Every finding on record at Seacrest Rehabilitation and Nursing Center

Based on observation, interview, and record review the facility failed to effectively clean and maintain the physical plant effecting four resident rooms out of 21 resident rooms sampled for a clean environment. Findings include:On 2/11/2026 at 11:16 AM, an environmental tour was conducted with Environmental Services Manager (ESM) B. The following items were noted:-room [ROOM NUMBER], the flooring was soiled and appeared yellow in color with wheelchair tire marks and dark stains.-room [ROOM NUMBER], the flooring was soiled with wheelchair tire marks and dark stains.-room [ROOM NUMBER], the flooring was soiled, yellow in color with wheelchair tire marks and dark stains.-room [ROOM NUMBER], the flooring was soiled, appeared yellow in color with wheelchair tire marks and dark stains.When ESM B was asked about the resident room flooring ESM B said the flooring should be white in color, the above-mentioned floors needed to be stripped and waxed. ESM B said the resident rooms had heavy markings from the wheelchairs that did not get cleaned with the regular housekeeping. ESM B stated, We haven't been able to strip and wax the floors since 2024 due to lack of proper equipment and lack of enough staff. ESM B further said the resident room floors should be stripped and waxed at least once a month.On 2/12/2026 at 9:55 AM, the Nursing Home Administrator (NHA) was interviewed and said the resident room floors needed to be deep cleaned, stripped and waxed or replaced entirely.Review of the facility policy titled, Physical Environment-Floors dated 7/11/2018 revealed in part.Floors shall be maintained in a clean, safe and sanitary manner. Floor cleaning procedures are maintained by the Environmental Services Director.

Based on observation, interview, and record review, the facility failed to ensure the drain lines from the dish machine were maintained in a safe and sanitary operating condition, resulting in the dish machine not being protected against contamination from sewage or other sources of contamination Findings include:During the initial tour of the kitchen on 2/10/26 at 9:17 AM with Dietary Manager (DM) F, the end of the drain lines from the dish machine were observed below the flood rim of the floor drain. DM F indicated maintenance will be contacted. On 2/11/26 at 2:22 PM, the Nursing Home Administrator indicated the position of the drain line from the dish machine will be addressed and properly air gapped. The 2013 FDA Food Code was reviewed and revealed the following in Section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed.

Based on observation, interview, and record review, the facility failed to: 1. Ensure proper cooling of cooked, potentially hazardous (time-temperature for safety) food, taco meat and beef tips; 2. Consistently test the dish machine to ensure proper sanitization; 3. Ensure pans were properly cleaned and allowed to air dry before stacking; 4. Effectively clean a mounted fan; and 5. Properly maintain resident refrigerator. These deficient practices had the potential to affect all residents who consumed food from the kitchen, resulting in the increased potential for food borne illness. Findings include:On 2/10/26 at 9:17 AM, a tour of the kitchen was conducted with Dietary Manager (DM) F. The following items were noted: A full-size pan containing taco meat, as identified by DM F, was cooked last night. DM F indicated that a cooling log was not available for the pan of taco meat. A full-size pan of beef tips, as identified by DM F, was cooked this morning. The internal temperature of the beef tips was obtained and determined to be 43.7 F (Fahrenheit). AM [NAME] H indicated the beef tips finished cooking at 7 AM this morning. AM [NAME] H stated, We don't document cooling temps and added the meat was not divided into smaller portions to facilitate proper cooling. Dietary Aide (DA) G was observed operating the dish machine. DA G said they visually observe the flow of sanitizing solution into the dish machine to determine that dishware was properly sanitized. DA G indicated that test strips were not used to determine if dishware was properly sanitized. DM F said we do not always test the sanitizing solution of the dish machine. Two wet and soiled full-size pans were stored in the clean pot/pan area. A round fan, mounted on a wall facing the clean side dish machine drain board, was turned on and blowing air. The fan cover, fan blades, and mounting bracket were covered with dust and dirt. DM F said the fan was blowing towards the cleaned dishware. DM F unplugged the fan and stated, I will have to call maintenance. On 2/10/26 at approximately 10:15 AM, the contents of the Unit D resident refrigerator freezer were observed with DM F and revealed the following:- an opened 1.5 quart container of strawberry ice cream was not labeled with a resident's name.- a 14 oz. boxed frozen entree of Buffalo style chicken macaroni and cheese was not labeled with a resident's name. On 2/11/26 at 1:51 PM during an interview, DM F said cooling food properly prevents undesirable bacterial growth. DM F stated, We want to make sure our residents don't get sick. DM F stated they have not been keeping a sanitizing log for the dish machine. DM F acknowledged the importance of testing the dish machine sanitizing solution in order to determine if the dish machine was properly sanitizing the dishes. On 2/11/26 at 2:22 PM, the Nursing Home Administrator (NHA) identified the following expectations: that cooling logs are kept, that kitchen policies and procedures are followed, and the kitchen should be maintained in a clean manner. A review of a facility policy titled, Food Brought by Family/Visitors, dated 7/11/18, documented the following: Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item and the 'use by' date. According to the 2013 FDA Food Code:- Section 3-501.14 Cooling. (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 135 F to 70 F; and (2) Within a total of 6 hours from 135 F to 41 F or less. - Section 4-204.117 Warewashing Machines, Automatic Dispensing of Detergents and Sanitizers. (B) Incorporate a visual means to verify that detergents and sanitizers are delivered - Section 4-602.13, Nonfood-Contact Surfaces, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. - Section 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and sanitizing, equipment and utensils shall be air-dried.

Based on observation, interview, and record review the facility failed to store unopened insulins at the proper temperature in two of three medication carts reviewed for safe storage of medications and biologicals resulting in the potential for decreased efficacy of the insulin.Findings include:On 2/11/2026 at 8:51 AM during inspection of medication cart #1 on C-South Hall with Licensed Practical Nurse (LPN) C, an unopened bottle of Humalog insulin was observed in the medication cart at room temperature. The bottle was inside an unopened box that was inside a plastic bag. Both the box and plastic bag were labeled with instructions to Keep refrigerated. Neither the box nor plastic bag had a delivery or received on date. Upon interview LPN C said, That insulin should be refrigerated. There is no way to tell how long it has been at room temperature. We'll have to waste this bottle. On 2/11/2026 at 9:54 AM during inspection of medication cart #2 on E-South Hall with LPN D, an unopened bottle of Novolog insulin was observed in the medication cart at room temperature. The bottle was inside an unopened box that was inside a plastic bag. Both the box and plastic bag were labeled with instructions to Keep refrigerated. Neither the box nor plastic bag had a delivery or received on date. A two-pack of insulin Kwik-pens (disposable, prefilled, multi dose injection device to deliver insulin) were observed unopened and undated inside a plastic bag. Both the Kwik-Pens and the bag they were stored in were labeled with instructions to Keep refrigerated. Neither the Kwik-pens nor the plastic bag had delivery or received on date. Upon interview LPN D said, Those are supposed to be in the refrigerator. I'm not sure why they aren't. There is no way to tell how long they have been at room temperature. LPN D removed both the bottle of insulin and set of Kwik-pens from the medication cart. On 2/12/26 at 1:00 PM during an interview with the Director of Nursing (DON) they confirmed the facility's policy was to store all medications according to the manufacturer's recommendations. This included storing unopened insulin at the proper temperature controls to maintain the potency and effectiveness of the medication. The DON was asked to provide the facility's policy for medication storage. According to the facility's policy for Medication Access and Storage adopted on 7/11/2018 read in part; It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. 11. Medications requiring refrigeration or temperatures between 2 C (36 F) and 8 C (46 F) are kept in a refrigerator with a thermometer to allow temperature monitoring.Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label.

Based on observation, interview, and record review, the facility failed to ensure staff completed appropriate hand hygiene during resident care for one resident (R60) of five residents reviewed for infection control, resulting in the potential for an increased risk of infection among residents. Findings include:On 2/10/2026 at approximately 11:20 AM, LPN A was observed conducting blood glucose tests on the 500-unit hallway. LPN A sneezed while in the hallway, did not perform hand hygiene, and continued down the hallway with a medication cart in front of them. On top of the medication cart were gloves, lancets, and a glucometer. Upon arriving at R60s room, LPN A donned gloves without performing hand hygiene. LPN A entered the room and performed a blood glucose test on R60. Upon exiting the room, LPN A removed the gloves but did not perform hand hygiene. LPN A then went to room [ROOM NUMBER]. LPN A did not perform hand hygiene, donned gloves, and proceeded into the room to conduct a blood glucose test. Upon exiting room [ROOM NUMBER], LPN A removed their gloves and did not perform hand hygiene. LPN A then went to room [ROOM NUMBER], did not perform hand hygiene, donned gloves, and proceeded into the room to conduct a blood glucose test. Upon exiting the room, LPN A removed their gloves and did not perform hand hygiene. A record review was conducted on 2/11/2026 which revealed R60 admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, bipolar disorder, osteoarthritis, dementia, generalized anxiety disorder, and metabolic encephalopathy. Section C of the Minimum Data Set with an Assessment Reference Date of 1/18/2026 revealed R60 scored a 9/15 on the Brief Interview for Mental Status assessment - indicative of a moderate cognitive impairment. R60 had a physician order to check blood glucose levels daily before meals and at bedtime. On 2/11/2026 at approximately 9:05 AM, LPN A was interviewed regarding the process of performing hand hygiene when completing blood glucose tests. LPN A stated, I should have performed hand hygiene before putting gloves on, after removing my gloves, and in between residents. When asked why hand hygiene should be performed at these times, LPN A stated, To decrease risk of infection between residents. On 2/12/2026 at approximately 9:00 AM, an interview was conducted with the Infection Preventionist/Director of Nursing (DON) regarding hand hygiene. When asked what their expectation was for performing hand hygiene during blood glucose checks, the DON stated, Hand hygiene should be completed before putting on gloves and entering a resident room to perform patient care and when they come out of the room to remove their gloves and perform hand hygiene. The DON further said there are potential infection control concerns for cross contamination when hand hygiene is not performed. A policy titled, Hand Hygiene, last updated 3/24/2022 revealed: Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: immediately before touching a resident; proper hand hygiene should be performed between all services to residents; after touching a resident or the resident's immediate environment; after contact with blood, body fluids, or contaminated surfaces; immediately after glove removal.

Based on interview and record review the facility failed to maintain accurate reconciliation records for controlled medications (narcotics) in two of three medications carts resulting in the potential for drug diversion to go undetected.Findings include: On 2/11/2026 at approximately 9:20 AM the 500 hall E-South cart was inspected with Licensed Practical Nurse (LPN) D. The 2/11/26 narcotic reconciliation log was not signed by the on-coming nurse, LPN D. LPN D stated, I forgot to sign. I did count with the night shift nurse. I know I should have signed it at the time of the count. A continued inspection of the cart revealed a discrepancy for R37's Morphine Sulfate Contin 30 milligram (MS Contin 30 mg) pills. There were 12 pills observed in the blister pack for R37's MS Contin 30 mg. The controlled substance reconciliation sheet documented 13 pills. LPN D stated, Oh, I gave that to the resident this morning. I just forgot to sign it out. LPN D confirmed that standard of practice is to sign out the medications when they are administered.Review of R37's Medication Administration Record (MAR) revealed that R37 was prescribed and administered the MS Contin 30 mg on 2/11/26 at 9:00 AM dose. On 2/11/2026 at approximately 9:40 AM the 200 hall B-North cart was inspected with Licensed Practical Nurse (LPN) E. The 2/11/26 narcotic reconciliation log was not signed by the on-coming nurse, LPN E. LPN E stated, I just forgot to sign that. I did it (the count). A continued inspection of the cart revealed a discrepancy for R47's Oxycodone 10 mg pills. There were 5 pills observed in the blister pack for R47's Oxycodone 10 mg. The controlled substance reconciliation sheet documented 6 pills. LPN E stated, I gave it. I forgot to sign it out. LPN E confirmed that standard of practice is to sign out the medications when they are administered.Review of R47's Medication Administration Record (MAR) revealed that R47 was prescribed and administered the Oxycodone 10 mg at the 9:00 AM dose. reviewed narc sheets. On 2/12/26 at 1:00 PM during an interview, the Director of Nursing (DON) confirmed the facility's policy was to count the narcotic reconciliation sheet and sign at the time of shift change. The DON stated, The nurse should sign out any narcotic at the time they take it out of the med cart. The policy for Medication Administration was requested for review.According to the facility's policy for Medication Administration for Controlled Drugs updated on 5/14/2020 read in part: Narcotic Count and Inventory:1. Controlled drugs are counted every shift by the nurse reporting on duty WITH the nurse reporting off duty.2. The inventory of the controlled drugs must be recorded on the narcotic records and signed for correctness of count.3. The controlled drug checklist must be signed by the nurse coming on duty and the nurse going off duty to verify that the count of all controlled drugs is correct.

Based upon interview and record review, the facility failed to notify the physician regarding elevated blood sugars for one resident (R54) of one resident reviewed for diabetes management. Findings include: A review of the clinical record for R56 documented an original admission date of 8/21/23 and readmission date of 10/25/25. R56's diagnoses included diabetes mellitus-type 2 (DMII), congestive heart disease and chronic obstructive pulmonary disease. A Minimum Data Set assessment dated [DATE] documented intact cognition. Physician ordered blood sugar sliding scale for R56 documented the following:Insulin Lispro Injection Solution 100 unit/ml (Insulin Lispro)Inject as per sliding scale:if 0 - 150 = 0 units;151 - 200 = 0 units;201 - 250 = 4 units;251 - 300 = 8 units;301 - 350 = 14 units;351 - 400 = 20 units,Administer subcutaneously before meals and at bedtime for DMII. A review of recorded blood sugars for R56 revealed the following:12/1/25 at 6:00 AM: 484 mg/dl. No corresponding nursing or medical provider (MP) note available.12/3/25 at 5:00 PM: 482 mg/dl. Corresponding nursing note documented: subcutaneously before meals and at bedtime for DMII (diabetes mellitus-type 2) - 26 units administered-MD (medical doctor) aware.12/20/25: at 9:00 PM: 404 mg/dl. No corresponding nursing or MP note available.12/26/25 at 9:00 PM: 480 mg/dl. No corresponding nursing or MP note available.1/11/26 at 6:00 AM: 532mg/dl. No corresponding nursing or MP note available.1/22/26 at 9:00 PM: 430 mg/dl. No corresponding nursing or MP note available.2/1/26 at 9:00 PM: 500 mg/dl. No corresponding nursing or MP note available. Review of R56's care plan documented in part the following:(R56) has risk for fluctuations in blood sugar and complications related to diabetes. Revised on 10/20/25. Interventions included: Obtain fingerstick glucose as ordered and as needed. Report abnormal (blood sugar level) or changes in pattern to physician for review and adjustment of plan of care as directed. Revised on 10/20/25. Review of referral to the endocrinologist dated 12/4/25 documented that R56 had uncontrolled diabetes mellitus-type 2 and blood sugars were fluctuating high. Endocrinology consult dated 1/29/26 documented in part the following:Progress note: A1c high at 10.4% - per patient, (R56) eats snacks all the time. Blood sugars are elevated, will increase insulin and follow up in six weeks. Updated Diagnosis: uncontrolled diabetes mellitus-type IIOrders: increase Lantus to 40 units in AM and 35 units at bedtime. Increase Lispro to 8 units three times a day with meals plus sliding scale. During an interview on 2/11/26 at 12:11 PM, Licensed Practical Nurse (LPN) D said the parameters for contacting the medical provider for a resident's elevated blood sugar were in the orders. LPN D said not all residents are managed the same, but generally if a resident has a blood sugar over 400, the MP was called to see if additional units of insulin were to be administered. During an interview on 2/11/26 at 12:14 PM, LPN A said, in the absence of an order, they would contact the MP if a resident's blood sugar was over 400 to find out the proper dose of insulin to give. During an interview on 2/11/26 at 1:42 PM, the Director of Nursing (DON) said that typically the physician will set parameters for when to call regarding an elevated blood sugar level. The DON added that if there were no parameters set, the physician should be contacted when a blood sugar value was higher than the sliding scale to obtain an order for additional insulin if needed. During an interview and review of R56's clinical record on 2/11/26 at 2:39 PM with the DON and Regional Nurse Consultant (RNC) J, it was determined that there were no current written instructions or orders for nurses to follow when R56's blood sugar exceeded the prescribed sliding scale. During an interview on 2/11/26 at 3:17 PM, Physician K indicated that hypoglycemia was more of an issue because R56 received a hefty dose of insulin. Physician K said he could not recall if R56's blood sugars had ever been over 450. Physician K stated the facility nurses were aware of R56's dietary noncompliance and consumption of junk food galore, potato chips, and pop. When queried about what nurses should do when R56's blood sugars were over 400, Physician K reiterated if R56 was given additional insulin, it may result in a hypoglycemic reaction. According to Physician K, it was unclear if written guidelines existed that directed the nurses on when to report R56's elevated blood sugars. Physician K acknowledged the medical provider directs medical care and it was the nurse's duty and responsibility to follow their orders. Physician K agreed that it should be communicated to nursing on when to contact the medical provider regarding R56's blood sugar levels.

Based on observation, interview, and record review, the facility failed to follow standards of practice for medication administration for one resident (R24) of two residents reviewed for medication administration.Findings include: On 2/10/2026 at approximately 9:45 AM, R24 was observed in their room. Observed on the bedside table were prescribed eye drop medication Vysulta Ophthalmic Solution, Combigan Ophthalmic Solution, and a nasal spray. R24 said they self-administer eye drops and nasal spray, but the nurse administers their other medications. On 2/10/2026 at approximately 11:38 AM, a second observation revealed the same medications at the resident's bedside. On 02/11/2026 at approximately 9:39 AM, a third observation revealed the same medications at the resident's bedside. A record review was completed on 2/11/2026 which revealed R24 admitted to the facility on [DATE] with diagnoses that included: atrial fibrillation, hypertension, chronic obstructive pulmonary disease, anemia, cognitive communication deficit, and peripheral vascular disease. Section C of the Minimum Data Set with an Assessment Reference Date of 11/20/2025 revealed R24 scored a 15/15 on the Brief Interview for Mental Status assessment - indicative of no cognitive impairment. A review of physician orders in the electronic medical record revealed R24 was to receive Vysulta Ophthalmic Solution 0.024% (Latanoprostene Bunod): Instill 1 drop in left eye at bedtime for cataracts, and Combigan Ophthalmic Solution 0.2-0.5% (Brimonidine Tartrate-Timolol Maleate): Instill 1 drop in both eyes every 12 hours for glaucoma, and Saline Spray Nasal Solution (Saline): 1 spray in each nostril as needed for nasal congestion. There were no orders allowing for self-administration of medications. There was no evidence in the electronic medical record of an interdisciplinary team assessment for self-administration of medications. Review of the care plan did not reveal any interventions for self-administration of medications. On 2/11/2026 at approximately 11:20 AM, LPN A was interviewed regarding medications at the bedside. LPN A stated, (R24) is alert and oriented and administers their inhalers and eye drops. LPN A confirmed that R24 did not have an order to self-administer medications. LPN A then stated, I dropped the medications off at the bedside. He does not have an order to self-administer medications and I've removed the medications. When asked what the potential risk was associated with leaving medications at the bedside, LPN A stated, R24 could overdose or double dose on their medications.On 2/12/2026 at approximately 3:12 PM, the Director of Nursing (DON) was interviewed regarding medication administration. The DON said they follow resident rights for administering medications. The DON further explained that residents would be assessed for their cognitive ability and return demonstrations prior to allowing self-administration of medications. In addition, a physician order would be obtained, and the care plan updated. When asked if R24 had an assessment or physician order to self-administer medications, the DON said no, and that R24 would be at risk for possible adverse medication effects without an assessment and physician order. A policy titled, Self-Administration of Medications dated 7/11/2018 revealed in part: 2: If a resident desires to participate in self-administration, the interdisciplinary team will assess and periodically re-evaluate the resident based on change in the resident's status. In addition, 4: If the resident is a candidate for self-administration of medications, this will be indicated in the chart.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 86 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 11/13/24 at 09:50 A.M., An initial tour of the food service was conducted with Dietary Manager C. The sole hand sink (hot and cold) water valves were observed misaligned, allowing the handles to invade the sink basin. Dietary Manager C indicated she would contact maintenance for necessary repairs as soon as possible. The garbage disposal overhead spray faucet assembly hot water supply valve was observed leaking, adjacent to the handle packing gland. Dietary Manager C indicated she would contact maintenance for necessary repairs as soon as possible. The garbage disposal overhead spray valve assembly was observed with gray duct tape and beige electrical tape covering the handle and valve assembly connection. Dietary Manager C indicated she would contact maintenance for necessary repairs as soon as possible. The 2017 FDA Model Food Code section 5-205.15 states: A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair. The Magic Cup chest freezer was observed with accumulated ice [NAME]. Dietary Manager C indicated she would have dietary staff remove all frozen food products and defrost the chest freezer as soon as possible. The Frigidaire Freezer #6 exterior surfaces were observed soiled with accumulated and encrusted dirt and food residue. The interior door gasket was also observed soiled with accumulated and encrusted dirt and food residue. Dietary Manager C indicated she would have dietary staff thoroughly clean and sanitize the freezer unit as soon as possible. The Univex stand mixer was observed soiled with accumulated and encrusted food residue. The spindle gear assembly and backsplash were also observed soiled with accumulated and encrusted food residue. The convection oven(s) side panel was further observed soiled with accumulated and encrusted food residue and splash. Dietary Manager C indicated she would have dietary staff thoroughly clean and sanitize the stand mixer and convection oven side panel as soon as possible. The mechanical dish machine exterior surfaces were observed heavily soiled with accumulated dust and dirt deposits. Dietary Manager C indicated she would have dietary staff thoroughly clean and sanitize the mechanical dish machine exterior surfaces as soon as possible. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 11/15/24 at 02:00 P.M., Record review of the Policy/Procedure entitled: Freezer dated 08/31/2018 revealed under Sanitation and Defrosting Freezers: Frequency: Monthly (1) Unplug freezer of shut off circuit breaker. (2) Remove all foods from freezer and place poultry in another freezer to keep from thawing. (3) Let freezer stand several hours until ice has melted. (4) Drain and wipe up water with sponge or clean cloth. (5) Wash inside racks and fans carefully and thoroughly. Use baking soda and water (mix according to directions). (6) Clean outside with sanitizing solution. (7) When finished, plug in or turn on circuit breaker, set temperature dials, and allow freezer to return to proper temperature. (8) When freezer has returned to proper temperature (0 degrees Fahrenheit to -10 degrees Fahrenheit), replace food. (9) Freezer should be frost free. On 11/15/24 at 02:15 P.M., Record review of the Policy/Procedure entitled: Mixer dated 08/31/2018 revealed under Sanitation of Equipment: (1) Turn off machine. (2) Remove bowl and attachments. Take to pot and pan sink for cleaning. (3) Scrub bowl and attachments in hot detergent. (4) Run through dish machine of use pot and pan sanitizing sink according to procedure. (5) Scrub machine (beater shaft, bowl saddle, shell, and base). Use a sanitizing solution with a brush or clean cloth. (6) Rinse with clean water and clean cloth. (7) Allow to air dry.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant environment effecting 86 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and cross-connections between the potable (drinking) and non-potable (non-drinking) water supplies. Findings include: On 11/14/24 at 12:20 P.M., A common area environmental tour was conducted with Director of Housekeeping and Laundry Services E and Director of Maintenance F. The following items were note: The facility main entrance concrete surface was observed uneven between the expansion joints. The uneven expansion joint surface measured approximately 8-12 feet-long, creating an approximate 0.5-1.0-inch-high lip between the concrete sections. Director of Maintenance F indicated he would request funding for necessary repairs as soon as possible. B-Hall (North) Shower Room: The atmospheric vacuum breaker was observed missing on the shower wand assembly. Director of Maintenance F indicated he would install an atmospheric vacuum breaker as soon as possible. B-Hall Nursing Station: The flooring surface was observed severely worn and stained, exposing the concrete subsurface. The damaged flooring surface measured approximately 12-inches-wide by 24-inches-long and 12-inches-wide by 12-inches respectively. 2 of 8 cabinet drawers were also observed damaged and/or missing. The flooring surface wall/floor junctures and corners were further observed soiled with accumulated and encrusted dust/dirt deposits. Restroom: The commode grab bar was observed loose-to-mount and heavily corroded. B-Hall (South) The Medify Air purification unit air intake side panels were observed soiled with accumulated dust and dirt deposits, adjacent to resident rooms [ROOM NUMBERS]. Director of Housekeeping and Laundry Services E indicated she would have housekeeping staff thoroughly clean and sanitize the purification unit air intake side panels as soon as possible. B-C Hall Dining Room: 2 of 4 window screens were observed missing. 4 of 4 window well tracks were also observed heavily soiled with accumulated dirt and debris (leaves, etc.). Director of Maintenance F indicated he would replace the missing window screens as soon as possible. C-Hall (North) Beauty Shop: The desk fan was observed heavily soiled with accumulated dust and dirt deposits. The return-air-exhaust fan was also observed heavily soiled with accumulated and encrusted dust/dirt deposits. Shower Room: The atmospheric vacuum breaker was observed missing on the shower wand assembly. The hand sink faucet was also observed loose-to-mount. The entrance door frame and lower door surface was additionally observed (etched, scored, particulate). C-Hall (South) Shower Room: The atmospheric vacuum breaker was observed missing on the shower wand assembly. The flooring surface was also observed with flex tape covering worn and broken ceramic tiles. The damaged flooring surface measured approximately 6-inches-wide by 18-inches-long. The return-air-exhaust ventilation grill was further observed soiled with accumulated dust and dirt deposits. The entrance door frame and lower door surface was additionally observed (etched, scored, particulate). The oscillating floor fan was observed soiled with accumulated dust/dirt deposits, adjacent to room [ROOM NUMBER] (Unit Managers Office). Director of Housekeeping and Laundry Services E indicated she would have staff thoroughly clean and sanitize the oscillating floor fan as soon as possible. C-Hall The C-Hall Nursing Station flooring surface was observed severely worn and stained, exposing the concrete subsurface. The damaged flooring surface measured approximately 18-inches-wide by 24-inches-long. The desk fan was also observed heavily soiled with accumulated and encrusted dust/dirt deposits. 4 of 8 cabinet drawers were further observed damaged and/or missing. The oscillating wall mounted fan was additionally observed heavily soiled with accumulated and encrusted dust/dirt deposits. The flooring surface wall/floor junctures and corners were further observed soiled with accumulated and encrusted dust/dirt deposits. Janitor Closet: The utility sink atmospheric vacuum breaker was observed missing the top cover. The entrance door interior surface and door frame were also observed severely (etched, scored, particulate). Soiled Utility Room: The return-air-exhaust ventilation grill was observed heavily soiled with accumulated dust and dirt deposits. D-Hall Nursing Station: The flooring surface was observed severely worn, adjacent to the restroom. The damaged flooring surface measured approximately 6-inches-wide by 8-inches-long. 1 of 2 overhead lights were also observed non-functional within the restroom. The restroom hand sink faucet cold water valve was further observed leaking water at the valve stem perimeter. The wall/floor vinyl coving was additionally observed missing, adjacent to the restroom entrance door. The missing vinyl coving measured approximately 15-inches-long. Janitor Closet: The flooring surface was observed worn with missing ceramic tiles. The utility sink was also observed heavily soiled with accumulated and encrusted dirt/grime deposits. E-Hall Nursing Station: The flooring surface was observed severely worn exposing the concrete subsurface. The damaged flooring surface measured approximately 12-inches-wide by 24-inches-long. The restroom was also missing 1 of 2 over sink basin light bulbs. E-Hall (North) Shower Room: The atmospheric vacuum breaker was observed missing on the shower wand assembly. The commode base caulking was also observed stained and missing. Director of Maintenance F indicated he would make necessary repairs as soon as possible. E-Hall (South) Janitor Closet: The utility sink basin was observed heavily soiled with accumulated and encrusted dirt/grime deposits. The entrance door interior surface and metal frame were also observed (etched, scored, particulate). Shower Room: Three ceramic corner tiles were observed missing within the shower stall. Two ceramic corner tiles were also observed damaged. The atmospheric vacuum breaker was further observed missing on the shower wand assembly. Director of Maintenance F indicated he would make necessary repairs as soon as possible. On 11/14/24 at 03:35 P.M., An interview was conducted with Director of Maintenance F regarding the facility maintenance work order system. Director of Maintenance F stated: We have the TELS software system. On 11/14/24 at 03:45 P.M., An environmental tour of sampled resident rooms was conducted with Director of Housekeeping and Laundry Services E and Director of Maintenance F. The following items were noted: 205: The oscillating floor fan was observed soiled with accumulated and encrusted dust/dirt deposits. The drywall surface was also observed (etched, scored, particulate), adjacent to the Bed 1 headboard. The damaged drywall surface measured approximately 12-inches-wide by 30-inches-long. 207: The overbed light assembly pull string switch was observed non-functional. 216: The flooring surface was observed scuffed and black, adjacent to the four Bed 1 rubber wheel castors. 219: The drywall surface was observed (etched, scored, particulate), adjacent to the Bed 1 headboard. The damaged drywall surface measured approximately 12-inches-wide by 18-inches-long. 220: The oscillating floor fan was observed heavily soiled with accumulated and encrusted dust/dirt deposits. On 11/15/24 at 08:15 A.M., An environmental tour of sampled resident rooms was continued with Director of Housekeeping and Laundry Services E and Director of Maintenance F. The following items were noted: 303: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. 305: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. The return-air-exhaust ventilation was also observed non-functional. 308: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. The return-air-exhaust ventilation was also observed non-functional. The perimeter metal radiator cover was further observed (etched, scored, particulate). Director of Maintenance F indicated he would make necessary repairs as soon as possible. 309: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. The return-air-exhaust ventilation was also observed non-functional. 310: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. The return-air-exhaust ventilation was also observed non-functional. The desk fan was further observed soiled with accumulated dust/dirt deposits. 508: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. 509: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. 511: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. 512: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. The Bed 2 desk fan was also observed heavily soiled with accumulated and encrusted dust/dirt deposits. 516: One acoustical ceiling tile was observed (cracked, chipped, missing), adjacent to Bed 1. The damaged ceiling tile measured approximately 18-inches-wide by 24-inches-long. On 11/15/24 at 01:30 P.M., Record review of the Direct Supply TELS Work Orders for the last 60 days revealed no specific entries related to the aforementioned maintenance concerns. On 11/15/24 at 01:45 P.M., Record review of the Policy/Procedure entitled: Physical Environment Environmental Services Cleaning Schedule dated 07/01/2022 revealed under Policy: To establish a schedule which ensures the building and equipment is maintained in a clean and sanitary manner. All items may be cleaned more frequently, if necessary.

