to get up by herself." Review of the Supervisor/Manager's Investigation for Resident #101, dated 4-14-12 documented under Quality Improvement Review, "Severe cognitive impairment. Non-redirectable. Unaware of limitations. Being seen by psychology. Continue with safety devices and present interventions." There was no documentation of additional interventions put in place to maintain Resident #101's safety. Review of the Unusual Occurrence form dated 4-16-12 at 2:00 AM, revealed Resident #101 was found on the floor with an alarm sounding. Review of the Evidence of Investigation of Unusual Occurrence form dated 4-16-12 at 2:00 AM documented the Resident was found with her back to the bed, sitting on the floor, with the bed and wheelchair alarms sounding. Under brief description of plan to avoid this situation documented Physical and Occupational Therapy to evaluate. Review of the Supervisor/Manager's Investigation for Resident #101, dated 4-16-12 at 2:00 AM documented under Quality Improvement Review, "May require in-patient psychiatric unit. Unaware of safety or limitations. Review of the Unusual Occurrence form dated 4-17-12 at 8:50 PM documented that Resident #101 was observed sitting on the floor in the hall in front of her wheelchair with her alarm sounding. Review of the Evidence of Investigation of Unusual Occurrence for Resident #101 dated 4-17-12 at 8:50 PM, documented under brief plan to avoid this situation, "activity daily, drawing, watching sports events on TV, bingo." Review of the Supervisor/Manager's Investigation for Resident #101, dated 4-17-12 at 8:50 PM documented under additional action taken, restraint evaluation and recommendation of self-releasing alarmed seat belt. Under systemic Quality Improvement Action the box was marked for increased supervision and the investigation was signed by the Director of Nursing (DON) #2. Review of the Unusual Occurrence form dated 4-23-12 at 4:00 AM, revealed Resident #101 was found on the floor in her room. Under immediate intervention was documented that Resident #101 received pain medication because she complained of pain. Review of the Evidence of Investigation of Unusual Occurrence for Resident #101, dated 4-23-12 at 4:00 AM, documented under brief description of occurrence that Resident #101 had an unwitnessed fall to the floor and an assumption was made that Resident #101 attempted to transfer from her chair to the bed. Under conclusion was documented, "Patient sitting in bedside chair with sensor alarm per patient request at 3:30 AM. Assuming patient rose from chair to either walk or move to bed. Found on bedside mat. Patient complained of left hip pain. X-ray ordered to be done in 24 hours." Under plan to avoid this situation was documented, "Continue present interventions. Do not leave in wheelchair in room unattended." Review of the Supervisor/Manager Investigation for Resident #101, dated 4-24-12 at 4:00 AM revealed "no new interventions and staff are aware that Resident #101 does not consistently verbalize her needs and frequently gets up and down through out the night". The investigation was signed by DON #2. Review of the Unusual Occurrence form dated 5-8-12 at 6:45 AM, revealed Resident #101 was found on the floor with abrasions to her left forehead, left nose and left eye. When Resident #101 was found on the floor it was noted she had an alarm in place and it was sounding. The form documented that Certified Nurse Aide (CNA) #1 was assigned to Resident #101 at the time of the injury and Licensed Practical Nurse (LPN) #1 signed that she completed the report. Review of the Evidence of Investigation of Unusual occurrence form dated 5-8-12, at 6:45 AM, revealed Resident #101 sustained a 3.5 centimeter abrasion to her left forehead, left nose and left eye. According to the investigation, CNA #2 and CNA #3 notified the nurse that Resident #101 was on the floor. Under brief description of conclusion was documented, "Resident was attempting to self-transfer from recliner and fell to the floor." Under plan to avoid this situation was documented, "Resident on 15 minute checks." No further interventions were documented. Review of the Patient Transfer Form dated 5-8-12 for Resident #101 revealed that Resident #101 was transferred to the hospital after being found on the floor with abrasions to her left forehead, eye and nose. In an interview on 6-27-12 at 10:00 AM, CNA #1 stated she was assigned to Resident #101 on 5-8-12 starting at 6:00 AM. CNA #1 said she observed Resident #101 sleeping in a recliner at the nurses station with her feet elevated at the start of her shift. CNA #1 said she did not hear Resident #101's alarm sound or see her stand because she was down the hall providing care in a resident room. CNA #1 explained that she was not aware that Resident #101 was care planed for a wheelchair with self releasing seat belt for safety. In an interview on 6-27-12 at 2:15 PM, CNA #4 stated she cared for Resident #101 the night of 5-7-12 and around 11:30 PM Resident #101 was restless up in her wheelchair, so she had CNA #5 help her put Resident #101 in a recliner at the nurses station. The Surveyor asked is CNA #4 was aware that Resident #101 was care planed to have a self releasing alarming seat belt in her wheelchair and she explained she was not sure what the care plan said but she thought she remembered a seat belt in the wheelchair. During the interview, CNA #4 reviewed Resident #101's care guide, but did not see the seat belt alarm on the care guide and could not find recliner or any information for agitation or restlessness. CNA #4 recalled that Resident #101 slept the rest of the night after placing her in the recliner and was unable to recall Resident #101 needing to use the bathroom or attempting to get out of the recliner. CNA #4 recalled that Resident 101 was still sleeping when she saw her near the end of her shift. In an interview on 6-27-12 at 10:10 AM, LPN #1 recalled seeing Resident #101 in the recliner at the nurses station at the start of the shift. LPN #1 recalled Resident #101 being agitated and pulling at her clothing and a CNA redirecting Resident #101 at that time. LPN #1 said she did not see Resident #101 stand or hear the alarm because she was in the medication room at the time. LPN #1 did not recall giving any direction or assistance to the CNA when she saw Resident #101 was in the recliner and showing agitated behavior. LPN #1 did not recall how Resident #101 got placed in the recliner and was not aware the recliner was not on the safety care plan. In an interview on 6-27-12 at 10:20 AM, CNA #2 stated that she see did not see Resident #101 stand, fall or hear her alarm sound on 5-8-12 at 6:45 AM. CNA #2 said she was out front preparing to take residents to dialysis when she heard someone yell for help. CNA #2 recalled going to get LPN #2 to assess Resident #101 and than assisting Resident #101 off the floor with CNA #5. CNA #2 said see did not see any staff in sight when she found Resident #101 on the floor. LPN #2 was interviewed on 6-27-12 at 12:25 PM. LPN #2 stated she was not aware of Resident #101's fall precautions or that she was a fall risk. LPN #2 said she was not aware that Resident #101 had a wheelchair with a self-releasing belt alarm and that the recliner was not care planned for safety or behaviors. LPN #2 could not recall who placed Resident #101 in the recliner but thought it happened around 6 AM. LPN #2 explained she did not assess Resident #101 safety while up in the recliner. Review of the Hospital Transfer Summary for Resident #101, dated 5-8-12 revealed that family present in the emergency room informed the hospital that the Resident was suppose to be using a seat belt to prevent falls and the resident had a history of [REDACTED]. ( )

This citation pertains to intake # MI 254 Based on observation, interview, and record review, the facility failed to implement fall safety interventions in 1 of 3 sampled Residents (Resident #101) from a total of 3 sampled Residents, resulting in Resident #101 sustaining a laceration to her head that required emergency medical care after a fall. Findings include: Review of the face sheet revealed Resident #101 was a [AGE] year old female admitted to the facility on [DATE]. According to a [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE], Resident #101 was no longer able to walk and required limited to extensive assistance with all activities of daily living. Resident #101 was started on Hospice care on 3-23-11 and passed away on 4-11-11. Review of the Unusual Occurrence report dated 3-7-11 at 11:30 PM, Resident #101 had an unwitnessed fall and "was observed sitting on the floor in her room in front of rocker". Resident #101 was unable to bear weight on her left side and an x-ray of her left hip was ordered. Review of the Nursing Notes dated 3-8-11 at 12:00 PM, Resident #101's "left hip x-ray negative for fracture, family notified." Review of the Nursing Notes dated 3-9-11 at 1:30 PM, "Resident (Resident #101) complained of increase pain in pelvic and left hip area. Unable to bear weight with 2 assist. Doctor notified. Ordered pelvic and left femur x-ray." Review of the Nursing Notes dated 3-9-11 at 4:00 PM, Resident #101's x-ray results indicated, "No fracture of pelvis. Left femur lucency in the intertrochanteric region with suggests follow up." According to Nursing Notes for Resident #101 dated 3-9-11, "4:20 PM Doctor notified of x-ray results. Order received to transfer to (name of hospital) emergency room for evaluation." According to Nursing Notes for Resident #101 dated 3-9-11, "8:30 PM call received from male nurse from (name of hospital) emergency room . Will be returning with [DIAGNOSES REDACTED]." Review of the Physician order [REDACTED]. [DIAGNOSES REDACTED]. Review of the Nursing Notes dated 3-11-11 at 10:30 AM, Resident #101 was found "sitting up on side of bed. Stated I'm getting up but I hurt so. Assisted Resident back to bed. Reminded Resident of bed rest status and broken femur. Bed alarm and fall mat implemented." Review of the Falls Care Plan dated 3/11/11, Resident #101 was at risk for falls. Interventions included: "Bed and chair alarm, fall mat to be utilized while in bed, and low bed in place." According to the Unusual Occurrence report dated 3-12-11 at 7:00 AM, Resident #101 had an unwitnessed fall and "was observed on the floor of her room." Resident #101 sustained a, "Laceration 3 cm above left eye". Physician instruction were to, "Send to emergency room for evaluation." Interventions in place at the time of the incident for Resident #101 included: "Call light in reach, Regular Bed (yet low bed was care planned), Bed locked, Alarm in place and Alarm sounding." During an interview with Certified Nurse Aide (CNA) #1, on 10-27-11 at 8:25 AM, CNA #1 stated she found Resident #101 on the floor on 3-12-11 and when she entered the room she saw blood and ran to get help. CNA #1 drew a diagram of the room which indicated Resident #101 exited the bed on the side were the bed was approximately 6 inches from the heater and the heater was mounted on the lower portion of the wall. There was no mat on that side of the bed. CNA #1 took the surveyor to the room to show her where she found Resident #101 and the placement of the bed. In an interview on 10-27-11 at 8:45 AM, Licensed Practical Nurse (LPN) #1 reviewed the Unusual Occurrence form completed by her, for Resident #101, regarding the fall that occurred on 3-12-11 at 7:00 AM. LPN #1 reported that Resident #101 was lying in blood with an alarm going off. LPN #1 could not recall a mat on the floor or a low bed. LPN #1 reviewed her documentation again and it did not show low bed or mat in place. LPN #1 said she would have documented the mat and low bed if they were in place. In an interview on 10-27-11 at 9:35 AM, LPN #2 reviewed her charting for Resident #101, dated 3-11-11. LPN #2 was asked if she remembered setting up the fall equipment she documented for Resident #101 on 3-11-11. LPN #2 said she did not set it up and did not remember who set up the equipment. LPN #2 said if she would have set up the equipment she would have placed the bed up close to the wall (not the wall with the heater) and place the fall mat on the other side of the bed. ( )