Based on observation, interview and record review the facility failed to include one resident (R8) out of four residents reviewed for limited ROM in the restorative program. Findings include: On 11/13/24 at 11:52 AM R8 was observed sitting in a wheelchair with her right upper extremity resting on a wheelchair arm platform and wearing a right-hand splint. R8 was unable to respond to questions about care. On 11/13/24 at 12:44 PM R8's legal guardian reported that R8 was not receiving therapy services or exercises. Record review of the Electronic Health Record (EHR) revealed R8 admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting right dominant side, dysphagia (difficulty swallowing) and aphasia (difficulty speaking) following cerebral infarction. Review of the Minimum Data Set (MDS) dated [DATE] for R8 revealed a Brief interview for Mental Status (BIMS) of not conducted resident is rarely/never understood. On 11/15/24 at 9:34 AM Certified Nursing Assistant (CNA) G was interviewed and said she did not perform any range of motion exercises with R8. Record review of R8's physical therapy discharge summary dated 7/26/24 revealed Functional Maintenance Program Established/Trained = Range of Motion Program ROM to both lower extremities with straight leg raises, ankle dorsiflexion/plantar flexion, hip abduction/adduction 10-20 repetitions 1- 2 sets each 3-5 times a week. Further review of the EHR for R8 revealed no orders, care plan and/or Kardex for a restorative ROM program. On 11/15/24 at 9:35 AM the Director of Rehab (DOR) H was interviewed and said there wasn't a formal restorative program at the facility. The DOR agreed a ROM program was recommended by R8's discharging therapist on 7/26/24. The DOR further said there was no follow through from therapy to nursing to conduct the ROM program. On 11/15/24 at 9:59 AM the Director of Nursing (DON) was interviewed and said the facility did not have a formal restorative program and that R8 was not receiving a ROM program. The DON agreed R8's discharging therapist wrote a ROM program, and the expectation was that therapy would instruct nursing on what is to be completed with the resident and that did not happen. Review of the facility policy titled Nursing Clinical Subject: Restorative Care adopted 7/11/2018 revealed in part . It is the policy of this facility to ensure that: -Restorative care will be provided to each resident according to his/her individual needs and desires as determined by assessment and interdisciplinary care planning. -The resident will receive services to attain and maintain the highest possible mental/physical functional status and psychosocial well-being defined by the comprehensive assessment and plan of care. -Resident's restorative care requires close intervention and follow-through by physical, occupational and speech therapies and the nursing department. It also requires participation of employees for other departments. -All employees will be informed and trained regarding their responsibility and role in resident restorative care.

Based on interview, and record review the facility failed to ensure R250 a resident with a known history of PICA (an eating disorder that involves eating or craving nonfood items) from access to an object that could be swallowed and choked on resulting in the swallowing of gauze requiring an emergency procedure. Findings include: On 6/14/24 at 1:15 PM, R250 was observed resting in a specially designed reclining wheelchair in the main dining and television area. Resident with eyes open, a wandering gaze, and with a relaxed facial expression. Resident was nonverbal. Upon record review, R250 had an initial admitted [DATE] and a recent admitted [DATE]. R50 had the following pertinent diagnoses: Cerebral Palsy (a group of conditions that affect movement and posture caused by brain damage before birth), Antiphospholipid Syndrome (a condition that causes the immune system to attack tissues and form blood clots), Other Specified Eating Disorder, Metabolic Encephalopathy (a brain disfunction also affecting the metabolism), Cerebral Infarction (a condition in which poor blood flow to the brain causes cell death), Dysphagia, Oropharyngeal Phase (a swallowing dysfunction), Gastrostomy Status (an insertion site surgically created for a feeding tube), and Adjustment Disorder with Mixed Disturbance of Emotions and Conduct. According to Minimum Data Set (MDS) documentation entered on 6/5/24 in the electronic medical record (EMR) a cognitive assessment was not performed and included a notation that resident was severely impaired. On 6/3/24 R250 was transferred to an emergency room due to aspiration which was noted in the facility EMR. emergency room notes stated that resident was seen for evaluation of respiratory problem, and further stated: . EMS state patient bit PEG tube off 1 hour ago. Prior to EMS arrival, staff suctioned airway and noted crackles in the lungs and discoloration in the feet and hands. Further record review revealed primary diagnoses at the hospital listed as Impacted foreign body in esophagus, initial encounter. Aspiration into respiratory tract, initial encounter. PEG tube malfunction. On 6/14/24 at 3:10 PM, during interview with the Director of Nursing (DON) the 6/3/24 hospitalization was discussed: DON explained that R250 had aspirated on gauze (the gauze that had been around the PEG tube insertion site) which was found in R250's esophagus at the hospital and removed by esophagogastroduodenoscopy (EGD). The staff took precautions by keeping resident in areas where resident could be easily observed. The DON said that the potential of resident swallowing the gauze had not been considered. On 6/14/24 at 4:15 PM, care plan review revealed that the facility failed to identify interventions to prevent R250 from coming into contact with nonfood items.

Based on observation, interview, and record review the facility failed to obtain physician's orders for oxygen maintenance (R269), properly date and change oxygen tubing in 4 of 4 residents (R5, R40, R218, and R269) reviewed for oxygen therapy, resulting in the increased potential for lung infections, and adverse side effect from oxygen administration. Findings include: R218 On 12/11/2023 at 11:24 a.m., R218 was observed with a nasal cannula (a device used to deliver supplemental oxygen) inserted into the nostrils. R218's oxygen tubing was observed with the date of 9/24/2023. When queried, R218 was unable to recall when the last time the oxygen tubing was changed. On 12/11/2023 at approximately 11:30 a.m., Licensed Practical Nurse (LPN) E verified the oxygen tubing that R218 was dated 9/24/2023 and explained the oxygen tubing should have December date not September's. LPN E said the oxygen tubing should be changed once a week on Sunday's midnight shift. According to the electronic medical records, R218 was initially admitted into the facility on [DATE] with Diagnoses of chronic obstructive pulmonary disease (COPD) and atrial fibrillation. R218's admission Minimum Data Set (MDS) with a reference date of 8/22/2023 indicated R218 cognition was intact with a BIMS (brief interview for mental status) score of 15/15. A respiratory care plan revision on 12/6/2023 documented R218 had altered respiratory functioning and/or difficulty breathing related to COPD and depending on oxygen. Review of the Physician's orders revealed Oxygen at three liters per minutes via Nasal cannula every shift for COPD and oxygen equipment management change out, date & label all tubing/bags/set ups .clean filter and wipe down machine every night shift every Sunday with a start date of 12/10/2023. Interview with the Director of Nursing (DON) on 12/13/2023 at approximately 2:30 p.m. confirmed the oxygen tubing should be dated and changed weekly. 49102 R5 On 12/11/23 at 11:19 AM, R5 was observed lying in bed with nasal canula tube around the neck with oxygen machine running on 3 liters per minute. R5's oxygen tubing was observed without a label with the date (indicating the number of days in use.) On 12/12/23 at 9:25 AM R5 was observed on the side of R5's face. R5's tubing was not labeled or dated. On 12/13/23 at 10:15 AM Licensed Pratical Nurse (LPN) F confirmed R5's oxygen concentrator was set at 3 liters. When asked how many liters of oxygen should be administered to R5, LPN F stated,the machine says 3L but she is supposed to be on 2L. Review of electronic medical record, R5 orders documented, O2 @ (at) 2 liters per minute via nasal cannula every shift for monitoring and Oxygen Equipment Management-change out, date & label all tubing/bags/set ups .clean filter and wipe down machine, as applicable every night shift A review of R5's medical record revealed an admitted [DATE] with pertinent diagnoses of Dementia, Anxiety Disorder, and Covid-19. According to the facility's 4/27/2018 Infection Prevention and Control Oxygen Use Policy/Procedure: It is the policy of this facility to promote resident safety in administering oxygen. Procedure: 1. The oxygen tubing is to be replaced every seven days. 39958 R40 In an observation on 12/11/23 at 11:08 a.m., R40 wore a nasal cannula and the tubing had no date to indicate the number of days the tubing was in use. Review of the electronic medical record revealed, R40 admitted to the facility on [DATE] with pertinent diagnoses which included Respiratory Failure with hypoxia, and Chronic Obstructive Pulmonary Disease (COPD). Review of a MDS assessment dated of 11/13/23 revealed R40 had cognitive impairment with a BIMS score of 8, out of a total possible score of 15 and required oxygen therapy. R40's Physicians orders dated 9/27/23 included O2 @ (at) 3L per nasal cannula for COPD every shift related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, maintain SpO2 above 90% and Oxygen Equipment Management--change out, date & label all tubing/bags/set ups .clean filter and wipe down machine every night shift every Sun for cleaning routine. R269 In an observation on 12/11/23 at 10:38 a.m., R269 laid in bed and had a nasal cannula in the mouth. In an observation on 12/11/23 at 11:07 a.m., R269's O2 tubing had no date and the O2 concentrator was set to 5 liters per minute. Review of an Admission Record revealed, R269 originally admitted to the facility on [DATE] and readmitted o 12/7/23 with pertinent diagnoses which included Respiratory Failure with hypoxia, Pneumonia, Chronic Obstructive Pulmonary Disease (COPD), and COVID-19. Review of a MDS assessment dated [DATE] revealed R269 had cognitive impairment with a BIMS score of 7, out of a total possible score of 15 and required oxygen therapy. Review of Physician orders revealed R269 did not have any orders for oxygen therapy. In an observation on 12/12/23 at 9:25 a.m., R269's O2 concentrator was set to 3 liters per minute. In an interview on 12/12/23 at 11:13 a.m., Licensed Practical Nurse (LPN) B reported R269 is on three liters of oxygen. LPN B was asked how was she aware R269 was on 3 liters of oxygen. LPN B stated, it is on the orders. LPN B was observed to review R269's Physician orders, LPN B then stated, (R269) does not have any orders. In an interview on 12/12/23 at 11:17 a.m., the Director of Nursing (DON) reported orders for oxygen use should have started when R269 admitted to the facility. The DON then reported R269 had a previous order for O2 at 4L/min for COPD, but the order was not restarted when R269 readmitted to the facility.

Based on observation, interview, and record review the facility failed to follow the standards of infection control for proper PPE (personal protective equipment) use, disposal of PPE, and hand hygiene, for three residents (R65 and R269) out of a 20 sampled residents reviewed for infection control, resulting in the potential for increased cross-contamination of diseases which place a vulnerable population at high risk for infections. Findings include: R65 In an observation on 12/11/23 at 2:12 p.m., Housekeeper C exited R65's room, wore gloves and carried a wet cloth. R65's room door had a droplet precaution sign. Housekeeper C reported a gown does not have to be worn in the room because I am double masked. Housekeeper C stated, What do you want me to do? Change my gloves every time. Houskeeper C then reentered R65's room with the same gloves she exited the room with. Review of an Admission Record revealed, R65 admitted to the facility on [DATE] with pertinent diagnosis which included COVID-19. Review of a MDS assessment dated [DATE] revealed R65 had no cognitive impairment with a BIMS score of 15, out of a total possible score of 15. Review of Physician orders revealed, R64 had an order, Droplet Precautions for Covid + every shift for patient monitoring for 10 Days . dated 12/7/23. R269 In an observation on 12/12/23 at 9:26 a.m., Certified Nursing Assistant (CNA) A wore a N95 mask, put on a gown, booties, gloves, and entered R269's room. CNA A did not wear eye protection and hand hygiene was not performed before application of PPE. Review of an Admission Record revealed, R269 originally admitted to the facility on [DATE] and readmitted o 12/7/23 with pertinent diagnoses which included COVID-19. Review of a MDS assessment dated [DATE] revealed R269 had cognitive impairment with a BIMS score of 7, out of a total possible score of 15. In an interview on 12/13/23 at 1:22 p.m., the Director of Nursing (DON) reported that the required PPE for droplet precaution is a gown, N95, face shield or eye protection. The DON then reported staff should wash their hands before putting on and removing PPE. Review of a Droplet Precaution policy updated on 2/22/21 revealed, It is the policy of this facility that Droplet Precautions shall be used in addition to standard precautions for residents with infections that can be transmitted by droplets . Droplets may be generated by the resident's coughing, sneezing, talking, or during the performance of procedures . Procedure as follows: 3. A mask should be worn when entering a resident's room. 4. Eye protection should be worn when entering a resident's room (e.g., google or face shield) . Review of a Hand Hygiene policy updated on 3/24/22 revealed, It is the policy of this facility that hand hygiene be regarded as the single most important means of preventing the spread of infection. Purpose: Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a resident. Proper hand hygiene should be performed between services to residents . After touching a resident or the resident's immediate environment. After contact with blood, body fluids, or contaminated surfaces. Immediately after glove removal. To cleanse hands to prevent transmission of possible infectious material. To provide a clean, healthy environment for residents and staff .

Based on observation, interview, and record review, the facility failed to obtain orders for a suprapubic catheter (catheter inserted through the abdomen and into the bladder) and failed to ensure the catheter had a securement device (prevents pulling of catheter tubing), for one (R269) of one resident reviewed for catheter care, resulting in the potential for urinary tract infections and skin trauma. Findings include: In an observation and interview on 12/12/23 at 9:30 a.m., R269 was observed with a catheter drainage bag while seated in a wheelchair. Certified Nursing Assistant (CNA) A transferred R269 into bed to perform peri care. At this time, it was observed that R269 had a suprapubic catheter without a securement device. When queried if R269 should have a securement device in place, CNA A stated, Probably, I would think so. Review of an Admission Record revealed, R269 originally admitted to the facility on [DATE] and readmitted o 12/7/23 with pertinent diagnoses which included Cirrhosis of the liver. Review of a Minimum Data Set (MDS) assessment, with a reference date of 11/27/23 revealed R269 had cognitive impairment with a Brief interview for Mental Status (BIMS) score of 7, out of a total possible score of 15. Review of a progress note with a date of 11/24/2023 at 10:00 p.m., revealed, Admit/Readmit . Resident readmitted back to facility at 2000 (8:00 pm) . Resident admitted back via stretcher with a suprapubic catheter . Review of Physician orders revealed R269 had no suprapubic catheter orders. In an interview on 12/12/23 at 11:13 a.m., Licensed Practical Nurse (LPN) B reported there should be orders if a resident has a catheter. LPN B then reported there should be an anchor (securement device) on R269's catheter and stated, So it doesn't get pulled. In an interview on 12/12/23 at 11:17 a.m., the Director of Nursing (DON) reported orders for R269's catheter should have been started on readmission.

Based on observation, interview, and record review, the facility failed to ensure proper working order of a walk-in freezer and the outlet pipe for an ice machine was protected against contamination from sewage or other sources of contamination, potentially effecting all residents in the facility. Findings include: On 1/9/2023 at 8:56 AM, during the initial tour of the kitchen, a mound of ice was observed on a box of puff pastry in the walk-in freezer. Mounds and pieces of ice were observed on the three shelves underneath the box of puff pastry. On 1/10/2023 at 9:00 AM during an observation and interview regarding the ice machine with Maintenance Director G, the drain line from the ice machine was observed to not have the required minimum one-inch air gap (an unobstructed vertical space between the end of the drain line and the flood rim of the floor drain). Maintenance Director G said, I will rectify that ASAP. During an interview on 1/11/2023 at 1:01 PM, Dietary Manager J described the sizes of the ice formed on the box of puff pastry as the size of a football, the ice formed on the lower shelves were of varying sizes similar to the size of a softball, baseball, with several smaller broken off pieces of ice. During an interview on 1/11/2023 at 1:18 PM Maintenance Director G said there was a leak of the condensate line in the walk-in freezer. According to the 2013 FDA Food Code, Section 5-202.13: An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 1 inch. On 1/11/2023 at approximately 5:00 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked.

Based on observation, interview, and record review, the facility failed to: 1. Ensure food items past the use-by-date were not stored with active food stock; 2. Ensure proper storage, sealing, and date-labeling of perishable food; 3. Ensure the walk-in cooler floor and walls were properly cleaned; 4. Ensure proper cooling of cooked, potentially hazardous (time-temperature for safety) food, cooked chicken and tomato soup; 5. Ensure wire storage racks were in good condition and cleanable; 6. Ensure a screen was installed in an opened window; 7. Ensure pans and lids were clean and allowed to air dry before stacking and storage; and 8. Maintain kitchen steam tables and dish tank areas in a clean and sanitary condition. These deficient practices had the potential to affect all the residents who consumed food from the kitchen, resulting in the increased potential for food borne illness. Findings include: On 1/9/2023 at 8:56 AM, during the initial tour of the kitchen the following was observed: An opened 44-ounce container of prune juice with a use-by-date of 12/11/2022 was observed in the cook's cooler. Dietary Manager (DM) J stated, It should have been thrown away. The following was observed in the walk-in cooler: - A 30-pound bag of ground beef mixed with textured vegetable protein (TVP) was opened and not date labeled with an opened date and discard date. The ground beef/TVP was observed unsealed and exposed to the refrigerator air. - A plastic storage bag of approximately 2 1/2 pounds of shredded cheese was not date labeled with an opened date and discard date. - A wall in the walk-in cooler was stained with multiple streams of a black colored substance. DM J described the substance as some type of mold and stated, It needs to be cleaned. Something dripped down and was never cleaned up. - The perimeter of the walk-in cooler floor and the area where wall baseboards might be installed were covered with food debris, dirt, and what appeared to be mold. - A third size pan of sweet and sour chicken and a third size pan of tomato soup were cooked on 1/8/2023. DM J said there should be cooling logs for the chicken and tomato soup but was unable to provide documentation that these items were cooled properly. - The protective covering on multiple storage racks was missing in several areas and the exposed metal was rusted. The following was observed in the walk-in freezer: - A 3 1/2 quart container of chicken and dumplings was labeled with a use-by-date of 11/13/2022. Near the mechanical dishwasher area, an exterior unscreened kitchen window was opened approximately four to five inches. DM J said there should be a screen at the window if it is open. The shelves and floor underneath the mechanical dishwasher were covered with a chalky white substance. The following was observed in the clean pot and pan area: - Two 1/2-size pans were wet and nestled with clean pans. - Two full-size pans contained food debris and were nestled with clean pans. - Three solid steam table lids of varying sizes, a full size, 1/2 size, and 1/3 size, contained food debris and were nestled with clean lids. On a return visit to the kitchen on 1/9/2023 at 10:40 AM the following was observed regarding the kitchen's two sets of steam tables: - The shelf underneath one steam table was stained with what DM J described as lime scale. - The shelf underneath the other steam table was stained with grease and food debris. DM J stated, They should be cleaned. During an observation and interview on 1/10/2023 at 4:03 PM, areas of the exhaust vent of the kitchen dish machine were noted to be sealed using foil tape. (A product used for taping joints and seams in duct work for ventilation systems.) However multiple areas of the foil tape were peeled back from the surface of the vents rendering the surfaces not smooth and easily cleanable. Maintenance Director G said the foil tape observed on the exhaust vents of the kitchen dish machine needed to be replaced. During an interview on 1/11/2023 at 1:01 PM DM J stated, When I arrived here two weeks ago, there was no cleaning schedule. (Kitchen staff) were not completing end of the day (cleaning) tasks. DM J said her expectations for date-labeling were to label and date every time something is opened. Regarding the floor in the walk-in cooler, DM J stated, There is a half tile missing and the rest is dirt and mold. DM J said the whole dish room needs to be wiped down and scrubbed. It needs a thorough deep cleaning. (The shelving underneath the mechanical dishwasher) is calcified water that has accumulated from not being wiped down. During an interview on 1/11/23 at 1:33 PM Nursing Home Administrator (NHA) said she was unaware of the condition of the kitchen storage racks and that foil tape was being used on the exhaust vents of the dish machine. A review of the 2013 FDA Food Code documented the following: - Section 3-101.11: Food shall be safe, unadulterated, and, as specified under S 3-601.12, honestly presented. - Section 3-501.14: (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 135 F (Fahrenheit) to 70 F; and (2) Within a total of 6 hours from 135 F to 41 F or less. - Section 4-601.11: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. - Section 4-903.11: (B) Clean equipment and utensils shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying. - Section 6-201.11: Except as specified under S 6-201.14 and except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable. - Section 6-202.15: Except as specified in (B) and (E) of this section, if the windows or doors of a food establishment, or of a larger structure within which a food establishment is located, are kept open for ventilation or other purposes or a temporary food establishment is not provided with windows and doors as specified under (A) of this section, the openings shall be protected against the entry of insects and rodents by: (1) 16 mesh to 25.4 mm (16 mesh to 1 inch) screens; (2) Properly designed and installed air curtains to control flying insects; or (3) Other effective means. On 1/11/2023 at approximately 5:00 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked.

Based on observation, interview, and record review, the facility failed to provide fresh water at bedside for three residents (R35, R44 and R49) and ensure one resident (R38) maintained a fluid restriction as ordered by the physician, of four residents reviewed for hydration, resulting in the potential for dehydration, abnormal lab values, and/or electroyte imbalances. Findings include: R35 On 1/9/2023 at 9:57 a.m., R35 was observed in the room alert and interviewable. During an interview, R35 stated, A couple of days ago I pressed my button (call light) trying to get some water. I finally got water later about 6 am on that morning on the midnight shift. They didn't give me any cold water until I asked for it, then it took hours. R35 was unable to recall the time cold water was requested or whether fresh water was provided on any prior shift. A foam water cup, labeled 1/9/2023 MN (denoting midnight shift) was observed on the resident's overbed table. The cup was less than 1/4 full and was room temperature to the touch. When R35 was asked about drinking water independently if it were available, R35 demonstrated the ability to reach the water cup to drink water without assistance. During an observation and interview on 1/10/2023 at 12:44 p.m., a water cup observed on the resident's bedside table, dated 1/9/2023 MN, was less than 1/4 full and was room temperature to the touch. R35 stated, No one brought in fresh water yet. According to R35's electronic medical record, R35 was admitted into the facility on [DATE] with diagnoses of muscle weakness and hypertension. R35's quarterly Minimum Data Set (MDS) assessment with a reference date of 12/20/22 indicated R35 was cognitively intact with a BIMS (brief interview for mental status) score of 15. A review of a 12/30/2022 Dehydration care plan revealed, (R35) had dehydration or potential fluid deficit related to poor intake, rectal bleeding . -Goal: (R35) will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor (a decrease in skin turgor is a late sign of dehydration). Review of lab results from a Comprehensive Metabolic Panel Laboratory, dated 12/27/2022, documented the following results: BUN (blood urea nitrogen) level of 73 with a normal reference range of 7 - 22. R38 On 1/9/2023 at 10:15 a.m., R38 was observed lying in bed alert and refused to be interviewed. An undated water cup was observed on the bedside table half filled with dark liquid. No water cup observed in R38's room. According to R38's electronic medical record, R38 was admitted into the facility on [DATE] with diagnoses of end stage renal disease and dependence on renal dialysis. R38's admission MDS assessment with a reference date of 11/11/22 indicated R38 had moderate cognitive impairement with a BIMS score of 11, was an extensive two-person assist for transfer, and extensive one-person assist for bed mobility. R38 required set up and supervision for meals/eating. Review of an undated Dehydration care plan revealed, (R38) has fluid overload (too much consumption of water can lead to fluid overload) or potential fluid volume overload related to kidney failure. -Goal: (R38) will comply with diet and /or fluid restrictions daily. -Interventions: Fluid restriction as prescribed. Encourage and monitor resident adherence. Report to medical provider as needed. Review of the physician's orders dated 11/11/2022 revealed, 1500 Milliliters (ml) fluid restriction (1200 milliliter from dietary and 300 milliliters from nursing every shift for end stage renal disease with hemodialysis. On 1/10/2023 at 12:44 p.m., a cup with approximately 480 ml of water was observed at R38's bedsided labeled 1/10/2023 MN. On 1/10/2023 at 3:36 p.m., Certified Nursing Assistance (CNA) P and CNA Q were interviewed in the hallway outside of R38's room regarding water pass for the residents. CNA P stated, We passed water in the morning. We get here at 7:00 a.m. and are here until 7:00 p.m. CNA Q stated, Me and (CNA P) were doing the set together technically. room [ROOM NUMBER] (R38) should not have water at bedside because he goes to dialysis. I don't believe he is supposed to have it because of his fluid restriction. I can check to see if he is supposed to have it at bedside. CNA Q walked into R38's room and observed a water cup filled with water within R38's reach and took the water cup away and stated to R38, You are not suppose to have it. R44 On 1/9/2023 at 10:20 a.m., R44 was observed lying in bed alert with a water cup at bedside labeled 1/9/2023 MN. R44 did not want to be interviewed. According to R44's electronic medical record, R44 was admitted into the facility on [DATE] with diagnoses of cerebral infarction and dysphagia. R44's quarterly MDS assessment with a reference date of 10/5/22 indicated R44 had no documented BIMS score. R44 required set up and supervision for meals/eating. Review of an undated Dehydration care plan revealed, (R44) has dehydration or potential fluid deficit related to diuretic use. -Goal: (R44) will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor. -Interventions: Educate the resident/family/caregivers on importance of fluid intake. -Invite the resident to activities that promote additional fluid intake. Offer drinks during one-to-one visits. On 1/10/2023 at 12:44 p.m., a water cup was observed at R44's bedside labeled 1/9/2023 MN. On 1/10/2023 at 3:36 p.m., CNA Q was interviewed in the hallway outside of R44's room regarding water pass for the resident. CNA Q verified that there was no fresh water passed to R44 and the water cup was not from the day shift. R49 On 1/9/2023 at 10:25 a.m., R49 was observed standing over the bed folding clothes. R49 appeared to be pleasantly confused and unable to be interviewed. No water was observed at R49's bedside or in R49's room. According to R49's electronic medical record, R49 was admitted into the facility on [DATE] with diagnoses of anxiety disorder, dysphagia, bipolar disorder, and epilepsy. R49's quarterly MDS assessment with a reference date of 11/28/22 indicated R49 had severe cognition impairment with a BIMS score of 6. Required supervision and one person set up for Activities Daily Living (ADL). Review of an undated Dehydration care plan revealed, (R49) has a potential fluid deficit related to fluid shift (associated with profound changes in vascular permeability and water electrolyte imbalance). -Goal: R49 will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor. -Interventions: Monitor/document/report as needed any signs and symptoms of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes. -R49 has tremors and is unable to safely hold regular cup, ensure drinks are in cup with handle and lid. -R49 requires Nectar thick fluids. On 1/10/2023 at 12:44 p.m., no water cup was observed on R49's bedside table or in the room. On 1/10/2023 at 3:36 p.m., CNA P and CNA Q were interviewed in R49's room regarding water for the resident. CNA P and CNA Q verified that there was no water cup in the room, and they had not passed water to R49 for the shift. During an interview on 1/10/2023 at approximately 4:53 p.m., the Director of Nursing (DON) was asked about water pass every shift. The DON stated, Water should be passed every twelve-hour shift and as needed. Water should be at the bedside unless the resident is on a fluid restriction and I believe thicken liquid but, I would have to look at the policy. The DON said R38 is on dialysis, has a fluid restriction, and should not have water at bedside. A review of the facility's policy titled, Hydration, dated 7/11/2018, revealed the following:: It is the policy of the facility to encourage fluid intake to maintain the resident's hydration in compliance with physician orders. Purpose: - To ensure that each resident is encouraged to consume adequate fluids in order to maintain proper hydration for optimum functioning of various body systems. Procedure: -3. Fluids will be offered at a minimum of every two hours for the dependent resident, unless contraindicated. -5. Additional beverages will be distributed throughout the day, depending on physician orders and resident preference. Residents may request additional fluids and receive them, if not contraindicated.

Based on observation, interview, and record review, the facility failed to 1.) maintain clean and sanitary bathroom flooring; 2.) ensure that there were no chipped paint and scuff marks on the bathroom doors and walls; 3.) ensure there were no missing bathroom floor tiles in resident's rooms (214, 215, 216, 217, 219, 220, and 221) on Unit B, and 4.) ensure the vent cover was placed securely over the heating/cooling unit in room [ROOM NUMBER], of 23 rooms reviewed for the enviroment, resulting in an unsafe, unsanitary, and uncomfortable environment for the residents. Findings include: On 1/9/2023 at 11:00 a.m. and on 1/10/2023 at 2:34 PM during a tour of the facility on Unit B, the bathroom of resident's rooms 214, 215, 216, 217, 219, 220, and 221 were observed with sticky substances and dark dirty areas on the floor. The bathrooms also had chipped paint and scuff marks on the doors and walls. In the bathroom of room [ROOM NUMBER] a white high raised toilet seat leaning against the wall was observed with dust and yellow stains resembling urine and missing floor tiles. On 1/10/2023 at 2:44 p.m., during an interview Housekeeper C stated, I am a regular on this unit and the bathroom floors have been like this for years. The high raised toilet seat, we housekeepers don't clean, the CNA (Certified Nursing Assistance) are supposed to clean the toilet seats because it's been sitting there for a long time. Housekeeper C verified the bathrooms had been cleaned already for the shift. Housekeeper C demonstrated mopping the bathroom floor of room [ROOM NUMBER]. Housekeeper C was asked to demonstrate her technique used to mop the floors. Housekeeper C prepared the water with cleaning solution and attached a light grey mop pad onto the mop handle. During Housekeeper C's mopping demonstration, the dark and sticky substances on the floor were being removed with each stroke. Housekeeper C was asked to mop the silver colored floor transition strip at the entrance of the bathroom. The dark and sticky areas on the transition strip were removed after Housekeeper C completed the demonstration. Housekeeper C was asked to confirm the color of the mop pad after completing the demonstration and said it was black. On 1/10/2023 at approximately 4:55 p.m., during an interview, Housekeeping Director (HKD) D stated, Mopping is to be done daily in every resident's room and as needed. I haven't been here long, about two months or so. I do walking rounds every day on every unit. I did notice the bathroom floors have been neglected. Some of the cleaning products are not working. I am trying to find a good cleaning product to clean properly and train staff on stripping and waxing. On 1/10/2023 at approximately 5:55 p.m., the Director of Nursing (DON) stated during an interview, Housekeepers clean the toilet seats, but I will have to check to see who cleans the high raised toilet seats. For the bathroom floors, my expectation for housekeeping is to mop the bathroom floors daily. On 1/10/2023 at approximately 6:05 p.m., a HKD D was asked to provide a deep cleaning environmental schedule. On 1/11/2023 at 2:30 p.m., HKD D presented a B unit housekeeping daily work area schedule and stated, This is what we are using now. Review of facility document titled, B Unit Housekeeping Daily Work Area schedule documented the following: -Start of Shift: All resident rooms .bathroom, toilet, sink, mirror, sweep and mop . A review of the facility's policy, Environmental Services, dated 3/8/2021, revealed the following: Environment Cleaning: -Thorough scrubbing/disinfecting shall be done for all environmental surfaces that are being cleaned in-patient care areas. -In patient care areas, cleaning of non-carpeted floors and other horizontal surfaces (e.g., bedside tables), shall be done daily. -Cleaning schedules and procedures for all patient rooms, corridors, nursing stations and other areas shall be maintained in the Department of Environmental Services. 46865 On 1/10/23 at 9:41 AM, the cover for the radiant heater was observed hanging off the heater exposing the radiant heater piping. During an interview on 1/10/23 at 9:42 AM, Maintenance Director I from a sister facility said that the radiant cover should be on the radiant heater. Also, Maintenance Director I explained that hot water travels through the piping of the radiant heater, allowing heat to come out of the vent. The exposed piping could cause harm to residents. During an interview on 1/11/23 at 9:44 AM, the facility's Maintenance Director G said that it was not okay for the cover to be off the heater. It could have caused too many safety hazards (cuts and burns) for the resident residing in the room.

Based on observation, interview, and record review, the facility failed to ensure palatability of meatloaf served to four residents (#'s 7, 16, 23, 52) of six residents reviewed for meal acceptance, resulting in dissatisfaction with the meal experience. Findings include: On 1/9/2023 at 8:56 AM, during the initial tour of the kitchen, an opened 30-pound bag of ground beef mixed with textured vegetable protein (TVP - soy meat extender) was observed in the walk-in cooler. When asked what was made from this product, Dietary Manager (DM) J said it was recently used to make a meatloaf. On 1/9/2023 beginning at 10:27 AM, Resident #7 (R7), Resident #16 (R16), Resident #23 (R23), and Resident #52 (R52) were individually and separately interviewed regarding the palatability of the meatloaf recently served in the facility. These interviews yielded the following comments: - R7 stated, I don't like it. It tastes funny. - R16 stated, The meatloaf was nasty. It was dry and crumbly. It tasted like cardboard. - R23 stated, It wasn't that good. It didn't taste right. - R52 stated, The meatloaf was terrible. It was more bread in there than meat. It didn't taste like meatloaf. During an interview and record review on 1/10/2023 at 10:49 AM, the recipe for the meat loaf was reviewed with DM J. The recipe specified the use of Ground beef 80/20 (80 percent lean beef to 20 percent fat). DM J said she was unsure if the meatloaf recipe needed to be altered based upon the meat product used. The Nutrition Facts label from the ground beef/TVP mixture documented that a four ounce serving size provided 28g (grams) of fat of which 11g were saturated fat. According to the website: https://www.nutritionvalue.org, a four ounce serving size of 80/20 ground beef provided 23g of fat of which 8.6g were saturated fat. During an interview on 1/10/2023 at 2:23 PM Registered Dietitian (RD) M said she had no knowledge of the facility using a ground beef/TVP product for the facility residents. RD M stated, I wouldn't care for that if she went to a restaurant and ordered meatloaf but found out the kitchen used ground beef/TVP product instead of 100% ground beef. In terms of the kitchen preparation, RD M stated, I would want them to use what the recipe called for. I support doing better with the meatloaf and meat products. A review of R7's Admission Record documented an initial admitted [DATE] and readmitted [DATE]. R7's diagnoses included schizoaffective disorder and atherosclerotic heart disease. A Minimum Data Set (MDS) assessment dated [DATE] documented moderate cognitive impairment, upper extremity impairment on one side, and one-person limited assistance for eating. R7 was prescribed a regular diet with mechanical soft texture. A review of R16's Admission Record documented an initial admitted [DATE] and readmitted [DATE]. R16's diagnoses included diabetes mellitus-type 2 and end stage renal disease. A MDS assessment dated [DATE] documented intact cognition, no upper extremity limitations, and supervision with set-up help only for eating. R16 was prescribed a renal 3g potassium, 2g sodium, 80g protein diet with regular texture. A review of R23's Admission Record documented an admitted [DATE]. R23's diagnoses included diabetes mellitus-type 2 and schizophrenia. A MDS assessment dated [DATE] documented intact cognition, no upper extremity limitations, and supervision with set-up help only for eating. R23 was prescribed a regular diet with regular texture. A review of R52's Admission Record documented an initial admitted [DATE] and readmitted [DATE]. R52's diagnoses included chronic obstructive pulmonary disease and atrial fibrillation. A MDS assessment dated [DATE] documented intact cognition, no upper extremity limitations, and supervision with set-up help only for eating. R52 was prescribed a regular diet with regular texture. A review of Resident Council meeting minutes documented concerns with food palatability on 10/20/2022 as follows: lack of seasoning on meals; the vegetables are sometimes undercooked and that the French fries are soggy. During an interview on 1/11/2023 at 1:33 PM, the Nursing Home Administrator (NHA) stated, Maybe the (meatloaf) recipe should have been tweaked after the way people responded to it. On 1/11/2023 at approximately 5:00 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked.

Citation pertains to intake MI 5804 Based on observation, interview and record review the facility failed to prevent a pressure ulcer, effecting one resident (R#8) out of three residents reviewed for pressure wound prevention, resulting in the formation of a pressure ulcer. Findings include: On 11/13/20 at 9:30 a.m., during observation of wound care provided Nurse A. It was observed that on the left posterior ankle, R#8 had an unstageable pressure ulcer. Facility had documented as left calf. Nurse A was asked if this wound was a facility acquired pressure ulcer, Nurse A stated, Yes. Nurse A then referred me to Director of Nursing (DON) for further explanation of how the pressure ulcer evolved. On 11/13/20 at 10:30 a.m., during interview with DON, when asked if the pressure ulcer on R#8 left heel was acquired in facility, DON said Yes. When asked how it evolved DON said, We (facility) had used a wedge to keep R#8's heels off of bed and it made a pressure ulcer. When asked if the pressure ulcer could have been avoided, DON stated, Yes. When asked if the anatomical area would be considered R#8's left posterior ankle and not left calf, DON stated, Yes. On 11/13/20, record review revealed R#8 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to Minimum Data Set (MDS), R#8 had impaired cognition and was extensive assist with Activities of Daily Living (ADLS). Review of Skin/Wound Progress notes documents on 9/14/20, Residents wound is pressure . Review of Wound Care Progress Notes dated 9/16/20 documented New area to LLE (left lower extremity) - Wound #2- Left Posterior Calf - UTD (Unable to determine- Not able to stage) - 3.0 cm (Centimeters) x 1.0 cm. Review of care plans documents R#8 has UTD of left posterior calf related to immobility and due to heel suspension wedge. 11/13/20, review of Skin Monitoring and Management- Pressure Ulcer adopted 7/11/18 documents the following: A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition or other factors demonstrate that a developed pressure ulcer was unavoidable; and A resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new, unavoidable sores from developing.

Based on observations, interviews, and record reviews, the facility failed to prevent the development of a pressure ulcer, conduct timely skin/wound assessments, initiate a timely care plan, or consistently administer prescribed treatments to the pressure ulcer area for one of three resident's (R101) reviewed for pressure ulcers, resulting in R101 developing a stage 3 pressure ulcer (crater-like, total loss of skin with exposed fat tissue) requiring a seven day hospitalization for surgical debridement (removal of dead, infected tissue) with intravenous antibiotics. Findings include: During an observation on 1/17/19 at approximately 9:30 AM the R101 was observed in her bed, laying on her right side, with a large occlusive dressing on her coccyx area. CNA 'A' was present and said the physician had just observed her pressure ulcer and was sending her out to the hospital for further debridement of the wound. At this time, Nurse 'B' was interviewed regarding the resident's pressure ulcer care. Nurse 'B' said she just completed wound care with the physician, and the pressure ulcer looked worse. The Physician ordered the resident out the hospital for evaluation and treatment. During an interview on 1/17/19 at 10:00 AM, R101's family member, and also the resident's Durable Power of Attorney (DPOA), said that during a care conference on 12/27/18, nurse 'C' did not report anything about the resident having a significant pressure ulcer. The family member said on 1/3/19, R101 had to be hospitalized for [REDACTED]. According to the hospital records, dated 1/3/19, R101 was admitted to the hospital with [REDACTED]. The resident was prescribed to have a surgical debridement of the dead/infected areas of the coccyx pressure ulcer, and intravenous antibiotics. R101 remained at the hospital for 7 days and was not transferred back to the facility until 1/11/19. According to the medical record, R101 had admitted to the facility in (YEAR) for multiple [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] indicated that R101 did not have any pressure ulcers and was not at risk for development of pressure ulcers. However, a shower sheet dated 11/1/18 identified the resident as having a 're-opened area on the buttock'. A shower sheet dated 11/8/18, indicated the resident had a 'small open area on her buttocks', and the 'nurse applied a patch'. A shower sheet dated 11/26 indicated the resident now had 'open areas on both buttocks between her cheeks', and the 'nurse applied a patch to her coccyx area'. On 12/17/18, a shower sheet revealed that the resident had a 'raw, blackened, and red open area on her coccyx'. A 'shower sheet' is body diagram documented on by a certified nursing assistant (CNA) during shower days. There are no nurse's notes or skin/wound assessments to correspond with these shower sheets. There is no care plan intiated for the pressure ulcer, until 12/17/18. On that date, a care plan for 'potential for skin impairment' indicates the resident has an 'unmeasurable deep tissue injury'. A review of the physician's orders [REDACTED]. 11/7/18: [MEDICATION NAME] to left buttocks for excoriation, change every three days. 11/27/18: change to wound cleanser, collagen sheets, cover with gauze dressing every day. 12/17/18: zinc oxide to buttocks every shift, and as needed. 12/20/18: air mattress. 12/12/18: change to wound cleanser with santyl (topical debridement agent). 1/3/19: transfer resident to hospital for wound care evaluation and treatment. A review of the Treatment Administration Records (TAR) for (MONTH) (YEAR) revealed that the skin treatments prescribed for 1/16/18, 11/19/18, and 11/28/18 - 11/30/18, were left blank, (had no nurse initials on it), therefore did not indicate the treatments were administered. A review of the TAR for (MONTH) (YEAR) revealed that skin treatments prescribed for 12/20/18, and on 12/22/18, were left blank, therefore did not indicate the treatments were administered. A review of the TAR for (MONTH) 2019 revealed that skin treatments prescribed from 1/1/19- 1/3/19, were not documented on as 'administered'. According to the MDS dated [DATE], R101 was now identified to have one pressure ulcer that was considered a deep tissue injury, and unstageable due to coverage of the wound bed by eschar (blackened dead tissue). The first nursing assessment for the pressure ulcer is dated 12/26/18 and is as follows: 13 centimeter (cm) x 11.5 cm necrotic tissue 20% slough (dead tissue, creamy or yellow) and 80% eschar. On 1/17/19 at 2:00 p.m., during an interview with nurse 'C', the Director of Nursing, and the Administrator they said they could not locate any documentation to support that skin/wound assessments or monitoring for R101's skin had been conducted prior to 12/26/18. They acknowledged the lack of documentation for the resident's prescribed skin treatments on the TAR sheets and the lack of a care plan for the pressure ulcer until 12/17/18. According to the facility's wound care management policy, revised 7/1/18, page 1, 3. Upon identification of the development of a wound, the wound assessment will be documented on the Initial Wound Assessment Form. 4. Identified risk factors should be discussed in CAA documentation and addressed in the Resident's care plan to assure appropriate interventions to manage the risk are implemented. 5. Residents should be examined thoroughly at least weekly by a licensed nurse to identify existing pressure ulcers. a. Findings from the weekly skin assessment should be documented by the licensed nurse on a Body Audit Assessment Form.

This citation pertains to intake #MI 587. Based on observation, interview and record review, the facility failed to provide treatment, interventions, and adequate monitoring of pressure ulcers for one (#806) of four sampled Residents reviewed for pressure ulcers in a total sample of 17, resulting in the worsening of a facility acquired pressure ulcer and the potential for further clinical compromise. Findings include: On 10/11/17 at 8:30 a.m., review of complaint intakes reported to the State Agency included an allegation that the facility was not cleaning and caring for pressure wounds (ulcers) properly. Observations of R#806 were conducted on 10/10/17 at 10:20 a.m., 2:00 p.m., 3:54 p.m., 10/11/17 at 8:34 a.m., 9:10 a.m., 10:50 a.m., and 10/12/17 at 8:13 a.m., and 9:00 a.m. At each of these observations, the Resident was observed lying in bed in the same position (on the back, leaning slightly to the left, with the right side of the right foot pressed onto the footboard of the bed - direct pressure on the side and bottom of the foot) on a regular mattress (not a pressure reducing mattress). Also, the left blue heel protector was observed resting on the seat of the geri chair recliner at the end of the bed, and not on the Resident's left foot. The Resident was unable to participate in any meaningful conversation due to significant cognitive impairment. On 10/11/17 at 9:10 a.m., the Director of Nursing (DON) was asked to observe R#806. At this time, the DON confirmed the observation of the Resident's right foot pressed onto the foot board, the lack of heel protector to the left foot and the lack of pressure reducing mattress and was unable to offer any explanation as to what specific skin care interventions were in place. Observation of the Resident's treatment to the right foot documented the date of the last time the Resident's wound was changed which read, 10-9-17 1400 (2:00 p.m.) (Initials of Wound nurse Licensed Practical Nurse/LPN H). The left foot was observed contracted at the knee with the left foot/toes pressed directly onto the mattress. At that time when asked about the pressure of the Resident's foot onto the mattress and foot board, the DON reported, Oh that's down really hard. He's a taller guy. May need a bigger bed. When asked why that hadn't already been identified by the facility, the DON was unable to offer any explanation. The DON was requested to observe the Resident's next treatment change with LPN H and reported LPN H was off today due to working midnights the night before and would follow up. On 10/12/17 at 9:00 a.m., observation of R#806's pressure ulcer to the right foot was conducted with LPN H. At that time, LPN H was asked reported she had only been the wound nurse for three weeks and when asked to report the measurements and description of the wound stated, I've only been doing wounds for three weeks. I don't usually measure. I'm not sure until she (wound consultant) teaches me. I haven't been trained on that. At that time, LPN H proceeded to utilize a paper ruler and reported R#806's wounds as, Area to the right side of the right foot is 5 centimeters (cm) in length by 2 cm width by can't tell it's scab. When asked about the interventions in place to prevent breakdown or worsening of pressure ulcers, LPN H reported, He should wear both of these (pointed to heal protectors) and when asked why there was only one to the right foot, was unable to offer any further explanation. Additionally, when asked about the repositioning of the Resident and observations of the lack of repositioning or any positioning devices observed thus far, LPN H reported, He should be (repositioned) but has a tendency to roll back (into same position). Hmm that would help. On 10/12/17 at 9:40 a.m., the DON was informed of the observation of R#806's pressure ulcer with LPN H and concerns regarding the lack of interventions to prevent the worsening of the right side of the right foot pressure ulcer, and lack of treatments provided as ordered. The DON reported, Until we get this staffing figured out, will continue being an issue. Review of R#806's physician orders [REDACTED].>cleanse right side of foot with NS (normal saline); Pat dry, cover with foam daily Review of R#806's skin care plan included: Start Date: 01/06/2016 Last Reviewed/Revised: 07/24/2017 03:54 PM Category: Pressure Ulcer Problem: Resident is at risk for/has actual skin breakdown R/T (related to) Limited Mobility/poor circulation, difficulty floating heels d/t (due to) leg movements. (r lateral foot) .Goal: Resident's skin will remain intact/heal without complications. Approaches included (interventions last edited 5/18/17 and did not identify worsening of the right foot pressure ulcer): Start date: 3/9/17; Edited: 05/18/2017 .Use puffy heel protector boot to relieve pressure on the heels and lateral foot Start date: 3/1/17 .Treatment as ordered Start date: 10/11/16 .Turn and reposition frequently Start date: 9/29/16 .Use pillows to relieve pressure on the heels Start date: 6/22/16 .Braden Quarterly Weekly Skin Assessment Start date: 6/22/16 .avoid pressure to toes on footboard Start date: 1/6/16 .Use PRESSURE REDUCING MATTRESS for pressure reduction when resident is in bed Review of R#806's pressure ulcer progress notes included: Wound 3 Date/Time Identified 03/01/2017 05:06 PM; Type Pressure Ulcer; Location Right top of foot side of foot; Present on Admission/Re-entry? No .Most Recent size: 09/29/17 at 10:38 AM 3 (cm) x 1 (cm); Previous Size 2.2 (cm) x 0.6 (cm) There was no further documentation of progress notes for the Resident's Wound 3 available for review. Review of the most recent Weekly Braden Scale for Predicting Pressure Sore Risk documented R#806 was at High Risk with a score of 12 on 8/14/17. There were no further Braden scales documented as completed in the clinical record. Review of the available documentation from the facility's wound consultant provided by the facility included: 9/7/2017 (Most recent) Vascular Surgery and Wound Care Note .is seen for follow up of wounds for right foot. Wounds are reported is healing. He is tolerating dressing changes with [MEDICATION NAME] and silver alginate .He grimaces with pain with treatment and cleansing of wound .He is wearing soft foods (sp) to assist with offloading .Ulcer to lateral right foot measures 0.8 x 2.3 x 0.2 cm (worsened from 8/10/17), there is minimal slough in the wound bed .Pressure Ulcer Right midfoot, stage IV .Plan: 1. Cleanse right midfoot ulcer daily with normal saline, apply [MEDICATION NAME] over the wound bed, cover with silver alginate .4. OFFLOAD WOUNDS AT ALL TIMES. Devices for offloading should be ASSESSED FREQUENTLY to ensure there is no pressure applied to wounds or to other parts of the foot . 8/10/2017 Vascular Surgery and Wound Care Note .is seen for follow up of wounds for right foot .Ulcer to lateral right foot measures 0.5 x 2.2 x 0.1 cm, there is dry purple scab/eschar over the wound bed .Plan: 1. Cleanse right midfoot ulcer daily with normal saline, apply foam dressing over wound bed .4. OFFLOAD WOUNDS AT ALL TIMES. Devices for offloading should be ASSESSED FREQUENTLY to ensure there is no pressure applied to wounds or to other parts of the foot . Review of the Treatment Administration Records (TARs) for R#806 included Cleanse R side of foot with NS (normal saline) pat dry, cover with foam daily 7-3. There were four blank entries (no treatment documented as provided) on 10/5, 10/7, 10/8, and 10/10/17. Further review of the clinical record revealed R#806 was initially admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/26/17, R#806 had impaired cognition, required total assistance of one person for bed mobility, transfers, had an unhealed pressure ulcers with skin and ulcer treatments that included pressure reducing device for bed, turning/reposition program, and ulcer care. On 10/12/17 at 3:30 p.m., review of the facility's undated Pressure Ulcer Prevention policy included: .Residents who enter the facility without pressure sores do not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable. UNAVOIDABLE means that the resident developed a pressure ulcer even though the facility had evaluated the resident's clinical condition and risk factors, developed and implemented interventions that are consistent with the resident's needs, goals and recognized standards of practice, monitored and evaluated the impact of the interventions and revised the interventions as appropriate .Steps to alleviate risk factors include, but are not limited to .Avoid friction with proper transfer & positioning techniques .Utilize pressure reducing mattress .Float heels in bed .Reposition every one to two hours depending on resident's need .Pressure ulcer prevention included identifying and evaluating a resident's risk factors for development of pressure ulcers. This information is utilized to develop a comprehensive care plan based on identified risk. The care plan is monitored to evaluate the effectiveness of the interventions to alleviate risk factors .

This citation pertains to intake #MI 313. Based on interview and record review, the facility failed to provide and implement interventions to prevent severe weight loss for one (#812) of six sampled Residents reviewed for weight loss in a total sample of 17, resulting in continued weight loss (severe - over 10 % in six months), and a potential for malnutrition and decline in health or death. Findings include: On [DATE] at 8:40 a.m., review of complaint intakes reported to the State Agency included concerns alleging a Resident was being neglected by the nursing home staff, that the Resident lost 40 pounds since being in the nursing home, and showed signs of being weak. On [DATE] at 11:00 a.m., review of the closed clinical record revealed R#812 had been admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. R#812 had been admitted on to hospice services on [DATE] with directives for do not resuscitate, and expired on [DATE]. According to the Minimum Data Set (MDS) assessments completed from [DATE] - [DATE], R#812 was not identified as having any unplanned weight loss coded on these MDS assessments. However, the following MDS assessments identified weights that compared to the previous assessments that had decreased, however there was no identification of what alternate interventions were implemented to address the weight loss, or to prevent continued weight loss: Quarterly MDS with an assessment reference date (ARD) of [DATE] documented R#812's weight was 172. Section K0300: Weight Loss - Loss of 5% or more in the last month or loss of 10% or more in last 6 months = 0. No. Annual MDS with an ARD of [DATE] documented R#812's weight was 172. Section K0300 was marked as 0.No. The CAA (Care Area Assessment) for this assessment which had been completed by the Certified Dietary Manager (Staff F) dated [DATE] read, resident is on a regular, thin liquid diet which he tolerates well. Current weight is stable, He generally is fed by staff average intake at meals about 65%. P(NAME) (plan of care) will continue and will monitor prn (as needed). Quarterly MDS with an ARD of [DATE] documented R#812's weight was 135. Section K0300 was marked as 0.No. Quarterly MDS with an ARD of [DATE] documented R#812's weight was 120. Section K0300 was marked as 0.No. Review of the Physician orders [REDACTED].>Pureed consistency, honey thick liquids Start: [DATE]. Prior to this, the Resident's diet was regular with thin liquids. Review of the care plan conference summary forms from [DATE] and [DATE] identified no dietary involvement or review - the section for Dietary was left blank with no identification of concerns regarding weight loss or alternate interventions to prevent the risk for further weight loss. The form dated [DATE] which had been signed by the facility's Certified Dietary Manager (Staff F) documented, Wt 120 lbs. Pureed diet honey thick . There was no further documentation available. Staff F was unavailable for interview due to illness during survey. On [DATE] at 11:20 a.m., Registered Dietician (RD A) was interviewed by phone. At that time, RD A reported she had only started working at the facility since [DATE] and was unable to offer any explanation as to if or what interventions and assessments had been completed for R#812 to address the significant weight loss. On [DATE] at 11:45 a.m., the Administrator was requested to provide any further documentation to support the facility had adequately addressed or attempted alternate interventions for the Resident's severe weight loss. On [DATE] at 1:50 p.m., the Administrator reported that he had only been at the facility since April and that the facility was unable to locate any evidence of nutritional assessment or documentation addressing the Resident's weight loss for R#812 since [DATE]. Additionally, the Administrator confirmed the nutritional care plan last reviewed on [DATE] did not identify any new interventions or discussion of alternative approaches to address the Resident's continued weight loss or interventions to limit further decline. Review of the interdisciplinary progress notes, and assessments revealed the last documented nutrition assessment was completed on [DATE]. There were no nutritional interventions documented which identified or addressed the Resident's significant weight loss. Included in the documentation provided by the facility revealed a consult for a swallow study dated [DATE] which read, The pt. presents with a severe oropharyngeal dysphagia with the pt. holding the bolus in mouth for longer than normal .swallow is not functional at this time as pt. is not able to clear bolus from throat even with repeat swallows. Recommend NPO (nothing by mouth) with alternate means of nutrition . This form also noted, Called (Name of Medical Director) .Dr ordered continue with current diet . There was no documentation which identified further monitoring or evaluation of the Resident's nutritional status since this recommendation. There were no advance directives available for review in the clinical record which identified whether the Resident's representative had signed off on alternate nutritional interventions such as a mechanical feeding tube to deliver nutrition. Review of the available documented weights in the clinical record included: [DATE] = 172 lbs; [DATE] = 136.2 lbs; [DATE] = 133 lbs; and [DATE] = 120 lbs. This indicated a severe weight loss (greater than 10 % in six month period) of 29.06% weight loss from [DATE] to [DATE], without any nutritional interventions identified or implemented. On [DATE] at 1:50 p.m., and 4:00 p.m., the Administrator was requested to provide documentation of the facility's process for monitoring and assessing Resident's nutritional status, however there was no documentation provided by the end of the survey.

This citation pertains to intake number MI 074 Based on observation, interview and record review, the facility failed to ensure a safe environment by keeping the walkway for a blind ambulatory resident free from an accident hazard for one (#611) of 18 sampled residents reviewed for accident hazards from a total of 21 sampled residents, resulting in the legally blind resident hitting his head on a light fixture cover that was hanging from the ceiling in the front lobby/entrance and sustaining a bump on the top of his head. Findings include: On 11/03/15 at 7:30 AM, during the entrance to the facility the front foyer area was noted with an missing ceiling tile (2) area. The fluorescent light fixture was exposed and the clear plastic cover of the light fixture was observed on the floor, in the corner leaning against the wall. On 11/3/15 at 3:00 PM observation of the front foyer noted that the light fixture and tiles remained missing. On 11/3/15 at 3:15 PM, the receptionist, employee B was interviewed. She stated, When the transportation driver was bringing the resident back into the facility from dialysis, the ambulatory resident's head hit the panel that had been hanging down in the entrance foyer. I got up to help him in the door when he complained of bumping his head, On 11/03/15 at 3:30 PM, resident #613's clinical record was reviewed. The resident was admitted [DATE], and had [DIAGNOSES REDACTED]. The Minimal Data Set (MDS) assessment dated [DATE], identified cognitive/decision-making skills that were independent The resident required limited to extensive assistance with activities of daily living that included transfers and ambulation. A plan of care was in place (dated 9-2015) noted at risk for falls/injury due to gait/balance, use of assistive devices and impaired vision. Interventions noted to assist. On 11/4/15 at 12:15 PM, resident #611 was interviewed. Resident #611 stated I am six foot three inches and when I entered the facility the light fixture cover was hanging down. I am blind was did not see it. The had a bump on the top of my head that hurt. On 11/04/15 at 8:30 am, the Director of Nursing (DON) was interviewed. The DON stated, This was a maintenance concern. They failed to fix the light fixture, it was not repaired. The facility was asked for a policy on accident/hazards that was not been provided by the end of the survey. ( )

Based on observation, interview, and record review, the facility failed to properly assess, and provide appropriate and timely interventions for a tibia/fibula fracture for one (#701) of four sampled residents reviewed for pain from a total sample of four, resulting in prolonged pain and suffering due to a delay in diagnosing the fractures. Findings include: On 8/21/14 at 9:30 AM, resident #701 was observed asleep in bed with a cast on the left lower leg. At 9:45 AM, the resident's clinical record was reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Per review of nurses notes dated 7/26/14, the resident was admitted into the hospital following a stroke that day and returned to the facility on [DATE] at 5:30 PM with speech slurred and left sided weakness. The resident was "alert and oriented x 1." At 7:20 PM, per review of a "Resident Fall Report" for resident #701, the resident was found on the floor lying on the left side and was complaining of left ankle pain. An X-ray of the left ankle was ordered "due to pain." Per review of the (portable) X-ray report dated 8/4/14 at 10:58 PM, the left ankle and foot were negative for fracture or dislocation. Nurses notes documented the following for resident #701: On 8/5/14, a physical therapy (PT) evaluation was completed and recommended PT for 3-5 weeks. The resident complained of left ankle pain. The resident was prescribed [MEDICATION NAME] (narcotic pain medication) 5/325 milligrams (mg) every four hours, as needed (PRN) and received one tablet on 8/5/14 per review of the Medication Administration Record [REDACTED]. On 8/6/14 at 2:30 AM, resident #701 was alert with confusion. The resident "complained of left foot pain. Resident (was) asked to elevate left foot...." At 10 AM: "complained of pain to left ankle when range of motion performed. Swelling noted at ankle....Purple discoloration noted to left great toe....Called doctor (the primary care physician-PCP) to request venous doppler (a test to detect poor circulation/blood clots). Doctor states 'I will see her tomorrow' (on 8/7/14)." The MAR indicated [REDACTED]. On 8/7/14 at 10:40 AM: "Complained of left ankle pain when touched." Resident #701's blood pressure was 162/78. At 7 PM, the resident's blood pressure was 200/100. "Resident yelling out 'Help me. I don't want to go through this anymore'." The PCP was called and ordered the resident's blood pressure medication, [MEDICATION NAME], to be increased from 25 mg twice a day to 50 mg twice a day, and added the drug, [MEDICATION NAME] 5 mg, for blood pressure. At 7:30 PM, the resident's blood pressure was 220/100. The PCP was notified that the blood pressure was higher. The PCP "stated 'medications need 2-3 hours to kick in'." The MAR indicated [REDACTED]. Per review of a progress note written by the PCP dated 8/7/14 for resident #701: "Apparently patient hurt her ankle. X-rays negative. Has some swelling of the left ankle. We will get podiatry (foot specialist) consult. No clinical evidence of gout or [MEDICAL CONDITION] ([MEDICAL CONDITION]-blood clot)." On 8/8/14 at 2:30 AM: "Complained of pain to ankle." At 10:10 PM: "Complained of pain to left ankle....left ankle swollen with small bruise to....great toe." The MAR indicated [REDACTED]. On 8/9/14 at 2:50 AM: "Complained of pain to left ankle." At 9 PM: "Resident yelling out most of shift. Complained of pain....Left ankle continues swollen with grey discoloration....elevated. Called (PCP)....New order-[MEDICATION NAME] (antipsychotic) 0.25 mg twice a day." [MEDICATION NAME] was given five times on 8/9/14 for complaints of left ankle pain per the MAR. On 8/10/14 at 3 AM: "Resident (#701) continues alert with confusion. Resident continues to yell out....complaining of left ankle pain....continues to yell out 'Help me' (nurse aide) sat with resident....(PCP) aware. New order noted. Give [MEDICATION NAME] 0.25 mg now then change previous order for [MEDICATION NAME].to 0.25 mg (in the morning) and....0.5 mg (at night)....[MEDICATION NAME] not yet effective. Continues to yell out." At 6 PM, resident #701's blood pressure was 162/114. At 8 PM: "Resident yelling out....increased confusion."The MAR indicated [REDACTED]. Per review of PT notes dated 8/11/14, the resident had received three therapy sessions by that date. The therapy included weight bearing on the left leg. On 8/11/14, the MAR indicated [REDACTED]. On 8/12/14: "Yelling out for help. Pain." The MAR indicated [REDACTED]. On 8/13/14 at 10:30 AM: "....lethargic....resident was leaning and lethargic in it (wheelchair)." There was no documented STAT (immediate) order for the podiatry consult mentioned by the PCP in the 8/7/14 notes. On 8/13/14 (six days later), the Podiatrist saw resident #701 and noted, per review of the consultation report: "Patient unresponsive....staff states she fell out of bed and was sent to hospital....moderate ecchymosis (purple discoloration) lateral left foot and ankle....left ankle sprain rule out fracture left ankle/foot....X-rays left foot and ankle." On 8/13/14 at 6 PM: "....order....X-ray, 3 views left foot, 3 views left ankle....(written by the Podiatrist)." On 8/13/14, the MAR indicated [REDACTED]. The PCP noted the following in a progress note dated 8/14/14: "The patient (resident #701) has some discomfort in the left ankle. Desires to have a pain pill given to her now. She was seen by podiatry. There is a concern about a [MEDICAL CONDITION]. We will refer back to podiatry about casting, if they would do it or if she would need to be referred to ortho (bone specialist) or would need to go to the ER (hospital emergency room )." On 8/14/14 at 10:30 AM: "X-ray here at 10:30 (AM)." A review of the (portable) X-ray report for resident #701 revealed: "....fracture seen in the distal shaft (ankle area) of the left fibula...." At 12:20 PM, the resident was transported to the hospital emergency room . Per review of a hospital X-ray report dated 8/14/14 at 4:49 PM: "....displaced fracture involving the left distal fibula....fracture involving the posterior....left tibia." The resident returned to the facility at 10:30 PM with a "temporary cast" on the left lower leg. On 8/21/14 at 12:15 PM, the PCP was interviewed regarding the delay in receiving an accurate [DIAGNOSES REDACTED].#701. The PCP said, "When I saw her, I didn't see anything." He then read his 8/7/14 note about observing swelling in the ankle and said, "I referred her to podiatry because it was the ankle and they (podiatry services) are in house all the time, so they could see her." The PCP did not respond why the Podiatrist did not see the resident until 8/13/14. When asked about the prescription for [MEDICATION NAME] when nursing staff informed him that the resident was yelling out in pain, the PCP said, "Who prescribed it? Psych (the Psychiatrist)?" When told that he prescribed it himself, the PCP said, Well I was called in the middle of the night and she was yelling and having behaviors." When informed that there was no documentation that the resident exhibited adverse behaviors or had received antipsychotic medications prior to the fall on 8/4/14, and asked if he suspected that the behavior could have been due to ankle pain, the PCP said, "The nurses never told me she was having pain." At 4:30 PM, when the Administrator was queried regarding the delay in diagnosing and providing appropriate care and treatment of [REDACTED]. At 6 PM, a review of the minimum data set ((MDS) dated [DATE] for resident # 701 noted that the resident had severe cognitive impairment, had no adverse moods/behaviors other than frequent wandering, was not prescribed antipsychotic medication, and experienced mild pain on rare occasions. Per review at 6 PM, of the facility's undated "Pain Assessment" policy: "Pain assessments will be completed to identify indicators of pain....Pain can be expressed verbally and non-verbally....The resident will be assessed for pain....with new onset of pain....Identify what causes or increases pain. Identify what relieves the pain." ( )

Based on observation, interview, and record review, the facility failed to adequately assess for appropriate devices and utilize proper safety techniques for two (#601 and #602) of five sampled residents reviewed for transfers from a total sample of five, resulting in falls, fractures, skin tears, and the potential for further injuries. Findings include: On 6/17/14 at 3 PM, the clinical record and Unusual Occurrence Incident Reports for resident #601 were reviewed. The resident was originally admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] noted that the resident had no cognitive impairment, was non-ambulatory, and required extensive assistance for transfers and bed mobility. The resident was noted as high risk for falls per review of fall risk assessments dated 8/22/13 and 9/9/13. A "Resident Lift Assessment Profile" for resident #601, written by nurse unit manager 'D' dated 8/22/13, noted that the resident was a candidate for transfers by a stand-up-type mechanical lift with bars that residents must be able to grip. When queried on 6/17/14 at 3:15 PM as to how she determined that resident #601 was safe to use the stand-up lift on 8/22/13, nurse 'D' stated that she got this information from the hospital discharge instructions. A "Continuing Care (hospital discharge instruction) Referral" form from the transferring hospital to the facility noted that the resident was high risk for falls, had staples to the hip, and required two to three-person assistance for mobility. The form however, did not identify specific equipment to be used during transfers. Therapy staff noted on a "Therapy to Nursing Communication Form" dated 8/26/13: "Continue use of (a sit-down-type, total body) lift for transfers at this time." Nurse 'D' however, noted on the resident's "Fall" care plan dated 8/22/13 to use the stand-up lift for transfers. Per review of therapy notes, the resident was not advanced from the total body lift to the stand-up lift until 8/30/13. Incident reports for resident #601 noted the following: 1). On 9/4/13, the resident sustained [REDACTED]. the resident through the bathroom doorway on a stand-up lift. The report noted: "....suddenly she began to lose her grip on the (stand-up) lift." The resident "....raised her arms causing the sling (connecting the resident to the lift) to slide up." The corrective action to prevent reoccurrence: "Resident informed to keep arms tucked in when going through doorways." There was a physician's orders [REDACTED]." There was no documented re-assessment of the type of lift to be used. Nurse aide 'B' gave the following account of the incident during a phone interview on 6/17/14 at 4:10 PM: "I didn't know anything about (resident #601) when I came in. She needed to use the bathroom. I got the lift and looked for help, but there was no one available. The (resident's) granddaughter was in the room. The granddaughter said 'go ahead and use the lift' and was getting frustrated because (the resident) really had to use the bathroom. (The granddaughter) said, 'I can help you get her in there.' (The resident's) knees buckled halfway through the door and she couldn't hold on. She kept saying, 'I'm going to fall.' I was able to get her to the toilet in time. I thought the granddaughter knew how to do it. I had no idea that she didn't have experience in using the lift." 2). On 9/5/13, while being transferred in the stand-up lift from wheelchair to bed by nurse aide 'E' (who was unavailable for comment), resident #601 "....raised both arms over her head and slid out of the sling onto the floor" and sustained a 5 centimeter round (cm) skin tear on the left arm and a 3.5 cm skin tear on the right arm. When the resident was asked what happened, she said, "I don't know what I was doing." There was no indication that a second person was present to assist with the transfer. The corrective measure: "Therapy to re-evaluate resident regarding transfer/lift status and equipment use. Staff educated." There was no documentation indicating that nurse aides were made aware of the incident that occurred on 9/4/13 to prevent reoccurrence and no indication that x-rays were ordered. There was an order for [REDACTED]. On the Therapy to Nursing Communication Form dated 9/6/13, a Physical Therapist noted to transfer the resident in a sit-down-type, total body mechanical lift "....until her upper extremities and lower extremities are stronger, and she can tolerate standing better." Resident #601's granddaughter stated during a phone interview on 6/15/14 at 6:30 PM that she was present when this incident occurred. She stated that the resident was unable to hold on to the lift, slipped underneath the sling, fell on her back, constantly complained of severe back pain ever since, and had to have back surgery because of the fall. The granddaughter stated that there were no x-rays taken after the incident. 3). On 10/2/14, "Resident this (morning) she was on the (stand-up) lift and she bumped her left hand on the lift...." The resident sustained [REDACTED]. There was no mention of the name of the staff member involved in the transfer of the resident or why the stand-up lift was used instead of the total body lift. The 'Fall" care plan, and lift assessments dated 10/10/13, 10/30/13, and 11/8/13 noted to continue the total body lift. Per review of hospital records, resident #601 was hosptalized on [DATE] for shortness of breath, but complained of severe back pain. A physician progress notes [REDACTED].so bad that she became nauseated....and going to faint." On 11/13/13, the resident was admitted into the hospital for back pain. At 3 PM and at 4:30 PM, when queried regarding the appropriateness of resident #601's granddaughter assisting with a transfer and the injuries sustained, in-service coordinator 'C', the Administrator, and the Director of Nursing (DON) did not respond. They did not offer a response as to why the stand-up lift continued to be used after the first incident on 9/4/13. On 6/23/14 at 11 AM, the following hospital records for resident #601 were reviewed: The resident was "very anxious, complaining of severe pain in the back....when she tries to move" per review of the hospital history and physical dated 11/14/13. Review of x-ray reports revealed the following: X-ray dated 11/14/13-fracture at the L1 level of the spine and a compression fracture at the T12 level. X-ray dated 11/15/13-the T-11 level "....suggests possibility of recent fracture.... (and) sacrococcyx region (of the spine) which may be related to prior trauma and fracture." Per review of a surgical procedure note dated 11/18/13 for resident #601 revealed: "....history of compression fracture and subsequent back pain....evidence of acute T11 uptake on bone scan." The resident had a kyphoplasty (surgical repair) at T11 and was transferred back to the facility on [DATE]. The resident was prescribed one Lidocaine (pain) patch daily to the back, but on 11/23/13, the order was changed to two patches daily. The resident was discharged home on[DATE]. On 6/17/14 at 10:30 AM, resident #602 was observed being transferred to the bathroom by nurse aide 'A' via the stand-up lift. The resident's elbows protruded outward during the transfer. Aide 'A' did not instruct the resident to tuck in the elbows. The resident's right elbow bumped the door frame going into the bathroom and the left elbow rubbed and bumped against the door frame on the way out. The resident said both times, "Ouch. It hit my elbow." Aide 'A' made no comment and proceeded with the resident's care. At 2:45 PM, when queried regarding the transfer, Aide 'A' said, "You're suppose to make sure elbows are at their side." When queried on 6/17/14 at 3 PM and at 4:30 PM, nurse 'C', the Administrator, and the DON did not offer a response regarding resident #602's unsafe transfer. On 6/23/14 at 11:30 AM, review of the facility's undated "Fall Management" policy noted: "The definition of a fall is when a resident....falls off or out of equipment;" "If a fall occurs, the staff will assess for injury and investigate the fall to identify causative factors. The care plan will be revised with post fall interventions when indicated." The facility's undated stand-up lift procedure noted: "Only use this or other methods after a satisfactory professional assessment has been carried out on the individual patient." ( )

Based on observation, interview and record review, the facility failed to ensure that one Resident (#802), who had been assessed as a high risk for falls, was transferred using a mechanical lift device when transferring the Resident, resulting in a fall with a fracture of the left leg, for one of four sampled Residents who were reviewed for falls out of a total sample of four Residents. Findings include: On 2/25/14 at 9:40 A.M., the Director of Nursing (DON) was queried in regards to Resident #802's fall which occurred on 2/8/14. The DON responded, "She (CNA "B") did not review the Care Tracker (CNA Care Guide). She (CNA "B") was instructed to do so and was reprimanded for that (not checking CNA Care Guide prior to showering Resident #802 to determine she required mechanical assistance for transfers at all times). She's (CNA "B") not supposed to take another person's word, she's supposed to check Care Tracker. I told her she puts herself and patients at risk for injury when you don't (follow proper procedure). She's new (CNA "B") and a little timid. She'd (CNA "B") been here a few months and is a new CNA (recently completed CNA Career Training Course). She (CNA"B") was working with another CNA. The CNA asked her if she (CNA "B") was ok giving a shower. She (CNA "B") said 'yes'." On 2/25/14 at 10:30 A.M., Resident #802 was observed in her room in her wheelchair with her left leg elevated on a leg immobilizer stand. The left leg was at a 90 degree angle to the Resident's torso while the right leg rested on the ground. Resident #802 did not make eye contact or verbally respond when spoken to. On 2/25/14 at 11:30 A.M., CNA (Certified Nursing Assistant) "A" stated, "I just want to let you know she (Resident #802) is completely deaf." CNA "A" further explained that she has cared for Resident #802 frequently and that she used some basic sign language to communicate with the Resident to determine the Resident's care needs. On 2/25/14 at 12:00 P.M., Resident #802's complete clinical record and recent "Fall Reports", with related witness statements, were reviewed. Resident #802's face sheet revealed the Resident was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Resident's most recent Minimum Data Set (MDS) Assessment, dated 12/28/13, indicated the Resident had severely impaired cognition, was incontinent of bowel and bladder, was totally dependant on staff for bathing, and required extensive assistance with dressing and personal hygiene. The MDS also indicated the Resident required extensive assistance of one person physical assist with transfers (from one surface to another i.e. from bed to wheelchair). A "Resident Fall Report", dated 2/8/14, was reviewed and revealed that on this date at 4:30 P.M., " 'I (CNA "B") went to give (Resident #802) a shower. I felt like her legs gave out. I slowly sat her down on the ground and made sure she was okay then asked for help.' Patient Description of fall: 'Ouch!' Nurse Evaluation/Post Fall Exam: WNL (within normal limit) except for c/o (complaints of) L (left) leg pain when moved. Immediate Care: Resident tempo lifted (mechanical device used to perform complete transfer from one surface to another) into wheelchair then assisted to bed." The Fall Report further indicated that CNA "B" was a trainee and that she was not the CNA assigned to Resident #802 on this date. A written statement, regarding Resident #802's fall on 2/8/14, was provided by the CNA showering the Resident at the time of the fall, CNA "B". CNA "B"'s statement, dated 2/10/14 revealed, "Date of Incident/Occurrence: 2/8/14 at 4:30 P.M. I (CNA "B") went to go give a shower -- thought that I could do it. I stood her (Resident #802) up to pull her brief up. It felt like she kind of gave out in her legs. I was told (by another staff member) that she was a stand and pivot (without mechanical assistance required), when I should've looked for myself. I yelled for help so (another CNA) came and helped and got the nurse so they could get the patient off the ground. I slowly laid her (Resident #802) down and made sure that she was okay. I was given my own run (Resident care giving assignments) and told I had 3 showers to give. I felt like I didn't have a choice but to do that. I didn't know that all the information (specific care giving instructions for each Resident) was in the computer. I was told different than what she was (alleges another staff person told her prior to the shower that Resident #802 could stand without mechanical assistance)." A written statement, regarding Resident #802's fall on 2/8/14, was also provided by CNA "F". CNA "F"'s statement, dated 2/10/14 revealed, "On Saturday, the other girl who was supposed to work with me didn't show up so they gave me a training (trainee). I had 3 showers so I asked the trainer (trainee) if she was comfortable giving a shower. She said 'yes', so I gave her one shower. I was going to do the others. So the trainer (trainee) gave a shower (to Resident #802) and she (CNA "B") ended up with having an accident." Nurses notes dated 2/8/14 at 4:30 P.M., written by Nurse "C", the nurse in charge of hall "D", where Resident #802 resided at the time of the incident, revealed, "(CNA "B") trainer (trainee) went to give (Resident #802) a shower, she (CNA "B") felt her (Resident #802's) legs gave out. She (CNA "B") slowly sat her (Resident #802) down on the ground and made sure she was okay then asked for help. Writer was called by (Nurse) to come down to "E" Unit South Shower Room. Writer observed Resident sitting on the floor in front of bath chair. Vital signs checked - WNL. Assessed Resident for pain or any injuries. Resident seemed sore on L (left) leg. Aides tempo lifted Resident into wheelchair then into bed. Writer continued to observe Resident L leg/hip. ROM (range of motion) WNL but Resident yell 'Ouch!' when slightly move L leg upwards. Call Guardian and left a voicemail. Called (doctor). He ordered an x-ray. Awaiting results. Resident resting in bed quietly at this time. Will monitor." Nurses notes dated 2/10/14 at 1:10 A.M., revealed, "No further incidents. CNA's aware of proper transfer techniques. Resident in bed all of shift thus far. Assessment just done. Resident able to pick up R (right) leg with difficulty, but states she cannot pick up L leg. She attempted to several times with much frustration. Resident screams when I touch thigh/knee area to L leg. Does not do anything when I touch L hip. Back of L thigh when rolled over with assistance noted with visual and palpable lump. When touched gently Resident yells 'Ouch that hurts'. L leg from thigh to knee noted slightly larger. Refuses any compress. Took 'as needed' (pain medicine). Resident unable to voice pain scale due to hard of hearing and unable to see writing. Facial and body language would be about 8 (on a 0-10 pain scale with 10 describing the worst pain). Will continue to monitor." Nurses notes dated 2/10/14 at 12:50 P.M., revealed, "(prior shift) nurse reports to writer Resident complains of left leg pain, thigh/knee. L thigh and knee noted with swelling. Non discolored. Tender to touch. New order for femur (thigh) and knee X-ray. S/Sx (signs and symptoms) of pain noted with repositioning. Awaiting X-ray results." Nurses notes dated 2/10/14 at 2:40 P.M., revealed, "L femur Fx (fracture) called (Doctor). New order to send to ER (Emergency Hospital Room). DON and Administrator notified. Called Guardian. Resident transferred via ambulance." On 2/25/14 at 2:00 P.M., CNA "B"'s training documentation was reviewed and revealed CNA "B" completed a CNA Career Training Course on 12/23/13 but did not sign off as having fully completed her "in-house" training until 2/17/14. On 2/25/14 at 2:10 P.M., the DON and the Staff Development Coordinator "D" were interviewed in regards to the training that CNA "B" received. The DON confirmed that CNA "B" had completed a CNA Career Training Course, but had not yet completed her State Certification Exam and was allowed to work independently providing care for Residents up to 120 hours prior to State Certification. The DON also confirmed CNA "B"'s hire date at the facility was 1/28/14. Staff Development Coordinator "D" indicated that when staff are hired having completed a "CNA Career Training" Course they also complete an "in-house" training curriculum. Staff Development Coordinator "D" was queried as to why CNA "B"'s in-house training documents did not indicate the CNA had completed her in-house training until 2/17/14, but was independently providing Resident care on 2/8/14. Staff Development Coordinator "D" indicated, and provided documentation which confirmed, that CNA "B" received training on the "Kiosk" (CNA Care Guide) Use and "Assisting Resident with a Shower" on 1/30/14, but that CNA "B" did not fully complete her in-house training and sign off as having the training completed until 2/17/14. The DON further indicated that CNA "B" was approved to give a Resident a shower alone on 2/8/14, despite CNA "B" being not completely done with her in-house training at that time. The DON and Staff Coordinator "D" were also queried as to if the facility followed a written policy regarding in-house staff training and what tasks staff in training are allowed to complete unassisted. The DON and Staff Coordinator "D" confirmed the facility had no such policy. The DON and Staff Coordinator "D" were queried as to how regular floor staff are made aware of which Resident care tasks trainees are approved to complete without assistance. Staff Coordinator "D" indicated that she personally informs floor staff of what tasks trainees are approved to complete without assistance. On 2/25/14 at 2:30 P.M., Resident #802's "Care Tracker Message Center" form (CNA Care Guide), Fall Care Plan and "Resident Lift Assessment Profile", documented as being active on 2/8/14, the date of the Resident's fall, were each reviewed with the DON. Resident #802's Care Tracker Message Center form, with a print date of 2/14/14 revealed, "ADL's (Activities of Daily Living): total care, Sara Lift (mechanical lift which Resident uses to assist to stand from sitting position and to maintain standing balance) with 1-2 staff assist; transfers (using) tempo lift with 1-2 (staff) assist as needed." The DON indicated that the Care Tracker Message Center with the print date of 2/14/14 was the CNA Care Guide in place on the date of the Resident's fall, 2/8/14. Resident #802's "Fall/Injury Assessment and Plan of Care" form, with a revision date of 1/2/14, revealed, "Assessments/Risk Factors: disoriented/confusion, poor decision making skills, unstable diabetes, cardiovascular disease, incontinent, impaired vision/legally blind. Goal: Resident will have interventions to alleviate risk of falls with significant injury. Approach: Therapy referral as needed, assist with transfers, Sara lift with 1 assist or 2 assist, tempo lift as needed large sling." Resident #802's "Resident Lift Assessment Profile" form, dated 1/15/14, revealed an algorithm which documented that because the Resident was not able to stand, pivot or walk without assistance, but was able to bear weight, the Resident was a candidate for the use of mechanical assistance for transfers, either a Sara lift or (Tempo). It was also noted on the form that each of the mechanical lift devices was to each be used with 1-2 person assist. The DON was queried as to if Resident #802 had any physical therapy assessments to determine the Resident's transfer abilities. The DON indicated that she was unable to locate any therapy documentation, assessments or screens, for Resident #802. On 2/25/14 at 4:00 P.M., Resident #802's "Fall Risk Data Collection" form was reviewed with the facility's DON and Administrator. The form dated 1/2/14 revealed, the Resident had a fall risk score of "15" indicating the Resident represented a "high risk" for falls due to the Resident's "intermittent confusion, being chair bound, incontinence, requiring the use of an assistive device for gait/balance, (prescribed) medications and predisposing diseases." The DON stated, "She (CNA "B") said she felt she could do it (shower Resident #802 unassisted) and she didn't realize the weakness (of Resident #802). She should have used some type of mechanical means. The nurse will gauge what she's (a CNA trainee) comfortable doing. She (CNA "B") said she was comfortable giving a shower. With the mechanical tools we have, we have the tools for her (CNA "B") to do it (give a shower to a Resident) safely." On 2/25/14 at 4:45 P.M., Nurse "C", the nurse in charge on 2/8/14 at the time of Resident #802's fall, was interviewed via telephone. Nurse "C" stated, "I wasn't aware she (CNA "B") was in there giving a shower alone (to Resident #802). I wasn't aware of anything until the incident occurred. We were short staffed that night due to call offs and regular nursing stuff. We pulled the trainer (trainee) down to give a hand. The aide asked the trainee (CNA "B") if she was comfortable (giving a shower) and it was checked off on her sheet (training record). I ordered an X-ray. I called the doctor. The aide (CNA "B") told me she (Resident #802 was lowered to the ground. It was hard to find she was hurt until we laid her (Resident #802) down and the Resident said 'Ouch, ouch'. She (Resident #802) doesn't talk very well." On 2/25/14 at 5:00 P.M., Resident #802's Radiology Report and Hospital Records were reviewed. The Radiology Report for Resident #802, dated 2/10/14 revealed, "Exam: left femur and knee x-ray. Findings: Acute complete mildly impacted and mildly angulated distal femoral fracture." Resident #802's hospital records dated 2/11/14 through 2/12/14 were revealed. The "Radiology/Diagnostics" records indicated that on 2/11/14 the Resident presented with pain and was assessed for surgery to repair the left leg fracture. According to the hospital records, Xray results revealed, "On lateral view the tibia is also subjuxed relative to the femur. This could relate to additional acute injury versus chronic change." The records further indicated that Resident #802 underwent surgery on 2/12/14 to repair the distal femur fracture requiring a metal plate and several screws to be placed in the left leg. The "Post Operative Plan" noted, "The patient will be nonweightbearing to left lower extremity. She is to maintain use of knee immobilizer." On 2/25/14 at 5:10 P.M., the facility's policies regarding falls were reviewed. The facility's policy entitled, "Policy/Procedure, Section: Nursing Standards of Practice, pg 604", undated, revealed, "Policy: The facility will identify each Resident at risk for falls and implement a plan of care to alleviate the risk for falls. The facility will provide and environment that is free from potential hazards. Procedure: 1. Residents will be assessed upon admission, quarterly and with significant change in condition. A plan of care will be developed for Resident's identified at risk with interventions to alleviate the risk for falls." A sample "Employee Acknowledgement of Protocols for (facility name)" form, with no creation date provided on the document, was reviewed and revealed, "Lift Training: Conduct a skills check-off on all new staff after they have received an in-service on the equipment and efore they work on the units with lifts." ( )

Based on observation, interview and record review the facility failed avoid a known safety hazard on the ramp threshold for the D Hall shower stall, for one (#901) of three sampled residents out of a total sample of three residents reviewed for falls, resulting in a fall with a subdural hematomas (bleeding around the brain) that required hospitalization . Findings include: On 01/22/14 at 9:55 a.m., resident #901's medical record, and the facility Resident Fall Report and Investigation was reviewed and revealed resident #901 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The plan of care for Activities of Daily Living (ADL's) indicated resident #901 required staff assist with all ADL's and bed mobility. The Minimum Data Set assessment dated [DATE] indicated resident #901 required extensive assist for hygiene and bathing.The Fall Report dated 01/14/14, under description of fall revealed: "CNA (certified nursing assistant) state was pushing res (resident) into shower stall lost footing, chair hit lip of shower stall causing resident chair to fall backward." The facility reported summary of the incident dated 01/17/14 revealed, "The chair wheel bumped the incline lip and started to tip backward. C.N.A. (K-name omitted) attempted to control the chair but lost balance and the chair with resident on it went onto the shower stall floor...The physician ordered resident to emergency room . Ambulance transport to (name of hospital)..." The Final Report of a CT (computed tomography) scan of the brain for resident #901 completed on 01/15/14 revealed: "Conclusion: Acute parafalcine subdural hematoma (bleeding around the brain) with also small right frontal lobe hematomas." A Neurosurgery consult report indicated resident #901"presents with traumatic subdural hemorrhage (bleed)...consistent with a recent injury..." On 01/22/14 at 1100 a.m., a tour of the facility shower room D was completed with the Director of Nursing. A empty shower chair indicated as the type used by resident #901, was pushed up the ramp and was stopped by the lip of shower stall D. Additional effort was required to get the chair over the lip and into the shower stall. Non-skid patches were observed on the shower stall ramp. On 01/22/14 at 11:15 a.m., CNA "A" who worked with resident #901 since 2008 provided a demonstration of how resident #901 was guided into the shower and reported, "would guide left wheel (over lip) while pulling backward, then right wheel, once in shower would move resident to one side, lock the wheels and proceed with shower." When queried if CNA K (the CNA involved with the fall) was shown this technique CNA "A" stated, "I did not train (CNA K)." CNA "A" was queried if the nonskid patches to the ramp were in place prior to resident #901"s fall and stated, "No." On 01/22/14 at 11:36 a.m., The Director of Nursing (DON)was queried if aware of the concern with the lip in the D hall shower stall the DON stated, "I was not aware of any concern prior to the event." On 01/22/14 at 11:38 a.m., During a phone interview with CNA"K", the CNA involved in the incident, CNA "K" stated, "It was the first time that I gave (resident #901) a shower." CNA "K" was asked to describe the incident on 01/14/14 and stated, "after wiping up the water from the ramp, proceeded up ramp with resident facing me...pushing chair up the ramp, one wheel went over lip the other didn't,... shower chair started to tip backwards, attempted to stop, slipped, was unable to stop, resident completed fall to ground...(resident) fell inside shower stall on back...I didn't realize the chair would get stuck." On 01/22/14 at 1:00 p.m., CNA "F" was queried on concerns with the D hall shower before the incident and stated, "even I had to struggle with a resident not that heavy...struggled with both heavy and light patients." On 01/22/14 at 1:49 p.m., Day D Unit manager, nurse "J" was queried on any CNA concerns with the D hall shower prior to the incident with resident #901 and stated, "No, not really, always complained about room being too small." On 01/22/14 at 1:55 p.m., CNA "A" a facility CNA for almost [AGE] years, was queried on how long the D hall shower was in the present configuration and stated, "..guess about 7-[AGE] years." On 01/22/14 at 3:20 p.m., CNA "C" was queried on concerns with showers given in D hall and stated, "Extremely difficult... need showers like E hall (a open concept without stall)." On 01/22/14 at 3:25 p.m., CNA "D" was queried on problems with the D hall shower prior to the incident and stated, "That little lip." On 01/22/14 at 3:30 p.m., afternoons D Unit Manager was queried on CNA concerns with the D hall shower and stated, "...not level...too small...should be open more." On 01/22/14 at 4:00 p.m., The report titled "Administer review of incident site" dated 01/15/14 revealed: Staff need to keep aware when pushing/pulling the shower chair in to the stall box as there may be a bump at the time the wheel on the shower chair meets the lip of the ramp...It appears this C.N.A. was unprepared for the bump and when the shower chair started to tip the C.N.A. became unbalanced and could not prevent the chair from going down...moisture may have contributed to the C.N.A. loss of balance. There were no anti-skid strips built on the ramp." On 01/22/14 at 4:07 p.m., The administrator was queried if aware of any concerns with the D hall shower prior to the incident and stated, "...not aware of any concern prior to the event." On 01/23/14 at 7:54 a.m., The maintenance director was queried if he knew about the concern with lip in the D hall shower and stated, "...issue with the drain leaking, not the lip." Is it something you would expect the CNA to report? "Yes." How would this get reported to maintenance? "Would have gone to the unit manager first, then to morning meeting then to maintenance." ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 771. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ASSESS COMPLAINTS OF PAIN, ADDRESS COMPLAINTS OF PAIN AND ADMINISTER PAIN MEDICATIONS IN ACCORDANCE WITH THE physician's orders [REDACTED]. FINDINGS INCLUDE: A REVIEW OF THE CLINICAL RECORD REVEALED THAT #504 WAS A [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. A REVIEW OF THE "ADMISSION DATA COLLECTION" SHEET DATED 4/19/13 REVEALED THAT #504 WAS ALERT AND ORIENTED TO PERSON, PLACE AND TIME AND PRESENTED WITH A FOLEY (INDWELLING URINARY) CATHETER AND SHINGLES RASH TO HER UPPER TORSO UNDER HER LEFT BREAST AND UPPER BACK. ON 4/26/13 AT 10:47 A.M., DURING A TOUR OF THE FACILITY, RESIDENT #504 WAS OBSERVED SITTING IN HER ROOM IN A WHEELCHAIR SLUMPED OVER HER OVER BED TABLE. WHEN RESIDENT #504, LOOKED UP, SHE WAS OBSERVED TO BE TEARFUL. WHEN ASKED IF SHE WAS ALRIGHT, RESIDENT #504 REPORTED, "...I'M IN PAIN..." RESIDENT #504 EXHIBITED FACIAL GRIMACING AND WAS ROCKING BACK AND FORTH IN HER WHEELCHAIR. WHEN ASKED IF SHE HAD REPORTED HER COMPLAINTS OF PAIN TO FACILITY STAFF, #504 REPORTED, "...I TOLD ONE OF THE CNAS (CERTIFIED NURSING ASSISTANTS) A WHILE AGO..." WHEN ASKED THE LOCATION OF HER PAIN AND TO GRADE HER LEVEL OF PAIN FROM A SCALE OF 1 - 10, #504 YELLED OUT, "...I HAVE SHINGLES! IT'S MORE THAN A 10..." WHEN ASKED IF SHE RECALLED THE LAST TIME SHE HAD RECEIVED SOMETHING FOR PAIN, #504 STATED, "...SOMETIME LAST NIGHT..." ON 4/26/13 AT 10:50 A.M., CNA #2 WAS OBSERVED WALKING IN THE HALLWAY CARRYING RESIDENT CARE ITEMS. WHEN ASKED IF SHE WAS THE ASSIGNED CNA FOR #504, CNA #2 REPORTED, "NO." WHEN ASKED WHO THE ASSIGNED CNA WAS FOR #504, CNA #2 REPORTED, "...I DON'T KNOW BUT SHE TOLD ME SHE NEEDED SOMETHING FOR PAIN...(BUT) I WAS PASSING WATER..." WHEN ASKED IF SHE (CNA #2) HAD REPORTED #504'S COMPLAINTS OF PAIN TO THE NURSE, CNA #2 SAID, "...NO. HER NURSE (REGISTERED NURSE/RN #1) IS ON BREAK. I WAS GOING TO TELL HER WHEN SHE GOT BACK FROM BREAK..." WHEN ASKED WHAT THE FACILITY'S POLICY WAS FOR REPORTING RESIDENT'S COMPLAINTS OF PAIN IF THE NURSE IS ON BREAK, CNA #2 OFFERED NO RESPONSE. WHEN ASKED IF SHE HAD REPORTED #504'S COMPLAINTS OF PAIN TO ANOTHER NURSE OR THE DIRECTOR OF NURSING (DON) SO THAT #504 COULD BE ASSESSED AND MEDICATED AS APPROPRIATE WHILE #504'S NURSE (RN #1) WAS ON BREAK, CNA #2 SAID, "NO." ON 4/26/13 AT 11:05 A.M., RN #1 WAS OBSERVED APPROACHING HER MEDICATION CART. WHEN ASKED IF #504 HAD ANYTHING ORDERED FOR PAIN, RN #1 REPORTED, "...YES. SHE GETS [MEDICATION NAME] 5/325 (NARCOTIC PAIN MEDICATION) 1/2 TABLET EVERY 6 HOURS..." WHEN ASKED WHEN WAS THE LAST TIME #504 HAD BEEN MEDICATED, RN #1 DID NOT ANSWER, BUT BEGAN WRITING ON #504'S "CONTROLLED DRUG RECORD" (NARCOTIC SHEET) THEN SCRIBBLED OVER THE INFORMATION SHE HAD WRITTEN. WHEN ASKED WHY SHE WAS CROSSING OUT INFORMATION SHE HAD JUST WRITTEN, RN #1 REPORTED, "THE LAST NURSE (RN #2) DIDN'T PUT THE TIME SHE MEDICATED (#504), SO I WROTE THE TIME IN, THEN I CROSSED IT OUT..." IT WAS OBSERVED THAT RN #1 WROTE THE TIME IN OF 6:00 A.M. ON THE PREVIOUS LINE OF THE CONTROLLED DRUG RECORD WHICH HAD BEEN LEFT BLANK BY RN #2. ON 4/26/13 AT 11:10 A.M., THE DIRECTOR OF NURSING (DON), WHO WAS PRESENT DURING THE INTERVIEW WITH RN #1, INSTRUCTED RN #1 TO WASTE THE NARCOTIC ([MEDICATION NAME]) SINCE IT COULD NOT BE DETERMINED WHEN SHE RECEIVED IT LAST DUE TO THE TIME NOT BEING RECORDED ON THE CONTROLLED DRUG RECORD BY THE PREVIOUS NURSE (RN #2). WHEN ASKED WHAT THE PLAN WAS TO ADDRESS #504'S UNRELIEVED PAIN, THE DON REPORTED, "...WELL, I'LL HAVE TO DO A MED (MEDICATION) ERROR FOR THE NURSE (RN #2) WHO CHARTED THE MED WHEN IT WAS NOT GIVEN. I'LL HAVE THE NURSE (RN #1) CALL THE DOCTOR FOR A ONE TIME ORDER TO GIVE THE MEDICATION ([MEDICATION NAME]) SINCE SHE (#504) IS IN PAIN..." THE DON THEN INSTRUCTED RN #1 TO NOTIFY THE PHYSICIAN OF THE INCIDENT AND DOCUMENT AS APPROPRIATE. A REVIEW OF THE "MEDICATION RECORD" AND physician's orders [REDACTED]. A "PAIN DATA COLLECTION" DOCUMENT (UNDATED) REVEALED THAT #504 EXPERIENCED ACHING PAIN (A DIAGRAM INDICATED PAIN TO MID BACK) THAT IS WORSE MORNING, AFTERNOON AND NIGHT. THE PATIENT PAIN RATING SECTION OF THE FORM WAS LEFT BLANK. "...PAIN IS RELIEVED BY/MEDICATIONS USED: [MEDICATION NAME] 1 MG PO Q6H (MILLIGRAMS BY MOUTH EVERY 6 HOURS), [MEDICATION NAME] 5/325 Q6H PRN (AS NEEDED)..." REVIEW OF THE "CONTROLLED DRUG RECORD" DATED 4/20/13 (FOR THE MEDICATION [MEDICATION NAME]) REVEALED AN ENTRY ON 4/22/13 THAT HAD BEEN SCRATCHED OUT. AN ENTRY ON 4/25/13 REVEALED THAT #504 HAD RECEIVED ONE [MEDICATION NAME] TABLET AT 9:00 P.M., AN ENTRY ON 4/26/13 REVEALED THAT #504 HAD RECEIVED ONE [MEDICATION NAME] TABLET ON 4/26/13. THERE WAS NO TIME DOCUMENTED. THE SECOND CONTROLLED DRUG RECORD SHEET (FOR THE MEDICATION [MEDICATION NAME]) DOCUMENTED THAT #504 HAD RECEIVED HER LAST DOSE OF HER PRESCRIBED [MEDICATION NAME] 1 ML (MILLILITER) ON 4/25/13 AT 7:50 A.M. A REVIEW OF #504'S "MEDICATION RECORD" FOR APRIL 2013 REVEALED THAT #504 RECEIVED HER LAST DOSE OF [MEDICATION NAME] ON 4/25/13 AT 11:15 A.M. NO DOCUMENTATION WAS NOTED ON THE MEDICATION RECORD WITH REGARD TO #504'S PRESCRIBED [MEDICATION NAME]. THE SECTION WHERE PAIN WAS TO BE ASSESSED BEFORE AND AFTER ADMINISTRATION OF PAIN MEDICATIONS REVEALED THAT #503'S PAIN HAD ONLY BEEN ASSESSED ON 4/22/13 AND 4/24/13. POST MEDICATION PAIN ASSESSMENT TO DETERMINE IF PAIN RELIEF WAS ESTABLISHED HAD ONLY BEEN ASSESSED ON 4/24/13. REVIEW OF THE MEDICATION RECORD REVEALED THAT #504 RECEIVED HER PRESCRIBED [MEDICATION NAME] 1 ML AT 11:30 A.M. ON 4/26/13. A REVIEW OF THE FACILITY'S "MEDICATION ADMINISTRATION" POLICY DATED 9/10 REVEALED: "...MEDICATIONS ARE ADMINISTERED IN ACCORDANCE WITH WRITTEN ORDERS OF THE PRESCRIBER..." A REVIEW OF THE FACILITY'S "PAIN ASSESSMENT" POLICY (UNDATED), REVEALED: "...PAIN ASSESSMENTS WILL BE COMPLETED TO IDENTIFY INDICATORS OF PAIN AND TO ASSIST WITH PAIN MANAGEMENT..." "...NOTE PAIN LOCATION, DATE OF ONSET, CAUSE OF PAIN AND DURATION OF PAIN..." "...USING THE PAIN SCALE OF 0 - 10 DOCUMENT THE PAIN RATING (USING NON-VERBAL SCALE FOR RESIDENTS THAT ARE UNABLE TO COMMUNICATE THE PAIN LEVEL)..."

THIS CITATION PERTAINS TO INTAKE NUMBER MI 771. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO 1) ENSURE THAT A WOUND CONSULT WAS CONDUCTED IN ACCORDANCE WITH THE physician's orders [REDACTED].#502) OF FOUR RESIDENTS REVIEWED FOR PRESSURE ULCERS, FROM A TOTAL OF FOUR SAMPLED RESIDENTS RESULTING IN UNMET CARE NEEDS, AND THE DEVELOPMENT OF A NEW PRESSURE ULCER. FINDINGS INCLUDE: ON 4/26/13 AT 10:20 A.M., DURING AN INITIAL TOUR OF THE FACILITY, #502 WAS OBSERVED IN HIS ROOM LYING IN BED ON HIS LEFT SIDE WATCHING TELEVISION. #502'S BED WAS PUSHED AGAINST THE WALL. OBSERVATION REVEALED THAT THERE WERE NO POSITIONING DEVICES IN PLACE TO AVOID SKIN TO SKIN CONTACT AND TO AID IN RELIEVE PRESSURE TO AFFECTED AREAS. ALTHOUGH RESIDENT #502 HAD BILATERAL HEEL PROTECTORS ON, HIS HEELS HAD NOT BEEN ELEVATED TO RELIEVE PRESSURE. ADDITIONAL OBSERVATIONS WERE MADE THROUGHOUT THE DAY REVEALING THAT RESIDENT #502 CONTINUED TO LIE ON HIS LEFT SIDE. ACCORDING TO THE CLINICAL RECORD, #502 WAS A [AGE] year OLD MALE WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. A REVIEW OF THE "ADMISSION DATA COLLECTION" assessment dated [DATE] REVEALED THAT #502 WAS admitted TO THE FACILITY WITH A PRESSURE ULCER TO HIS LEFT HIP WHICH MEASURED 6 CM (CENTIMETERS) X 3 CM, A LEFT OUTER HEEL PRESSURE ULCER 1.7 CM X 2.8 CM AND REDNESS TO HIS COCCYX AREA. THE MINIMUM DATA SET (MDS) assessment dated [DATE] REVEALED THAT #502 HAD A BIMS (BRIEF INTERVIEW FOR MENTAL STATUS) SCORE OF 15 (13 - 15 = COGNITIVELY INTACT), BUT REQUIRED EXTENSIVE TO TOTAL ASSISTANCE OF STAFF WITH ALL ACTIVITIES OF DAILY LIVING (ADLS) INCLUDING BED MOBILITY, TRANSFERS DRESSING TOILETING PERSONAL HYGIENE AND BATHING. THE MDS NOTED THAT #502 WAS NON-AMBULATORY AND USED A WHEELCHAIR FOR MOBILITY. ON 4/26/13 AT 11:35 A.M., DURING AN INTERVIEW, THE DIRECTOR OF NURSING (DON) REPORTED, "...HE (#502) REFUSES TO BE REPOSITIONED OFF HIS LEFT SIDE AND HE REFUSED POSITIONING DEVICES BETWEEN HIS KNEES OR BEHIND HIS LEGS. THERE IS A NON-COMPLIANCE CARE PLAN IN PLACE ALSO..." UPON REVIEW OF THE CLINICAL RECORD, THERE WAS NO NON-COMPLIANCE CARE PLAN IN PLACE. A "72 HOUR BEHAVIOR LOG" FOR THE MONTH OF APRIL 2013 REVEALED THAT ON 4/10/13, #502 WAS NOTED TO BE NON-COMPLIANT, "...RESIDENT WILL NOT STAY OFF HIS RIGHT SIDE IN BED. IF STAFF REPOSITION HIM, ON HIS RIGHT SIDE, HE WILL CALL WITHIN 20 MINUTES TO BE TURNED OVER..." THERE WAS NO DOCUMENTED EVIDENCE IN THE CLINICAL RECORD THAT STAFF CONSISTENTLY ENCOURAGED REPOSITIONING OR THAT STAFF EXPLAINED THE BENEFITS OF REPOSITIONING. FURTHER, THERE WAS NO DOCUMENTED EVIDENCE THAT #502 REFUSED TO BE REPOSITIONED, REFUSED ANY POSITIONING DEVICES OR FAVORED THE AFFECTED SIDE. ADDITIONALLY, THERE WAS NO DOCUMENTED EVIDENCE THAT STAFF INCREASED ROUNDS TO ENSURE THAT #502 REMAINED OFF THE AFFECTED SIDE FOR THE SPECIFIED TIME NOR WAS THERE DOCUMENTED EVIDENCE THAT AN INCREASE IN THE FREQUENCY OF REPOSITIONING WAS INITIATED. ON 4/26/13 AT 3:43 P.M., DURING A FOLLOW UP INTERVIEW, THE DON REPORTED, "...WELL, HE (#502) DOESN'T ACTUALLY SAY NO; HE (#502) JUST REPOSITIONS HIMSELF BACK TO THE SAME SIDE..." ON 4/29/13 AT 9:30 A.M., #502 WAS OBSERVED IN HIS ROOM SEATED IN A GERI CHAIR. RESIDENT #502 REPORTED, "...THEY (FACILITY STAFF) DIDN'T GET ME UP OUT OF BED AT ALL YESTERDAY. THEY JUST CAME AND GOT ME UP IN THIS CHAIR A FEW MINUTES AGO..." ON 4/29/13 AT 1:00 P.M., A SKIN ASSESSMENT AND WOUND CARE OBSERVATION WAS CONDUCTED ALONG WITH THE TREATMENT NURSE, LICENSED PRACTICAL NURSE (LPN) #2. PRIOR TO REMOVAL OF #502'S DRESSING, WHEN LPN #2 WAS ASKED TO CLARIFY WHICH HIP PRESENTED WITH THE STAGE III PRESSURE ULCER, LPN #2 REPORTED, "...IT'S ON HIS RIGHT HIP..." REMOVAL OF #502'S LEFT HIP DRESSING REVEALED A STAGE III PRESSURE ULCER WITH A PINK CENTER AND SLOUGH NOTED ALONG THE WOUND EDGES AND CENTER. MINIMAL SEROSANGUINOUS DRAINAGE WAS OBSERVED. #502'S LEFT HIP PRESSURE ULCER WAS CLEANSED WITH NORMAL SALINE. CALCIUM ALGINATE (WOUND CARE DRESSING) AND A DRY DRESSING WAS APPLIED. DURING THE DRESSING CHANGE TO #502'S LEFT HIP STAGE III PRESSURE ULCER, MEASUREMENTS WERE REQUESTED. LPN #2 REPORTED, "...I HAVE THE MEASUREMENTS DOWN FROM EARLIER. LENGTH 3.1 CM X WIDTH 1.6 CM X DEPTH 0.2 CM ..." OBSERVATION OF #502'S RIGHT HIP REVEALED A LARGE REDDENED AREA OVER #502'S BONY HIP PROMINENCE WITH ANOTHER REDDENED AREA EXTENDING TOWARD #502'S BUTTOCKS. ACCORDING TO LPN #2, "...THAT AREA TO HIS RIGHT HIP IS NEW. IT'S A STAGE I PRESSURE SORE. THAT WASN'T THERE THIS MORNING..." FURTHER OBSERVATION REVEALED THAT RESIDENT #502 HAD BULKY DRESSINGS AND HEEL PROTECTORS TO HIS BILATERAL LOWER EXTREMITIES. UPON REMOVAL OF THE DRESSINGS, #502 WAS OBSERVED TO HAVE A SIGNIFICANT AMOUNT OF REDNESS, SWELLING AND MULTIPLE SORES WITH NECROTIC SKIN PATCHES UNEVENLY DISTRIBUTED TO BILATERAL LOWER EXTREMITIES. MODERATE SEROSANGUINOUS DRAINAGE WAS OBSERVED ON THE OLD DRESSING. RESIDENT #502'S WOUNDS TO HIS LOWER EXTREMITIES WERE CLEANSED WITH NORMAL SALINE AND [MEDICATION NAME] OINTMENT (FOR PAIN AND WOUND HEALING) AND A DRY BULKY DRESSING WAS REAPPLIED. UPON COMPLETION OF THE DRESSING CHANGE, #502 WAS AGAIN POSITIONED ON HIS LEFT SIDE. A REVIEW OF #502'S "COMPREHENSIVE PLAN OF CARE - PRESSURE SORE" DATED 3/13/13 REVEALED THE FOLLOWING INTERVENTIONS: "...ALLEVIATE RISK FOR DEVELOPMENT OF PRESSURE ULCER..." "...TURN AND REPOSITION Q (EVERY) 2 HOURS..." "...MONITOR SKIN CONDITION DAILY AND REPORT CHANGES..." "...WEEKLY SKIN ASSESSMENT..." ON 4/29/13 AT 1:59 P.M., DURING AN INTERVIEW, LPN #2 WAS ASKED ABOUT THE WOUND CARE SPECIALIST'S EVALUATION OF #502'S WOUNDS, LPN #2 REPORTED, "...HE (#502) HAS NEVER BEEN SEEN BY THE WOUND CARE SPECIALIST..." WHEN ASKED WHY, LPN #2 REPORTED, "...THE WOUND CARE DOCTOR REFUSES TO SEE HIM BECAUSE HE HAS MEDICARE A (INSURANCE COVERAGE ISSUES)..." WHEN ASKED HOW #502'S WOUNDS WERE EVALUATED AND TREATED IN THE ABSENCE OF THE WOUND CARE SPECIALISTS' OVERSIGHT, LPN #2 REPORTED, "...WHEN SHE (WOUND CARE DOCTOR) COMES IN TO SEE HER OTHER PATIENTS, WE JUST ASK HER FOR HER SUGGESTIONS AND OPINIONS BUT SHE DOESN'T GO IN TO SEE HIM (#502). HE SHOULD PROBABLY BE SENT OUT SOMEWHERE ELSE..." LPN #2 FURTHER REPORTED, "...WHEN THE WOUND CARE DOCTOR GIVES ME HER SUGGESTIONS, I USUALLY CALL #502'S DOCTOR TO GET APPROVAL FOR THE TREATMENT SUGGESTED BY THE WOUND CARE SPECIALIST. WHENEVER I CALL HIM (#502'S DOCTOR) HE NEVER GIVES ME ANY ORDERS..." A "NURSE'S NOTES" DATED 4/15/13 REVEALED, "...WOUND CARE SERVICES UNABLE TO CONSULT DUE TO INSURANCE REASONS, SPOKE WITH WOUND CARE SPECIALIST, SUGGESTED [MEDICATION NAME] (WOUND CARE TREATMENT)..." WHEN ASKED IF THE WOUND CARE SPECIALIST HAD MADE DIRECT OBSERVATIONS OF #502'S WOUNDS PRIOR TO SUGGESTION OF TREATMENTS, LPN #2 SAID, "NO." WHEN ASKED IF #502'S DOCTOR HAD ASSESSED #502'S WOUNDS AND PRESCRIBED TREATMENT WHEN HE CAME IN TO SEE HIS PATIENTS, LPN #2 SAID, "...I DON'T THINK SO..." A REVIEW OF THE CLINICAL RECORD REVEALED NO DOCUMENTED EVIDENCE THAT #502'S DOCTOR (MD #1) HAD ASSESSED #502'S WOUNDS. ON 4/29/13 AT 2:34 P.M., DURING A TELEPHONE INTERVIEW WITH #502'S DOCTOR (MD #1), HE REPORTED, "...I HAVE NEVER RECEIVED ANY CALLS FROM THE NURSES THERE (FACILITY)..." WHEN ASKED IF HE (MD #1) WAS AWARE OF OR HAD EXAMINED AND ASSESSED #502'S LEFT HIP PRESSURE ULCER AND LOWER EXTREMITY WOUNDS, WHICH APPEARED TO BE REDDENED AND SWOLLEN, WHEN HE CAME IN TO MAKE ROUNDS, MD #1 REPORTED, "...I WOULDN'T SEE THEM UNLESS THE NURSE INFORMED ME THAT THERE WAS A PROBLEM..." WHEN ASKED HOW HE WOULD CONDUCT A HISTORY AND PHYSICAL EXAM WITHOUT PERFORMING A HEAD TO TOE ASSESSMENT, MD #1 INITIALLY OFFERED NO RESPONSE AND THEN REPORTED, "...LET'S JUST SEND HIM (#502) OUT TO THE HOSPITAL AND HAVE VASCULAR TAKE A LOOK AT HIM..." UPON REVIEW OF THE CLINICAL RECORD, IT WAS OBSERVED THAT THE physician's orders [REDACTED].#502'S WOUNDS. FURTHER RECORD REVIEW REVEALED INCONSISTENCY WHEN CLARIFYING WHETHER #502'S STAGE III PRESSURE ULCER WAS ON HIS RIGHT OR LEFT HIP. ON 4/29/13 AT 3:00 P.M., DURING AN INTERVIEW, WHEN THE DIRECTOR OF NURSING (DON) WAS ASKED WHY THE FACILITY FAILED TO CONDUCT A RESEARCH TO SEE WHAT WOUND CARE PROVIDER COVERED MEDICARE A PATIENTS AND REPORTED, "...I REALLY CAN'T ANSWER THAT..." A physician's orders [REDACTED]. WHEN ASKED ABOUT THE WOUND CONSULT THAT WAS ORDERED 3/15/13, THE DON REPORTED, "...WELL, IT OBVIOUSLY WASN'T DONE..." A REVIEW OF THE FACILITY'S "PRESSURE/NON - PRESSURE ULCERS" POLICY, (UNDATED), REVEALED THE PROCESS FOR COMPLETING THE FACILITY'S "WEEKLY WOUND ROUND RECORD," BUT THE POLICY DID NOT ADDRESS ANY AREAS OF PREVENTION SUCH AS REPOSITIONING, INCREASED ROUNDS, INCREASED FREQUENCY OF REPOSITIONING OR POSITIONING DEVICES.

REFER TO INTAKES MI 323 AND MI 361. BASED ON OBSERVATIONS, INTERVIEWS, AND RECORD REVIEW, THE FACILITY FAILED TO INVESTIGATE POSSIBLE CAUSES OF FALLS, AND FAILED TO DOCUMENT AND IMPLEMENT INTERVENTIONS ON THE CARE PLAN TO REDUCE A RISK OF FALLS FOR 2 (#504, #503) OF 4 SAMPLED RESIDENTS REVIEWED FOR FALLS IN A TOTAL SAMPLE OF 8, RESULTING IN INJURY (NASAL BONE FRACTURES) FOR RESIDENT #504 AND RESULTING IN REPEATED FALLS FOR RESIDENT #503, POTENTIALLY CONTRIBUTING INJURY. FINDINGS INCLUDE: RESIDENT #504 RESIDENT #504, [AGE] years OLD, WAS admitted to the facility on [DATE], PER THE FACE SHEET. ACCORDING TO A PHYSICIAN'S PROGRESS NOTE ON [DATE], RESIDENT #504 HAD A CLOSED HEAD INJURY WITH BRAIN DAMAGE IN THE 1970'S. PER THE PROGRESS NOTE, SHE HAD AN ALTERED MENTAL STATUS, DEMENTIA, AND BIPOLAR DISEASE. A PSYCHIATRIC EVALUATION ON [DATE] DOCUMENTED THAT RESIDENT #504 HAD RECENTLY TRIED LEAVING THE FACILITY, YELLING OUT THAT SHE DID NOT WANT HELP. THE EVALUATION FURTHER NOTED THAT HER MOOD WAS APATHETIC. HER AFFECT WAS FLAT. HER THOUGHT PROCESS WAS ILLOGICAL. HER JUDGMENT WAS POOR, AND HER MEMORY WAS IMPAIRED. THE PSYCHIATRIST INCREASED RESIDENT #504'S ANTIPSYCHOTIC MEDICATION. THERE WAS A NOTE FOR "ATIVAN (ANTI-ANXIETY MEDICATION) PRN (AS NECESSARY) AGGRESSIVE BEHAVIORS OR ANXIETY." RESIDENT #504 WAS OBSERVED WALKING IN HER ROOM ON [DATE] AT 2:10 P.M. SHE MOVED SLOWLY WITHOUT ANY APPARENT GOAL AND NO DESIRE TO ENGAGE IN ANY ACTIVITY. SHE SAT ON HER BED. SHE BEGAN TO SPEAK SOFTLY, MUCH OF HER SPEECH NONSENSICAL. SHE WAS UNABLE TO ANSWER QUESTIONS ABOUT FALLS SHE HAD SUSTAINED AT THE FACILITY. RESIDENT #504 HAD A [DATE] FALLS CARE PLAN. RISK FACTORS INCLUDED A HISTORY OF FALLS, CONFUSION, POOR DECISION-MAKING SKILLS, DEMENTIA, CARDIOVASCULAR DISEASE, AND MEDICATIONS FOR ANXIETY, DEPRESSION, AND PSYCHOSIS. THE GOAL WAS TO "ALLEVIATE RISK OF FALLS WITH SIGNIFICANT INJURY." INTERVENTIONS TO ADDRESS RESIDENT #504'S FALL RISK INCLUDED 1) THERAPY REFERRAL AS NEEDED, 2) PROVIDE VERBAL CUES, 3) MONITOR CARDIAC STATUS, 4) MONITOR LABS, 5) BLOOD PRESSURE PER ORDERS AND AS NECESSARY, 6) ENCOURAGE ACTIVITIES, 7) MONITOR SEDATIVE AND MEDICATION SIDE EFFECTS, AND 8) INDEPENDENT IN BUILDING ([DATE]). PER AN INCIDENT REPORT, DATED [DATE], RESIDENT #504 WAS FOUND ON THE FLOOR, BLEEDING FROM A LACERATION TO THE BACK OF HER HEAD. RESIDENT #504, PER THE INCIDENT REPORT, WAS SENT TO THE HOSPITAL emergency room . ACTION TO PREVENT REOCCURRENCE OF FALLS, DOCUMENTED ON THE INCIDENT REPORT, WAS "EDUCATED RESIDENT ABOUT SITTING DOWN IF STARTING TO FEEL DIZZY." THERE WAS NO DOCUMENTATION THAT RESIDENT #504 WAS "DIZZY" AND NO ASSESSMENTS DOCUMENTED TO SUPPORT THE FINDING. NO INFORMATION WAS ADDED TO THE [DATE] FALLS CARE PLAN. A [DATE] INCIDENT REPORT DOCUMENTED THAT RESIDENT #504 REPORTED SHE fell AND THAT HER HEAD HURT. A RAISED RED AREA WAS NOTED ON THE RIGHT SIDE OF HER HEAD. THERE WAS NO INFORMATION ABOUT HOW THE RESIDENT fell AND NO ACTION IDENTIFIED TO PREVENT FUTURE FALLS. NO INFORMATION WAS ADDED TO THE [DATE] FALLS CARE PLAN. A [DATE] INCIDENT REPORT DOCUMENTED THAT A NURSE PASSING MEDICATIONS SAW RESIDENT #504 FALL AND HIT HER FACE ON THE FLOOR. ABRASIONS WERE NOTED ON THE BRIDGE OF THE NOSE, BETWEEN THE NOSE AND THE TOP LIP, AND ON THE INTERNAL UPPER LIP. THERE WAS NO STATEMENT FROM RESIDENT #504 REGARDING THE FALL. THERE WAS DOCUMENTATION THAT THE GUARDIAN WAS NOTIFIED TO PROVIDE MORE APPROPRIATE SHOES. NO INFORMATION WAS ADDED TO THE [DATE] FALLS CARE PLAN. THERE WAS A [DATE] INCIDENT REPORT REPORTING THAT RESIDENT #504 WAS FOUND ON THE FLOOR, LYING BY THE EDGE OF THE BED ON HER BACK. THE RESIDENT WAS UNABLE TO RESPOND. THE RESIDENT WAS TRANSFERRED TO THE HOSPITAL. A HOSPITAL X-RAY REPORT ON [DATE] DOCUMENTED THAT RESIDENT #504 HAD SUSTAINED NASAL BONE FRACTURES. THERE WAS A NOTE THAT RESIDENT #504 WAS WEARING LOOSE FITTING CLOGS AT THE TIME OF THE FALL. AN ENTRY ON THE INCIDENT REPORT DOCUMENTED THAT THE GUARDIAN WAS INFORMED ABOUT THE INAPPROPRIATE FOOTWEAR. THERE HAD BEEN NO INFORMATION ADDED TO THE [DATE] FALLS CARE PLAN ABOUT APPROPRIATE FOOTWEAR. THE DON, INTERVIEWED ON [DATE] AT 3:15 P.M., SAID RESIDENT #504 GETS "WOBBLY" WHEN SHE STANDS TOO LONG. HE SAID STAFF ENCOURAGE HER TO SIT WHEN THEY SEE HER STANDING IN THE HALLWAY. HE SAID HE DID NOT KNOW WHY THIS WAS NOT ADDED TO THE CARE PLAN. THE DON ALSO SAID THE RESIDENT NOW HAD MORE APPROPRIATE FOOTWEAR. ( ) RESIDENT #503 RESIDENT #503, [AGE] years OLD, WAS admitted to the facility on [DATE], PER THE FACE SHEET. ACCORDING TO A [DATE] PHYSICIAN'S PROGRESS NOTE, RESIDENT #503 HAD HYPERTENSION, ARTHRITIS, AND ADVANCED DEMENTIA. A QUARTERLY NURSING DATA COLLECTION AND ASSESSMENT SHEET, DATED [DATE], INDICATED THAT RESIDENT #503 WAS ALERT, CONFUSED, AND AGITATED. SHE WAS INCONTINENT OF BOWEL AND BLADDER. THE RESIDENT WAS INDEPENDENT IN MOBILITY, PER THE ASSESSMENT SHEET. RESIDENT #503 HAD A CARE PLAN FOR FALLS, DATED [DATE]. RISK FACTORS IDENTIFIED ON THE CARE PLAN INCLUDED A HISTORY OF FALLS, CONFUSION, DEMENTIA, STROKE, INCONTINENCE, AND IMPAIRED VISION AND HEARING. THE GOAL WAS TO "ALLEVIATE RISK OF FALLS WITH SIGNIFICANT INJURY." INTERVENTIONS TO ADDRESS RESIDENT #503'S FALL RISK INCLUDED 1) PROVIDE VERBAL CUES, 2) MONITOR CARDIAC STATUS, 3) MONITOR LABS, 4) TOILETING PROGRAM, 5) ASSURE GLASSES WORN - REFUSES, 6) BLOOD PRESSURE AS ORDERED AND AS NECESSARY, 7) ENCOURAGE ACTIVITIES, AND 8) MONITOR MEDICATION SIDE EFFECTS. RESIDENT #503, ACCORDING TO A NURSE'S NOTE ON [DATE], "SLID OFF SHOWER CHAIR AFTER SHOWER COMPLETE, EASED TO SHOWER FLOOR, AGITATED PRIOR TO AND DURING SHOWER, NO INJURY, WILL CONTINUE TO MONITOR." THE DIRECTOR OF NURSING (DON), INTERVIEWED ON [DATE] AT 2:30 P.M., SAID HE COULD NOT FIND THE INCIDENT REPORT FOR THIS FALL THAT OCCURRED ON [DATE]. THERE WAS NO DOCUMENTATION ON THE [DATE] CARE PLAN FOR FALLS INDICATING THAT THE INCIDENT HAD OCCURRED. THERE WERE NO INTERVENTIONS ADDED WHICH ADDRESSED AGITATION OR SHOWERS ON THE CARE PLAN. ON [DATE] AT 2 P.M., A NURSE'S NOTE DOCUMENTED THAT RESIDENT #503 "WAS EASED TO FLOOR SITTING ON BUTTOCKS. NOTED WITH BILATERAL LE (LOWER EXTREMITY) EDEMA. DISCOLORATION ON (L) INNER ANKLE, 4 IN. X 2 IN., BLUISH TENDER TO TOUCH." A NURSE'S NOTE ON [DATE] DESCRIBED THE RESIDENT "YELLING OUT" IN PAIN. A NURSE'S NOTE AT 7:40 P.M. DOCUMENTED THAT THE RESIDENT WAS SENT TO THE HOSPITAL FOR EVALUATION. THE RESIDENT RETURNED FROM THE HOSPITAL ON [DATE] AT 2 A.M., PER A NURSE'S NOTE. A NURSE'S NOTE ON [DATE] DOCUMENTED THAT RESIDENT #503 HAD A "PODIATRIC SHOE ON (L) FOOT." THE CARE PLAN FOR FALLS HAD NO DOCUMENTATION ABOUT THE FALL ON [DATE], AND THERE WERE NO NEW APPROACHES ABOUT RESIDENT #503'S ABILITY TO AMBULATE, A PODIATRIC SHOE, OR THE INJURED ANKLE. THE DON, INTERVIEWED ON [DATE] AT 2:30 P.M., SAID HE COULD NOT FIND THE INCIDENT REPORT FOR THE [DATE] FALL. A NURSE'S NOTE ON [DATE] DOCUMENTED THAT RESIDENT #503 HAD A MEDICAL APPOINTMENT FOR FOLLOW-UP "FOR FRACTURE TO 3 LEFT TOES." THERE WERE NO ENTRIES ON THE [DATE] FALLS CARE PLAN ABOUT FRACTURED TOES. ON [DATE] (NO TIME DOCUMENTED) THERE WAS A NURSE'S NOTE INDICATING THAT RESIDENT #503 WAS "ASSISTED TO FLOOR WHILE AMBULATING TO RECLINER FROM BATHROOM" WHILE BEING ASSISTED BY TWO CERTIFIED NURSING ASSISTANTS (CNA). "RESIDENT (#503) JUST WENT LIMP AND TO THE FLOOR. RES (RESIDENT #503) C/O (COMPLAINED OF) FOOT PAIN AFTER INCIDENT, X-RAY OF FOOT REVEALS FX (FRACTURE) TO LT (LEFT) LITTLE TOE." THERE WERE NO ASSESSMENTS OF THE RESIDENT DOCUMENTED IN THE NURSES' NOTES. NOTHING WAS ADDED TO THE CARE PLAN REGARDING THE FALL OR THE FRACTURED TOES. A [DATE] NURSE'S NOTE (NO TIME DOCUMENTED) FOR RESIDENT #503 REPORTED "BLISTERS/OPEN AREAS" ON "BILATERAL TOES." THE NOTE DOCUMENTED THAT THE RESIDENT WAS TRANSFERRING FROM THE CHAIR WITH LEG RESTS ELEVATED TO THE BED, SUGGESTING AN UNSAFE PRACTICE. THERE WAS NOTHING ON THE [DATE] FALLS CARE PLAN ABOUT WOUNDS ON THE FEET AND HOW THIS AFFECTED AMBULATION. ACCORDING TO A [DATE] INCIDENT REPORT, RESIDENT #503 WAS FOUND SITTING ON THE FLOOR IN HER ROOM BY THE HOUSEKEEPER AT 1:40 P.M. RESIDENT #503 EXHIBITED SOME PAIN WHEN ATTEMPTING TO STAND FROM A CHAIR. RIGHT LOWER EXTREMITY X-RAYS TAKEN ON [DATE] REVEALED NO FRACTURES. X-RAYS TAKEN OF THE LEFT HIP, FEMUR (THIGH BONE), TIBIA & FIBULA (LOWER LEG BONES), LEFT KNEE, ANKLE, AND LEFT FOOT AND TOES ON [DATE] REVEALED NO DEFINITE FRACTURES. ON [DATE] AN X-RAY SHOWED A LEFT HIP FRACTURE. THE RESIDENT HAD NO FALLS DOCUMENTED IN THE NURSES' NOTES AFTER [DATE]. RESIDENT #503'S CARE PLAN FOR FALLS ([DATE]) HAD TWO ADDED INTERVENTIONS WHICH INDICATED THAT RESIDENT #503 HAD BEEN INDEPENDENT IN THE BUILDING AND WAS TO WEAR NON-SKID SOCKS AT ALL TIMES. THERE WAS NO DATE WHEN THE TWO INTERVENTIONS WERE ADDED. BOTH INTERVENTIONS WERE DISCONTINUED ON [DATE]. TWO INTERVENTIONS WERE ADDED TO THE CARE PLAN ON [DATE]; A PERSONAL ALARM TO BE WORN BY THE RESIDENT WHILE UP IN THE CHAIR AND USE OF A MECHANICAL LIFT TO TRANSFER THE RESIDENT. A PHYSICAL THERAPY DISCHARGE NOTE, DATED [DATE], DOCUMENTED THAT RESIDENT #503 REQUIRED MAXIMUM ASSISTANCE FOR TRANSFERS AND AMBULATION. THIS WAS NOT DOCUMENTED ON THE RESIDENT'S [DATE] FALLS CARE PLAN. A PHYSICAL THERAPY EVALUATION, DATED [DATE], DESCRIBED RESIDENT #503'S WEIGHT BEARING STATUS: "DR. ORDER: DO NOT AMB (AMBULATE) ON FOOT UNTIL WT (WEIGHT) BEARING IS RELATIVELY PAINLESS (L) LE (LOWER EXTREMITY)." THIS WAS NOT DOCUMENTED ON THE [DATE] CARE PLAN. THE DON, INTERVIEWED ON [DATE] AT APPROXIMATELY 11:30 A.M., SAID HE COULD NOT EXPLAIN THE DISCREPANCIES IN AMBULATION STATUS BETWEEN THE [DATE] FALLS CARE PLAN FOR RESIDENT #503 AND THE PHYSICAL THERAPY EVALUATION INDICATING THAT THE RESIDENT WAS NOT INDEPENDENTLY AMBULATORY. THE DON SAID HE DID NOT KNOW THE CAUSE OF THE FOOT WOUNDS AND DID NOT KNOW HOW THEY AFFECTED AMBULATORY STATUS. RESIDENT #503, PER A [DATE] NURSE'S NOTE, EXPIRED AT THE FACILITY. ( )

THIS CITATION HAS TWO DEFICIENT PRACTICES: DEFICIENT PRACTICE #1 BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND FAILED TO ENSURE PROPER FUNCTIONING OF A SENSOR PAD ALARM FOR TWO (#'S 701 & 707) OF 11 RESIDENTS REVIEWED FOR FALLS, OUT OF A TOTAL OF 20 SAMPLED RESIDENTS, RESULTING IN A WRIST FRACTURE, NASAL FRACTURE, HEAD INJURY, A 0.3 CM (CENTIMETER) LACERATION TO BRIDGE OF NOSE, A SMALL HEMATOMA ABOVE LEFT EYE BROW, AND A LOWER BACK STRAIN. FINDINGS INCLUDE: ON 8/21/12 AT 9:25 A.M., DURING THE INITIAL TOUR, ACCOMPANIED BY NURSE "AA," RESIDENT #701 WAS NOTED MAKING SEVERAL ATTEMPTS TO STAND FROM HER WHEELCHAIR. SHE WAS SITTING IN A WHEELCHAIR WITH A SENSOR PAD AND TAB ALARM ATTACHED. NURSE "AA" VOICED SEVERAL REMINDERS FOR RESIDENT #701 TO STAY SEATED IN THE WHEELCHAIR. REVIEW OF RESIDENT #701'S FACE SHEET REVEALED AN ADMISSION INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MOST RECENT QUARTERLY MINIMUM DATA SET (MDS), dated [DATE], INDICATED RESIDENT #701 HAD SEVERELY IMPAIRED COGNITION AND REQUIRED EXTENSIVE ASSISTANCE FOR ALL ACTIVITIES OF DAILY LIVING (ADL'S). REVIEW OF A FACILITY'S DOCUMENT ENTITLED, "UNUSUAL OCCURRENCE INCIDENT REPORT," DATED 6/24/2012 AT 7:25 P.M., DOCUMENTED: "CENA (CERTIFIED NURSING ASSISTANT) HEARD ALARM GO OFF, WENT INTO RES. (RESIDENT'S) ROOM AND FOUND RESIDENT SITTING BETWEEN BED AND WHEELCHAIR STATING "I COULDN'T GET MY SHOE OFF," THEN STATED 'MY WRIST HURTS.' RIGHT WRIST NOTED TO BE SWOLLEN AND DISCOLORED." "ACTIONS TAKEN TO PREVENT POTENTIAL FOR REOCCURRENCE TO: "RE-EDUCATE STAFF ON NOT LEAVING RESIDENT ALONE IN ROOM WHEN THEY HAVE WHEELCHAIR ALARM. CONTINUE 15 MINUTE CHECKS. KEEP RESIDENT IN COMMON AREA WHEN UP IN WHEELCHAIR." REVIEW OF THE NURSE'S NOTE DATED 6/24/12 AT 11:30 P.M., REVEALED THE FOLLOWING "RECEIVED REPORT FROM X-RAY. FRACTURED RIGHT WRIST. DOCTOR NOTIFIED. RESIDENT TO BE SENT TO THE emergency room (ER)..." REVIEW OF AN X-RAY REPORT OF RESIDENT #701'S RIGHT WRIST, DATED 6/24/12, CONFIRMED A FRACTURE. THE RESULTS READ: "COMMINUTED IMPACTED DISTAL RADIAL FRACTURE. AVULSION FRACTURE TIP OF ULNAR STYLOID PROCESS." REVIEW OF RESIDENT #701'S CARE PLAN ENTITLED, "FALL/INJURY ASSESSMENT AND PLAN OF CARE," INITIATED 4/30/12, INCLUDED, "KEEP IN PUBLIC AREAS WHEN UP IN WHEELCHAIR AS ABLE." ON 8/21/12 AT 2:10 P.M., NURSE "B" WAS QUERIED AS TO WHY RESIDENT #701 WAS FOUND ALONE IN HER ROOM ON THE FLOOR ON 6/24/12 AT 7:25 P.M. THAT RESULTED A FRACTURED RIGHT WRIST. NURSE "B" (INTERIM DIRECTOR OF NURSING) REPORTED THAT RESIDENT #701 WAS ON 15 MINUTE CHECKS (MONITORED EVERY 15 MINUTES) DURING THE TIME OF THE INCIDENT. RESIDENT #701'S ACCIDENT CARE PLAN WAS REVIEWED AND DID NOT INDICATE ANY NEW INTERVENTIONS AFTER THE INCIDENT. NURSE "B" REPORTED THAT THE INTERVENTION WAS TO KEEP RESIDENT #701 IN PUBLIC AREAS WHEN UP IN HER WHEELCHAIR. NURSE "B" WAS THEN QUERIED AS TO WHY RESIDENT #701 WAS ON EVERY 15 MINUTE CHECKS PRIOR TO THE FALL. NURSE "B" STATED, "BECAUSE SHE LIKES TO GET UP." REVIEW OF CNA "I'S" WITNESS STATEMENT, DATED 6/27/12, REVEALED, "I WAS ON LUNCH BREAK. AS SOON AS I CAME BACK I SAW OTHER AIDE WALK BY ME WITH A SLING. SHE TOLD ME RESIDENT #701 WAS ON THE FLOOR..." REVIEW OF THE "24 HOUR MONITORING" LOG REVEALED DOCUMENTATION OF CNA "I'S" INITIALS THAT INDICATED SHE WAS SUPERVISING RESIDENT #701 DURING THE TIME OF THE INCIDENT. REVIEW OF THE 24 HOUR MONITORING" LOG DID NOT REVEAL DOCUMENTATION THAT CNA "H" MONITORED RESIDENT #701 DURING. CNA "H'S" (COVERING CNA) WITNESS STATEMENT WAS REVIEWED WITH NURSE "B" AND REVEALED THE FOLLOWING: "I WAS WALKING DOWN B-UNIT AND HEARD AN ALARM. I WENT TO SEE WHO IT WAS, WALKED INTO RESIDENT #701'S ROOM AND FOUND HER ON THE FLOOR ON HER BOTTOM. SHE WAS COMPLAINING OF WRIST PAIN...WENT TO FIND THE NURSE." NURSE "B" WAS THEN QUERIED REGARDING THE LACK OF DOCUMENTATION ON THE 24 HOUR MONITORING" LOG FROM CNA "H" FOR RESIDENT #701. CNA "H" DID NOT INITIAL TO INDICATE SHE WAS THE ONE MONITORING RESIDENT #701 WHILE THE ASSIGNED CNA ("I") WAS ON BREAK. CNA "I" INITIALED THE "24 HOUR MONITORING" LOG DURING THE TIME SHE SAID SHE WAS ON BREAK. NURSE "B" THEN STATED, "THE NURSE DOES THE MONITORING ALSO." ON 8/24/12 AT 10:20 A.M., CNA "H" (COVERING CNA) WAS INTERVIEWED VIA TELEPHONE. CNA "H" STATED, "I HEARD THE ALARM SOUNDING. WHEN I WALKED INTO THE ROOM, I SAW RESIDENT #701 ON THE FLOOR. I MADE ROUNDS. I THOUGHT I SIGNED MY NAME ON THE ROUNDS SHEET (HOUR MONITORING LOG). CNA "I" SHOULD NOT HAVE SIGNED THE SHEET." ON 8/24/12 AT 10:25 A.M., CNA "I" (ASSIGNED CNA) WAS QUERIED REGARDING THE INCIDENT BY WAY OF PHONE. CNA "I" STATED, "I WAS ON MY WAY BACK FROM MY LUNCH. SHE (RESIDENT #701) WAS ON THE FLOOR. I SIGNED MY INITIALS DURING THE TIME I WAS ON BREAK." ON 8/24/12 AT 2:30 P.M., THE ASSIGNED NURSE (NURSE "BB") FOR RESIDENT #701 DURING THE NIGHT OF THE INCIDENT WAS INTERVIEWED. WHEN ASKED WHO DID THE EVERY 15 MINUTE CHECKS/ROUNDS DURING THE TIME OF THE INCIDENT, NURSE "BB" STATED, "THE CNA'S WERE DOING THE CHECKS." ( ) ON 8/21/12 AT 9:20 A.M., DURING THE INITIAL TOUR OF THE FACILITY WITH UNIT NURSE, EMPLOYEE "N," RESIDENT #707 WAS OBSERVED RECLINED IN A TILT BACK CHAIR WITH A SENSOR PAD ALARM IN PLACE. RESIDENT #707'S ROOM OBSERVATION REVEALED A BED ALARM, FALL MAT TO FLOOR AND BILATERAL BOLSTERS TO BED. EMPLOYEE "N" REVEALED THAT RESIDENT #707 had a history of [REDACTED]. RESIDENT #707'S "FALL RISK DATA COLLECTION," DATED 5/7/12 REVEALED A FALL RISK SCORE OF 15 WITH A TOTAL SCORE OF 10 OR ABOVE REPRESENTING HIGH RISK. THE RESIDENT'S CARE PLAN TITLED "HISTORY OF FALLS," DATED 3/13/12, REVEALED AN APPROACH "SENSOR PAD ALARM BED AND CHAIR, DATED 3/16/12. REVIEW OF RESIDENT #707'S A FACE SHEET REVEALED A RE-ADMISSION INto the facility on [DATE], WITHY A [DIAGNOSES REDACTED]. THE RESIDENTS MINIMUM DATA SET ASSESSMENT (MDS), dated [DATE], INDICATED A SEVERELY IMPAIRED COGNITION AND REQUIRED EXTENSIVE ASSISTANCE FOR ACTIVITIES OF DAILY LIVING (ADL'S). REVIEW OF RESIDENT #707'S NURSES' NOTES REVEALED FALLS ON 2/7/12, 2/11/12, 3/7/12, AND 7/14/12. ON 7/30/12 RESIDENT #707 HAD A FALL THAT RESULTED IN A NASAL FRACTURE ALONG WITH A 0.3 CM (CENTIMETER) LACERATION TO BRIDGE OF NOSE, A SMALL HEMATOMA ABOVE LEFT EYE BROW, A HEAD INJURY, AND A LOWER BACK STRAIN. RESIDENT #707'S "UNUSUAL OCCURRENCE INCIDENT REPORT," DATED 7/30/12, REVEALED THAT THE INCIDENT WAS AN "UNATTENDED FALL, TYPE OF INJURY: 0.3 CM (CENTIMETER) LACERATION TO BRIDGE OF NOSE. FULL DESCRIPTION OF OCCURRENCE: ACTIVITIES AIDE CALLED NURSE TO C DINING ROOM, STATED, RESIDENT ON THE FLOOR...OTHER FOLLOW UP: RESIDENT IS A (HAS) A SENSOR ALARM IN CHAIR, ALARM WAS FUNCTIONING AT BEGINNING OF SHIFT ALARM CHECKS. WHEN FOUND ON FLOOR ALARM WAS NOT SOUNDING UNTIL WE MOVED WHEELCHAIR FROM THE AREA." AN ATTACHED "WITNESS STATEMENT," DATED 7/30/12, BY ACTIVITY AIDE, EMPLOYEE "D" REVEALED "THE ALARM HAD NEVER WENT OFF." ON 8/22/12 AT 10:50 A.M., RESIDENT #707'S MEDICAL RECORD WAS REVIEWED WITH UNIT MANAGER "A," AND REVEALED THE FOLLOWING: NURSE'S NOTE, DATED 7/30/12 AT 1915 (7:15 P.M.), "RESIDENT WAS SITTING ON THE FLOOR IN THE DINING ROOM BY ACTIVITY AIDE WHO WAS NOTIFIED BY ANOTHER RESIDENT. RESIDENT'S NOSE WAS SWOLLEN AND BLEEDING, WITH A SMALL CUT TO THE BRIDGE." RESIDENT #707'S NURSE'S NOTE DATED, 7/30/12 AT 22:45, (TIME OF INCIDENT INDICATED AT 19:15, 7:15 P.M.), REVEALED FURTHER DOCUMENTATION THAT READ: "ACTIVITIES AIDE CALLED WRITER TO C DINING ROOM. STATING 'RESIDENT #707 IS ON THE FLOOR.' FOUND RESIDENT IN SITTING POSITION. RESIDENT NOSE NOTED BLEEDING AND SWOLLEN WITH SMALL CUT ON BRIDGE AND SMALL HEMATOMA ABOVE LEFT EYE BROW." RESIDENT #707'S PHYSICIAN ORDER, DATED 7/30/12, REVEALED "SEND TO HOSPITAL FOR EVAL AND TREATMENT." RESIDENT #707'S "NURSE'S NOTE," DATED 7/30/12 2210, REVEALED DOCUMENTATION THAT READ: "PATIENT RETURNED FROM HOSPITAL. PATIENT RETURNS WITH [DIAGNOSES REDACTED]." A "24 HOUR MONITORING," DATED 7/30/12, FOR RESIDENT #707 REVEALED THAT RESIDENT #707 WAS ON 15 MINUTE CHECKS. THE TOOL INDICATED THAT RESIDENT #707 WAS IN THE C DINING ROOM. WHEN QUERIED, UNIT MANAGER "A" WAS UNABLE TO EXPLAIN WHY THE ALARM HAD NOT FUNCTIONED. ON 8/23/12 AT 12:25 P.M., ACTIVITY AIDE, EMPLOYEE "D" WAS QUERIED REGARDING RESIDENT #707'S INCIDENT ON 7/30/12.. EMPLOYEE "D" STATED, "I WAS LOOKING DOWN DOING ACTIVITIES. ANOTHER RESIDENT INFORMED ME THAT RESIDENT #707 HAD FALLEN. I LOOKED OVER AND RESIDENT #707 WAS ON THE GROUND. THE PRESSURE ALARM WAS ON THE CHAIR BUT DID NOT GO OFF." EMPLOYEE "D" WAS UNABLE TO COMMENT WHETHER RESIDENT #707 WAS ALONE OR WITH SOMEONE WHEN THE INCIDENT OCCURRED. ON 8/22/12 AT 12:25 P.M., THE FACILITY'S ADMINISTRATOR WAS QUERIED REGARDING THE INVESTIGATION OF RESIDENT #707'S UNWITNESSED INCIDENT AND THE NON FUNCTIONING ALARM. THE ADMINISTRATOR WAS UNABLE TO EXPLAIN WHY THE ALARM HAD NOT FUNCTIONED UNTIL AFTER RESIDENT #707 HAD FALLEN AND THE WHEELCHAIR MOVED. REVIEW OF THE FACILITY'S POLICY ENTITLED "FALL MANAGEMENT," UNDATED, REVEALED DOCUMENTATION THAT READ, "3. IF A FALL OCCURS, THE STAFF WILL ASSESS FOR INJURY AND INVESTIGATE THE FALL TO IDENTIFY CAUSATIVE FACTORS. THE CARE PLAN WILL BE REVISED WITH POST FALL INTERVENTION (S) WHEN INDICATED." THE FACILITY'S POLICIES AND IN-SERVICES WERE REQUESTED ON EVERY 15 MINUTE CHECKS AND 1:1 SUPERVISION, BUT WERE NOT RECEIVED BY THE SURVEY'S EXIT. ( ) DEFICIENT PRACTICE STATEMENT #2 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ADEQUATELY SUPERVISE ONE (#712) OF SEVEN RESIDENTS PARTICIPATING IN A GROUP SHOPPING OUTING, RESULTING IN THE RESIDENT BEING ABLE TO PURCHASE TWO PACKAGES OF CIGARETTES AND SEVEN LIGHTERS AND THE POTENTIAL FOR A FIRE HAZARD. FINDINGS INCLUDE: A REVIEW OF RESIDENT #712'S CLINICAL RECORD REVEALED A FACE SHEET WHICH DOCUMENTED ADMISSION INto the facility on [DATE], WITH [DIAGNOSES REDACTED]. THE MOST RECENT QUARTERLY MINIMUM DATA SET ((MDS) dated [DATE] NOTED THE RESIDENT AS COGNITIVELY, MENTALLY INTACT AND ABLE TO MAKE HER NEEDS KNOWN. A CARE PLAN DATED 2/14/12 NOTED RESIDENT HAD A "HISTORY OF SMOKING." ON 7/6/12 AT 1:00 P.M., RESIDENT #712 ATTENDED AN ACTIVITY OUTING TO SHOP AT THE LOCAL DEPARTMENT STORE. WHEN INTERVIEWED ON 8/23/12 AT 3:30 P.M., THE ACTIVITY DIRECTOR INDICATED RESIDENT #712 AND 6 OTHER RESIDENTS ATTENDED THE OUTING. THE ACTIVITY DIRECTOR STATED "I DROVE THE FACILITY BUS" TO THE DEPARTMENT STORE. WHEN QUERIED ABOUT SUPERVISION FOR RESIDENT #712'S PURCHASES, THE ACTIVITY DIRECTOR STATED, "AS SOON AS WE ENTERED THE STORE, (THE RESIDENT) WENT STRAIGHT TO THE CHECKOUT AND GRABBED A BAG OF CHIPS. SHE WENT THROUGH THE LINE AND WAITED AT OUR SPOT NEAR THE FRONT ENTRANCE, UNTIL EVERYONE GATHERED AT 3:00 P.M." THE ACTIVITY DIRECTOR WAS QUERIED IF RESIDENT #712 WAS EVER LEFT UNMONITORED IN THE DEPARTMENT STORE, SHE NODDED HER HEAD UP AND DOWN TO SIGNAL " YES " . THE ACTIVITY DIRECTOR WAS QUERIED REGARDING THE VISUALIZATION OF RESIDENT #712 ' S PURCHASED ITEMS AND STATED, "I COULD SEE THE BAG OF CHIPS THROUGH THE BAG. THERE WAS NO REASON TO ASK." A REVIEW OF THE INCIDENT REPORT DATED, 7/6/12 AT 4:35 P.M., REVEALED THE FOLLOWING: "CERTIFIED NURSING ASSISTANT (CNA) FOUND RESIDENT IN THE BATHROOM IN BETWEEN ROOMS 311 - 313 SMOKING A CIGARETTE. WHEN RESIDENT SAW CNA SHE THREW CIGARETTE IN THE TOILET...FOUND TWO PACKS OF CIGARETTES AND A 7-PACK OF LIGHTERS." ACTIONS TAKEN: "RESIDENT WAS INFORMED THIS IS A NO SMOKING FACILITY AND THAT SHE CANNOT HAVE THESE ITEMS IN HER POSSESSION. ALSO INFORMED ACTIVITIES DIRECTOR THAT IF RESIDENT GO ON OUTING WHERE SHOPPING INVOLVED TO WATCH HER PURCHASES CAREFULLY." ON 8/22/12 AT 10:40 A.M., INTERIM DIRECTOR OF NURSING, EMPLOYEE "B", WAS INTERVIEWED REGARDING THE INCIDENT OF LIGHTERS AND CIGARETTES BEING PURCHASED BY RESIDENT #712. EMPLOYEE " B " STATED, "THEY (THE ACTIVITIES STAFF) ARE SUPPOSED TO MONITOR (THE RESIDENTS) PURCHASES. THE ACTIVITIES DIRECTOR HAS BEEN COUNSELED. " ( )

THIS CITATION PERTAINS TO INTAKE: MI 828 BASED ON OBSERVATIONS, INTERVIEWS, AND RECORD REVIEWS, THE FACILITY FAILED TO PROVIDE ADEQUATE ASSISTANCE AND SUPERVISION DURING A TRANSFER WITH A MECHANICAL LIFT FOR 1 (#102) OF 3 RESIDENTS SAMPLED FOR FALLS, IN A TOTAL SAMPLE OF 4, RESULTING IN RESIDENT #102 FALLING OFF THE BED ONTO THE FLOOR, WITH THE SUBSEQUENT DISCOVERY OF A FRACTURED LEFT FEMUR. FINDINGS INCLUDE: ACCORDING TO THE FACILITY'S INVESTIGATION REPORT DATED 8/22/11, ON 8/16/11 AT APPROXIMATELY 10:00 A.M., RESIDENT #102 "INDICATED LEFT HIP PAIN DURING ADL (ACTIVITIES OF DAILY LIVING) CARE." A PHYSICAL EXAM WAS COMPLETED BY A LICENSED NURSE AT THAT TIME THAT DID NOT REVEAL ANY SWELLING, BRUISING, OR REDNESS OF THE AREA. THE PHYSICIAN WAS NOTIFIED AND AN X-RAY OF THE HIPS AND PELVIS WERE ORDERED. ON 8/17/11, THE X-RAY REVEALED AN "ACUTE FRACTURE OF THE LEFT FEMUR, SLIGHT IMPACTION." A REVIEW OF THE CLOSED MEDICAL RECORD REVEALED THAT RESIDENT #102 WAS A [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE] WITH MULTIPLE [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SET, RESIDENT #102 HAD SEVERE COGNITION DEFICITS AND WAS MOSTLY NON-VERBAL EXCEPT FOR REPEATING PHRASES OF PRAYER AND CALLING OUT FOR "MOTHER." RESIDENT #102 WAS IDENTIFIED TO BE TOTALLY DEPENDENT ON STAFF FOR ADL CARE, BED MOBILITY, AND REQUIRED THE USE OF A MECHANICAL LIFT WITH A 1 PERSON ASSIST FOR TRANSFERS FROM BED TO RECLINER CHAIR. RESIDENT #102 HAD SEVERE CONTRACTURES OF BOTH LOWER EXTREMITIES AND THERAPY HAD PRESCRIBED BILATERAL KNEE SPLINTS WHILE IN BED. DURING THE CLOSED RECORD REVIEW IT WAS DISCOVERED RESIDENT #102 HAD FALLEN OUT OF BED ON 8/10/11 (7 DAYS PRIOR TO THE X-RAY FINDINGS). ACCORDING TO THE NURSE'S NOTE FROM 8/10/11 AT 6:45 P.M., RESIDENT #101 WAS OBSERVED ON THE FLOOR AFTER SHE WAS PLACED IN BED WITH THE USE OF A MECHANICAL LIFT (THE TEMPO). THE CERTIFIED NURSING ASSISTANT (CNA #5) STATED SHE PUT THE RESIDENT IN THE BED USING THE LIFT THEN TURNED AROUND TO GRAB 2 PILLOWS. CNA #5 STATED THAT SHE HEARD A LOUD "THUD" AND SAW THE RESIDENT ON THE FLOOR LAYING ON HER RIGHT SIDE. FURTHER REVIEW OF THE NURSE'S NOTES, PAIN ASSESSMENTS, AND SKIN ASSESSMENTS FROM 8/10/11 THROUGH 8/16/11 DID NOT REVEAL ANY CHANGE IN LEVEL OF PAIN OR SKIN CONDITION. ACCORDING TO THE MEDICATION ADMINISTRATION RECORDS (MAR) FOR AUGUST 2011, RESIDENT #102 RECEIVED SCHEDULED VICODIN ES (EXTRA STRENGTH), TWICE A DAY, IN ACCORDANCE TO THE physician's orders [REDACTED].#102 COMPLAINED OF PAIN IN THE LEFT HIP AREA WHILE BEING SEATED IN THE RECLINER WHEELCHAIR. THE PHYSICIAN WAS NOTIFIED AND X-RAYS WERE ORDERED. THE XRAY WAS POSITIVE FOR A LEFT FEMUR FRACTURE AND THE PHYSICIAN AND FAMILY WERE NOTIFIED. DURING AN INTERVIEW ON 9/6/11 AT 1:00 P.M., CNA #3 SAID THAT ON 8/16/11 SHE WAS ASSIGNED TO RESIDENT #102 AND NOTICED THAT SHE HAD HER HAND ON HER LEFT HIP AREA WHILE IN THE RECLINER WHEELCHAIR. CNA # 3 SAID WHEN SHE REPOSITIONED RESIDENT #102, THE RESIDENT CRIED "OUCH" AND KEPT HER HAND ON HER LEFT HIP AREA. CNA #3 SAID RESIDENT #102 HAD NEVER COMPLAINED LIKE THAT BEFORE AND SHE NOTIFIED THE NURSE IMMEDIATELY. CNA #3 SAID RESIDENT #102 WAS REPOSITIONED IN BED, ASSESSED BUT NO BRUISES OR SWELLING WAS NOTED ON THE LEFT HIP AREA. THE NURSE NOTIFIED THE PHYSICIAN OF THE COMPLAINTS OF PAIN OVER THE TELEPHONE. DURING AN INTERVIEW ON 9/6/11 AT 12:30 P.M., THE DIRECTOR OF NURSING (DON) SAID SHE REPORTED RESIDENT #102'S FRACTURE OF THE LEFT FEMUR AS AN INJURY OF UNKNOWN ORIGIN TO THE STATE AGENCY BECAUSE IT COULD NOT BE CONCLUSIVELY DETERMINED THAT RESIDENT #102 HAD SUSTAINED THE FRACTURE DURING THE FALL ON 8/10/11. THE DON SAID RESIDENT #102 DID NOT HAVE ANY CHANGE IN CONDITION, SIGNS OF INJURY OR PAIN UNTIL 8/16/11. ON 8/17/11, WHEN IT WAS DISCOVERED RESIDENT #102 HAD A FRACTURE OF THE LEFT FEMUR, ANOTHER INVESTIGATION WAS CONDUCTED AND IT WAS STILL INCONCLUSIVE THAT THE FRACTURE WAS AS A RESULT OF THE FALL ON 8/10/11. HOWEVER, CNA #5 WAS GIVEN ADDITIONAL TRAINING ON HOW TO SAFELY REPOSITION A RESIDENT IN BED ON 8/15/11 AND THEN SUBSEQUENTLY RESIGNED FOR PERSONAL REASONS. DURING A TELEPHONE INTERVIEW ON 9/7/11 AT 1:50 P.M., CNA #5 SAID SHE WAS ASSIGNED TO RESIDENT #102 FOR THE FIRST TIME ON 8/10/11, AND REQUESTED ASSISTANCE FROM CNA #6 WITH RETURNING RESIDENT #102 TO BED WITH THE USE OF A TEMPO LIFT (MECHANICAL LIFT). CNA # 5 SAID THAT RESIDENT #102 WAS AGITATED DURING THE TRANSFER, FIDGETING AROUND AND YELLING OUT, "MOTHER OF GOD." AFTER RESIDENT #102 WAS PLACED IN BED WITH THE TEMPO LIFT, CNA #6 LEFT THE ROOM. CNA #5 SAID SHE THEN TURNED AWAY FROM THE RESIDENT ON THE BED, TO RETRIEVE TWO POSITIONING PILLOWS FROM THE BEDSIDE TABLE. AT THAST POINT CNA #5 STATED THAT SHE HEARD A LOUD "THUD." WHEN SHE (CNA #5) TURNED AROUND RESIDENT #102 WAS ON THE FLOOR LAYING ON HER RIGHT SIDE. CNA #5 SAID SHE CALLED OUT FOR CNA #6 AND TOGETHER THEY REPOSITIONED THE SLING FROM THE MECHANICAL LIFT BACK UNDER THE RESIDENT WHILE SHE WAS ON THE FLOOR. THE TWO NURSE AIDES THEN PLACED HER (THE RESIDENT) BACK IN BED WITH THE USE OF THE LIFT. LICENSED PRACTICAL NURSE (LPN) #7 CAME INTO THE ROOM AND EXAMINED RESIDENT #102 AND ONLY NOTED BLOOD ON THE RESIDENT'S RIGHT INDEX FINGER FROM A SMALL FINGERNAIL SCRATCH. ACCORDING TO THE FACILITY'S INCIDENT REPORT DATED 8/10/11, ON 8/10/11 AT 6:45 P.M., RESIDENT #102 WAS NOTED TO BE ON THE FLOOR WITH BLOOD ON HER RIGHT INDEX FINGER. THE DOCUMENTATION OF THE FULL DESCRIPTION OF THE OCCURRENCE HAD A NOTATION MADE BY THE NURSE (LPN #7) THAT WAS WRITTEN DIAGONALLY OVER THE TOP OF THE ORIGINAL DESCRIPTION OF THE OCCURRENCE, WHERE IT WAS CLARIFIED THAT THE RESIDENT WAS ON HER RIGHT SIDE IN THE FETAL POSITION. THE PHYSICIAN WAS NOTIFIED ON 8/11/11 BY A DIFFERENT NURSE. DURING A TELEPHONE INTERVIEW WITH LPN #7 ON 9/7/11 AT 1:58 P.M., LPN #7 SAID SHE DID NOT KNOW HOW RESIDENT #102 fell , BUT WAS TOLD SHE fell OFF THE BED AFTER A TRANSFER. LPN #7 STATED THAT SHE COULD NOT RECALL WHERE THE SLING BELONGING TO THE MECHANICAL LIFT WAS POSITIONED AT THE TIME SHE (LPN #7) ASSESSED RESIDENT #102 OR EXACTLY HOW THE RESIDENT WAS RETURNED TO BED, BUT STATED THAT SHE WAS CERTAIN THE RESIDENT WAS LYING ON HER RIGHT SIDE ON THE FLOOR AFTER THE FALL. LPN #7 SAID SHE DID NOT NOTE ANY SIGNS OF INJURY OR PAIN DURING HER ASSESSMENT OF RESIDENT #102 EXCEPT FOR A SCRATCH ON THE RIGHT INDEX FINGER. LPN # 7 SAID SHE NOTIFIED THE FAMILY, BUT DID NOT RECALL IF SHE NOTIFIED THE PHYSICIAN. DURING AN INTERVIEW WITH THE PHYSICIAN ON 9/7/11 AT 2:45 P.M., HE SAID RESIDENT # 102 COULD HAVE POSSIBLY FRACTURED HER LEFT FEMUR DURING THE TIME OF THE FALL ON 8/10/11, BUT DID NOT DISPLAY ANY SIGNS OF INJURY UNTIL SHE INDICATED SHE HAD PAIN ON 8/16/11. THE PHYSICIAN SAID RESIDENT #102'S FRACTURE WAS ALMOST IMPOSSIBLE TO DETECT ON JUST PHYSICAL ASSESSMENT BECAUSE RESIDENT #102 WAS NONVERBAL, NONAMBULATORY, AND RECEIVING SCHEDULED VICODIN ES TWICE A DAY FOR ARTHRITIS PAIN. THE PHYSICIAN SAID HE ORDERED THE XRAY AFTER IT WAS DETERMINED THE RESIDENT HAD PAIN IN THE HIP AREA. THE PHYSICIAN SAID HE DID NOT ROUTINELY ORDER AN XRAY FOR RESIDENT #102 AFTER THE FALL ON 8/10/11 BECAUSE SHE DID NOT SHOW ANY SIGNS OF INJURY. ALSO, RESIDENT #102 WOULD NOT BE A CANDIDATE FOR SURGICAL REPAIR OF THE FEMUR. THE RESIDENT'S FAMILY WAS INFORMED OF THE FRACTURE AND DID NOT WANT SURGICAL INTERVENTION. RESIDENT #102 WAS TRANSFERRED TO A DIFFERENT FACILITY (FACILITY "B") ON 8/31/11, PER THE FAMILY'S REQUEST. ON 9/7/11 AT 10:30 A.M., RESIDENT #102 WAS OBSERVED AT FACILITY "B" IN A RECLINER CHAIR WITH AN ABDUCTOR PILLOW BETWEEN HER KNEES. RESIDENT #102 WAS UNABLE TO BE INTERVIEWED DUE TO SEVERE COGNITIVE DEFICITS. THE RESIDENT DID YELL OUT THE PHRASE, "MOTHER OF GOD" REPEATEDLY DURING A TRANSFER WITH A MECHANICAL LIFT. RESIDENT #102 HAD OBVIOUS CONTRACTURES OF BOTH LOWER EXTREMITIES. THERE WERE NO VISIBLE BRUISES, OR SWELLING NOTED ON THE RESIDENT. ON 9/7/11 AT 3:00 P.M., THE DON SAID RESIDENT #102 WAS DETERMINED BY THE THERAPY DEPARTMENT TO REQUIRE THE USE OF A MECHANICAL LIFT WITH A 1 PERSON ASSIST FOR TRANSFERS. THE DON SAID THE FACILITY'S POLICY IS TO ONLY USE 1 PERSON TO TRANSFER A RESIDENT WITH THE USE OF THE LIFT, UNLESS THE RESIDENT IS VERY LARGE, COMBATIVE, OR AGITATED. THE DON SAID SHE WAS NOT AWARE RESIDENT #102 WAS AGITATED DURING THE TRANSFER BACK TO BED ON 8/10/11. ( )